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A In(QX Academic health centers, 48, 66, 83, 111, 148-149, 195, 209 Academic medical centers, 4, 23, 24, 56, 65-66,72,84,114,116-117,135, 145, 146, 148-149, 161 Accessibility, health care, 1, 3, 4, 8, 10, 21, 27, 74, 175 beneficiary choice, 7, 25, 30, 83-84, 166-170, 206-207; see also "mainstreaming" infra commercial vs Medicaid managed care, 161 community funding, 13, 14 community health centers, 59-60 cost sharing/out-of-plan decisions, 32-33 emergency care, 36 local health departments, 63 mainstreaming, 26, 30, 38-39, 135, 170-173, 176, 195 Medicaid managed care, 161, 162-164, 170-173 nonfinancial barriers, 166 cultural factors, 21, 24, 41, 60, 159 language barriers, 21, 24, 41, 48, 52, 53, 59, 73 telephone access, 14, 161, 217 transportation to care, 7, 21, 48, 56, 59,137,161,163,166,185,197 outreach, 7, 13, 34, 48, 51, 57, 61, 74, 95, 97, 109, 166, 168, 208 special-needs patients, 181, 195, 197, 198, 199, 218 primary care, 7, 164 primary care case management, 31- 32, 139, 148, 149, 150, 162-163 private practitioners, 162 special-needs patients, 13, 51, 195, 197, 198, 199, 218 outreach, 181, 195, 197, 198, 199, 218 see also Advocacy; Core safety net providers; Insurance; Uninsured / underinsured persons Accountability, 11, 136, 214 community services funding, 13 Medicaid, 29, 107, 133 special-needs patients, 199, 201 Administrative requirements community health centers, 63, 102(n.25) cost-based reimbursement, 102(n.25) 263

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264 federally qualified health centers, 142 hospitals, 145-146, 208 protocols, 136, 211 rural areas, 150 state Medicaid programs, 18, 108, 132, 135, 145-146, 147, 150, 161, 172,185,208 waivers, 71 Adverse risk selection, 12, 148, 194, 215 Advocacy, 26, 63, 136, 168, 198, 199-201, 231 self-advocacy skills, 161 special-needs patients, 199-200 African Americans, 54, 73 AIDS/HIV patients, 193 uninsured, 40 Agency for Health Care Policy and Research, 74 AIDS/HIV, 20, 51, 53, 57, 72, 141, 181, 192-195, 200 African Americans, 193 homeless persons, 196 local health departments, 64, 125, 151 Medicare, 192, 193 Aid to Families with Dependent Children, 26, 92, 146, 147, 184 Alabama, 112 Alpha Center, 133 Ambulatory care, 25, 58, 60, 194-195 charity care, 65 core safety net providers, 21, 48, 55 disproportionate share hospital funds, 100 Native Americans (FQHCs), 60 public hospitals, 25, 55, 58 state policy, 153 see also Clinics; Community health centers; Federally qualified health centers Ambulatory Care Group, 194-195 American Hospital Association, 65-66 American Indians, see Native Americans American Indian Self-Determination Act, 60 Americans with Disabilities Act, 181, 182 Arizona, 30 INDEX B Bad debt, see Uncompensated care Balanced Budget Act (BBA), 5, 12, 24, 34, 35-37, 101-102, 103, 154, 206, 211, 215 Medicare, 35, 142 special-needs patients, 35, 182 State Children's Health Insurance Program (SCHIP), 11-12, 34, 40, 69, 92, 97-98, 215 Balanced Budget Refinements Act, 5-6, 35, 101 Black persons, see African Americans Blue Cross Blue Shield, 133(n.1) Boston, Massachusetts, 84, 174 Bureau of the Census, 86 Current Population Survey, 52, 85, 89 Bureau of Primary Health Care, 41, 73, 143-144 C California, 23 hospital market consolidation, 112 Medicaid managed care, 30, 153, 154, 169 special-needs children, 187 Capitation rates, 16, 139, 161 Medicaid, 9, 30, 36, 38, 93, 109-111, 152, 155-156, 161, 173, 176, 209 special-needs patients, 187-188, 192, 194-195 CareOregon, 141, 172 Census Bureau, see Bureau of the Census Center for Health Services Research and Policy, 170 Center for Studying Health System Change, 33-34 Centers for Disease Control and Prevention, 14, 213, 217 Charity care, 9, 24, 55, 174, 175 homeless persons, 197 hospitals, 55, 65, 113 Medicaid and, 6, 8, 40-41 physicians and, 6, 24, 67-68 see also Core safety net providers; Disproportionate share hospitals; Uncompensated care

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INDEX Children, 32 African Americans, infant mortality, 73 AIDS/HIV patients, 194 Aid to Families with Dependent Children/Temporary Assistance to Needy Families, 26, 92, 146, 147, 184 community health centers, 73-74 Early and Periodic Screening, Diagnosis, and Treatment program, 56, 64-65, 126, 186 homeless, 196 immunizations, 56, 57, 61, 64, 125, 164, 186 local health department services, 64, 124 Medicaid enrollment trends, 94, 184 Title V (Social Security Act), 12, 56, 185, 186, 188 uninsured, 133; see also State Children's Health Insurance Program see also Special-needs children Chronically ill persons, 21(n.3), 181 core safety net, 51 homeless, 196 Medicaid managed care populations, 162, 180 public teaching hospitals, 161 state disability payments, 111 vulnerable populations, 159 see also AIDS/HIV; Disabled persons; Mental health and illness; Special health care needs; Special needs children Cities, see Urban areas Clinics, 4, 13, 17, 22, 23, 28, 41, 47 homeless persons, 197-198 Medicaid patients, 48 uninsured patients, 48 see also Community health centers; Federally qualified health centers Colorado, 145-146, 173 The Commonwealth Fund, 52, 68, 113, 140 Community Access Program, 14, 153, 217 265 Community health centers (CHCs), vii- viii 4, 5-6, 47, 59-63, 72-74, 119- 123 disproportionate share hospital funds, 100 funding, proposed, 22, 23, 25 homeless persons, 197 managed care organizations (MCOs) and, 41, 137-139, 144 Medicaid, general, 61, 62, 72-73, 119- 122, 138-139 Medicaid managed care, 41, 133, 135, 136, 137-144 mental health, 189 organizational factors, 83, 84, 212 rural areas, 28, 54, 62-63 self-paying patients, 61 study at hand, methodology, 23, 25, 27 welfare reform, 93 see also Federally qualified health centers Community Health Plan of Washington, 138 Competition, 6, 8, 14, 16, 25, 35, 106 disproportionate share hospitals, 100 economies of scale, 136, 145, 211 grants, 12 hospitals and clinics, 16, 71, 112-113, 209 managed care, general, 40, 41, 42, 106-107, 136, 140 market share, 6, 16, 22, 106, 108, 112- 113, 132-133, 136 Medicaid market, 25, 31, 38, 39, 126, 132,170 price, 3, 19, 82, 83-84, 106, 153, 206 see also Market forces Congress (U.S.) committee mission, 11 core safety net providers, 54 cost-based reimbursement, 71 low-income uninsured, bills, 34 managed care, 30 see also Legislation Congressional Budget Office (CBO), 97, 101 Consumer Assessment of Health Plans, 165

