• 1090 II. Assuring Access to Care

“Access” is defined as “[a]dmittance, admission, the way or means by which a thing may be approached, or the liberty to approach, come into or use.” [FN]86 In health care, access is the pathway by which necessary services are rendered to patients. Access involves much more than merely a pathway or approach to health care. It involves both the actual delivery of health care and the quality of health care received. Access to health care is meaningless, however, if the health care lacks quality, is inappropriate, or is unavailable. [FN]87 Congress instituted the Medicaid program as an effort to provide increased access to mainstream health care for the poor and underserved.

A. Medicaid and Access

A primary goal of Medicaid is to assure access to comprehensive, quality health care. Medicaid regulations attempt to assure that states meet goals requiring: (1) adequate provider fees; (2) statewideness; (3) comparability; and (4) sufficient services.

  1. Adequate Provider Fees

The Medicaid program reimburses physicians for the Medicaid patients that they treat. States are required to assure that health care services provided to Medicaid recipients are available in proportion to similar services provided to the general population in the same geographic region. [FN]88 Moreover, states must meet this obligation by paying reimbursement rates sufficient to enlist enough providers. [FN]89 When these reimbursement rates are not sufficient, access is negatively affected. In particular, physicians may decline to render those services. This may prove to be a crucial issue in section 1115 waivers which implement managed care systems because managed care systems are typically paid at a rate of 90-95% percent of the Medicaid fee-for-service rate. [FN]90

  1. Statewideness

Statewideness refers to the availability of services across the *1091 state. The Medicaid Act requires that a service accessible in one area of the state must be accessible in all areas of the state. This can be a particular problem where some services are simply not made available in an area. It poses even more problems when a recipient is restricted to a health maintenance organization or a preferred provider organization and cannot seek care elsewhere. For example, it was determined that in California, access to dental services varied statewide and some areas had no access at all. [FN]91 Under a section 1115 waiver, many states request a waiver from the statewideness requirement.

  1. Comparability

Federal law requires that services provided to any individual in a categorically or medically needy group must be equal in amount, duration, and scope for all individuals within that group. [FN]92 Comparability requirements may pose unique problems for section 1115 waiver systems. When utilization review decides that a service is not needed, managed care can restrict access to care that might otherwise be available. Yet, under comparability standards, states must not reduce access for individual managed care participants. [FN]93 Thus, without a section 1115 waiver of this requirement, states would fail to meet this requirement when managed care plans do not provide services that are covered for nonparticipant beneficiaries. [FN]94

For the most part, comparability has been evaluated based on whether a service is provided to nonparticipating beneficiaries. [FN]95 The real question, however, is whether the service is actually being provided. [FN]96 If the service in question is provided only in a limited amount and in a limited area, then it is not being provided to the general beneficiaries. This is critical in a managed care system where the participants have no other choice in seeking such treatment. In essence, the managed care system is depriving the individuals of treatment to which they would otherwise be entitled. [FN]97


  1. Sufficient Services

Federal law requires that each service “be sufficient in amount, *1092 duration, and scope to reasonably achieve its purpose.” [FN]98 Essentially, providers must conform to an acceptable medical standard of sufficient services. It is unclear whether that medical standard includes the cost containment constraints associated with managed care. Although states are free to limit care to that which is “medically necessary,” such limitation must apply equally to all beneficiaries. [FN]99 It may be, however, that “medically necessary” was never intended to be defined by a health care plan rather than a doctor.

A major selling point of section 1115 waivers has been demonstrating that statewide managed care plans can provide increased access to comprehensive quality health care services and save money. However, to effectively improve access in minority communities, section 1115 waivers will need to reduce both financial and nonfinancial barriers.

B. Financial Barriers to Health Care

Proportionally, minorities spend more of their disposable income on health care than whites. [FN]100 However, they constitute only a small portion of persons who are high medical expenditures. For instance, in 1980, African-Americans represented only 9.6% of persons in the top 1% of health care expenditures. [FN]101 Yet, a much larger percentage of minorities are covered by Medicaid--53.2% of African-Americans, 42.6% of Hispanics, and 33.8% of European-Americans. [FN]102 Nevertheless, financial access to health care services by minorities presents some special problems. A high percentage of African-Americans, Hispanics, and European-Americans are uninsured. [FN]103 For example, in 1987, 42.6% of Hispanics, 31.5% of European-Americans, and 31.3% of African-Americans had no insurance. [FN]104 Consequently, an expansion of Medicaid through section 1115 waivers could have a positive impact on access. [FN]105

  • 1093 Even where insurance is available, poverty can still inflict other financial restraints that limit access. For example, the working poor may be unable to afford missing work to seek medical care for themselves or their children. [FN]106 They may lack transportation and cannot afford the expense of child care needed when obtaining health care. [FN]107 Even more important, they could lack the financial resources for a copayment or a deductible. Thus, the positive impact experienced if lack of insurance was removed as a financial barrier could be counterbalanced by the imposition of other financial restraints.

