Public Health Access to Health Care
by
Ronald Andersen
  • LAST REVIEWED: 23 February 2011
  • LAST MODIFIED: 23 February 2011
  • DOI: 10.1093/obo/9780199756797-0001

Introduction

“Access to health care,” along with the cost and quality of that care, is generally considered one of the three major indicators for evaluating the performance of a health-care system. Even though access is a major indicator of performance and a continuing problem for the US health-care system, it is often not clearly defined and its meaning has been changing over time. This entry will consider general overviews and key reference works on access, as well as textbooks, anthologies, and journals including sections on access to care. It will also provide references to definitions of access to health care, models of access to care based on different disciplines, the multiple dimensions of access in a comprehensive model, the role of access in understanding and attempting to reduce disparities in health and health care, and the importance of access in the recently passed Health Care Reform Bill in the United States and efforts to implement it.

General Overviews

These general overviews of access to health care provide contrasting international perspectives on the meaning of access (Gulliford and Martin 2003) and discuss improving access from a management perspective (Buss and Van de Water 2009), as well as special issues of access for low-income Americans (Lillie-Blanton, et al. 1999).

  • Gulliford, Martin, and Myfanwy Morgan, eds. 2003. Access to health care. New York: Routledge.

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    Considers whether it is possible to offer universal and comprehensive services without waiting lists and unacceptable delays in treatment. Access to care is considered in an international context by means of contrasting health policies in the United States and European Union. Provides both health-care researchers and health professionals and managers with definitions of access and related issues for research and health policy.

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  • Buss, Terry F., and Paul N. Van de Water. 2009. Expanding access to health care: A management approach. Transformational Trends in Governance and Democracy. Armonk, NY: M. E. Sharpe.

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    Analyzes challenges to management in expanding health coverage. Provides a practical guide to administrators, researchers, and students regarding administrative functions required to assure access to health coverage, how these functions are performed at present and under proposed alternatives, and lessons from experience in the United States and abroad.

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  • Lillie-Blanton, Marsha, Rose Marie Martinez, Barbara Lyons, and Diane Rowland, eds. 1999. Access to health care: Promises and prospects for low-income Americans. Washington, DC: Kaiser Commission on Medicaid and the Uninsured.

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    Emphasizes issues affecting access to health care for low-income Americans. Assesses the importance of expansions of health coverage for the poor, the challenges providers who serve low-income and uninsured populations face, and the effects of these changes on vulnerable populations. Available online.

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Reference Works

Works indexing multiple terms regarding access to health care include Mulner 2009 (health services research), Breslow 2002 (public health), and Kronenfeld and Kronenfeld 2004 (health-care reform).

  • Breslow, Lester, ed. 2002. Encyclopedia of public health. 2 vols. Farmington Hills, MI: Macmillan Reference USA.

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    Authoritative source appropriate for upper high school and university students, professionals, and public-library users interested in health and medical issues. Examines a broad range of topics related to access to care. Includes overviews, definitions, and biographical entries.

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  • Kronenfeld, Jennie Jacobs, and Michael R. Kronenfeld. 2004. Healthcare reform in America: A reference handbook. Santa Barbara, CA: ABC-CLIO.

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    Considers the core issues of the health-care debate in the United States, with a focus on reform of the system. Well-conceived resource for information on access to healthcare in the United States. Useful for students in secondary schools and colleges.

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  • Mulner, Ross, ed. 2009. Encyclopedia of health services research. 2 vols. Thousand Oaks, CA: SAGE.

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    Health-services research (HSR) is a multidisciplinary field, including health administration, health economics, medical sociology, medicine, political science, public health, and public policy. This encyclopedia is the first single source to capture the diversity of HSR. With more than four hundred entries, perhaps one-third investigating the relationship between access to healthcare and its impact upon medical outcomes. Provides an introduction to HSR for undergraduate and graduate students as well as general readers.

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Textbooks

There are no course textbooks totally devoted to access to health care. However, substantial proportions of texts used in courses on surveying public health, the organization of health services, health-services research, and evaluation of health programs include substantial treatment of various dimensions of access to health care.

Surveying Public Health

Public health is the practice of preventing disease and promoting good health within groups from small communities to entire countries. It includes health professionals from many fields working together to protect the health of a population. Access to health care is one means to attain its goals. The texts cited below are among the most used by schools and programs in public health in their introductory survey courses on public health practice. As a tool of public health, these texts frequently reference access to health care.

