DEFINING ACCESS

Access is a shorthand term 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 concept, people equate access with insurance coverage or with having enough doctors and hospitals in the geographic area 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 resources do, indeed, receive services.

For the purposes of its work the committee defined access as follows: the timely use of personal health services to achieve the best possible health outcomes. An important characteristic of this definition is that it relies on both the use of health services and health outcomes as yardsticks for judging whether access has been achieved. The test of equity of access involves determining whether there are systematic differences in use and outcomes among groups in U.S. society and whether these differences result from financial or other barriers to care.

In applying its definition of access, the committee sought to occupy a practical middle ground between all care that people might want or need and the belief that medical care can make an important difference in people's lives. The definition forces us to identify those areas of medical care in which services can be shown to influence health status and then to ask whether the relatively poorer outcomes of some population groups can be explained by problems related to access. The definition also emphasizes the need to move beyond standard approaches that rely mainly on enumerating health care providers, the uninsured, or encounters with health care providers to detect access problems.

No matter how generally efficacious a particular health service may be, a good health outcome cannot always be guaranteed. The most important consideration is whether people have the opportunity for a good outcome—especially in those instances in which medical care can make a difference. When those opportunities are systematically denied to groups in society, there is an access problem that needs to be addressed.

The access monitoring indicators recommended by the committee are intended to detect when and where access problems occur in the personal health care system. They do not explain the exact causes of these problems, but they can provide a better basis for generating theories about why differences in access exist among populations. Although they are only proxies for complicated phenomena, over time the indicators give important information about the direction and speed of change. They also provide clues about the relative status of groups of people at the same moment in time. Indicators will not always move in the same direction. Some may increase,



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