the costs of health care, increasing their reluctance to seek care when they need it. Spurred in part by the malpractice insurance crisis, obstetrical services are reported to be in short supply in some areas. Residents of this country's rural areas are fighting an uphill battle to keep hospitals open so that, at a minimum, they have access to emergency services and essential primary care. To avoid having to admit emergency room patients who may not have insurance, growing numbers of hospitals have ceased offering emergency services.

There is no shortage of stories depicting these and related problems. What policymakers and the public lack, however, is a systematic way of looking at the barriers people face in getting needed health care and the impact those barriers have on society. Data describing barriers to health care are incomplete, scattered, underanalyzed, or outdated. The information that has been gathered is not organized in ways that promote systematic thinking about how access to health care has changed over time, nor can differences among affected groups be compared. For these and other reasons, the desirable objective of improving access to health care remains elusive.

The IOM Access Monitoring Project was designed to develop a way to monitor access to health care that will be useful to health care policymakers. The charge to the IOM committee was to develop a rationale and framework for gauging how well or how poorly the nation provides access to personal health care. The focus of this effort was to be the development of a limited set of indicators that could reliably sense the direction and extent of change at the national level in access problems and at the same time give clues about what factors might be driving that change. In addition to clarifying perceptions about the status of health care access in the United States, it was hoped that these indicators would serve as a general guide to decisionmaking.

Unfortunately, the data and methods available to devise a reliable system for monitoring access to health care are incomplete in some areas. Thus, in addition to developing indicators, the committee was instructed to recommend strategies for improving state-of-the-art access monitoring. This included identifying ways to enhance ongoing data collection activities and refine measurement techniques as well as encouraging research on access problems in areas in which there are currently insufficient data or in which the appropriate indicator for measuring access is unclear.

BACKGROUND

Unlike many of IOM's activities, this project was self-initiated—neither mandated by federal legislation nor directly requested by a public or private agency. The call for such a study of health care access came from



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