Medicaid Managed Care and Racial Disparities in AIDS Treatment
Guwani, James M., Weech-Maldonado, Robert, Health Care Financing Review
Well-documented racial and ethnic differences in care have attracted increased attention from policymakers. Healthy People 2010, for example, established eliminating racial and ethnic disparities as a formal public policy goal for the U.S. health care system (U.S. Department of Health and Human Services, 2000). The AIDS epidemic in particular is recognized as a major health and socioeconomic problem that disproportionately affects low-income minorities who are at risk of poor access to care. Notwithstanding the implementation of health care policies to reduce disparities among populations with HIV/AIDS, significant racial/ethnic differences in access to care remain (Cunningham et al., 1999; Cunningham et al., 2000; Crystal et al., 2001).
In 1996, a CDC treatment guideline recommended the use of HAART for the clinical management of all HIV/AIDS patients with a CD4 cell count lower than 500 cells/mm3. CDC (1998) defines HAART as specific combinations of three classes of antiretroviral (ARV) drugs. Prior to the introduction of ARV therapies, HIV/AIDS patients had a very poor prognosis. The ARV drug treatment helps prevent HIV, the retrovirus that causes AIDS, from reproducing and infecting cells in the body. HAART treatment has been proven to be effective in controlling the deterioration of CD4 cells, which are the white blood cells that help direct the body's infection-fighting cells (Centers for Disease Control and Prevention, 1998). A study by Gebo et al. (2001) indicates that hospitalization rates among HIV patients decreased between 1995 and 1997 after the introduction of HAART. Valenfi (2001) concluded that the drug combination improves outcomes, patients live longer and have more sustained viral load suppression, and have lower health care costs. Despite the benefits, Black people have less access to HAART compared with White people (Shapiro et al., 1999; Andersen et al., 2000; Keruly, Conviser, and Moore, 2002).
Policymakers have traditionally focused on Medicaid insurance as one means of increasing access to care among vulnerable populations. Medicaid served more than 50 percent of all persons living with AIDS, and 90 percent of all children with AIDS, at an estimated cost of $35 billion to the Federal and State governments in 1998 (Health Care Financing Administration, 1998). Increasingly, government is relying on the managed care sector to provide coverage for the Medicaid population as a cost-containment mechanism. While 40 percent of Medicaid beneficiaries were enrolled in managed care in 1996 (Health Care Financing Administration, 1998), the percentage increased to more than 55 percent in 2000 (Henry J. Kaiser Family Foundation, 2000). Concurrently, the numbers of people with HIV/AIDS receiving services in managed care organizations (MCOs) have increased within the last two decades and concerns over access, quality of care, and satisfaction with services have grown as well.
Studies have produced inconclusive results on the effect of managed care on access to care for vulnerable populations. These inconsistent findings, perhaps, could be explained by variations in State practices, different payment methodologies, and different conception and definitions of access measures (Hughes and Luft, 1998; Szilagyi, 1998).
This study uses a nationally representative sample to analyze the effects of managed care on access to the recommended HIV/AIDS treatment (HAART) for Black and White Medicaid patients. Specifically, the study addresses three research questions:
* Does access to HAART differ between Black and White Medicaid patients?
* Does Medicaid managed care increase access to HAART?.
* Does Medicaid managed care reduce racial disparities in access to HAART?.
Medicaid managed care participants represent primarily those enrolled in health maintenance organizations (HMOs), prepaid health plans (PHPs), health insuring organizations (HIOs), and primary care case management (PCCM) (Centers for Medicare & Medicaid Services, 1997). …