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266 Contact Health Services program, 70 Core safety net providers, 4-8, 9, 10, 21- 24, 47-75, 205, 206 defined, 3-4, 6, 21-22, 47, 54 disabled persons, 183-184 federal initiative, 215-217 grants, 6-7, 12-13, 14, 39, 49, 54-55, 120, 121 hospitals, 22, 23, 41, 105, 114-115, 118, 147-149; see also Disproportionate share hospitals local government role, general, 23, 103-105, 113, 148 Medicaid, general, 49, 113-114 Medicaid managed care, 21, 25, 41-43, 111-112, 126, 132, 134, 136-152, 206-208, 209-210 Medicare, 42, 55, 56, 57, 58, 60, 61, 62 organizational factors, 24-25, 38, 54- 55, 56-57, 62, 74, 75 subsidies, 4, 10, 17, 23, 25, 40-42, 49, 209-210 uninsured persons, 3-4, 5, 21-24, 27- 28, 47-48, 50, 55, 56, 58, 59, 209 see also Charity care; Community health centers; Disproportionate share providers, general; Federally qualified health centers; Uncompensated care Cost and cost-effectiveness, 16 AIDS/HIV treatment, 192-194, 199 community health centers, 73 core safety net providers, 48-49 employer-based insurance, 50 hospitals, financial performance, 114- 119, 144-145 local health departments, 125-126 Medicaid managed care, 29, 30, 31, 32, 35-37, 43, 107, 135, 139, 140- 141, 142, 143, 153 mentally ill persons, treatment, 188 outreach efforts, 166 pharmaceuticals, 91 special-needs patients, 188, 192-194, 199, 200 uncompensated care, hospitals, 58-59, 105 INDEX underinsured persons, 91 see also Efficiency, economic; terms beginning "Risk... " Cost-based reimbursement, 5, 20(n.2), 24, 31, 35, 39, 40, 60 federally qualified health centers, 24, 35, 40, 71-72, 101-103, 120-121, 126, 206, 210 Rural Health Clinic program, 63 County-level efforts, 23, 56, 57, 64-65, 66, 73, 74, 103, 104-105 hospitals, 105 special-needs children, 187-188 Cultural factors, 21, 24, 41, 159 federally qualified health centers, tax- exempt, 60 language barriers, 21, 24, 41, 48, 52, 53, 59, 73 Current Population Survey, 52, 85, 89 D Dallas, Texas, 62 Demographic factors, 175, 198 access to care, 175 AIDS/HIV patients, 193 educational attainment, 21 risk adjustment, 173 see also Children; Immigrants; Migrant health care; Minority groups; Women Dental care, 55, 57, 61, 70, 72, 73, 125, 152, 197, 198 Denver Health, 55, 56, 59(n.4), 145-146, 151, 212 Department of Agriculture, 214 Department of Commerce, see Bureau of the Census Department of Defense, 214 Department of Health and Human Services Agency for Health Care Policy and Research, 74 Bureau of Primary Health Care, 41, 73, 143-144 Centers for Disease Control and Prevention, 14, 213, 217 grant funding, 13-14, 216-217

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INDEX homelessness, 197 Indian Health Service, 69-70, 85, 213- 214 local health departments, guidelines, 63 Medicaid managed care, state waivers, 31, 37, 71, 93-94 study at hand, directives for, 17 see also Health Care Financing Administration; Health Resources and Services Administration; Maternal and Child Health Bureau Department of Health and Human Services Appropriations Act, 153 Department of Housing and Urban Development, 196, 214 Department of State, 214 immigrants, 40 Department of Veterans Affairs, 214 see also Veterans Administration Detroit, Michigan, 23 Disabled persons, 21, 29, 32, 51, 161, 181, 198 Americans with Disabilities Act, 181, 182 defined, 181-182 see also Chronically ill persons; Mental health and illness; Special health care needs; Special needs children Disproportionate share hospitals (DSHs), 5, 12, 17, 23, 56, 65-66, 98-101, 104, 106 Balanced Budget Act, 36-37 case study, 141 drugs, discounts, 91 funding, 10, 12-14, 23, 40-41, 49, 59, 98-100 historical perspectives, 40, 98-100 Medicaid, 10, 18, 29, 36-37, 40, 49, 98- 101 (passim), 110, 126, 141, 174, 184, 213 Medicare, 10, 40, 56, 98(n.18), 100, 213 public, 17, 40 state government role, 40, 98-101, 110 taxes, 99 267 Disproportionate share providers, general, 17, 21-22 Drugs, see Pharmaceuticals and pharmacists; Substance abuse E Early and Periodic Screening, Diagnosis, and Treatment program, 56, 64-65, 126, 186 Economies of scale, 136, 145, 211 Education, public, 63, 168, 169 see also Outreach Education and training, professional academic health centers, 48, 66, 83, 111, 148-149, 195, 209 academic medical centers, 4, 23, 24, 56,65-66,72,84,114,116-117, 135, 145, 146, 148-149, 161 graduate medical education, 28, 56, 66, 72, 106, 148, 251 minority students, 68 public teaching hospitals, 48, 148, 161 school-based health centers Efficiency, economic, 16, 28, 140 buildings, 13 hospital ownership consolidation, 113 hospitals, general, 144-145 local health departments, 125 provider-level, 41-42, 70-71 see also Cost and cost-effectiveness; terms beginning "Risk...' Elderly persons, 32, 94, 184 see also Medicare Emergency care, 161 access to, 36 children, 73-74 homeless persons, 196 local health departments, 64 uninsured persons, 1-2, 65 Emergency Food and Shelter Program, 197 Employer-sponsored insurance, 86, 173 costs, 50, 86 eligibility, 86 Health Insurance Portability and Accountability Act, 34, 95, 97(n.13)