  • Aday, Lu Ann, ed. 2005. Reinventing public health: Policies and practices for a healthy nation. San Francisco: Jossey-Bass.

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    An important resource for students and professionals who want to understand the implications of the growing body of research on the determinants of health for the design of more health-centered programs and policies. Stresses the need to integrate public-health practice and access to care.

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  • Scutchfield, F. Douglas, and William Keck, eds. 2009. Principles of public health practice. 3d ed. Florence, KY: Delmar Cengage Learning.

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    Text with contributed chapters by recognized experts in their fields, including a foreword by C. Everett Koop. Useful for those involved in the management and provision of care or the study of public-health systems. The third edition emphasizes evidence-based practice and what is currently known about effective public-health practice.

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  • Tulchinsky, Theodore H., and Elena Varavikova. 2009. The new public health. 2d ed. Boston: Elsevier.

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    Provides an international perspective and a unified approach to public health appropriate for all masters-level students and practitioners. The updates are based on the 2005 accreditation criteria of the Council for Education in Public Health.

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  • Turnock, Bernard J. 2009. Public health: What it is and how it works. 4th ed. Sudbury, MA: Jones and Bartlett Learning.

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    This text by an experienced public-health professional characterizes the public health system by its mission, functions, and outcomes. It covers the origins and development of the modern public-health system and how well its core functions are currently being addressed. Directed toward students in the health and social sciences.

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Organization of Health Services

These texts provide surveys of how the health-services system is organized and financed. They provide considerable detail regarding the relationship between organization and finance and access to health care. Some are primarily intended for an introductory course for graduate students in schools of public health, the health sciences, public policy, and management (Andersen, et al. 2007, Williams and Torrens 2007). Others, with fewer technical references, are aimed at undergraduate college students (Barton 2009).

  • Andersen, Ronald, Thomas Rice, and Gerald Kominski, eds. 2007. Changing the U.S. health care system: Key issues in health services policy and management. 3d ed. San Francisco: Jossey-Bass.

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    Textbook written by faculty in the UCLA School of Public Health in response to a grant from a national health-care leader. This authority requested a readable account for health care managers and policy makers of what health-services research tells us about increasing access, controlling costs, and improving quality of health care. Further, it is a readable guide to students in health-care policy and management of health-care reform over the next decade.

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  • Barton, Phoebe Lindsey. 2009. Understanding the US health service system. 4th ed. Chicago: Health Administration.

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    Easy to read and use. Fairly comprehensive review of the US health-care system. A good introductory college-level book to learn about the health-care system.

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  • Williams, Stephen Joseph, and Paul Roger Torrens, eds. 2007. Introduction to health services. 7th ed. Clifton Park, NY: Thomson Delmar Learning.

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    Written by a group of nationally recognized authors. The seventh edition emphasizes approaches to improve efficiency and access to care in the nation’s health-care system.

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Evaluation of Health Programs

With increasing emphasis on the accountability, effectiveness, and efficiency of health care delivery programs, most programs in health-services research and management require courses in evaluation of health programs. Texts commonly used are referenced below. A great deal of the methodology and examples provided in these texts—such as Shi 2008, Grembowski 2001, and Rossi, et al. 2004— address evaluation of programs concerning access to health care.

  • Grembowski, David. 2001. The practice of health program evaluation. Thousand Oaks, CA: SAGE.

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    Interesting take on evaluation as a metaphoric “three-act play” with a variety of actors and interest groups, each having a role that involves entering and exiting the “stage” at different points in the evaluation process. Describes methods to evaluate health programs. Emphasizes the “politics of evaluation” to prepare the evaluator to work with funders, decision makers, managers, and other interest groups in the “three-act play.”

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  • Rossi, Peter H., Howard E. Freeman, and Mark W. Lipsey. 2004. Evaluation: A systematic approach. Thousand Oaks, CA: SAGE.

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    The most widely used evaluation text concerning the design, implementation, and appraisal of social programs, with extensive illustrations for health care. Emphasizes examples to help students understand how evaluators deal with the challenges of evaluation requiring “art” as well as science.

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  • Shi, Leiyu. 2008. Health services research methods. 2d ed. Clifton Park, NY: Delmar.

