V. Conclusion

For millions of Americans, Medicaid is their primary source of health insurance. Medicaid is a long established program that provides insurance for those who could not otherwise afford it. However, states have found a need to implement new and innovative ways to deliver health care under Medicaid law. Traditional Medicaid expenses have become unmanageable as the number of poor in America has increased and the provision of medical care has become prohibitively costly. Therefore, more and more states are turning to the waiver provision of Medicaid law. Section 1115 Medicaid waivers have been developed by a number of states in an attempt to better effectuate the purpose of the Medicaid Act. These waivers have been the focus of this paper. The waiver applications were evaluated to determine how well the applications would improve access, assure quality and manage cost containment. Section 1115 waivers are supposed to improve access to care. They do so by relying on managed care plans. However, if managed care is not carefully controlled, it could become a place where the uninsured, the indigent, and persons-of-color are systematically relegated to the lowest tier of health care. All of the waivers except Hawaii are ambiguous, at best, in articulating their ability to assure access. Hawaii's waiver fails entirely. Furthermore, there is a significant possibility that the waivers will erode access to traditional providers without replacing them with sufficient other providers. To the extent that the waivers results in long term corrosion 1141 of safety net providers capacity, individuals will be further disadvantaged in gaining access to adequate medical care. Assuring quality health care is extremely important in the managed care environment. Managed care actually operates under inverse incentive, where the providers make more money and the third party payers spend less as they reduce services. This incentive may encourage plans to cut services, particularly to vulnerable populations, which are marginally necessary. It is not enough for the states to increase access to health care, they must also assure the quality of the care given. While no waiver completely ignored this area, none of them were positive overall in the treatment of this criteria. The most striking feature about all of the states was the lack of detail with which they addressed this issue. This was particularly true with regard to standards to assure quality of health care to minority patients. As to cost containment, many of the plans have positive aspects which will provide some protection for patients. This is particularly true in the area of financial risk shifting where all the states had at least one or two positive aspects to their plan. However, as the waiver applications stands, there is sparse mention of special health concerns of minority populations. The failure of the waivers to require managed care plans to collect utilization review data is an oversight that overrides all other aspects of the states' cost containment efforts. Given the states' intentions of providing health insurance for those who are uninsured, the demonstration waivers should be viewed as a positive effort. However, there are important areas where the waivers fail to protect the populations they are meant to serve. Perhaps the biggest fault of the waivers is the failure to address the needs of minority communities--their particular health issues as well as their particular life styles that differ from the white middle-class population. All the state waivers reviewed are guilty of this lack of acknowledgment of minority population health needs. Through this article, we have addressed only several of the aspects of the state waivers: access to health care; quality assurance; and cost containment. On paper, the waivers tout how they are improving health care delivery in these areas. A look at Tennessee and Hawaii, though, reveals that what looks good on paper does not necessarily play out in the real world. Other vital areas that must be critiqued in future writings are patient protection from experimentation and antidiscrimination provisions of the waivers. 1142 In conclusion, Section 1115 Medicaid Demonstration Waivers are granted by HCFA to a state because the state wants to test a program improvement of the health care delivery system. States must take this opportunity to address the unique needs of the uninsured poor and minority communities as part of the overall health care reform initiative.