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268 Health Plan Employer Data and Information Set, 164-165 managed care, 16, 67-68 private practitioners, 67-68 tax incentives, 34-35 Employment, other, see Self-employed persons; Unemployed persons; Workers Ethnicity, see Immigrants; Minority groups F Families USA Foundation, 39 Family planning, 4, 61, 62, 64, 65, 125, 152, 154 Federal government, 9, 10, 69-70, 152- 153, 212 Revolution of responsibility to state/ local governments, general, 16, 29, 74, 104, 164(n.2), 185, 210 monitoring of delivery systems, 10- 12, 36, 210-211, 213-215 poverty level, 29, 33, 58, 67, 86 (n.3), 87-88, 97 tax credits, 34-35, 95 technical assistance, 11, 14, 140, 143, 171,214,217 uninsured persons, 34-35 see also Funding; Legislation; Medicaid; Medicaid managed care; Medicare; specific departments and agencies Federally qualified health centers (FQHCs), 4, 5, 12, 48, 52-53, 56, 57, 60-61 commercially insured patients, 54 cost-based reimbursement, 24, 35, 40, 71-72, 101-103, 120-121, 126, 206, 210 drugs, discounts, 91 financial condition, 119-123, 133 grants, 20(n.2), 29, 120, 121, 122 "look-alikes," 62, 102-103 managed care organizations and, 35, 36, 137-138, 142-143 Medicaid patients, 5, 31, 35, 36, 48, 54, 120-123, 133, 137-144, 153 INDEX Medicare patients, 31, 60, 62, 102-103, 120, 142 minority patients, 52-53 number of patients served, 60 payment structure, 49 poor patients, 52; see also "Medicaid patients" supra state support, 101-103, 153 study at hand, methodology, 19-20, 27 technical assistance, 11, 14, 140, 143, 171,214,217 uninsured patients, 5, 52, 61, 119-122 (passim) Fee-for-service coverage, 16 AIDS/HIV patients, 195 core safety net providers, 42 Medicaid, 29, 31, 32, 35, 42, 110, 163 Florida, 112, 113, 153, 174 Food and Drug Administration, 193 Funding, vii, 6, 17, 126, 215-217 charity care, 8 disproportionate share hospitals, 10, 12-14, 23, 40-41, 49, 59, 98-100 diversification, 136, 155, 211 local health departments, 65 local safety nets, support for, 10, 65 Medicaid waivers, 93-94, 103 Omnibus Budget Reconciliation Act, 30, 31, 98 patchwork, 9, 17, 54-55, 56-57, 62, 75, 210, 211-212 rural areas, 28, 55, 57 school-based health centers, 69 study at hand, methodology, 19 study at hand, sponsorship, 2, 19 see also Balanced Budget Act; Balanced Budget Refinements Act; Grants; Subsidies The Future of Public Health, 63 FY 2000 Appropriations Act, 14 G General Accounting Office (GAO), 39, 101, 169 Geographic factors, 1, 24, 84 Medicaid managed care, 36

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INDEX medically underserved areas (MUAs), 5, 21, 53-54, 60 uninsured persons, 89-91 see also Local areas, general; Regional factors; Rural areas; State-level trends; Urban areas George Washington University, 170, 190 Georgia, 112 Grants, 49 core safety net providers, general, 6- 7, 12-13, 14, 39, 49, 54-55, 120, 121 federal, 12-13, 14, 49, 50, 54-55, 56, 64, 120, 121, 122, 140, 151-152, 189, 196-197, 215-216 section 330 grants, 20(n.2), 56, 57, 60 federally qualified health centers, 20(n.2), 29, 120, 121, 122 homeless persons, 196-197 local health departments, 64, 151 local/state governments, 5, 6, 13, 49, 54-55, 56, 57, 122, 140, 151, 189, 196 mental health, 189 State Children's Health Insurance Program (SCHIP), 11-12, 34, 40, 69, 92, 97-98, 215 H Hawaii, 133, 147 Head Start program, 213 Health and Hospital Corporation, 147- 148 Health Care Financing Administration (HCFA), 14, 31, 98, 213 disabled persons, 182 Medicaid capitation rates, 110 Medicaid managed care costs, 30 Quality Assurance Reform Initiative, 164 Health insurance, see Insurance Health Insurance Portability and Accountability Act, 34, 95, 97(n.13) Health maintenance organizations enrollment/profit trends, 16, 107, 110, 113, 171 269 local health departments and, 65, 124 nonprofit, conversion to for-profit, 113 Medicaid participation, 32, 38, 65, 109, 110, 111, 138-139, 146, 148, 149-150, 171 quality of care, 163-164 special-needs children, 187 Health Plan Employer Data and Information Set, 164-165 Health Resources and Services Administration (HRSA), 2, 14, 56, 57, 140, 213, 217 Community Access Program, 14, 153 federally qualified health centers, 41, 122 local health departments, 64 study at hand, methodology, 19-20, 26-27 study at hand, sponsorship, 19 Uniform Data System, 19-20 uninsured persons, 174-175 Hispanics, 54 access to care, 175 uninsured, 34 Historical perspectives community health centers, 73, 119-123 disabled persons, Medicaid expenditures on, 184 disproportionate share hospitals. 40. 98-100 - -A -- - ~ HMO enrollment/profits, 16, 107, 110, 113, 171 homeless persons, 196-197 hospitals, 55, 112-113, 114-119 Medicaid coverage, 87-88, 91, 94-95, 98 Medicaid funding, 104 Medicaid market, 135, 171 school-based health centers, 69 uncompensated care costs and state/ local subsidies, 105 uninsured persons, 16-17, 40, 85-88, 120-121 HIV, see AIDS/HIV Homeless persons, 21, 51, 195-198 local health departments, 64, 151 Hospitals and hospitalization, vii-viii, 113

