About This Literature Summary
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. Please note: The terminology used in each summary is consistent with the respective references. For additional information on cross-cutting topics, please see the Access to Primary Care literature summary.
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Literature Summary
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.2This 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 under-resourced communities.
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 People with lower incomes are often uninsured,6,7,8,9 and minority groups 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 years became eligible for Medicare at age 65 years, 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.16 Medicaid coverage is also critical for enabling children with special health needs or chronic illnesses to access health services. The Children’s Health Insurance Program (CHIP) offers sole coverage for 41 percent of children with special health care needs.17 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.15,18,19
Health insurance alone cannot remove every barrier to care.3 Limited availability of health care resources is another barrier that may reduce access to health services and increase the risk of poor health outcomes.20,21 For example, physician shortages may mean that patients experience longer wait times and delayed care.19
Inconvenient or unreliable transportation can interfere with consistent access to health care, potentially contributing to negative health outcomes.22 Research has shown that individuals from racial/ethnic minority groups who had an increased risk for severe illness from COVID-19 were more likely to lack transportation to health care services.23 Transportation barriers and residential segregation are also associated with late-stage presentation of certain medical conditions (e.g., breast cancer).24,25,26
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,3,21 as must new strategies to increase the efficiency of health care delivery.19,27,28 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.
Citations
Institute of Medicine (U.S.) Committee on Monitoring Access to Personal Health Care Services. (1993). Access to health care in America (M. Millman, Ed.). National Academies Press.
Institute of Medicine (U.S.) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care (2003). Unequal treatment: Confronting racial and ethnic disparities in health care (B. D. Smedley, A. Y. Stith, & A. R. Nelson, Eds.). National Academies Press.
Call, K. T., McAlpine, D. D., Garcia, C. M., Shippee, N., Beebe, T., Adeniyi, T. C., & Shippee, T. (2014). Barriers to care in an ethnically diverse publicly insured population: Is health care reform enough? Medical Care, 52(8), 720–727.
Pryor, C., & Gurewich, D. (2004). Getting care but paying the price: how medical debt leaves many in Massachusetts facing tough choices. The Access Project.
Herman, P. M., Rissi, J. J., & Walsh, M. E. (2011). Health insurance status, medical debt, and their impact on access to care in Arizona. American Journal of Public Health, 101(8), 1437–1443.
Hadley, J. (2003). 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. Medical-Car Research and Review, 60(2_suppl), 3S–75S.
Franks, P., Clancy, C. M., & Gold, M. R. (1993). Health insurance and mortality: Evidence from a national cohort. JAMA, 270(6), 737–741.
Zhu, J., Brawarsky, P., Lipsitz, S., Huskamp, H., & Haas, J. S. (2010). Massachusetts health reform and disparities in coverage, access and health status. Journal of General Internal Medicine, 25(12), 1356–1362.
DeNavas-Walt, C. (2010). Income, poverty, and health insurance coverage in the United States (2005). Diane Publishing.
Majerol, M., Newkirk, V., & Garfield, R. (2015). The uninsured: A primer. Kaiser Family Foundation Publication, 7451-10.
Institute of Medicine (U.S.) Committee on Health Insurance Status and Its Consequences. (2009). America’s uninsured crisis: Consequences for health and health care. National Academies Press.
Ayanian, J. Z., Weissman, J. S., Schneider, E. C., Ginsburg, J. A., & Zaslavsky, A. M. (2000). Unmet health needs of uninsured adults in the United States. JAMA, 284(16), 2061–2069.
Baicker, K., Taubman, S. L., Allen, H. L., Bernstein, M., Gruber, J. H., Newhouse, J. P., ... & Finkelstein, A. N. (2013). The Oregon experiment — effects of Medicaid on clinical outcomes. New England Journal of Medicine, 368(18), 1713–1722.
McWilliams, J. M., Zaslavsky, A. M., Meara, E., & Ayanian, J. Z. (2003). Impact of Medicare coverage on basic clinical services for previously uninsured adults. JAMA, 290(6), 757–764.
Buchmueller, T. C., Grumbach, K., Kronick, R., & Kahn, J. G. (2005). Book review: The effect of health insurance on medical care utilization and implications for insurance expansion: A review of the literature. Medical Care Research and Review, 62(1), 3–30.
Myerson, R., & Laiteerapong, N. (2016). The Affordable Care Act and diabetes diagnosis and care: Exploring the potential impacts. Current Diabetes Reports,16(4), 1–8.
Musumeci, M. (2018). Medicaid’s role for children with special health care needs. Journal of Law, Medicine & Ethics, 46(4), 897–905.
Decker, S. L. (2012). In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help. Health Affairs, 31(8), 1673–1679.
Bodenheimer, T., & Pham, H. H. (2010). Primary care: Current problems and proposed solutions. Health Affairs (Project Hope), 29(5), 799–805. doi: 10.1377/hlthaff.2010.0026.
National Association of Community Health Centers and the Robert Graham Center. (2007). Access denied: A look at America’s medically disenfranchised. National Association of Community Health Centers, Incorporated.
Douthit, N., Kiv, S., Dwolatzky, T., & Biswas, S. (2015). Exposing some important barriers to health care access in the rural USA. Public Health, 129(6), 611–620. doi: 10.1016/j.puhe.2015.04.001.
Syed, S. T., Gerber, B. S., & Sharp, L. K. (2013). Traveling towards disease: Transportation barriers to health care access. Journal of Community Health, 38(5), 976–993. doi: 10.1007/s10900-013-9681-1.
Clay, S. L., Woodson, M. J., Mazurek, K., & Antonio, B. (2021). Racial disparities and COVID-19: Exploring the relationship between race/ethnicity, personal factors, health access/affordability, and conditions associated with an increased severity of COVID-19. Race and Social Problems, 1–13. doi: 10.1007/s12552-021-09320-9.
Dai, D. (2010). Black residential segregation, disparities in spatial access to health care facilities, and late-stage breast cancer diagnosis in metropolitan Detroit. Health & Place, 16(5), 1038–1052. doi: 10.1016/j.healthplace.2010.06.012.
Tarlov, E., Zenk, S. N., Campbell, R. T., Warnecke, R. B., & Block, R. (2009). Characteristics of mammography facility locations and stage of breast cancer at diagnosis in Chicago. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 86(2),196–213. doi: 10.1007/s11524-008-9320-9.
Wang, F., McLafferty, S., Escamilla, V., & Luo, L. (2008). Late-stage breast cancer diagnosis and health care access in Illinois. Professional Geographer, 60(1), 54–69. doi: 10.1080/00330120701724087.
Green, L. V., Savin, S., & Lu, Y. (2013). Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication. Health Affairs (Project Hope), 32(1), 11–19. doi: 10.1377/hlthaff.2012.1086.
Rieselbach, R. E., Crouse, B. J., & Frohna, J. G. (2010). Teaching primary care in community health centers: Addressing the workforce crisis for the underserved. Annals of Internal Medicine, 152(2), 118–122. doi: 10.7326/0003-4819-152-2-201001190-00186.