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    Systematically describes the design, methodology, and analysis commonly used in health services research. Directed toward doctoral- and masters-level students in health services administration programs. Health-services practitioners and researchers also use the book as a reference.

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Anthologies

Because studies of access to health care are done from several disciplinary perspectives, are often collaborative, and represent a major part of the broader field of health services research, many of the relevant overviews, referenced works, and texts are collections of articles or passages with different authors (e.g., Gold and Stevens 1998). Additional anthologies focus on access, including Robert Wood Johnson Foundation 1997–2010.

  • Gold, Marsha, and B. Stevens. 1998. Measuring access through population-based surveys in a managed care environment: A special supplement to HSR. Health Services Research (August): 611–766.

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    Focuses on the challenge of measuring access to care in a health system reconfigured by the growth of managed care. Examines in particular the implications of using population-based surveys to measure access. The supplement is based on a Robert Wood Johnson Foundation invitational symposium that brought together thirty to forty of the leading public- and private- sector researchers and policy analysts.

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  • Robert Wood Johnson Foundation. 1997–2010. To improve health and health care: The Robert Wood Johnson Foundation anthology. 13 vols. San Francisco: Jossey-Bass.

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    The Robert Wood Johnson Foundation came into being in 1972 as the nation’s largest philanthropy devoted to health. It elected to place major emphasis on improved access to health care. Since 1997, the Robert Wood Johnson Foundation has published the Anthology annually to provide an in-depth look into the programs it funds, many of which directly address improving access to care.

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Bibliographies

The literature on access to health care has grown extensively in recent years as documented elsewhere in this entry. Here we refer to the early access literature (Aday and Andersen 1975) that was published later in the 20th century (Haley and Deevy 1997). The UC Atlas of Global Inequality is an online source for students referencing current access data sources with a global perspective.

  • Aday, Lu An, and Ronald Andersen. 1975. Development of indices of access to medical care. Ann Arbor, MI: Health Administration.

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    Reviews the literature, provides selected annotation, and describes the data sources on the concept of access to health care up to 1974.

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  • Haley, Barbara A., and Brian Deevey. 1997. American health care in transition: A guide to the literature. Bibliographies and Indexes in Medical Studies 14. Westport, CT: Greenwood.

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    Provides easy-to-find reliable information about access to and costs of health care and performance of different health-care systems. Provides a guide with annotated bibliographies to academic and practice journal literature and to the health reports from the US Accounting Office and the Agency for Health Care Research and Quality.

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  • UC Atlas of Global Inequality

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    The mission of the UC Atlas of Inequality is to provide online teaching resources and tools to enable student exploration of global change including issues of health and access to health care. Provides a bibliography of sources.

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Journals

Core journals on health services research would be of most interest to researchers and students surveying the field of access to heath care. These journals include those listed below.

Definitions

The current perspective of access in Andersen and Davidson 2007 emphasizes the multidimensionality of access and the importance of contextual as well as individual indicators. Earlier perspectives also pointed to multiple dimensions validated by patient satisfaction (Penchansky and Thomas 1981), and the finding that access implies good outcomes as well as the use of health services (Milman 1993).

  • Andersen, Ronald, and Pamela Davidson. 2007. Improving access to care in America: Individual and contextual indicators. In Changing the U.S. health care system: Key issues in health care policy and management. 3d ed. Edited by Ronald Andersen, Thomas Rice, and Gerald Kominski, 3–31. San Francisco: Jossey-Bass.

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    Defines access as the “actual use of personal health services and everything that facilitates or impedes their use. It is the link between health services systems and the populations they serve. Access means not only visiting a medical care provider but also getting to the right services at the right time to promote improved health outcomes” (p. 3). Presents a conceptual frame work for understanding the multiple dimensions of access to health care.

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  • Milman, Michael, ed. 1993. Access to health care in America. Washington, DC: National Academy Press.

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    The mandate of the Institute of Medicine to a seventeen-member committee of experts chosen for the Access Monitoring Project was to develop a set of indicators for monitoring access to personal health-care services. They conceived access as a shorthand term for a broad set of concerns about the degree to which individuals and groups are able to obtain needed services from the medical-care system.

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  • Penchansky, Roy, and J. William Thomas. 1981. The concept of access: Definition and relationship to consumer satisfaction. Medical Care 19.2: 127–140.