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270 INDEX academic medical centers, 4, 23, 24, 56,65-66,72,84,114,116-117, 135, 145, 146, 148-149, 161 administrative requirements, 145-146 208 AIDS/HIV patients, 193 charity care, 55, 65, 113; see also "uncompensated care," infra core safety net providers, 22, 23, 41, 105, 114-115, 118, 147-149 county-level support, 105 drugs, discounts, 91 financial performance, 114-119 historical perspectives, 55, 112-113, 114-119 HMO enrollment and admissions trends, 107 homeless persons, 196 Indian Health Service, 69-70 local support, 103-106 Medicaid patients, 5, 19, 23, 36-37, 55, 114-119, 135, 147-149, 153 Medicare patients, 66, 98, 114, 116, 117, 119 mergers and consolidations, 16, 112- 113, 209 organizational factors, 83-84, 212 price competition, 19, 83 revenue sources, 55, 58, 114-119 rural areas, 116, 117 self-paying patients, 56, 55, 58, 59, 115, 118 study at hand, methodology, 22, 23, 24, 26 uncompensated care, 19, 40-41, 58-59, 65-66, 72, 105, 113, 115-119, 145, 147; see also Disproportionate share hospitals uninsured patients, 1-2, 4-5, 24, 148- 149, 174-175 urban areas financial situation, 115-117, 148 uncompensated care, 19, 41, 55, 58-59, 66, 72 Veterans Health Administration, 70 see also Academic medical centers; Disproportionate share hospitals; Emergency care; Public hospitals Human immunodeficiency virus, see AIDS/HIV I Immigrants, vii, 21, 49, 53 local health departments, 64 Medicaid coverage, 39-40, 90, 92-93 uninsured, 89-90 see also Language barriers Immigration and Naturalization Service, 40 Immunizations, 56, 57, 61, 64, 125, 164, 186 Indian Health Service, 69-70, 85, 213-214 Insurance, 16, 56, 57 Balanced Budget Act (BBA), 35 expansion efforts, 34-35, 85 Health Insurance Portability and Accountability Act, 34, 95, 97(n.13) medical savings accounts, 95 point-of-service plans, 106, 201 self-employed persons, 34, 95 special-needs patients, 51 unemployed persons, 34 see also Employer-sponsored insurance; Fee-for-service coverage; Health maintenance organizations; Managed care; Medicaid; Medicaid managed care; Medical savings accounts; Medicare; Risk-based coverage; Uninsured / underinsured persons Integrated delivery systems, 42, 83-84, 208, 211-212, 215 federal safety net initiative, 152-153, 215 homeless persons, 197 horizontal, 82, 138-139 mental health, 189-190 special-needs patients, 186-187, 189, 190-191, 197, 201 vertical, 82, 145-146, 151-152 InterStudy, 106-107

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INDEX Johns Hopkins University, 195 K Kaiser Commission on the Future of Medicaid, 37, 97(n.14) Kaiser Family Foundation, 164 Kassebaum-Kennedy law, see Health Insurance Portability and Accountability Act Kellogg Foundation, W.K., 175 L Language barriers, 21, 24, 41, 48, 52, 53, 59, 73 Legislation American Indian Self-Determination Act, 60 Americans with Disabilities Act, 181, 182 Balanced Budget Act, 5, 12, 24, 34, 35- 37, 101-102, 103, 154, 211, 215 special-needs patients, 35, 182, 206 State Children's Health Insurance Program (SCHIP), 11-12, 34, 40, 69, 92, 97-98, 215 Balanced Budget Refinements Act, 5- 6, 35, 101 Department of Health and Human Services Appropriations Act, 153 FY 2000 Appropriations Act, 14 Health Insurance Portability and Accountability Act, 34, 95, 97(n.13) Omnibus Budget Reconciliation Acts, 30, 31, 98 Personal Responsibility and Work Opportunity Reconciliation Act (PWORA), 90, 92-93 Public Health Service Act, 20(n.2) Ryan White CARE Act, 57, 62, 193 Social Security Act, 31 AFDC/TANF, 26, 92, 146, 147, 184 271 Title V, 12, 56, 64, 185, 186, 188 Stewart B. McKinney Homeless Assistance Act, 197 The Lewin Group, 143-144, 190 Local areas, general, 211 core safety net providers, 54 neighborhood health centers, 73, 139 Neighborhood Health Plan, 138-139 uninsured persons, number of, 33-34 variations across, 28, 37 see also Community health centers Local government, 10-11, 16, 56, 81, 210, 211, 213 core safety net providers, 23, 103-105, 113, 148 county-level efforts, 23, 56, 57, 64-65, 66,73,74,103,104-105 special-needs children, 187-188 grants from, 5, 6, 13, 49, 54-55, 122, 140, 151, 189, 196 Medicaid managed care, 7-8, 33, 42 monitoring information provided to, 12 organization of health delivery, 83-84 private takeovers of public hospitals, 113 tax base, 4, 6, 83, 113, 151 see also specific jurisdictions (e.g., New York CityJ Local health departments, vii-viii, 22, 62, 63-65, 212 AIDS/HIV patients, 64, 125, 151 children, 64, 124 fiscal viability, 123-126, 133 grants, 64, 151 HMOs and, 65, 124 homeless persons, 64, 151 managed care, general, 20, 151 Medicaid, general, 64, 124-126, 133 Medicaid managed care, 41, 123-124, 126, 141, 146-147, 150-152, 153 primary care, 124-125 sexually transmitted diseases, 64, 125 study at hand, methodology, 20, 27 uninsured patients, 53 Los Angeles, California, 23, 89 Low-income persons, see Poverty

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272 M Mainstreaming, 26, 30, 38-39, 135, 170- 173, 176, 195 Making the Grade program, 69 Managed care, 10, 16, 56, 57, 132, 136- 152, 206 beneficiary choice, 7, 25, 30, 83-84, 166-170, 206-207 mainstreaming, 26, 30, 38-39, 135, 170-173, 176, 195 commercial managed care vs Medicaid, 7, 19, 135, 161-162, 185 competition, 40, 41, 42, 106-107, 136, 140 price, 3, 19, 82, 83-84, 106, 153, 206 discounting, 40-41 employer-sponsored, 16, 67-68 local health departments, 20, 151 mandated, 6, 8, 31, 35, 36, 38, 42, 103, 133, 134, 145, 147, 150, 151, 165, 170, 209, 211 special-needs patients, 187, 194, 199 market penetration, 106-107 Medicare, 37 mental health, 189-191 minority physician participation, 68 organizational factors, 83 physicians and charity care, 6, 41, 107(n.30) rural areas, 36, 57, 110, 139-140, 169 special-needs patients, 187, 194, 198, 199 study at hand, methodology, 18-19, 20,231 technical assistance for, 14, 217 urban areas, 68, 106-107 see also Health maintenance organizations; Medicaid managed care Managed care organizations (MCOs), 42, 136 community health care centers and, 41, 137-139, 144 discounting, 40-41 federally qualified health centers and, 35, 36, 137-138, 142-143 INDEX local health departments and, 151 Medicaid and, 33, 36, 108, 111, 137- 139, 142-143, 154 primary care case management, 31- 32, 139, 148, 149, 150, 162-163 risk-based plans, 32 rural areas, 149 state incentives, 154 urban/rural locations, 36, 37 see also Health maintenance . . Orgamzatlons Market forces, 1, 9, 14, 15, 16, 74, 81, 83- 84, 175, 210 core safety net providers, 25, 71, 132- 133 hospital mergers and consolidations, 16, 112-113, 209 market share, 6, 16, 22, 106, 108, 112- 113, 132-133, 136 Medicaid, 25, 31, 33, 38-39, 82, 107- 112, 126, 134-152, 160, 161, 175, 170, 176, 206-207 regional variations, 22 special-needs patients, 13 see also Competition; Cost and cost- effectiveness Maryland, 173 Massachusetts, 138-139, 153-154, 188 MassHealth, 188 Maternal and Child Health Bureau, 64, 185 see also Title V (Social Security Act) Mathematica Policy Research, Inc., 73, 141-143, 149-150 MDS Associates, 122 Medicaid, vii, 4, 6-9, 12, 20, 29-33, 212 accountability, 29, 107, 133 AIDS/HIV treatment, 192-194 Aid to Families with Dependent Children/Temporary Assistance to Needy Families (TANF), 26, 92, 146, 147, 184 Balanced Budget Act State Children's Health Insurance Program (SCHIP), 11-12, 34, 40, 69, 92, 97-98, 215 Balanced Budget Refinements Act, 5- 6, 35, 101 charity care and, 6, 8, 40-41

