Access to health care has dominated the health policy scene for several decades. In the early 1990s, national legislation, “universal access” to health care, was introduced by President Clinton and the Congress as a way to provide health security for all Americans. Lively debates were generated and the topic commanded national attention. The effort, although unsuccessful, has kept the problem of health care access on the public agenda. Access to care generally refers to the timely use of personal health services to achieve the best possible outcomes. initially, the premise was access to physicians and hospitals. More recently, health care access has included a variety of providers, services, and facilities. in addition, access describes the actual use of health services and factors that facilitate or impede health care.
Aday (2001) and Anderson (see Anderson et al., 1996) describe six types of access: Potential access refers to health care system characteristics that influence the use of services. Realized access is the actual use of health services. Equitable access is the use of health services determined by demographic characteristics and need. Inequitable access refers to the use of health services that is determined by social characters and available resources. Effective access is the use of health services that improves health status or satisfaction. Efficient access minimizes the cost of health care services and maximizes health status or satisfaction. Thus, each type of access to care is influenced by a number of characteristics and events. In an effort to understand the influences on access to health care, numerous studies have examined the barriers to care in specific populations.
It is clear that groups and individuals at risk may experience multiple barriers in trying to access health care. These are often individuals and groups who are vulnerable and need multiple services. Aday (2001) notes that the principal health needs of vulnerable populations are physical (high-risk mothers and infants, chronically ill and disabled, persons living with HIV/ AIDS); psychological (mentally ill and disabled, alcohol or substance abusers, suicide or homicide prone); social (abusing families, homeless persons, immigrants and refugees). Many of these vulnerable groups have crosscutting health needs such as battered pregnant women, pregnant, homeless, substance-abusing women. These women are all at increased risk, requiring specialized services and experiencing multiple barriers to accessing care. A single-parent Hispanic woman with three children and no insurance, living in a rural area, likely experiences the following barriers:
- Fewer providers in rural areas
- Providers may not take uninsured
- Providers may not understand language and culture
- Transportation and childcare may not be available
- Fearful of her immigrant status being questioned
Concern over access to health care services is generated by the observations that some population groups may experience differences in access to health and subsequently experience poorer outcomes. Testing the equity of access involves measuring utilization of services as well as outcomes and determining barriers to care. In a landmark report, Access to Health Care in America (1993), the Institute of Medicine proposed five indicators for assessing access:
- Promoting successful birth outcomes
- Reducing the incidence of vaccine-preventable diseases
- Early detection and diagnosis of treatable diseases
- Reducing the effects of chronic disease and prolonging life
- Reducing morbidity and pain through timely and appropriate treatment
Access to timely prenatal care, immunizations, Pap tests, chronic disease management, and dental visits, for example, are all personal health services that contribute to favorable health outcomes. Thus, measurement of these indicators provides useful clues to how Americans access health care. In these selected examples, notable differences in access to care and health disparities can be determined. For example:
- There is a striking difference between Caucasians and African Americans receiving prenatal care (73.5% and 50.7% respectively) and a notable gap in black/white infant mortality rates (black rates twice as high as Caucasians).
- Childhood immunization rates reveal differences based on race, ethnicity, and geography.
- Elderly white women were more than twice as likely as younger white women to never have had a Pap test in 1987.
- Persons from poor areas are two thirds as likely as those from high-income areas to have access to hospital admission and referral services.
- Those with dental insurance made an average of about one more visit to the dentist than those without insurance. Differences by race persist after insurance.
Insurance, as a key to accessing health services in this country, deserves special note. Studies support that Americans without health insurance are generally sicker, die sooner, and when they receive care, it is likely to be of poorer quality than those with insurance. The 43 million uninsured Americans and 30 million underinsured reveal further racial, ethnicity, and income disparities. Hispanics, Asian Americans, American Indians, Alaskan Natives, and African Americans are all less likely to have insurance, have more difficulty getting care, and have fewer choices than Caucasians. Those in the population who are low-income can expect to have only limited access to preventive and primary, specialty care and subsequently suffer from poor health/outcomes. While many strides have been made in improving access for women to prenatal care, many services essential to low-income women are government-supported programs (food stamps, WIC, etc.). These programs are subject to the availability of resources and women are often left vulnerable by changing eligibility requirements, work program time limits, lack of culturally and linguistically sensitive services, and cross-cutting health issues.
While numerous federal and state initiatives have attempted to provide universal access to specific groups, to date a fragmented system with large numbers of uninsured is the current reality. The implications for women are significant. As high users of health services, access to appropriate care has a significant impact. Women are likely to have lower wages when they work and are more likely to be uninsured or underinsured. Women also need preventive services to maintain their health, Pap tests, family planning services for example. Women are frequently heads of household and experience barriers such as childcare and transportation. Minority women, low-income women, and immigrant women are at particular risk for experiencing barriers to care resulting in negative health outcomes. Access to health care will be a major area of concern for women and will require policy actions to remediate this gap.