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    Suggests access to health care previously had not been defined or employed precisely. Some previous authors stated that “access” referred to use of the health-care system, while to others it characterized factors influencing use. This article proposes a definition of “access” as a general concept summarizing a set of more specific dimensions, including the patient’s view of the availability, accessibility, accommodation, affordability, and acceptability of health care.

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Models of Access

Models of health-care access provide guidance for defining variables, specifying the relationships among them, and evaluating programs and policies concerned with access to and utilization of health care. Models may be used to guide the conduct of descriptive, analytic, or evaluative studies of the operation and performance of the health services delivery system. Models of health-care access have been constructed from a variety of theoretical or disciplinary perspectives that will be referenced in the subsections to follow. These include models from sociology, social psychology, economics, geography, quality of care, complementary and alternative medicine, and comprehensive models.

Sociology Models

Models from sociology often emphasize, as determinants of access to health care, characteristics of the environment, community, and family in which the individual lives, as well demographic, social-class, and social-support variables (Suchman 1966, Pescosolido 2000). Measures of access in these models often stress measures and actions related to an entire episode of illness rather than a single experience such as seeing a doctor or visiting a hospital.

  • Pescosolido, Bernice A. 2000. Rethinking models of health and illness behavior. In Complementary and alternative medicine: Challenge and change. Edited by Merrijoy Kelner, Beverly Wellman, Bernice Pescosolido and Mike Saks, 175–193. Amsterdam: Harwood.

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    Proposes a Network Episode Model. Focuses on the entire set of responses a person has to the onset of illness. Emphasizes “community,” including both lay and professional influences.

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  • Suchman, Edward. A. 1966. Health orientation and medical care. American Journal of Public Health, Nations’ Health 56.1: 97–105.

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    Suchman’s framework for stages of decision making about seeking medical care is focused on episodes of illness and how demographic social class and group membership variables might influence decision making. The process of seeking medical care for illness is divided into five stages: experience of the symptom, assumption of the sick role, medical-care contact, dependent patient role, and recovery or rehabilitation.

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Social-Psychology Models

Social-psychological models stress the attitudes, values, and knowledge of the patient regarding illness and health care (Mechanic 1968, Kosa and Robertson 1969, Rosenstock 1966, Theory of Planned Behavior/Reasoned Action). They often consider nature of communication between patient and therapist and patient perceptions of need for care and address access to preventive health services as well as treatment for illness.

  • Kosa, John, and L. S. Robertson. 1969. The social aspects of health and illness. In Poverty and health: A sociological analysis. Edited by John Kosa, Aaron Antonovsky, and Irving Zola, 35–68. Cambridge, MA: Harvard Univ. Press.

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    Postulates that behavior is motivated by the individual’s need to reduce the anxiety aroused by threat of illness. Assumes stages of individual decision making in response to illness: (1) assessment of a disturbance in usual functioning, (2) anxiety arousal based on perception of the symptoms, (3) application of one’s medical knowledge to address the problem, and (4) performance of activities to alleviate anxiety.

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  • Mechanic, David. Medical sociology: A selective view. 1968. New York: Free Press.

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    Catalogues an array of social and psychological factors that might influence the likely impact of symptoms on individuals seeking care. These include (1) perception of symptoms (e.g., salience, seriousness, disruptiveness, frequency), (2) characteristics of individuals (e.g., tolerance of discomfort, knowledge of illness, competing needs), and (3) disruption in the treatment process (e.g., inconvenient location or hours of service, out-of-pocket costs) interfering with accessibility of care.

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  • Rosenstock, I. M. 1966. Why people use health services. Milbank Memorial Fund Quarterly 44.3: 94–127.

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    The much-used health belief model was originally conceived to understand preventive health care (health behavior) but has subsequently been applied to response to illness (illness behavior) and activities required for recovery from illness (sick role behaviors). The major components of the model are (1) an individual’s subjective state of readiness to take action, (2) assessment of costs of and benefits from engaging in a given health-care-seeking behavior, and (3) presence of cues to action to trigger the appropriate action.

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  • Univ. of Twente. Theory of Planned Behavior/Reasoned Action

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    The theory of reasoned action and the theory of planned behavior are part of a range of theories presented at this website related to the study of communication. Students are encouraged to use these theories to understand the theoretical fieldwork of health communication. Ajzen and Fishbein formulated the theory of reasoned action in 1980. It has been used extensively to estimate the discrepancy between attitudes and voluntary health behavior. Since not all health behavior is involuntary, “perceived behavioral control” was added, and the new model was called the theory of planned behavior.

