Coverage is not the same as access, which has been defined in another Institute of Medicine report as the timely use of personal health services to achieve the best possible health outcomes. Some who have coverage still face access problems by virtue of their location, race, education, or other personal characteristics or as a result of specific characteristics of their coverage, such as low rates of payment for physician services. Likewise, even those who lack health insurance have some access to care on an emergency basis for serious illness or injury, and some needy individuals receive primary and preventive services through public and private programs and charity care offered by individual practitioners. Access overall is, however, often not timely and is rarely coordinated, and the financial burden of uncompensated and public care for the uninsured is very unevenly borne across communities.
For more than two decades, concerns about high and escalating medical care expenditures and strategies to control those costs have been a major focus of health policy. The continuation of the former and the ineffectiveness of the latter not only have made it more difficult to extend health coverage to those now uninsured and underinsured but also have been partly responsible for the growth of this pool.
High health care costs are frequently portrayed as the nation's number one health policy problem, but the problem is more complex. That is, the country is spending a greater share of national resources on medical care and making such care less affordable for many without having much evidence or confidence that it is achieving better health outcomes or other equivalent value for its increased investment. Efforts to accumulate such evidence, to evaluate and compare the costs and benefits of alternative medical practices, and to generally assess the quality of medical care are increasing in numbers and sophistication. Nonetheless, the public and private resources devoted to these efforts are minuscule compared with those devoted to developing more advanced treatments and technologies.
The health care market is in a variety of respects not currently structured to achieve the efficiency expected of properly functioning markets. The debate over health care reform centers on several questions: Can major changes in public policy create an effectively functioning market? Should the employer have a major role in a market-oriented approach? Would, on balance, the projected effects of one or another kind of reformed market be better or worse than the effects of major alternatives, which occupy a spectrum of possibilities from the current system on the one hand to a single payer, single national health plan on the other hand?