setting appropriate capitation rates for those with HIV/AIDS. Also, many of the providers who do have experience in providing HIV/AIDS care do not have experience working within managed care environments (Kaiser Family Foundation, 1998b). More time is needed to gain experience providing HIV specialty services and to build systems that can monitor and evaluate the quality of care in the managed care setting and provide oversight. One strategy chosen by some states is to "carve out" or exclude specific services or populations from the managed care contract and allow them to be provided as they were before the affected individuals were placed in the managed care program. Some MCOs deal with HIV/AIDS care in this way.

Medicaid managed care arrangements compete with public providers and private community-based providers serving the uninsured and publicly insured. Before the advent of managed care, these providers were frequently the only ones who served the poor or near-poor patient. Reimbursement from Medicaid for eligible populations allowed these providers to cross-subsidize the uninsured or underinsured patient (Davis, 1997). Now, competition for Medicaid funds is threatening the ability of these providers to support services to those without adequate insurance coverage. In addition, "many public hospitals and … providers of care to the poor with a mission to render care to the uninsured are being sold to private, for-profit organizations without a comparable mission to provide uncompensated care" (Wehr et al., 1998).

Managed care contracts, like traditional insurance contracts, do not typically identify specific conditions, and services are limited to what the purchaser specifies. In 1996, 18 states covered counseling and testing for HIV in their Medicaid managed care contracts, usually in the context of family planning services only. Access to the ACTG 076 protocol was assured through specific language only in Florida, but specific clinical services are often not mentioned in these contracts (Wehr et al., 1998).

Conclusions

Improvements in the prevention and treatment of HIV/AIDS in women and children and the efforts to promote the application of these new procedures have taken place in the context of a health care system that is undergoing a revolution in structure and funding. Major changes in Medicaid and welfare programs, the growing number of uninsured, and the growing presence of managed care in both the public and the private sector, are having a significant impact on the health care system, affecting not only the availability of quality services, but access to those services.

An array of federal, state, and local laws, regulations, policies, institutions, and financing mechanisms shapes the services in any given locality and 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



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