continuity of Medicaid coverage. Due to Medicaid recertification processes and/or temporary or permanent changes in a recipient's eligibility status, about half of the Medicaid population is continuously enrolled for less than 12 months. This means that many women and children are without coverage for medical care for varying periods of time, an issue critical to continuity of care, counseling, testing for HIV, and the ability to comply with complex HIV drug regimens.
Access to care is also affected by the reduction in the disproportionate share hospital (DSH) payments enacted in the Balanced Budget Act of 1997. DSH payments compensate hospitals serving a large volume of uninsured and Medicaid patients. This program supports such safety net providers as outpatient HIV clinics at public and nonprofit hospitals across the nation. This legislation also provided states with the option of expanding access to Medicaid by creating a "buy-in" for persons whose income was under 250% of poverty and who would be eligible for SSI, but whose income was too high. This option has important implications for women with HIV (Families USA Foundation, 1997).
Managed care has become a major strategy to control health care costs in both the public and the private sectors. Although managed care arrangements can take different forms, they all include enrollment of individuals, contractual agreements between the provider and a payor, and varying degrees of gatekeeping and utilization control (Kaiser Commission on the Future of Medicaid, 1996). Because it is responsible for delivering care to a defined group of enrollees, managed care makes possible, for the first time, accountability for the quality of care of populations, including access to care and health outcomes (IOM, 1996a).
Enrollment in managed care arrangements has increased dramatically in both the public and the private sector over this decade. Not only has the percentage of employees enrolled in managed care plans increased from 48% in 1992 to 85% in 1997 (EBRI, 1998) but federal law now allows states to mandate the enrollment of Medicaid beneficiaries in managed care organizations (MCOs). Almost half of Medicaid recipients were enrolled in managed care in 1997 (HCFA, 1997). Women, children, and youth are moving most quickly into managed care. This population as a whole, particularly those with or at risk for HIV/AIDS, has unique and complex needs requiring a broad array of multidisciplinary medical and support services. For example, relationships have to be built between the MCOs and the type of providers that adolescents seek—teen clinics, school health clinics, community family practice sites, and family planning clinics.
Some of the problems encountered by persons with HIV enrolled in MCOs include reduced access to specialty care providers, including HIV specialists; reduced access to specific drug formularies and specific services; clinical decisions apparently made on the basis of cost; limitations placed on the information providers can provide; and insufficient time with providers. MCOs have difficulty