Women's access to the health care system varies by income, ethnicity, and education (Wyn et al., 1996). How and where women seek health care reflects both the structure and the organization of the health care system, as well as women's awareness or knowledge of health care practices and their satisfaction with health care professionals (Falik, 1996). The majority of women and children in the United States receive care in a private provider's office. The more affluent and educated a woman is, the more likely she is to use two providers—an obstetrician—gynecologist and an internist or family care practitioner (Weisman, 1996). Most adolescents receive health care at community teen clinics, school-based clinics, community family practices, private family practices, and private pediatric practices (Blum et al., 1996).
The poor or nearly poor, the population most affected by HIV infection, is more likely to use publicly funded providers or programs (public and nonprofit hospitals, community health centers, family planning clinics, and public health clinics (Lyons et al., 1996). Most children, youth, and families affected by AIDS depend on these "safety net" programs for their care. While more than 61% of women in care for HIV (Rand, 1998) and 90% of children (under 18) with AIDS (DHHS, 1998) receive care paid for through the Medicaid Program, the rapid growth of public managed care programs for those on Medicaid is moving service delivery into the managed care setting.
The significant developments in prevention and treatment for women and children and the efforts to promote the application of these developments have taken place in the context of a health care system that is undergoing a revolution in structure and funding. Significant changes in Medicaid and welfare programs, the growing presence of managed care in both the public and private sector, the growing number of uninsured, and the recently introduced Children's Health Insurance Program are having a significant impact on our health care system, affecting not only the availability of quality services, but also access to services.
The lack of a unified set of goals or policies that guides how health care services in the United States are organized challenges our ability to respond optimally to an epidemic as complex and challenging as HIV/AIDS. An array of federal, state, and local laws, regulations, policies, institutions, and funding mechanisms not only shapes the services in any given locality (Hess, 1994) but determines who has access to those services. The current mix of public and private services and funding streams not only varies significantly from state to state and community to community, but is undergoing rapid change and is financially vulnerable. In addition to a growing number of uninsured and a reduction in public funding of health care services, the rapid growth of managed care is competing for clients in both the public and the private sector and reduces the ability of public programs, and private sector programs using public funds, to subsidize care through Medicaid reimbursement (Davis, 1997).