not be explained by differences in the desire to receive such therapies (Gifford et al., 2002). Blacks, Hispanics, women, the uninsured, and Medicaid beneficiaries also had less favorable patterns of use of hospitals, emergency departments, and ambulatory office or clinic settings (Shapiro et al., 1999). Patients in rural areas were also less likely to receive antiretroviral therapy (Cohn et al., 2001).

Additional compelling evidence supporting the hypothesis that improved financing of HIV care would reduce disparities in access is offered in the recent study using HCSUS data conducted by Bhattacharya and Goldman (2003). Data from this study show that patients with public health insurance (Medicaid) have much lower death rates than uninsured patients (controlling for severity illness). The authors estimate that expanding public insurance coverage for HIV/AIDS patients could reduce HIV/AIDS-related deaths among the uninsured up to 66 percent. The researchers also found that states with Medicaid programs with less restrictive eligibility rules and more generous drug coverage had significantly lower death rates than states with more restrictive eligibility rules and less generous drug coverage.

Demographic variables and comorbidities also play an important role in accessing HAART. Additional HCSUS analyses found that women, blacks, those with less education, and injection drug users were least likely to have received early access to HAART (Andersen, 2000). The results of a study of service claims data from four states (California, New York, Florida, and Texas) supports racial and ethnic differentials found in the HCSUS study. Significant racial/ethnic disparities were found in the reduction of AIDS-related mortality and in reduction of AIDS-related mortality by state. AIDS-related mortality was reduced by 64 percent in California compared with 52 percent in Texas (Morin et al., 2002). Mortality reductions for Latinos and African Americans were found to be lower than for non-Latino whites. These disparities were associated in part with policy barriers, such as limits on Medicaid eligibility based on disability requirements and state-imposed income and benefit limits on ADAP, as well as social barriers (HIV-related stigma).

Marcus and colleagues (2000) analyzed HCSUS data to assess access to dental services. He found that perceived unmet need was greatest among those on Medicaid in states that did not provide dental coverage through the Medicaid program, and for others lacking dental insurance. Persons with low incomes (under $5,000) and those with less than a high school education also had higher odds of having perceived unmet needs (Marcus et al., 2000).

Case management services have been found to support individuals’ access to care. Katz et al. (2000) found a high level of unmet need for supportive services among persons in care. Unmet need was significantly higher among nonwhites and persons with less education. Those with a



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