As a whole, indicators of access to personal health care services provide little encouraging evidence of progress over the past decade. Stagnation is the single best word to characterize our current state. Successes like improvements in breast cancer screening are counterbalanced by the return of diseases that can be avoided, like tuberculosis and congenital syphilis. Underlying most of the indicators is a growing division between the haves and the have-nots in our society.

A large group of citizens in this country make contact with medical providers only a little more than half as often as their fellows. This group lacks health care coverage and is generally at the low end of the income scale. Indicators that measure health outcomes suggest that at least for people from low-income neighborhoods the difference in health care use has a profound impact on their health and well-being. Admission rates to hospitals for conditions that should be controlled with appropriate ambulatory care are on average four times higher for residents of low-income than for high-income neighborhoods. The committee believes that evidence is building to demonstrate that no or inadequate health care coverage is the reason many of these people fail to obtain the timely and appropriate care that would make a difference in the state of their health. Further work is required, however, to establish solid causal linkages between the access barriers of lack of health insurance, low-income, and nonfinancial factors such as culture and geographic isolation and measures of outcome such as premature death, sickness, disability, and avoidable hospitalization.

Compared with other groups in society, blacks and some ethnic minorities are more likely to have low-incomes and inadequate health insurance. The effects of these burdens are borne out by utilization and outcome indicators virtually across the board. There is evidence of inequity in the timely receipt of ambulatory care, immunizations, dental visits, and some sophisticated procedures. Even in instances in which general improvement can be seen that spans the U.S. population, improvement is slower for these groups—especially blacks.

Some of the most striking differences can be found in mortality rates by race. After controlling for a number of behavioral risk factors, a wide gap persists between mortality rates of middle-aged black men and women and their white counterparts. A reasonable estimate is that one-third to one-half of the gap may be attributable to access problems. In 1970 black infants were 85 percent more likely than whites to die during the first year of life; by 1988 black infants were more than twice as likely as whites to die during their first year. A related measure is the slow but steadily growing disparity in low birthweights for blacks and whites during the past 20 years.

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