C. Nonfinancial Barriers to Health Care

Meaningful access involves much more than financial access. In order to effectively remove barriers from health care, section 1115 waivers need to be designed to assure that services are provided in a culturally appropriate manner. Such services will take into consideration language needs, socio-cultural perspectives, and the availability of an adequate infrastructure.

  1. Language

Language is an essential component of effective access. Individuals who speak English as their primary language are more likely to seek health care. [FN]108 Language serves as a barrier not only in seeking services, but in carrying out medical orders as well. Instructions and medical orders conveyed in English are problematic when the patient population speaks another language; this clearly interferes with effective access. [FN]109 Yet, health care institutions have not been aggressive in providing instructions and medical orders in a language applicable to the population served.

  1. Socio-cultural Perspective

Effective access includes health care offered within the socio-cultural content of the patient. Although health care which is responsive to socio-cultural perspectives will strain physician staffing patterns and also increase the operating cost of the providers, it is a *1094 key component to meaningful access. [FN]110 For instance, health care systems serving the working poor will need to maintain nontraditional office hours--staying open in the evenings as well as on the weekends. Other inadequacies of the system which are particularly significant to minority communities include the lack of transportation to facilities and lack of multidisciplinary services, such as preventive medicine and outreach groups. [FN]111

Furthermore, Western health care itself is biased towards a medical/hospital delivery model of services. Thus, the more the person's cultural perspective differs from the norm, the less likely the patient will find accessible health care. This problem is illustrated by those seriously ill Mexican-Americans who choose to stay at home with their family instead of going to a hospital or nursing home. [FN]112 In fact, minority utilization of health care is very different from that of the white population. For example, half as many Hispanics visit doctors for general exams as whites. [FN]113 Certainly, difference in utilization may be due to financial issues but utilization is also affected by socio-cultural differences.


  1. Insufficient Health Care Resources

Another significant problem is the basic nonavailability of physicians, hospitals, and other providers in minority communities. [FN]114 Although some data indicate that the number of providers participating in Medicaid care delivery is quite high, it is important to remember that in accumulating the data, states include as participating physicians those who only provide one Medicaid service a *1095 year. [FN]115 In reality, about one-half of all physicians either fail to participate or severely restrict the number of Medicaid patients that they serve. [FN]116 Physicians maintain that Medicaid does not pay enough to cover their costs; indeed, studies show a direct correlation between reimbursement levels and provider participation. [FN]117

For instance, one study indicated that doubling Medicaid fees in a specific geographic area would increase physicians' services to Medicaid patients by 70%. [FN]118 The administration of the program, particularly claims processing, further contributes to the problem. [FN]119 One study found that, nationwide, 52.4% of pediatricians complained about the unpredictability of Medicaid payments. [FN]120 Finally, physicians also believe that Medicaid limits their professional autonomy. [FN]121 In particular, physicians view the prior authorization criteria as ill-defined and arbitrary. [FN]122 Notwithstanding these legitimate complaints, some physicians simply do not want to serve minority communities and poor patients. [FN]123

  1. Racism [FN]124 Racial barriers to hospital access are manifested in the adoption, administration, and implementation of policies that restrict admission; [FN]125 the closure, *1096 relocation, or privatization of hospitals that serve the minority communities; and the transfer of unwanted patients (known as “patient dumping”) by hospitals and institutions. [FN]126 This barrier to facilities has also been documented in other health institutions. For instance, nursing homes are considered the most segregated publicly licensed health care facilities in the United States. [FN]127

The shortage of minority professionals further affects health care availability not only by limiting the available resources but also by limiting minority input into the health care system. Although the control of health care distribution is ultimately in the hands of the individual physician, that control is influenced and limited by law, hospital practices and policies, and the medical organization of the physician's practice. With so few minority healthcare professionals, the control of the health care system lies almost exclusively in European-American hands.

