accessible, and affordable. Today, would such confidence be justified?

Medicare beneficiaries are substantially different from those who have typically enrolled in managed care organizations. Several of the researchers whose works were cited in this paper observed indications that the plans studied lacked experience dealing with particular types of chronically ill patients or did not understand the importance of certain treatment modalities that are of importance to those with chronic care needs (e.g., Clement et al., 1994; Shaughnessy at al., 1994). Furthermore, the research evidence is inconclusive. Some studies indicate that older individuals and/or those with chronic conditions have fared well, whereas others indicate that the experiences of older, sicker populations have been less than satisfactory. Moreover, the studies that have been conducted have been hampered by the absence of well-defined norms to adequately evaluate plan performance, particularly in the treatment of chronic conditions. It would be imprudent to generalize from the findings because the reported results may have been peculiar to the model type of the plans investigated, the payment arrangements, or the particular market in which the plans were situated. Clearly, a great deal of research is needed before it will be possible to make unequivocal statements, in either direction, about the experiences of vulnerable populations in managed care plans.

Regrettably, waiting for research results will not be an option for today's beneficiaries. The U.S. Congress is poised to expand managed care and other options in Medicare in the short term. At the same time, Congress is also intent on achieving ''savings" from the Medicare program. These savings will be realized in both the traditional and managed care programs. Unfortunately, the present payment methodology used to reimburse HMOs is widely recognized as flawed (U.S. General Accounting Office, 1995b). The adjusted average per capita cost methodology does not contain an adequate risk adjuster, thereby giving plans an incentive to "cherry pick" the healthiest risks. The U.S. General Accounting Office (GAO) has identified several promising efforts in the area of risk adjustment but predicts that an effective risk adjuster is not likely to be available in the near future (U.S. General Accounting Office, 1994). This



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