摘要：Objectives . This project used a long-term, multi-method approach to study the impact of Medicaid managed care. Methods . Survey techniques measured impacts on individuals, and ethnographic methods assessed effects on safety-net providers in New Mexico. Results . After the first year of Medicaid managed care, uninsured adults reported less access and use (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.34, 0.64) and worse barriers to care (OR = 6.60; 95% CI = 3.95, 11.54) than adults in other insurance categories. Medicaid children experienced greater access and use (OR = 2.11; 95% CI = 1.21, 3.72) and greater communication and satisfaction (OR = 3.64; 95% CI = 1.13, 12.54) than children in other insurance categories; uninsured children encountered greater barriers to care (OR = 6.29; 95% CI = 1.58, 42.21). There were no consistent changes in the major outcome variables over the period of transition to Medicaid managed care. Safety-net institutions experienced marked increases in workload and financial stress, especially in rural areas. Availability of mental health services declined sharply. Providers worked to buffer the impact of Medicaid managed care for patients. Conclusions . In its first year, Medicaid managed care exerted major effects on safety-net providers but relatively few measurable effects on individuals. This reform did not address the problems of the uninsured. Most states have implemented programs requiring some or all of their Medicaid recipients to enroll in managed care. 1 While the principal goal of converting Medicaid systems to managed care arrangements has been cost reduction, some states also have expressed an intention to use resources gained from the conversion to expand the number of lowincome persons eligible for Medicaid. 2– 5 Thus far, the impact of Medicaid managed care on access to care for low-income persons remains unclear. While some states have expanded their Medicaid eligibility criteria over the last few years, Medicaid enrollment lists have contracted in almost half the states. 6, 7 The effects of Medicaid managed care either on overall costs to the states or on coverage of previously uninsured persons are difficult to separate from concurrent developments, such as welfare reform, reductions in employerpaid insurance, and state budget cuts, that influence the number of people eligible for Medicaid. In particular, welfare reform has severed the link between cash assistance and Medicaid assistance and has adversely affected the ability of legal immigrants to gain Medicaid coverage. Eroding employment-based coverage, rising insurance costs relative to family income, and decreasing capability of providers to cross-subsidize the costs of health care also have contributed to access problems for low-income and uninsured persons. 8 Although the assignment of a primary care provider offers the potential for improved access for some Medicaid recipients, disruption of previous care-seeking patterns and programmatic barriers may affect overall access, including access for uninsured, lowincome persons. 9 The uncertain future of safety-net institutions under Medicaid managed care has raised wide concern. 8, 10– 15 For instance, if community health centers cut services owing to the effects of Medicaid managed care, the costs of caring for uninsured patients may shift to counties and municipalities. Through reduced reimbursement, Medicaid managed care could hinder the ability of remaining safety-net providers to serve the uninsured. 8, 16 Such concerns apply especially to rural areas, where several theoretical and practical questions have arisen. 17 States include rural areas in Medicaid managed care for several presumed reasons: cost savings, increased access to services, improved quality, and simplicity of operating one statewide program. 16, 18 Some of the foremost architects of managed care nationally have noted that approximately one third of the US population lives outside of metropolitan areas with populations large enough to support 3 or more managed care organizations in competition. In these settings, the advantages of market competition for cost control, access, and quality assurance may be weakened. 19 Barriers that states encounter with Medicaid managed care in rural areas include an insufficient number of covered lives to make prepayment feasible, limited prior penetration by managed care organizations, limited willingness of managed care organizations to participate in rural areas, and few primary care or specialty providers; such issues have led to the initiation of primary care case management in some rural areas. 16, 20 Difficulties facing rural providers include unfamiliarity with managed care concepts, inexperience in negotiating payment arrangements, few alternative revenue sources, greater use of mid-level providers whom managed care organizations may not recognize, and inadequate information systems. 21 On the other hand, the small number of providers in rural areas may lead to an enhanced bargaining position with managed care organizations. Few studies to date have evaluated the impacts of Medicaid managed care for rural populations or safety-net institutions. 22