D. Critiquing State Waiver Applications

To improve access to health care through Section 1115 waivers, states must do much more than expand coverage. [FN]128 They must provide: (1) mechanisms for recipients to maintain their existing patient-provider relationships; (2) standards by which health care plans will be evaluated to determine whether recipients have adequate access; (3) for the availability of “Culturally Competent” health care; (4) for adequate case management and continuity of care; (5) for adequate provider participation including providers of color; (6) for comprehensive health care services; and (7) allow for cost sharing which might be a financial barrier to health care. [FN]129 



  1. Does the Waiver Contain Guidelines Which Provide Protection for the Patient-Provider Relationships?

Mechanisms for patients to maintain existing patient-provider relationships are important to the quality of health care. Because the practice of health care is as much based on intuition as it is *1097 science, it is important that patients be able to maintain relationships with providers who know them and know their problems. It is also important to sustain the providers who are currently serving minority communities. If these relationships are not maintained, a state could find itself in a situation where providers who traditionally served minority communities are shut out of the community due to insufficient business and managed care agencies that choose not to replace those providers with new ones.

To protect the provider-patient relationship, a waiver, at a minimum, must have guidelines or standards which assures the participation in the waiver of the traditional Medicaid providers, including minority providers, allows mechanisms for patients to continue with their established providers, and includes the participation of alternative health care providers. Florida is the one state that appeared to have an overall positive waiver in this area.

Only Florida, Illinois, and Missouri had guidelines which provided mechanisms for traditional Medicaid providers to continue serving minority communities, [FN]130 thus recognizing the importance of allowing patients to continue with their established providers. [FN]131 For example, the Missouri Medicaid Managed Care Program states that members shall have freedom of choice in selecting a primary care provider. [FN]132 The process of selecting a primary care provider must include the preference of continuing with a current physician and plan choices which include that specific physician. [FN]133 When a member does not select a primary care provider within fifteen days of enrollment, an automatic assignment is made. The assignment must be made with consideration of such known factors as current provider relationships, language needs, and area of residence.

Florida and Illinois were unclear, however, on specific standards related to providers of color. Missouri, as well as Hawaii, Oregon and Tennessee had no standards addressing the participation of providers of color; [FN]134 Oregon and Tennessee further failed to protect the provider-patient relationship.

New York, Florida, and Missouri had guidelines which allowed *1098 for the participation of alternative health care providers (that is, nurse practitioners and other nontraditional providers). [FN]135 New York State's proposed Partnership Plan expects accepted providers to utilize alternative health care providers such as nurse practitioners, midwives, and physician assistants. Although, the inclusion of alternative health care providers is not mandated by the plan. [FN]136  





Does the Waiver Provide Guidelines to Assure Adequate Provider Participation?

The most significant indirect impact on availability of health care is physicians' availability. An unacceptable queue of patients will develop if the number of providers is insufficient. Thus, the waiver should establish standards for the number of full-time equivalent physician per enrollees, the number of specialists, the number of pediatricians, and the number of primary care/family practice physicians. [FN]137 Three states (Missouri, New York, and Tennessee) had guidelines requiring a minimum number of physicians per enrollee. [FN]138 For example, the Missouri Medicaid Managed Care Program states that Obstetric/Gynecologic physicians should have caseloads of no more than 350 pregnant women under the Program. [FN]139

In addition to guaranteeing a minimum number of providers, the waiver should have steps, such as a phase-in of the new enrollees, to assure availability of adequate providers. [FN]140 Missouri, New York, and Oregon provided such guidelines. [FN]141 The New York *1099 Waiver Application has tried to address the disproportionate distribution of health care providers throughout the state. To remedy the problem of underserved rural counties, the waiver contemplates redistributing primary care physicians to rural areas through the Primary Care Initiative and the State Health Care Department's Physician Placement Plan. [FN]142

Missouri and New York had overall positive waivers setting standards for adequate provider participation, while Florida and Hawaii had no standards; Oregon and Tennessee were ambiguous in addressing standards for adequate provider participation.