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Economics Models

Economic models of consumer choice stress the means (e.g., health insurance or income) through which people can attain services or translate their perceived need into economic demand for medical care and, subsequently, health (Grossman 1972). More recently, the effectiveness of the demand model has been challenged (Rice and Unruh 2009).

  • Grossman, Michael. 1972. On the concept of health capital and the demand for health. Journal of Political Economy 80.2: 223–255.

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    Argues that what consumers really demand when they purchase medical care is health. Hypotheses generated by this model include (1) as people age, their stock of health declines and they will increase their consumption of medical care to offset the decline; and (2) as people’s income increases, their consumption of medical care will increase because they will place increased value on healthy days.

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  • Rice, Thomas S., and Lynn Unruh. 2009. The economics of health reconsidered. 3d ed. Chicago: Health Administration.

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    Challenges the field of health economics as it is largely taught and practiced. Questions the proposition that a competitive health-care marketplace results in the most effective, efficient health-resources allocation and produces the best health outcomes. Written in understandable fashion for students in health economics, non-economists, and health policy makers.

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Geography Models

The geography of health care comprises the analysis of spatial organization (number sizes, types, and locations) of health services, how and why spatial organization changes over time, how people gain access to health services, and the impacts on health and well-being. Mc Lafferty 2003 discusses a specific spatial technique, while Andrews and Moon 2005 reviews some key geographic concepts.

  • Andrews, Gavin J., and Grant Moon. 2005. Space, place, and the evidence base: Part 1— An introduction to health geography. Worldviews on Evidence-Based Nursing 2.2: 55–62.

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    Outlines key geographic concepts and approaches and introduces a range of geographical perspectives from quantitative research on the distributive features of disease and health to qualitative research focused on the dynamic relationship between health and place.

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  • McLafferty, Sara L. 2003. GIS and health care. Annual Reviews of Public Health 24:25–42.

    DOI: 10.1146/annurev.publhealth.24.012902.141012Save Citation »Export Citation » Share Citation »

    Geographic information systems (GIS) and related spatial analytic techniques provide a set of tools for describing and understanding the changing spatial organization of health care, for examining its relationship to health outcomes and access, and for exploring how health-care delivery can be improved. This review emphasizes recent literature on GIS and health care.

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Quality-of-Care Models

The import of access to health care on the health of the population cannot be understood without reference to the quality of health care. The classic work on quality assessment is Donabedian 1980.

  • Donabedian, Avedis. 1980. The definition of quality and approaches to its assessment. Explorations in Quality Assessment and Monitoring 1. Ann Arbor, MI: Health Administration.

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    Provides a definition of quality based on the structure, process, and outcomes of health care. The model can be used to evaluate access to health care by linking structure (characteristics of health-care providers and organizations), process (the amount and appropriateness of care provided), and outcomes of care (death, disease, disability, discomfort, dissatisfaction).

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Complementary- and Alternative-Medicine Models

Most models have focused on access to conventional medical services. An alternative model includes access to complementary and alternative medicine as well (Barrett, et al. 2003).

  • Barrett, Bruce, Lucille Marchand, Jo Scheder, Mary Beth Plane, Rob Maberry, Diane Appelbaum, David Rakel, and David Rabago. 2003. Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine. Journal of Alternative and Complementary Medicine 9.6: 937–947.

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    The evolving process of integration between complementary and alternative medicine (CAM) and conventional medicine leads to new conceptual frameworks. Interviews with users and practitioners of CAM therapies have revealed four primary themes: holism, empowerment, access, and legitimacy (HEAL). While CAM is perhaps more psychologically accessible to many patients in that it better reflects commonly held values, it is often less financially and institutionally accessible.

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Comprehensive Models

An early effort to combine variables from some fourteen sociology and psychology models was made by Cummings, et al. 1980. Later efforts have attempted to be somewhat more comprehensive, incorporating multiple disciplinary perspectives and types of medical services in the precede-proceed model (Green and Kreutner 2005) and behavioral model of access to health care (Andersen 1995).

  • Ronald Andersen. 1995. Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior 36:1–10.

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    The behavioral model is the most frequently employed comprehensive model of health-care use. It considers predisposing, enabling, and need factors at both the contextual and individual levels that influence access to health care and outcomes of care.

