摘要：Objectives. Health care reforms associated with managed care may adversely affect the health care safety net for disadvantaged populations. This study compared changes in health care use among poor and nonpoor individuals enrolled in managed care. Methods. Data from 3 waves of a random community sample were collected on approximately 3000 adults. Changes in use of mental health services were assessed in a pretest–posttest, quasi-experimental design. Results. Managed care increased use of specialty services among the nonpoor while maintaining the same level of use for the poor in the public sector. Conclusions. Reallocation of mental health services may be a result of expanding Medicaid eligibility. Concerns have been raised about the differential impact of managed mental health care on poor Medicaid populations. 1 , 2 The poor tend to have more need of care 3 – 5 but appear less successful in obtaining services from managed care organizations. 6 Several investigators contend that low-income enrollees suffer access problems in managed care relative to those with conventional insurance, 7 , 8 while others report a neutral 9 , 10 or positive 11 effect on access for the poor. As states' Medicaid programs enter managed care, 12 , 13 there is a growing need to assess the effects on poor populations. Recently, some states (such as Oregon and Tennessee) have broadened the reach of Medicaid programs beyond the very poor to the near poor and working populations in an attempt to provide insurance coverage for the uninsured population. 14 , 15 Similarly, Puerto Rico initiated a health reform that enabled the medically indigent and those with incomes up to 200% of the federal definition of poverty to be included in a comprehensive managed health care plan (with pharmacy benefits, no co-pays, and no costs for private specialty care). Thus, nonpoor individuals without insurance who qualified under this exemption could also participate in the reform. In this report, we evaluate the impact of the reform on use of mental health services among the poor and nonpoor in Puerto Rico. In 1994, Puerto Rico initiated a health care reform policy that dramatically altered the health care system that had operated since the 1960s, serving about half of the island's 3.6 million inhabitants. Dividing the island into 10 health regions, the government privatized public health facilities and instituted managed competition in a fixed health and mental health service package for public sector service recipients. The government solicited proposals from private insurers to provide managed health and mental health care for a fixed capitation rate but at no charge to eligible residents. Eligibility was based on residence in a reform area and the expanded income limits just noted. Members of the police force, veterans, and their families (who in the past had had limited health coverage) were also eligible. Managed care services were initiated in 1 region in 1994 and in 2 regions each year thereafter. Less densely populated areas were selected for reform early, so reformed and unreformed regions remained in close proximity. The prequalification process for enrollees required proof of residency; thus, individuals in unreformed regions were unable to receive services in reformed regions. Enrollees in the reformed regions were issued private health insurance cards that enabled them to access private health care services from providers contracting with the insurance company responsible for their region. As of 1997, 7 of 10 regions were reformed. Because of the phased introduction of reform, a third of the island's population remained within the traditional public health sector at the time of our study, yielding a comparison group of poor and nonpoor individuals residing in regions not yet subject to reform. People living in nonreformed regions continued to have free access to providers affiliated with the government-owned public health system, or, if they were privately insured, they were subject to the co-payments (typically $15–$18 per visit) of private health insurance. In the case of public outpatient mental health services, individuals residing in unreformed regions continued to receive free services, typically provided by counselors, psychiatric nurses, or bachelor's-level therapists, in community mental health centers and drug detoxification centers. With the exception of a group of approximately 40 000 enrollees in 1 region, coverage for private mental health care in the population under reform was provided by behavioral health care companies (mostly those operating in the United States). Specialty providers contracted by the behavioral health care company supplied outpatient mental health, alcohol, and drug services to clients in reform. Only 1 insurer contracted with the community health centers to provide care for chronically ill patients. In 1997, these companies received between $3.00 and $3.50 per member per month in a capitation payment to cover mental health services.
