of the local health care system—knowledge that is not available at the national level—to draw conclusions about access problems faced by their vulnerable populations. In addition, decisions about whether to invest in new data collection can be helped by the knowledge of what can be done with the data. Understanding the potential payoffs, and the extent to which emerging national trends apply to local circumstances, will allow communities to determine their data collection needs.

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

Racial and Ethnic Differences Anyone who reads this report will be struck by the persistent and in some cases widening disparities in access between blacks and whites. Studies of health care access that compare the experience of whites with that of racial and ethnic minorities other than blacks frequently reveal similar disparities. When certain factors, such as insurance status and income, are taken into account, some of these disparities diminish. There continues to be a need to oversample minorities in national surveys as well as to conduct specialized surveys focused on minorities. To understand the roles that income and insurance play, all surveys should include questions that elicit such information.

Because it is not always feasible to improve the utility of national data bases—that is, by recording the race or ethnicity of patients—it will be necessary to mount studies that more fully characterize unexplained problems of access.

Directions for Health Services Research In its analysis the committee has reaffirmed that lack of health care coverage is, to a great extent, a good proxy for access. Evidence is mounting about the role insurance plays in influencing not only health care use but outcomes as well. Much work remains to be done in fleshing out these relationships.

Nonetheless, the committee is convinced that other factors play an important role in explaining differences in access to care. This sense is illustrated by the experience of other industrialized nations in which financial barriers to services have been removed but serious inequities among various population groups still occur. Many believe that these inequities would be diminished by changes in the way the delivery of care is organized and by greater responsiveness of providers to the personal and cultural characteristics of their clients. Thus, the committee has concluded that, even if the United States were to adopt universal entitlement, achieving the objectives around which its indicators are organized is likely to remain a great challenge. Further research into these aspects of access is clearly needed.



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