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  • Cummings, K. Michael, Marshall H. Becker, and Maria C. Maile. 1980. Bringing the models together: An empirical approach to combining variables used to explain health actions. Journal of Behavioral Medicine 3:123–145.

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    Many investigators had long felt that the actual number of truly distinct concepts relevant to explaining health-related actions was considerably lower than the large number of variables then employed. This paper explores selected approaches and models advanced to explain health actions, in terms of structural similarities and differences identified by a panel of expert judges.

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  • Green, Lawrence, and Marshall Kreutner. 2005. Health promotion planning. 4th ed. New York: McGraw Hill.

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    Precede-proceed is the most frequently employed comprehensive planning model for health education and health promotion programs. It can be employed to improve access to care by examining predisposing, enabling, and reinforcing factors that shape behavioral actions, such as getting annual mammograms, and environmental conditions, such as availability of prevention services.

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Dimensions of Access

The use of the term “access to health care” was not common until the 1960s. However, some dimensions of access were conceptualized, measured, and used to formulate and evaluate health-care policy in the United States in the early decades of the 20th century including potential, realized, and equitable access (Andersen and Anderson 1999). Other dimensions of access have been conceptualized and measured more recently, including effective access and efficient access (Andersen and Davidson 2007, National Center for Health Statistics (NCHS) 2010, Healthy People). Subsections below will identify sources specific to each dimension of access.

  • Andersen, Ronald, and Odin W. Anderson. 1999. National medical expenditure surveys: genesis and rationale. In Informing American health care policies: The dynamics of medical expenditure and insurance surveys, 1977–1996. Edited by Alan Monheit, Renate Wilson, and Ross Arnett III, 11–30. San Francisco: Jossey-Bass.

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    Documents the legacy of national health surveys to the collection and analysis of measures of potential, realized, and equitable access beginning with the Committee on the Cost of Medical Care Survey conducted from 1928 to 1931.

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  • Andersen, Ronald, and Pamela Davidson. 2007. Improving access to care in America: Individual and contextual indicators. In Changing the U.S. health care system: Key issues in health services policy and management. 3d ed. Edited by Ronald Andersen, Thomas Rice, and Gerald Kominsky, 3–31. San Francisco: Jossey-Bass.

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    Describes and references the multiple dimensions of access: potential, realized, equitable, effective, and efficient.

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  • National Center for Health Statistics (NCHS). 2010. Health, United States, 2009 with special feature on medical technology. Hyattsville, MD: National Center for Health Statistics.

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    An invaluable source for researchers and students presents national trends related to all dimensions of access, including such topics as birth and death rates, infant mortality, life expectancy, morbidity and health status, risk factors, use of ambulatory and inpatient care, health personnel and facilities, financing of health care, health insurance, and managed care.

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  • National Center for Health Statistics (NCHS). Healthy People

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    Healthy People is a project to set measurable health goals for the nation related to all the dimensions of access. Since 1979 the National Center for Health Statistics has set and monitored success in achieving science-based, ten-year national objectives for promoting health and preventing disease. DATA2010 is an interactive database system containing the most recent monitoring data for tracking Healthy People.

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Potential-Access Dimension

Potential access is measured by the supply of health-care personnel and facilities and the availability of means for the individual (such as having health insurance) to use health-care services.

Realized-Access Dimension

Realized access is the actual use of health-care services.

Equitable-Access Dimension

Equitable access is determined by people’s degree of access to the health care they need. Aday, et al. 2004 provides a detailed discussion of equity of access and its level of achievement in the United States.

  • Aday, Lu Ann, Charles F. Begley, David R. Lairson, and Rajesh Balkrishnan. 2004. Evaluating the healthcare system: Effectiveness, efficiency, and equity. 3d ed. Chicago: Health Administration.

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    The audiences for this book have been practicing professionals and graduate students in public health, health administration, and the health professions, as well as policy makers and program planners. Chapter 6, “Equity: Concepts and Methods,” and chapter 7, “Equity: Policy Strategies, Evidence, and Criteria,” introduce a sound conceptual framework of equity grounded in theories of deliberative, distributive, and social justice and apply it to assessing the progress of the US health-care system in achieving equity along each of these dimensions.

