extent of change in structural, financial, and personal barriers. At the state and local levels, these barriers are increasingly more definable in terms of a specific set of Medicaid benefits, institutional providers, population demographics, and physical features of the environment. (The advantage of proximity is being able to relate changes to more concrete circumstances.) However, local data are often incomplete, and resources may be insufficient to analyze the local data that do exist. The first step in addressing this problem is to identify clearly what data are needed (i.e., develop a monitoring framework) and how the data might be interpreted and then implement a cost-effective strategy for obtaining missing data.

The committee has proposed a framework for monitoring access and has analyzed specific indicators, demonstrating how they might be related to barriers. As a first step, in instances in which local data exist, states and localities can compare themselves with the national averages. They can also use additional data (such as those in surveys intended to determine which physicians accept Medicaid) and their general familiarity with the contours of the local health care system to draw conclusions about access problems faced by their vulnerable populations. In addition, an understanding of what can be done with the data will contribute to decisions about whether to invest in new data collection. Understanding the potential payoffs and the extent to which emerging national trends apply to local circumstances will allow communities to determine their needs for data collection.

The committee recognizes that constrained state and local public health budgets are likely to limit investment in major new surveys, hospital discharge systems, and cancer registries. To the extent that research and development costs can be borne by the federal government or by private foundations, the cost of implementing enhanced data systems could be reduced for local jurisdictions.

The Federal Role

Recommendation. The committee recommends that there be a federal organization responsible for monitoring access to personal health care services. This ongoing function should include the central collection, analysis, improvement, and dissemination of information on changes in access. The same organization should be responsible for providing technical assistance and consultation to local organizations that wish to conduct their own analyses of access indicators. This assistance will include activities to encourage improved technical capacity and, where appropriate, to promote consistent definitions and analytic approaches.

It was beyond the scope of the IOM committee's charge to identify precisely what entity in the government or private sector should have continuing responsibility for both monitoring access to health care and improving

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