program so rapidly to managed care raises key questions about this approach, in part because the intended shift is so rapid and also because many are not persuaded that managed care plans are ready for a large influx of vulnerable new members (Braveman and Bennett, 1995). Others caution that the expectations of managed care are unrealistic (Ginzberg, 1995; Mashaw and Marmor, 1995; Meyer et al., forthcoming).
Unlike their younger counterparts, Medicare beneficiaries have had relatively little exposure to diverse managed care models. As of January 1996, only slightly more than 10 percent, or approximately 4 million individuals, have been enrolled in any form of managed care, mainly risk-based health maintenance organizations (HMOs). Enrollment is concentrated in just a few areas. In January 1996, about 50 percent of the Medicare beneficiaries enrolled in risk-based HMOs lived in just four states, California, Florida, Arizona, and New York (Health Care Financing Administration, Office of Managed Care, 1995a). Furthermore, those beneficiaries who have been enrolled in Medicare HMOs have tended to be healthier and younger than those enrolled in the traditional Medicare program (Brown et al., 1993). In January 1994, only 4.8 percent of Medicare risk enrollees were disabled (compared with approximately 11 percent in the traditional Medicare program) (Health Care Financing Administration, Office of Managed Care Operations and Oversight Team, 1995b). Finally, a recently released survey of Medicare beneficiaries (U.S. Department of Health and Human Services, 1995a) indicates that many beneficiaries (64 percent) do not even know if they live in areas where they could currently enroll in a managed care plan—this, in spite of the fact that three fourths of beneficiaries do have such an option. Thus, managed care is unknown or unfamiliar to many beneficiaries.
The purpose of this paper is to consider the prospect of managed care enrollment for Medicare beneficiaries, particularly those who are vulnerable. How can such individuals be expected to fare in a health delivery environment that is vastly different from the one that most of them have known and understood? The paper first defines "vulnerable" and presents selected demographic characteristics of such individuals. The experiences of vulnerable individuals in managed care programs is