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Effective-Access Dimension

Effective access is the extent to which health care received improves patient health and satisfaction with health care. Aday, et al. 2004 documents effectiveness in the United States while Eddy 2005 discusses “evidence based medicine” as a means to increase effectiveness. The Agency for Healthcare Research and Quality Effective Health Care Program describes an ongoing research program to improve effectiveness, and National Center for Health Statistics (NCHS) 2010 provides national trend data on effectiveness measures.

  • Aday, Lu Ann, Charles F. Begley, David R Lairson, and Rajesh Balkrishnan. 2004. Evaluating the healthcare system: Effectiveness, efficiency, and equity. 3d ed. Chicago: Health Administration.

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    Chapter 2, “Effectiveness: Concepts and Methods,” and chapter 3, “Effectiveness: Policy Strategies, Evidence, and Criteria,” explain what effectiveness is and how it can be assessed in clinical and nonclinical interventions. Also addressed are the extent to which effectiveness has been achieved in the US system and the policies that contribute to enhancing effectiveness.

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  • Agency for Healthcare Research and Quality (AHRQ). Effective Health Care Program

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    Funds individual researchers, research centers, and academic organizations to work together with the Agency for Healthcare Research and Quality to produce effectiveness and comparative-effectiveness research for clinicians, consumers, and policymakers. The website provides reviews and syntheses of published and unpublished scientific evidence, and new scientific evidence and analytic tools.

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  • Eddy, David. 2005. Evidence based medicine: A unified approach. Health Affairs 24.1: 9–17.

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    The practice of “evidence-based medicine” may be one approach to improve medicine’s effectiveness. Eddy discusses two different approaches to applying evidence to medicine and recommends a unified approach to improve effectiveness.

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  • National Center for Health Statistics (NCHS). 2010. Health, United States, 2009 with special feature on medical technology. Hyattsville, MD: National Center for Health Statistics.

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    Trend tables on “Mortality and Determinants and Measures of Health” (tables 17–74, pp. 176–307) provide national trend data for variable years 1900–2007 for measures of mortality and health related to the effectiveness of health care. Tables are updated yearly.

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Efficient-Access Dimension

Efficient access means minimizing the cost of health care to improve patient outcomes. Aday, et al. 2004 discusses the concepts of efficiency and performance in the United States. Warner and Hutton 1980 describes cost-benefit and cost-effectiveness analyses as two common ways to measure efficiency. National Center for Health Statistics (NCHS) 2010 provides national trend data on efficiency-related measures.

  • Aday, Lu Ann, Charles F. Begley, David R. Lairson, and Rajesh Balkrishnan. 2004., Evaluating the healthcare system: Effectiveness, efficiency, and equity. 3d ed. Chicago: Health Administration.

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    Chapter 4, “Efficiency: Concepts and Methods,” and chapter 5, “Efficiency: Policy Strategies, Evidence, and Criteria,” examine the concepts of production and allocative efficiency and the major findings regarding the performance of the United States and other countries in terms of these efficiency measures.

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  • National Center for Health Statistics (NCHS). 2010. Health, United States, 2009 with special feature on medical technology. Hyattsville, MD: National Center for Health Statistics.

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    Trend tables on “national health expenditures” and “state health expenditure” (tables 132–136 and 148–149) provide national trend data for variable years 1960–2007 for health-care-expenditures measures associated with efficient access. Tables are updated yearly.

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  • Warner, Kenneth E, and Rebecca C. Hutton. 1980. Cost-benefit and cost-effectiveness analysis in health care: Growth and composition of the literature. Medical Care 18.11: 1069–1084.

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    Cost-benefit and cost-effectiveness analyses are two commonly used approaches to measure efficiency in health care. This article describes the two approaches and the early related literature in the field.

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Health and Health Care Disparities

Significant differences existed in the past and continue to exist today in the United States (and other nations as well) in health-care and health care access according to income and ethnicity. Understanding, measuring, and reducing these differences or “disparities” is major federal, state, and local health policy. Reducing health-care-access disparities is one means for reducing health disparities (although other factors including personal health practices, environment, and genetics are major determinants of health disparities). This section examines some key references to understanding, measuring, and reducing health (Yancey, et al. 2007, Barr 2008, Laviest 2005, Aday 2001) and health-care disparities (Smedley, et al. 2003, Morales and Ortega 2007, Williams 2007, AHRQ 2010).

