Access and Delivery

A second major characteristic of a healthcare system is access, which has multiple definitions, including the following:

1. The ability to obtain needed care

2. The potential and actual entry of a given population into the health system

3. The timely use of personal health services to achieve the best possible outcome

4. The timely use of needed, affordable, convenient, acceptable, and effective personal health services

Different countries approach the issue of access in various ways and define the term differently. Health systems with strong central control, such as those in Great Britain, the Scandinavian countries, and the countries of the former Soviet Union, emphasize equal access to care for all their citizens. Those countries have a single-payment system, with most healthcare providers working as salaried government employees and a single government-defined set of benefits. There tends to be strong emphasis on primary care by general practitioners and relatively tight control of the number and distribution of providers and facilities that provide highly technical services. In some countries this degree of government control results in substantial waiting times for some services and limited access to advanced technologies. Thus, whereas this approach produces an apparently high level of equal opportunity to obtain needed health services, it may deny some individuals access to lifesaving technologies and restrict both provider and patient choices. This depends on the level of spending a country is willing to commit to healthcare.

Countries with less centralized systems vary more in regard to the level of access. In some countries access to healthcare for the poor is restricted by the ability to pay. Moreover, providers' freedom to choose their patients can restrict access to medical services among insured low-income individuals. For example, many providers in the United States refuse to serve Medicaid recipients because of the low payment rates. In countries with less centralized health systems working individuals employed in low-paying jobs often face financial barriers (high out-of-pocket expenses for copayments, deductibles, or premiums) to receive needed care (Lee and Tollen). Similarly, the limited control of healthcare workers and facility location tends to result in geographic maldistribution of providers and healthcare facilities.

The degree of access varies widely in the United States. Financial barriers to access are substantial for more than 41 million Americans without health insurance coverage and about the fifth of insured individuals who have inadequate insurance (Mills; Hadley and Holahan; Kaiser Commission on Medicaid and the Uninsured). Studies have shown that those who are poor and have no health insurance have a markedly lower use of almost all forms of healthcare despite their tendency to have a lower baseline health status. This lack is especially great in terms of primary care and preventive services (Bayer and Fiscella). Although the uninsured have some access to high-technology care, especially in urban areas, through use of the emergency rooms and outpatient clinics of public hospitals, research has shown that they have poorer outcomes of hospitalization (controlling for severity) and a markedly lower use of high technology compared with those who have insurance. There is also growing evidence that limited access to primary care results in not only poorer health outcomes but also higher overall costs through delayed treatment, reduced patient adherence to therapeutic regimens, and increased emergency room and hospital admissions.

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