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INDEX community health centers, 61, 62, 72- 73, 119-122, 138-139 competition, 25, 31, 38, 39, 126, 132, 170 core safety net providers, general, 49, 113-114 cost-based reimbursement, 5, 20(n.2), 24, 31, 35, 39, 40, 60 federally qualified health centers, 24, 35, 40, 71-72, 101-103 Rural Health Clinic program, 63 disproportionate share hospitals, 10, 18,29,36-37,40,49,98-101 (passim), 110, 126, 141, 174, 184, 213 Early and Periodic Screening, Diagnosis, and Treatment program, 56, 64-65, 126, 186 eligibility, 4, 7, 9, 29, 39-40, 87-88, 92, 101, 122, 132, 207 waivers, 30-32, 35, 71, 93-95, 103, 133, 134, 141, 146-147, 153-154, 160, 194-195 enrollment, 1, 6, 30, 34, 39, 50, 85, 87- 88, 92, 94-95, 185, 212 expansion, 26, 29, 31, 39, 41, 74 federally qualified health centers, 5, 31, 35, 36, 48, 54, 120-123, 133, 137-144, 153 fee-for-service coverage, 29, 31, 32, 35, 42, 110, 163 historical perspectives, 87-88, 91, 94- 95, 98, 104, 135, 171 HMO participation, 32, 38, 65, 109, 110, 111, 138-139, 146, 148, 149- 150,171 hospitals, 5, 19, 23, 36-37, 55, 114-119, 135, 147-149, 153 immigrants, coverage, 39-40, 90, 92- 93 local health departments, 64, 124-126, 133 mainstreaming, 26, 38-39, 176 managed care organizations and, 33, 36, 108, 111, 137-139, 142-143, 154 market forces, 25, 31, 33, 38-39, 82, 107-112, 126, 134-152, 160, 161, 170, 175, 176, 206-207 273 mentally ill patients, 188 provider participation, 51, 70 public hospitals, 55, 115, 118, 119, 135 reform, effects of, 5, 39, 65, 84-85, 90, 92-93, 173, 196 risk-based coverage, 29, 31-32, 110, 111, 154, 156 rural areas, 37, 57, 63, 67 state actuarial methods, 109-111 state administrative requirements, 18, 108, 132, 135, 145-146, 147, 150, 161, 172, 185, 208 state eligibility, enrollment and benefits, 4, 7, 9, 30, 31, 37, 39, 90-91, 93-95, 96, 107, 109, 132, 168, 169-170 disabled persons, 184 mainstreaming, 26, 30, 38-39, 135, 170-173, 176 waivers, 30-32, 35, 71, 93-95, 103, 133, 134, 141, 146-147, 153-154, 160, 194-195 state government, market forces, general, 38-39 state government, other, 29-42 (passim), 101-103, 210; see also State Children's Health Insurance Program study at hand, methodology, 1, 18, 22, 23-24, 26 waivers, 30-32, 31, 35, 71, 93-95, 103, 133, 134, 141, 146-147, 153-154, 160, 194-195 Medicaid Access Study Group, 162 Medicaid managed care, 6, 9, 103, 107- 112, 126, 208-209, 211, 212 access to care, 161, 162-164, 170-173 AIDS/HIV patients, 194 Balanced Budget Act (BBA), 5, 12, 24, 34, 35-37, 211 beneficiary choice, 7, 25, 32, 33, 36, 37, 108, 109, 147, 159, 166-170, 206-207 mainstreaming, 26, 30, 38-39, 135, 170-173, 176, 195 capitation rates, 9, 30, 36, 38, 93, 109- 111,152,155,156,161,173,176, 209

