Strategies other than raising Medicaid payment levels will be needed to achieve equitable access to office-based primary care for the poor residing in cities.

This study investigated individual and neighborhood factors associated with late entry into prenatal care. Data from 220,694 New York City birth certificates were linked with data from the 1990 census and other secondary sources to determine the effect of women's individual characteristics and their neighborhood context on timing of prenatal care entry. Results indicate that 15 percent of New York City's pregnant women entered prenatal care late and that residence in a distressed urban neighborhood significantly increased the risk of late initiation, even in a model controlling for individual risk factors. Implications for social workers include the importance of outreach and case management for pregnant women, the value of health and social policies targeting distressed urban neighborhoods, and the need to ensure that Medicaid managed care implementation fosters use of prenatal care. The findings also underscore the importance of continuing to strive for a policy that ensures lifelong universal access to health care.

In this article we examine how increasing the reimbursement of physicians and expanding Medicaid eligibility affect access to care for children in Cook County, Illinois, which overlies Chicago. Using Medicaid claims and other data at the zip-code level, we compare the places where Medicaid children live with the places where all the physicians who treat children and those who accept Medicaid patients have their practices. Our findings suggest that the recent changes in legislation are unlikely to benefit extremely poor children, who are more likely to live in depressed inner-city areas, where there are few physicians. "Near-poor" children whose homes are dispersed throughout the county, who are now eligible for Medicaid as a result of the recent changes, are likely to see improvements in their access to care. Further changes in policy, aimed at enhancing the capacity of institutions providing care, could improve access for the children of the inner city.

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Many state Medicaid programs are implementing managed care, and more can be expected to do so in the future. Medicaid managed care will have an important impact on Medicaid recipients and uninsured people who live in cities. It will also pose significant new challenges for hospitals, community health centers, and clinics serving these populations and for social workers practicing in these settings. Social workers need to understand the reasons for Medicaid managed care's development and phenomenal growth and its likely impact or clients, service delivery, and access to care in medically underserved urban neighborhoods. This article identifies roles for social workers in supporting clients in the transition to Medicaid managed care and advocating for policies that will improve access to care for disadvantaged urban populations.