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Access to Health Care in America
care services, with the lines between social and health services often becoming blurred. It is generally believed that the character of these services and how they are organized make a difference for outcome; specifically, they need to be comprehensive, coordinated, and family centered. Those outcomes will most likely be measured in terms of quality of life and the prevention of secondary disabling disease conditions.
Enactment of the Americans with Disabilities Act further inspired the growing desire by policymakers and researchers to have better and more objective data on disabilities. During the course of the IOM Access Monitoring Project, the National Center for Health Statistics was formulating plans to conduct a 1993–1994 supplement to the NHIS that focused on the noninstitutionalized disabled population. This survey should provide an opportunity to clarify definitions and measurement tools that would be instrumental in developing a practical access indicator for disability.
The inclusion of a separate chapter on violent and abusive behavior in the publication Healthy People 2000 (U.S. Public Health Service, 1991) reflects a growing recognition of the problem as one that must be addressed not only by the legal, educational, and social welfare systems but by the health care system as well. The rubric of violent and abusive behavior can include the term "family violence," referring to child abuse, spousal abuse (especially battered women), and elder abuse.
Progress in developing an access indicator for this problem depends on ientifying a generally agreed-upon personal health service that should be available to all who are at risk. For example, one of the Healthy People 2000 objectives calls for the nation to "increase to at least 30 the number of states in which at least 50 percent of the children identified as neglected or physically or sexually abused receive physical and mental evaluation with appropriate follow-up as a means of breaking the intergenerational cycle of abuse." There are few patient outcome studies on the impact of medical interventions for battered women, but it seems clear that, at a minimum, referral to supportive services outside the personal health care system ought to be part of a standard of care.
Another facet of developing an indicator must be consideration of the potential barriers to access to services and how they might be measured. For example, battering is a major factor in illness and injury among women, but it is often overlooked by medical professionals. Some studies have shown that between 17 and 25 percent of all emergency department visits involve battered women, but emergency care providers typically identify less than 5 percent of the women with injuries or illnesses suggestive of abuse (McLeer and Anwar, 1989). In fact, the majority of battering-related