Back to Front PageVOLUME 6, NUMBER 4
 

A 1993 report from the Institute of Medicine defined access to health care as “the timely use of personal health services to achieve the best possible health outcomes.” Since that report was published, it has become abundantly clear that there are some daunting barriers to access, and they fall into three distinct categories.

Personal barriers—including those related to cultural and racial background or educational level—make a significant impact on the timely use of health services. Physical barriers, such as geographical location and the absence of transportation, affect access to both providers and services. But it is financial barriers—the inability of uninsured or unsponsored patients to access health services solely because they lack health insurance and the ability to pay—that account for the largest part of the problem. More than half of the people who say they have not been able to obtain the health care they want or need cite financial reasons.

Over each of the past 10 years, approximately 1 million people have been added to the ranks of the uninsured. In 1998, fully 16 percent of Americans (46 million of the non-elderly population) were uninsured, and this number is projected to continue increasing, at the alarming rate of 1 to 1 1/2 million, every year. This increase seems paradoxical, in view of the robust U.S. economy and the current high level of employment. In fact, 80 percent of the uninsured are either employed themselves, or live in a household where a family member is employed. However, these people typically work for employers that cannot or do not provide health insurance. The unemployed poor have access to social insurance programs such as Medicaid, but once they find jobs, they often become ineligible. They are left in the terrible predicament of being unable to pay for health care, but not having employer-sponsored health benefits. This is the dark side of welfare-to-work programs.

In the past, some asserted that the lack of health insurance and the inability to pay for health care did not prevent individuals from ultimately receiving the services they needed, but there is now abundant evidence to the contrary. The uninsured gain access to health services, especially preventative services, at a quarter of the rate of those who have insurance. Further, by the time the uninsured are hospitalized, they are sicker than their insured counterparts, and their inpatient mortality rate is twice as high. Clearly, the absence of health insurance is a risk factor for poor health.

Even more disturbing is the fact that the plight of the uninsured, and the resulting threat to public health, have virtually disappeared from the nation’s social and political agendas.

I believe that academic health centers and the health professionals who staff them need to become more aggressive champions on behalf of access to health care, for all Americans. While the hospitals associated with academic health centers represent only 4 percent of the nation’s hospitals, they provide 25 percent of the nation’s unsponsored care. The fact that academic health centers are finding it increasingly difficult to subsidize their public missions, including the provision of care to unsponsored patients, only increases their stake in solving the problem.

As members of an accountable profession, all health professionals have a responsibility to address the needs of their individual patients, as well as to make sure that society, as a whole, has access to the health care it needs and deserves.

Some have equated universal access with the provision of universal health coverage. In my mind, the former doesn’t necessitate the latter. We have other options, in the form of public/private partnerships, tax credits, and other creative approaches to financing universal access.

Throughout the last century, academic health centers and health professionals have been instrumental in addressing the health problems that afflict society. The transitional period into the next millennium presents a window of opportunity for mustering the same sort of leadership, intellect, and energy. I believe we must break down the barriers to access—particularly the financial barriers—and place the issue of universal access squarely back on the social and political agendas of this nation.