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Access to Health Services

The Healthy People 2020 Social Determinants of Health topic area is organized into 5 place-based domains:

  1. Economic Stability
  2. Education
  3. Health and Health Care
  4. Neighborhood and Built Environment
  5. Social and Community Context

Access to Health Services is a key issue in the Health and Health Care domain.

The National Academies of Sciences, Engineering, and Medicine (formerly known as the Institute of Medicine) define access to health care as the “timely use of personal health services to achieve the best possible health outcomes.”1 Many people face barriers that prevent or limit access to needed health care services, which may increase the risk of poor health outcomes and health disparities.2 This summary will discuss barriers to health care such as lack of health insurance, poor access to transportation, and limited health care resources, with a special focus on how these barriers impact vulnerable populations.

Inadequate health insurance coverage is one of the largest barriers to health care access,3 and the unequal distribution of coverage contributes to disparities in health.2, 3 Out-of-pocket medical care costs may lead individuals to delay or forgo needed care (such as doctor visits, dental care, and medications),4 and medical debt is common among both insured and uninsured individuals.4, 5 Vulnerable populations are particularly at risk for insufficient health insurance coverage; people with lower incomes are often uninsured,6, 7, 8, 9 and minorities account for over half of the uninsured population.10

Lack of health insurance coverage may negatively affect health.10, 11 Uninsured adults are less likely to receive preventive services for chronic conditions such as diabetes, cancer, and cardiovascular disease.11, 12 Similarly, children without health insurance coverage are less likely to receive appropriate treatment for conditions like asthma or critical preventive services such as dental care, immunizations, and well-child visits that track developmental milestones.11

In contrast, studies show that having health insurance is associated with improved access to health services and better health monitoring.13, 14, 15 One study demonstrated that when previously uninsured adults ages 60 to 64 became eligible for Medicare at age 65, their use of basic clinical services increased.14 Similarly, providing Medicaid coverage to previously uninsured adults significantly increased their chances of receiving a diabetes diagnosis and using diabetic medications.13 Insurance coverage is also critical for enabling children with special health needs or chronic illnesses to access health services.11, 16

However, health insurance alone cannot remove every barrier to care.3 Inconvenient or unreliable transportation can interfere with consistent access to health care, potentially contributing to negative health outcomes.17 Studies have shown that lack of transportation can lead to patients, especially those from vulnerable populations, delaying or skipping medication, rescheduling or missing appointments, and postponing care.17 Transportation barriers and residential segregation are also associated with late-stage presentation of certain medical conditions (e.g., breast cancer).18, 19, 20

Limited availability of health care resources is another barrier that may reduce access to health services3 and increase the risk of poor health outcomes.21, 22 For example, physician shortages may mean that patients experience longer wait times and delayed care.23 Many health care resources are more prevalent in communities where residents are well-insured,11 but the type of insurance individuals have may matter as well. Medicaid patients, for instance, experience access issues when living in areas where few physicians accept Medicaid due to its reduced reimbursement rate.15, 23, 24

Expanding access to health services is an important step toward reducing health disparities. Affordable health insurance is part of the solution, but factors like economic, social, cultural, and geographic barriers to health care must also be considered,3, 22 as well as new strategies to increase the efficiency of health care delivery.23, 25, 26 Further research is needed to better understand barriers to health care, and this additional evidence will facilitate public health efforts to address access to health services as a social determinant of health.

For additional information, please see the Access to Primary Care literature summary.

Disclaimer: This summary of the literature on access to health services as a social determinant of health is a narrowly defined examination that is not intended to be exhaustive and may not address all dimensions of the issue.1, 2 Please keep in mind that the summary is likely to evolve as new evidence emerges or as additional research is conducted.

Endnotes

i Terminology used in the summary is consistent with the respective references. As a result, there may be variability in the use of terms, for example, black versus African American.

ii The term minority, when used in a summary, refers to racial/ethnic minority, unless otherwise specified.

References

1 Milliman M, editor. Access to health care in America. Institute of Medicine (US) Committee on Monitoring Access to Personal Health Care. Washington (DC): National Academies Press (US); 1993.

2 Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington (DC): National Academies Press (US); 2002.