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274 INDEX special-needs patients, 187-188, 192, 194-195 charity care and, 6, 8, 40-41 commercial managed care vs. 7, 19, 135, 161-162, 185 commercial plan participatin, 38-39, 109, 135, 171-172, 207 community health centers, 41, 133, 135, 136, 137-144 core safety net providers, 21, 25, 41- 43, 111-112, 126, 132, 134, 136- 152, 206-208, 209-210 costs and cost-effectiveness, 29, 30, 31, 32, 35-37, 43, 107, 135, 139, 140-141, 142, 143, 153 disabled persons, 182 enrollment in, 6, 41, 107-112, 205, 212 federal initiative, 215-216 federally qualified health centers, 122-123 Health Plan Employer Data and Information Set, 164-165 historical perspectives, 29-32, 38, 39 implementation problems, 30, 165, 191, 208-209 local government role, general, 7-8, 33,42 local health departments, 41, 123-124, 126, 141, 146-147, 150-152, 153 managed care organizations and, 33, 36, 108, 111, 137-139, 142-143, 154 mandatory, 6, 8, 31, 35, 36, 38, 42, 103, 133, 134, 145, 147, 150, 151, 165,170,209,211 special-needs patients, 187, 194, 199 market forces, 25, 31, 38-39, 82, 107- 112, 126, 134-135, 170 mental health, 41, 182-183, 188, 189, 190-191 models of, 31-32 organizational factors, 25, 33, 82, 83 political factors, 29, 132, 160 primary care, 2, 17, 162-163, 164 public hospitals, 144-146, 147-148 quality assurance, 29, 36, 38-39, 42, 136, 162-166, 192 quality of care, 162-165 regional variations, 18 risk-based coverage, 29, 31-32, 110, 111, 154, 156 rural areas, 41, 67, 110, 139-140, 149- 150, 153 school-based health centers, 69 special-needs children, 181, 186, 187- 188 special-needs populations, 20, 26, 35, 170, 182-188, 190 capitation rates, 187-188, 192, 194- 195 state government, 107-111, 133-134, 138-139, 141, 142, 143, 151, 152, 153-156, 159-160, 163, 164, 165- 170,198,208,209 AIDS/HIV patients, 194-195 disabled persons, 182-183 mentally ill persons, 190-191, 192 special-needs children, 187-188 study at hand, methodology, 2, 8, 17, 22, 23-24, 26, 229-231, 250-251 Supplemental Security Income recipients, 12 uninsured/underinsured persons, 7, 8, 29, 109, 111-112, 159-160, 206-208, 213 urban areas, 107-108, 110, 148 Medically underserved areas (MUAs), 5, 21, 53-54, 60 Medical savings accounts, 95 Medicare, 5, 206, 210 academic health centers, 66 academic medical centers, 106 AIDS/HIV treatment, 192, 193 Balanced Budget Act, 35, 142 core safety net providers, 42, 55, 56, 57,58,60,61,62 disabled persons, 182 disproportionate share hospitals, 10, 40, 56, 98(n.18), 100, 213 federally qualified health centers, 31, 60, 62, 102-103, 120, 142 hospitals, 66, 98, 114, 116, 117, 119 managed care plans, general, 37 mentally ill persons, 189 rural areas, 63, 140 upper limit payment, 98 urban areas, 56 waivers, 103

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INDEX Medicare Payment Advisory Commission (MedPAC), 11, 214 Mental health and illness, 20, 51, 181, 188-192 homeless persons, 196, 197 Medicaid managed care, 41, 182-183, 188, 189, 190-191 public hospitals, 72 substance abuse, 53, 196, 197 Miami, Florida, 83, 89, 174 Michigan, 153 Migrant health care, 20, 57, 60(n.5), 61, 102, 121, 186, 225 Minnesota, 153, 169, 173 Minority groups, vii, 1, 24, 49, 52, 68 African Americans, 40, 54, 73, 193 Hispanics, 34, 54, 175 Native Americans, 35, 60, 69-70, 85, 103, 213-214 physicians of minority status, 68 uninsured, 16-17, 34, 40, 52 see also Immigrants Missouri, 112, 169 N National Academy for State Health Policy, 37, 153 National Association of City and County Health Officials, 124 National Association of Community Health Centers, 102 National Association of Public Hospitals and Health Systems (NAPH), 48, 54, 59, 104, 105 National Health Interview Survey, 73 Native Americans, 35, 60, 103 Indian Health Service, 69-70, 85, 213- 214 Neighborhood health centers, 73, 139 Neighborhood Health Plan, 138-139 New Jersey, 153-154 New York City, 23, 72, 91, 140-141, 147, 163, 168, 170 New York State, 153, 169, 250 North Carolina, 139-140 275 o Ohio, 169 Omnibus Budget Reconciliation Acts, 30, 31,98 Oregon, 94, 95, 141, 160, 172-173 Organizational factors, 17, 24-25, 81-84, 155 barriers to access to care, 24 community health centers, 83, 84, 212 core safety net providers, 24-25, 38, 54-55, 56-57, 62, 74, 75 hospitals, 83-84, 212 Medicaid managed care, 25, 33, 82, 83 Medicaid market, 38, 108-109, 161 patchwork, 9, 17, 54-55, 56-57, 62, 75, 210, 211-212 physician supply, 74 tracking of delivery systems, 10-11, 36, 210-211, 213-215 uninsured persons, 82-83, 84 see also Administrative requirements; Integrated delivery systems Outcomes, health academic health centers, 148 community health centers, 73 low-income persons, 14, 74, 216 Medicaid managed care, 163 nonmedical factors, 217 pregnancy, 163 prisoners, 191 special-needs patients, 191, 192, 200 tracking, 12, 13, 71, 215, 216 uninsured persons, 1-2, 13, 173 Outpatient care, see Ambulatory care Outreach, 7, 13, 34, 48, 51, 57, 61, 74, 95, 97, 109, 166, 168, 208 special-needs patients, 181, 195, 197, 198, 199, 218 see also Advocacy p Peer review, methodology of study at hand, viii, xiii-ix, 18, 27 Personal Responsibility and Work Opportunity Reconciliation Act (PWORA), 90, 92-93

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276 Pharmaceuticals and pharmacists, 51, 57, 61,68,70,161,189,193 AIDS/HIV treatment, 193 costs and underinsurance, 91 immunizations, 56, 57, 61, 64, 125, 164, 186 mentally ill patients, 189 Philadelphia, Pennsylvania, 83-84 Physicians, 61, 74 charity care, 6, 24, 67-68 gag rules, 36 managed care, impact on charity care, 6, 41, 107(n.30) minority, 68 rural areas, 54 Picker-Commonwealth Fund, 73 Point-of-service plans, 106, 201 Political factors, vii, 4, 47, 103-104 Medicaid managed care, 29, 132, 160 regional variations, 22 Poverty, vii, 1, 3, 4, 24, 28, 47-48, 49-50, 200, 217 AIDS/HIV patients, 193 community health centers, 59, 72 disabled persons, 32 elderly persons, 32 INDEX Preventive health interventions, 141, 151-152, 161, 162, 175, 208 AIDS/HIV, 186 children, 164 community health centers, 59, 61 disproportionate share hospitals, 100 immunizations, 56, 57, 61, 64, 125, 164, 186 Indian Health Service, 70 special-needs patients, 196 Primary care, 2, 7 17, 23 community health center/managed care organization partnerships, 41 core safety net providers, 4 homeless persons, 197 local health departments, 124-125 Medicaid managed care, 2, 17, 162- 163, 164 Medicaid reimbursement, 32 safety net providers, 36 Primary care case management, 31-32, 139, 148, 149, 150, 162-163 Primary Care Development Corporation, 140-141 Prisoners 191 , federal poverty level, 29, 33, 58, 67, 86 Private practitioners, 67-68 (n.3), 87-88, 97, 133 access to, 162 homeless persons, 21, 51, 64, 151, 180, 195-198 mandatory care, general, 54 medically underserved areas, 5, 21, 53-54, 60 organization of health care, 83-84 privately insured poor persons, 164 regional variations in care, 22 underinsured /uninsured, 1, 21, 86- 87, 173-175, 216 see also Aid to Families with Dependent Children; Medicaid; Medicaid managed care; Temporary Assistance to Needy Families Pregnant women, 29, 62, 74, 149, 162, 163, 172 President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 214 charity care, 6, 17, 24, 41, 67-68 gag rules, 36 Medicaid patients, 67, 68, 74 minority, 68 rural areas, 54, 67-68 uninsured patients, 24, 67, 68 Provider-sponsored organizations, 37, 142 Public health, 14, 56, 212, 251-252 see also Local health departments Public Health Service Act, 20(n.2) Public hospitals, 55, 58-59, 74 AIDS/HIV patients, 72 ambulatory care, 25, 55, 58 core safety net providers, 4-5, 22, 23, 47-48, 55, 58-59, 147-148 disproportionate share hosnitals.17. 40 - -r ~ drugs, discounts, 91 financial performance, 114-118, 144- 145