  1. Does the Waiver Provide Guidelines Which Assure the Availability of Comprehensive Health Care Services?

The waiver should assure that both the traditionally eligible and the demonstration eligible receive the basic Medicaid benefits. This includes the following: chiropractors, community mental health centers, substance abuse treatment centers, nursing home care, EPSDT screening services, early intervention services for children, family planning centers, FQHCs, home and community-based services for disabled persons at risk for institutionalization, home health care for those homebound and medically in need, hospice care for the terminally ill. [FN]143 Four states (Florida, Hawaii, Illinois, and New York) had provisions which assured the basic Medicaid benefit package. [FN]144

The services available should be comprehensive and there should not be fewer services to compensate for the expanded eligibility. [FN]145 Unless a waiver is granted, the application should have mechanisms to assure that services are available statewide. [FN]146 Florida *1100 and Hawaii requested waivers from statewideness; [FN]147 Missouri's demonstration project is limited to Franklin, Jefferson City, St. Charles, and St. Louis counties and St. Louis City [FN]148; and Illinois, New York, Oregon, and Tennessee had guidelines to assure statewideness. [FN]149

The services to be acquired by the recipients in the demonstration project should be comparable to those not on Medicaid or in the project. [FN]150 Florida requested waivers from comparability; [FN]151 Hawaii, Illinois, Oregon, and Tennessee had guidelines to assure comparability; Missouri's demonstration project is limited to Franklin, Jefferson City, St. Charles, and St. Louis counties and St. Louis City [FN]152; and New York's waiver was ambiguous in this area.

Managed care standards potentially reflect managed care's philosophy of saving money with the potential outcome of offering inferior services. The waiver application should prohibit managed care from substituting its lower standards for Medicaid. Only one state (Hawaii) specifically prohibited managed care plans from substituting their own standards for that of Medicaid. [FN]153 Oregon was the only state to have no guidelines related to this criteria. [FN]154

As indicated below, the services should include not only non-Western health care but also particular services important to communities of color (i.e., prenatal care, drug and alcohol treatment, and violence prevention). [FN]155 Four states (Florida, Illinois, New York, and Oregon) had guidelines related to assuring services important to the community. [FN]156 For example, Florida Health Security Plan would make services available that are important to communities of color through the Basic Benefit Standard. [FN]157 Extensive mental health and substance abuse benefits, inpatient rehabilitation, and organ transplants are included in the Basic Benefit Standard. [FN]158*1101 Missouri has no guidelines. [FN]159

Finally, managed care plans should be required to conduct prevention program which address motivational, attitudinal, and client behavioral issues. [FN]160 Only Oregon provided clear guidelines. [FN]161 Three states (Hawaii, Illinois, and Missouri) did not. [FN]162 In summary, all of the states, except Missouri, offered ambiguous information on whether their waivers provided sufficient guidelines to assure the availability of comprehensive health care services. Missouri did not address this issue at all.




  1. Does the Waiver Require the Provision of Culturally Competent Health Care?

The traditional health care system, including managed care plans, has been structured around delivering care to middle-class patients. As discussed earlier, access to care means much more than merely having insurance or having a provider. Meaningful health care must address a person's social and cultural needs as well. Thus access is rendered meaningless if socio-cultural barriers prevent a person from obtaining health care services.

Culturally competent care starts with the provision of health care in the language of the patient. Interpreter services should pertain not only to oral communication, but to information provided via written materials. Furthermore, to assure the quality of interpreting services, the state plan should provide for the certification of interpreters. [FN]163 Five states (Illinois, Missouri, New York, Oregon, and Tennessee) have standards requiring the provision of *1102 health care services in languages other than English. [FN]164 For example, Oregon's Medicaid Demonstration Project requires the prepaid health plan to have qualified interpreters for each substantial population of non-English-speaking members, as well as written information in the primary language of these populations. [FN]165

A culturally competent health care system must be designed to go beyond the assurance of culturally appropriate language services. The waiver must recognize that the traditional health care systems has been designed around the needs of the middle class. As a result, certain essential services for low-income individuals are generally not available, i.e., transportation assistance and telephone assistance. [FN]166 Only Illinois, Missouri, and Oregon have guidelines requiring managed care plans to provide transportation and telephone assistance. [FN]167 Under the Missouri plan, emergency and nonemergency transportation must be provided to members with nonemergency transportation provided to those individuals who do not have the ability to provide their own transportation. Missouri has also included an established procedure for telephone reminders of, and follow-ups to, appointments and telephone outreach to members. [FN]168

Furthermore, many patients' health problems are directly impacted by their social conditions. If the health care status of poor individuals is to be improved, it is important to have social services support and outreach services. [FN]169 Four states (Florida, Illinois, Oregon, and Tennessee) had guidelines regarding the provision of outreach services. [FN]170 Only two states (Florida and Illinois) had guidelines regarding the provision of social services. [FN]171 In Illinois, MediPlan Plus will provide social service support and outreach *1103 services as part of its case management services. One role of the social service worker is to inform clients of upcoming health screening and vaccinations. [FN]172

The waiver should require managed care plans to make available nonmedical health care treatment. [FN]173 For instance, acupuncture and midwifery are two proven health care practices that any health care plan serving diverse communities ought to have available. No state had clear guidelines regarding non-Western health care services.