  • Aday, Lu Ann. 2001. At risk in America: The health and health care needs of vulnerable populations in the United States. 2d ed. Hoboken, NJ: Wiley.

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    The best source for a detailed analysis of those key population groups most vulnerable to health disparities in the United States today, including homeless persons, refugees and immigrants, people living with AIDS, alcohol and substance abusers, high-risk mothers and infants, victims of family or other violence, and the chronically or mentally ill. Examines the specific health needs and risks faced by these groups and the research and policy initiatives that might be undertaken to help reduce their vulnerability.

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  • Barr, Donald A. 2008. Health disparities in the United States: Social class, race, ethnicity, and health. Baltimore: Johns Hopkins Univ. Press.

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    Explores how socioeconomic status, race, and ethnicity are associated with health disparities; what this means for the medical community and society at large; and some possible strategies to reduce these disparities. Considers how and when race and ethnicity should be taken into account in treating illness. An important teaching tool for students in the health professions and health services and a comprehensive reference for social-science and medical professionals.

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  • LaVeist, Thomas. 2005. Minority populations and health: An introduction to health disparities in the United States. Hoboken, NJ: Wiley.

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    A very readable textbook covering major issues and approaches to reduce race disparities in health-related outcomes. Covers the role of race and ethnicity in mortality and access to health care.

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  • Morales, Leo S., and Alexander N. Ortega. 2007. Disparities in health care. In Changing the U.S. health care system. 3d ed. Edited by Ronald Andersen, Thomas Rice, and Gerald Kominski, 57–80. San Francisco: Jossey-Bass.

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    Begins by defining disparities in care. Reviews some of the historical factors that have contributed to the patterns of disparity. Documents some of the evidence of racial and ethnic disparities in the treatment of some diseases and summarizes a number of ongoing initiatives to reduce disparities in care.

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  • Smedley, Brian D., Adrienne Y. Stith, Alan Ray Nelson, and Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. 2003. Unequal treatment: Confronting racial and ethnic disparities in health care. Vol. 1. Landover, MD: National Academies Press.

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    Report from the Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care and the Board on Health Sciences Policy. Examines how disparities in treatment may arise in health-care systems and looks at aspects of the clinical encounter contributing to such disparities. Highlights cross-cultural education to improve communication.

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  • Agency for Healthcare Research and Quality (AHRQ). National healthcare disparities report 2009 AHRQ Publication No. 10-0004.

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    This report measures trends in access to care, effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. Summarizes disparities among racial, ethnic, and income groups. A fundamental data source for both students and researchers.

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  • Williams, Richard A., ed. 2007. Eliminating healthcare disparities in America: Beyond the IOM Report. Totowa, NJ: Humana.

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    A collection of articles with important perspectives on health-care disparities. Valuable reading for students, researchers, and health professionals. Divided into five sections: (1) a primer on the underlying causes of health-care disparities, (2) a discussion of current problems, (3) chapters discussing different approaches to health-care disparities, (4) chapters highlighting programs that work, and (5) a chapter offering guiding principles for eliminating health-care disparities. Also available as an e-book.

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  • Yancey, Antronette K., Roshan Bastani, and Beth A. Glenn. 2007. Ethnic disparities in health status. In Changing the U.S. health care system. 3d ed. Edited by Ronald Andersen, Thomas Rice, and Gerald Kominski, 33–56. San Francisco: Jossey-Bass.

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    Despite improvement in the health of all Americans, ethnic minorities continue to experience poorer health status. This chapter describes current health status disparities, reviews the potential determinants of observed disparities, and outlines future direction for policy and practice.

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Health Care Reform

The Patient Protection and Affordable Care Act, passed into law in March 2010, is the most important federal legislation to affect access to health care in the United States since the implementation of Medicare and Medicaid in 1965. It is intended to substantially affect all the dimensions of access: potential (improve health insurance coverage), realized (increase use of preventive services), equitable (expand Medicaid, community health centers, and Indian health programs), effective (support comparative-effectiveness research), and efficient (reduce the national debt). A number of organizations, including governmental (e.g., Democratic Policy Committee, Congressional Budget Office), nongovernmental research (e.g., RAND), and foundations (e.g., Kaiser Family Foundation, Commonwealth Fund), are following the implementation and effects of the act. Their work is referenced on their websites as well as in Davidson 2010 concerning where we need to go from here.

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