but they also are in general less healthy. This may be due to not only the amount of care they receive but also the content, quality, and continuity of what care they do receive.

Access to services is not an end in and of itself. The purpose of gaining access to the personal health care system is to achieve one or more of an array of possible health outcomes—not only avoidance of untimely death and relief of acute symptoms but also maintenance of long-term functioning and relief from anxiety about the meaning of symptoms. This said, however, it should be emphasized that the relationship between desired benefits of positive health outcomes and health care services is not clear-cut. Even countries that have reduced many of the barriers faced by those in the United States by establishing universal health care still experience differences in access to health care according to social class (Illsley and Svensson, 1990). Moreover, other mechanisms in addition to medical care, such as environmental control, education, and occupational safety, contribute to the health of populations.

Despite the difficulties of sorting out the effects of health care services from those of other factors, society has a stake in monitoring how equitably its investment in health services is working, by being able to identify who has access problems and why. The challenge before the IOM committee was to identify a limited set of different personal health care services in which the connection between timely receipt of care and desired outcomes is relatively strong. These indicators can then be used to track changes in access over time and differences in access across groups in society.

DEFINING ACCESS

Access is a shorthand term used for a broad set of concerns that center on the degree to which individuals and groups are able to obtain needed services from the medical care system. Often because of difficulties in defining and measuring the term, people equate access with insurance coverage and having enough doctors and hospitals in the areas in which they live. But having insurance or nearby health care providers is no guarantee that people who need services will get them. Conversely, many who lack coverage or live in areas that appear to have shortages of health care facilities do, indeed, receive services.

Perhaps the most extensive effort to sort out the meanings of access and the related concept of equity was mounted by the 1983 President's Commission for the Study of Ethical Problems in Medicine and Biomedicine and Behavioral Science Research. The commission described society's ethical obligation to ensure access as follows: "Equitable access to health care requires that all citizens be able to secure an adequate level of care without excessive burdens" (President's Commission for the Study of Ethical Problems



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