Barriers to Access

There are three primary types of barriers to health care. Structural barriers are impediments to medical care directly related to the number, type, concentration, location, or organizational configuration of health care providers. Financial barriers may restrict access either by inhibiting the ability of patients to pay for needed medical services or by discouraging physicians and hospitals from treating patients of limited means. Personal and cultural barriers may inhibit people who need medical attention from seeking it or, once they obtain care, from following recommended posttreatment guidelines.

These barriers interact in complicated ways. The simple presence or absence of a barrier does not guarantee that one can predict whether services can be obtained. For example, many women without insurance receive prenatal services from community health centers or public health clinics. In some cases these services may better meet their needs than the care women with insurance coverage receive. In addition, many who live in areas designated as having a shortage of health care professionals actually have physicians available to them locally or are willing to travel to the nearest physician. In contrast, many people live in areas with high physician-to-population ratios but are unable to secure needed services (Berk et al., 1984).

Structural Barriers

The post-World War II solution to health care access problems was to expand the basic supply of hospital beds and later, in the 1960s, the supply of health care professionals. The federal government adopted a policy of capacity building at the local level partly in recognition of the fact that the recently enacted Medicare and Medicaid entitlements would strain the health care delivery system by increasing the demand for medical care. Community health centers, the national health service corps, and other programs designed to increase the number of health care professionals in underserved areas were seen as mechanisms by which local communities could take advantage of the broader availability of public insurance. The legacy of this period was to measure access in terms of beds, facilities, and providers in relation to population.

With the strain that growing demand placed on public budgets, however, the 1960s gave way to a move from expansion to constraining capacity in the 1970s through regulatory mechanisms such as certificate-of-need programs. During the 1980s, disillusionment with planning and regulatory approaches led to greater reliance on market forces to control costs.

How health care resources are organized in the 1990s may be as important for improving access as the production of hospital beds and health



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