It is not enough, however, to have standards related to the provision of culturally appropriate care; managed care plans must be required to train their health care providers to give culturally appropriate care. [FN]174 That training should include: (1) the use of nonmedical trained providers and interpreters; (2) the importance of patients' belief patterns and support systems to ensure adherence to treatment, and the identification and treatment of illnesses not found frequently in the “white middle class male” patient population. [FN]175 Two states (Florida and Illinois) had provisions regarding provider orientation and training. [FN]176

Finally, all the standards related to the provision of “culturally competent care” will be for naught without administrative support systems and procedures. This includes: (1) computerized tracking system for preventive health screening; (2) cultural responsive appointment making and advice nurse system; (3) ombudsman responsible for addressing special difficulties of culturally distinct minorities; and (4) computerized information system capable of generating patient profiles. [FN]177 Although four states (Florida, Illinois, Oregon, and Tennessee) had guidelines regarding administrative support, the support was not targeted toward the assurance of culturally competent care. [FN]178 For example, Florida Health Security is required to have marketing materials and applications available in such languages as may be reasonable required to meet applicant's needs; the plan will also assure sufficient numbers of intake workers who can address the special needs of diverse populations. [FN]179*1104 Only Illinois had overall positive guidelines. Hawaii had no guidelines at all and, at best, the other states were ambiguous.




  1. Does the Waiver Provide Clear and Adequate Access Standards to Evaluate Managed Care Plans?

No waiver can be adequate without clear standards by which managed care plans can measure access. Ultimately, access should be measured by improved health status of communities of color. However, in the interim, accessibility can be measured by such things as: (1) how long a patient has to wait for an appointment (appointment waiting times); (2) how far a person has to travel or how long it takes a patient to get to the provider (travel and distance times); and (3) how well maintained the patients' ability is to choose a provider who does not meet travel/distance standards but who meet other needs and the availability of emergency and urgent care. [FN]180

These standards must be as specific as possible. For instance, the appointment waiting times will need to vary based on whether the appointment is for primary care, specialty care, dental care, mental health care, or hospitalization. [FN]181 Four states (Illinois, Missouri, Oregon, and Tennessee) had specific guidelines with regard to appointment waiting times. [FN]182 For example, in Tennessee, the TennCare contract requires under “Availability and Accessibility of Services,” that services, service locations, and service sites are made available and accessible in terms of timeliness, amount, duration, *1105 and personnel, sufficient to provide covered services. Emergency medical services must be available twenty-four hours a day, seven days a week. [FN]183

Similarly, travel times and distance should be as detailed as appointment waiting times, and guidelines should also include travel times and distance to pharmacies. [FN]184 Three states (Missouri, Florida, and Tennessee) had specific standards on travel times and distance. [FN]185 Under TennCare, the following standards are provided: (1) primary care physicians must be within thirty miles or thirty minutes; (2) the time to hospital cannot exceed forty-five minutes; 3) general dental services must be within thirty miles or forty-five minutes. [FN]186

Although waivers should have travel time and distance standards, a waiver should not restrict recipients to providers who fall within a travel and distance standards. [FN]187 There many reasons why a patient my choose a provider outside the standards. For example, a provider who the patient feels comfortable with, or has confidence in, may live outside the distance standard. Whatever the reason, a patient should be assured the ability to choose a provider that does not practice within the travel/distance standards. Only Missouri, Tennessee, and Florida provide such guidelines. [FN]188 For example, it can be inferred that Florida would meet this criteria. After defining access to care according to travel time, FHS states that the definition is not intended to limit an Accountable Health Partnership's utilization of specialty care providers and centers of excellence.