3 Call K, McAlpine D, Garcia C, Shippee N, Beeba T, Adeniyi T, et al. Barriers to care in an ethnically diverse publicly insured population: is health care reform enough? Med Care. 2014;52:720–27.

4 Pryor C, Gurewich D. Getting care but paying the price: how medical debt leaves many in Massachusetts facing tough choices. Boston (MA): Access Project; 2004.

5 Herman PM, Rissi JJ, Walsh ME. Health insurance status, medical debt, and their impact on access to care in Arizona. Am J Public Health. 2011;101(8):1437–43.

6 Hadley J. Sicker and poorer—the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income. Med Care Res Rev. 2003;60(2 Suppl):3S–75S.

7 Franks P, Clancy C, Gold M. Health insurance and mortality: evidence from a national cohort. JAMA. 1993;270(6):737–41.

8 Zhu J, Brawarsky P, Lipsitz S, Huskamp H, Haas JS. Massachusetts health reform and disparities in coverage, access and health status. J Gen Intern Med. 2010;25(12):1356–62.

9 DeNavas-Walt C, Proctor BD, Smith J. Income, poverty, and health insurance coverage in the United States: 2009. Washington (DC): U.S. Census Bureau; 2010. Available from: www.census.gov/prod/2010pubs/p60-238.pdf

10 Majerol M, Newkirk V, Garfield R. The uninsured: a primer: key facts about health insurance and the uninsured in America. Menlo Park, CA: Kaiser Family Foundation; 2015.

11 Institute of Medicine (US) Committee on Health Insurance. America’s uninsured crisis: consequences for health and health care. Washington (DC): National Academies Press (US); 2009.

12 Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA, Zaslavsky AM. Unmet health needs of uninsured adults in the United States. JAMA. 2000;284(16):2061–69.

13 Baicker K, Taubman S, Allen H, Bernstein M, Gruber J, Newhouse J, et al. The Oregon experiment—effects of Medicaid on clinical outcomes. N Engl J Med. 2013;368(18):1713–22.

14 McWilliams JM, Zalavsky AM, Meara E, Ayanian J. Impact of Medicare coverage on basic clinical services for previously uninsured adults. JAMA. 2003;290(6):757–64.

15 Buchmueller T, Grumbach K, Kronick R, Kahn J. The effect of health insurance on medical care utilization and implications for insurance expansion: a review of the literature. Med Care Res Rev. 2005;62(1):3–30. doi:10.1177/1077558704271718

16 Skinner AC, Mayer ML. Effects of insurance status on children’s access to specialty care: a systematic review of the literature. BMC Health Serv Res. 2007;7:194.

17 Syed S, Gerber B, Sharp L. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38(5):976–93.

18 Dai D. Black residential segregation, disparities in spatial access to health care facilities, and late-stage breast cancer diagnosis in metropolitan Detroit. Health Place. 2010;16(5):1038–52.

19 Tarlov E, Zenk SN, Campbell RT, Warnecke RB, Block R. Characteristics of mammography facility locations and stage of breast cancer at diagnosis in Chicago. J Urban Health. 2008;86 (2):196–213.

20 Wang F, McLafferty S, Escamilla V, Luo L. Late-stage breast cancer diagnosis and health care access in Illinois. Prof Geogr. 2008;60(1):54–69.

21 National Association of Community Health Centers and the Robert Graham Center. Access denied: a look at America’s medically disenfranchised. Washington (DC): National Association of Community Health Centers and the Robert Graham Center; 2007.

22 Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public Health. 2015;129(6):611–20. doi:10.1016/j.puhe.2015.04.001

23 Bodenheimer T, Pham HH. Primary care: current problems and proposed solutions. Health Aff (Millwood). 2010;29(5):799–805. doi: 10.1377/hlthaff.2010.0026

24 Decker SL. In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help. Health Aff (Millwood). 2012;31(8):1673–79

25 Green LV, Savin S, Lu Y. Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication. Health Aff (Millwood). 2013;32(1):11–19.

26 Rieselbach RE, Crouse BJ, Frohna JG. Teaching primary care in community health centers: addressing the workforce crisis for the underserved. Ann Intern Med. 2010;152(2):118–22.