living with HIV/AIDS, with more than 61.5% of women in care for HIV (Rand, 1998) and 90% of children with AIDS (DHHS, 1998) relying on this program for health care coverage. The costs associated with Medicaid have been rising and there have been several efforts to change the entitlement status of the program, impose per capita caps, and change the structure of payments to providers. While the program remains an entitlement, passage of the Balanced Budget Act of 1997 resulted in several important changes:
- Medicaid has experienced funding cuts in two important areas that affect HIV services. In response to abuses by states, the disproportionate share hospital (DSH) payments, which compensate hospitals serving a large volume of uninsured and Medicaid patients, have been curbed and reporting requirements imposed. The DSH program is important to health care access for people with HIV and AIDS by supporting such safety net providers as outpatient HIV clinics at public and nonprofit hospitals across the nation. The second cut in Medicaid comes from repeal of the Boren Amendment, which established a standard for reimbursement to hospitals and nursing homes. States must now provide public notice of their rates and how they were calculated.
- States now have the authority to mandate that beneficiaries enroll in managed care plans without application to the federal government; plans can consist of only Medicaid beneficiaries, and states can impose cost sharing charges allowed under fee for service plans. These changes may well affect the ability of persons with HIV to access services needed for their care (see comments in following section, below.)
- States now have the option to extend Medicaid coverage for 12 months for all children, whether or not they continue to meet income eligibility tests. This provision is expected to expand coverage by up to one million children.
- States have the option of creating a Medicaid "buy-in" for persons whose income is under 250% of poverty and who would be eligible for SSI, if their income were not too high. This has important implications for increasing access to Medicaid for women with HIV (Families USA Foundation, 1997).
Enrollment in managed care arrangements has increased dramatically in this decade. The percentage of employees enrolled in managed care plans increased from 48% in 1992 to 855 in 1997 (Employee Benefit Research Institute, 1998). Almost 50% of Medicaid recipients were enrolled in managed care in 1997, with two states reporting 100% enrollment and five states reporting more than 80% enrollment (HCFA, 1997). The movement into managed care represents a fundamental change in the way health care services are delivered in both the public and the private sector, raising issues of access to care and quality of care.
- Through public sector managed care arrangements, women, children, and