Another measure of access can be the availability of emergency and urgent care. [FN]189 Consequently, the state waiver should establish minimum standards assuring that managed care plans will provide patients with emergency medical care, dental care and mental health care. Five of the seven states (Florida, Illinois, Missouri, *1106 Oregon and Tennessee) had specific guidelines related to the delivery of emergency and urgent care. [FN]190 The Missouri Managed Care Program requires emergency services to be available at all times and urgent care appointments to be available within three days of referral to the provider. [FN]191

The worst state by far was Hawaii, which had absolutely no standards or guidelines related to standards for access. [FN]192 On the other hand, Missouri and Tennessee had detailed access standards. [FN]193 The other states (Florida, Illinois, New York, and Oregon) were ambiguous in establishing clear and adequate access standards. [FN]194



  1. Does the Waiver Provide for Case Management and Continuity of Care?

Case Management services are essential to the provision of care. The waiver should have a clear definition of case management and should include services for both children and adults. [FN]195 Four states (Florida, Illinois, Missouri, and Oregon) had clear definitions. [FN]196 Oregon's demonstration waiver provides for a “Primary Care Case Management Group” which will monitor the care of each covered individual through the coordination and management efforts of a designated primary care provider. The case manager's *1107 responsibilities include provision of routine care services, referral of enrollees to specialists with follow-up on the referral, and maintenance of enrollees' medical records. [FN]197 Two states (Hawaii and Tennessee) inadequately addressed this issue. [FN]198 For example, under Hawaii's Health Quest plan, patients have a primary care physician but there are no provisions for case management services. [FN]199

To assure continuity of care, the waiver should require that each plan appoints one single provider who ensures “continuity of care,” by assuring that all necessary referrals are made, maintaining medical records, and ensuring that appropriate personnel receive medical files. [FN]200 Two states (Hawaii and Missouri) had such provisions. [FN]201 For example, under the plans of both Missouri and Hawaii, the primary care physician ensures continuity of care by assuring that the patient has access to specialists and other needed services. [FN]202

It is important that the case management services and the gatekeeper role be done by those who are appropriately qualified. Generally, a primary care or family practice physician, or a pediatrician for children, may be a sufficient case manager. However, the waiver should require the managed care plans to allow a specialist to be the gatekeeper where necessary, such as a specialist for chronically ill or disabled persons. [FN]203 Two states (Illinois and Oregon) made such provisions. [FN]204 The other states' applications were ambiguous.

Finally, the waiver should include standards which set clear time limits after enrollment within which managed care plans must assign a gatekeeper and conduct initial assessments. [FN]205 Two states (Illinois and Oregon) had appropriate guidelines. [FN]206 Three states *1108 (Florida, Hawaii, and Missouri) had inadequate guidelines. [FN]207 Two states (Illinois and Oregon) have adequately outlined standards for case management and continuity of care. Hawaii and Tennessee had inadequate outline standards; and Florida, Missouri, and New York were ambiguous in how they addressed this issue.







  1. Does the Waiver Have Mechanisms to Assure the Affordability of Cost-sharing Arrangements?

Managed care plans shift part of the financial risk to the patients through copayments, premiums, and deductibles. The plans need to have mechanisms to assure that these risk-shifting behaviors remain affordable for even those with the lowest income. [FN]208 Three states (Hawaii, Illinois, and Oregon) have guidelines addressing the affordability of cost-sharing arrangements. [FN]209 For example, the Illinois MediPlan Plus plan will hold yearly client copayments to $150 and monthly copayments to $15. [FN]210 Florida did not address this issue. [FN]211







E. Assuring Access to Care: Conclusion

Section 1115 waivers are supposed to improve access to care. They do so by relying on managed care plans. If managed care is not carefully controlled, however, it could become a place where the uninsured, the indigent, and persons of color, are systematically *1109 relegated to the lowest tier of health care. As Professor Reinhardt argues, “the best the champions of the poor can hope for under managed care is a three-tiered system”. [FN]212 The waivers show questionable ability to prove Professor Reinhardt wrong.

All of the waivers except Hawaii are ambiguous, at best, in articulating their ability to assure access. Hawaii's waiver fails entirely. One problem is the failure of the waivers to account for lack of providers in minority communities. At the same time, the waivers provide little protection of the traditional providers for minority communities and little assurance that minority physicians will be included in the managed care structure. Thus, there is a real possibility that physicians who have developed caring relationships with patients will be severed from the care of those patients.

This can be a particular problem for the traditional Medicaid patients who are more likely to be handicapped, disabled, or have chronic illness, and need a caregiver who is culturally understanding with the ability to manage their long-term care. [FN]213 Further, these patients require intense care, often at higher costs. [FN]214 None of the waivers seems to recognize that the culture of the medical professions (and physicians' attitudes towards serving the poor or uninsured) varies markedly among different communities. [FN]215

Thus, there is a significant possibility that the waivers will erode access to traditional providers without replacing them with sufficient *1110 other providers. To the extent that the waivers result in long-term erosion of safety net provider capacity, communities of color will be further disadvantaged in gaining access to adequate medical care.