Health maintenance organizations as Medicaid providers.

Evolution of a one-door, one-class system of medicine for all Americans was the professed goal of the social legislation of the 1960s. The development of health maintenance organizations (HMOs) was seen to be a major mechanism for assuring access to care and at the same time reducing the costs of social health programs. This has currently been reinforced by procompetitive proposals, which predict great efficiency resulting from the envisaged competition among organized systems of care. This article argues that established HMOs have no incentives to enroll Medicaid beneficiaries and that under current arrangements. Medicaid beneficiaries have no incentives to enroll in HMOs. As Medicaid programs across the states are cut, resulting in fewer benefits and more restricted physician payments, beneficiaries may have greater incentives to enroll in organized systems. Private physicians may also face greater incentives to develop HMOs to serve Medicaid beneficiaries. If that happens, however, a two-class system--one for the poor and one for others--will be institutionalized; and to assure minimum standards of care for the poor, more, not less, regulation will be required.