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INDEX homeless persons, 197 Medicaid managed care, 144-146, 147-148 Medicaid patients, 55, 115, 118, 119, 135 Medicare revenues, 119 mental health, 72 National Association of Public Hospitals and Health Systems (NAPH), 48, 54, 59, 104, 105 organizational factors, 83, 212 private acquisition of, 112-113 professional education provided by, 48 rural areas, 54 self-paying patients, 55, 58, 59, 115, 118 special-needs patients, 72 teaching hospitals, 48, 148, 161 uninsured patients, 55, 56, 58, 59, 174- 175 urban areas, 55, 72 Q Quality Improvement System for Managed Care, 165 Quality of care, 13, 27, 155, 162-164, 176 federal monitoring of delivery systems, 10-12, 36, 210-211, 213-215 local health department role, 63-64 Medicaid managed care, 29, 36, 38-39, 42, 136, 162-166, 192 mental health, 192 protocols, 136, 211 see also Accountability; Outcomes, health R Race/ethnicity, see Immigrants; Minority groups Regional factors, 22, 63, 211 study at hand, methodology, 18, 249- 257 see also Geographic factors; State-level trends 277 Rhode Island, 133, 147, 160, 163, 197 Risk adjustment, 111, 136, 141, 162, 173, 209 special-needs patients, 185, 191-192, 194-195, 199 Risk-based coverage, 16 adverse risk selection, 12, 148, 194, 215 Medicaid, 29, 31-32, 110, 111, 154, 156 Risk pools, 194, 195, 199 Robert Wood Johnson Foundation, 69, 175 Rural areas, vii, 4, 28, 53-54 community health centers, 28, 54, 62- 63 employer-sponsored insurance, 67-68 federally qualified health centers, tax- exempt, 60-61 funding sources for safety net providers, 55, 57 hospital financial performance, 116, 117 managed care organizations, 36, 37, 149 Medicaid, general, 37, 57, 63, 67 Medicaid managed care, 41, 67, 110, 139-140, 149-150, 153 Medicare, 63, 140 private practitioners, 54, 67-68 Rural Health Clinic program, 62-63 study at hand, methodology, 18, 258- 259 Rural Health Care Group, 139-140 Ryan White CARE Act, 57, 62, 193 S Safety Net Organizations and Patient Advisory Commission (proposed), 11-12 San Diego, California, 23 San Francisco, California, 62 School-based health centers, 5, 64, 65, 69, 70, 146, 151, 152, 186 Section 1115 waivers, 30, 31, 35, 71, 93- 95, 103, 133, 141, 146-147, 153- 154, 160, 194-195 Self-employed persons, 34, 95

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278 Self-paying patients, 56, 55, 58, 59, 61, 115, 118 see also Uninsured/underinsured persons Sexually transmitted diseases, 53, 64, 125 see also AIDS/HIV Social factors, 4, 159 homeless persons, 21, 51, 64, 151, 180, 195-198 regional variations, 22 risk factors, 161 see also Cultural factors; Demographic factors Social Security Act, 31 Aid to Families with Dependent Children, 26, 92, 146, 147, 184 Title V, 12, 56, 64, 185, 186, 188 Social Security Disability Insurance, 192 Special health care needs, vii, 1, 21, 26, 51 access to care, 13, 51, 195, 197, 198, 199, 218 outreach, 181, 195, 197, 198, 199, 218 accountability, 199, 201 advocacy, 199-200 Balanced Budget Act (BBA), 35, 182, 206 definitional issues, 181-182, 198 cost-based payment, 72 - - r - r - costs and cost-effectiveness issues, 98-101, 110 188, 192-194, 199, 200 county-level efforts, 187-188 extent of, 181-182 HMOs, 187 homeless persons, 21, 51, 64, 151, 180, 195-198 integrated delivery systems, 186-187, 189, 190-191, 197, 201 local health departments, 53 managed care, mandated, 187, 194, 199 INDEX preventive health interventions, 196 risk adjustment, 185, 191-192, 194- 195, 199 risk pools, 194, 195, 199 state government, 198, 199 AIDS/HIV patients, 194-195 disabled persons, 182-183 medical necessity laws, 199 mentally ill persons, 190-191, 192 special-needs children, 187-188 urban areas, 56 see also AIDS/HIV; Chronically ill persons; Disabled persons; Mental health and illness Special-needs children, 20, 181, 185-188 AIDS/HIV patients, 194 Balanced Budget Act (BBA), 35 Special Supplemental Nutrition Program for Women, Infants, and Children, 56, 57, 64 SSI, see Supplemental Security Income State Children's Health Insurance Program (SCHIP), 11-12, 34, 69, 97-98, 215 immigrants, 40, 92 State government, 16, 81, 153-156, 211 Balanced Budget Act (BBA), 35, 101- 103; see also State Children's Health Insurance Program disproportionate share hospitals, 40, federally qualified health centers, support for, 101-103, 153 grants from, 5, 6, 13, 49, 54-55, 56, 57, 122, 140, 151, 189, 196 homeless persons, 196 insurance premium limits, 95 Medicaid actuarial methods, 109-111 Medicaid administrative requirements, 18, 108, 132, 135, 145-146, 147, 150, 161, 172, 185, 208 Medicaid managed care, 20, 26, 35, 170, 182-188, 190 capitation rates, 187-188, 192, 194- 195 outcomes, health, 191, 192, 200 outreach, 181, 195, 197, 198, 199, 218 Medicaid eligibility, enrollment, and benefits, 4, 7, 9, 30, 31, 37, 39, 90-91, 93-95, 96, 107, 109, 132, 168, 169-170 disabled persons, 184 mainstreaming, 26, 30, 38-39, 135, 170-173, 176

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INDEX waivers, 30-32, 35, 71, 93-95, 103, 133, 134, 141, 146-147, 153-154, 160, 194-195 Medicaid managed care, 107-111, 133-134, 138-139, 141, 142, 143, 151, 152, 153-156, 159-160, 163, 164, 165-170, 198, 208, 209 AIDS/HIV patients, 194-195 disabled persons, 182-183 mentally ill persons, 190-191, 192 special-needs children, 187-188 Medicaid market, general, 38-39 Medicaid, other, 29-42 (passim), 101- 103, 210; see also State Children's Health Insurance Program monitoring information provided to, 12 provider-sponsored organizations, 37 school-based health centers, 69 special-needs patients, 198, 199 AIDS/HIV patients, 194-195 disabled persons, 182-183 medical necessity laws, 199 mentally ill persons, 190-191, 192 special-needs children, 187-188 State Children's Health Insurance Program, 11-12, 34, 40, 69, 92, 97-98, 215 uninsured, 84, 173, 174-175 State-level trends data variability across states, 27, 210 immigrants, uninsured, 90 uninsured persons, number of, 33, 34, 89-91 see also Regional factors; specific states Stewart B. McKinney Homeless Assistance Act, 197 Subsidies, 4, 13, 28, 205, 213, 216 core safety net providers, 4, 10, 17, 23, 25, 40-42, 49, 209-210 graduate medical education, 28, 106 Medicaid, 5, 33, 39 organization of delivery service, 83 phaseout, 6, 8, 10, 17, 40-41 rural areas, 28 uncompensated care costs and state/ local subsidies, trends, 105 279 see also Disproportionate share hospitals; Federally qualified health centers; Grants Substance abuse, 53, 196, 197 Substance Abuse and Mental Health Services Administration, 14, 190, 213, 217 Supplemental Security Income, 12, 184, 188, 190 Taxation deductions for self-employment insurance coverage, 95 disproportionate share hospitals, 99 employer-sponsored insurance, 34-35 federally qualified health centers, tax- exempt, 60 local government, 4, 6, 83, 113, 151 private takeovers of public hospitals, 113 state, 141 uninsured, coverage for, 174 Technical assistance, 11, 14, 140, 143, 171,214,217 Telephone services, 14, 161, 217 Temporary Assistance to Needy Families (TANF), 26, 146, 147, 184 Temporary Emergency Food Assistance Program, 197 TennCare, 95, 111, 133-134, 148, 160, 162, 191, 194, 195 Tennessee, 94-95, 133, 147, 160, 194 Texas, 112, 148 Title V (Social Security Act), 12, 56, 64, 185, 186, 188 Training, see Education and training, professional Transportation to care, 7, 21, 48, 56, 59, 137,161,163,166,185,197 U Uncompensated care, 3, 6, 28, 126, 206 core safety net providers defined, 21- 22, 90

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280 HMOs and, 107 hospitals, 19, 40-41, 58-59, 65-66, 72, 105, 113, 115-119, 145, 147; see also Disproportionate share hospitals private practitioners, 67 state variations, 90-91 see also Charity care; Disproportionate share providers, general Unemployed persons, 34, 51 Uniform Data System, 19-20 Uninsured/underinsured persons, 1-3, 4, 9, 21, 84-93, 126, 173-175, 205- 206, 212-213 African Americans, 40 children, 133 community health centers, 59, 62 core safety net providers, 3-4, 5, 21- 24, 27-28, 47-48, 50, 55, 56, 58, 59, 209 definition of, 85 discounting under managed care, 40- 41 emergency care, 1-2, 65 federally qualified health centers, 5, 52, 61, 119-122 (passim) geographic variation, 84 historical perspectives, 16-17, 40, 85- 88, 120-121 hospitals, 1-2, 4-5, 24, 148-149, 174- 175 HRSA, 174-175 immigrants, 89-90 length of time uninsured, 89, 207 local health departments, 64-65 mainstreaming, 26 Medicaid managed care and, 7, 8, 29, 109, 111-112, 159-160, 206-208, 213 minority groups, 16-17, 34, 40, 52 number of, vii, 1, 5, 8, 16-17, 33-34, 50, 84,85,173,210 organization of health care, 82-83, 84 private practitioners, 24, 67, 68 public hospitals, 55, 56, 58, 59, 174- 175 Rural Health Center program, 63 self-employed persons, 95 INDEX self-paying patients, 56, 55, 58, 59, 61, 115, 118 state government role, 84, 173, 174- 175 workers, 86-87, 173 see also Charity care; Disproportionate share hospitals; Disproportionate share providers, general; Uncompensated care University of California, 74 Urban areas, vii, 4, 23, 28, 53-54 ambulatory care clinics, 22 federally qualified health centers, tax- exempt, 60-61 funding sources for safety net providers, 55, 56 hospitals, financial situation, 115-117, 148 uncompensated care, 19, 41, 55, 58-59, 66, 72 local health departments, 124-125 managed care, 68, 106-107 Medicaid managed care, 107-108, 110, 148 Medicaid patients, 37, 55, 56 minority physicians, 68 private practitioners, 67-68 public hospitals, 55, 72 school-based health centers, 69 see also specific cities Urban Institute, 100, 106, 143, 153 V Veterans Health Administration, 69-70 see also Department of Veterans Affairs W Waivers, 30-32, 35, 71, 93-95, 103, 133, 134, 141, 153-154, 160, 194-195 Washington State, 138, 146, 153, 160, 169, 173 Welfare, see Aid to Families with Dependent Children; Medicaid; Supplemental

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INDEX Security Income; Temporary Assistance to Needy Families Welfare reform, 5, 39, 65, 84-85, 90, 92- 93, 173, 196 Wisconsin, 163-164 "Wrap-around" services, 48 Women, 32, 56, 74, 114-115, 133 community health centers, 73 homeless persons, 196 local health departments, 124 pregnant, 29, 62, 74,149,162,163,172 281 Title V (Social Security Act), 12, 56, 64, 185, 186, 188 see also Family planning Workers low-income, 86-87 self-employed, 34, 95 unemployed, 34, 51 uninsured, 86-87, 173 see also Employer-sponsored insurance