Access: Measures, Trends and Equity

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AccessMeasures, Trends and Equity

• Professor Ronald Andersen, PhD
• April 26,2006
• Health Services 100

2
A Definition of Access

• We define access as the actual use of personal
  health services and everything that facilitates
  or impedes the use of personal health services.
  It is the link between health services systems
  and the populations they serve. The
  conceptualization and measurement of access is
  key to the understanding and formulating health
  policy because it predicts health services use,
  can be used to promote social justice and can be
  used to promote health outcomes.

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Today we will consider

• A model of access to care
• How the model might be used to define and suggest
  improvements in dimensions of access to care
• Trends in access to care

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A Behavioral Model of Health Services
Use Stressing Contextual as well as Individual
Characteristics
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
5
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
6
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
7
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
8
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
9
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
10
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
11
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
12
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
13
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
14
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
15
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
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Improving Dimensions of Access to Care
Dimension Intended Improvement
To Increase or Decrease Health Services Use
To Monitor and Evaluate Policies to Influence
Health Services Use
Realized Access (Use of Services)
2.
To Insure Health Services Distribution is
Determined by Need
To Insure Health Services Distribution is
Determined by Need
Equitable Access
3.
To Reduce the Influence of Social Characteristics
and Enabling Resources on Health Services
Distribution
To Reduce the Influence of Social Characteristics
and Enabling Resources on Health Services
Distribution
To improve the Outcomes (Health Status,
Satisfaction) from Health Services Use
5.
5.
Effective Access
To Minimize the Costs of Improving Outcomes from
Health Services Use
Efficient Access
6.
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A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
18
Improving Dimensions of Access to Care
Dimension Intended Improvement
To Increase or Decrease Health Services Use
To Monitor and Evaluate Policies to Influence
Health Services Use
To Insure Health Services Distribution is
Determined by Need
To Insure Health Services Distribution is
Determined by Need
Equitable Access
3.
To Reduce the Influence of Social Characteristics
and Enabling Resources on Health Services
Distribution
To Reduce the Influence of Social Characteristics
and Enabling Resources on Health Services
Distribution
To improve the Outcomes (Health Status,
Satisfaction) from Health Services Use
5.
5.
Effective Access
To Minimize the Costs of Improving Outcomes from
Health Services Use
Efficient Access
6.
19
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
20
Improving Dimensions of Access to Care
Dimension Intended Improvement
To Increase or Decrease Health Services Use
To Monitor and Evaluate Policies to Influence
Health Services Use
Realized Access (Use of Services)
2.
To Insure Health Services Distribution is
Determined by Need
To Reduce the Influence of Social Characteristics
and Enabling Resources on Health Services
Distribution
To Reduce the Influence of Social Characteristics
and Enabling Resources on Health Services
Distribution
To improve the Outcomes (Health Status,
Satisfaction) from Health Services Use
5.
5.
Effective Access
To Minimize the Costs of Improving Outcomes from
Health Services Use
Efficient Access
6.
21
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
Personal Health Practices Process of
Medical Care Use of Personal Health Services
22
Improving Dimensions of Access to Care
Dimension Intended Improvement
To Increase or Decrease Health Services Use
To Monitor and Evaluate Policies to Influence
Health Services Use
Realized Access (Use of Services)
2.
To Insure Health Services Distribution is
Determined by Need
To Insure Health Services Distribution is
Determined by Need
Equitable Access
3.
To Reduce the Influence of Social Characteristics
and Enabling Resources on Health Services
Distribution
To improve the Outcomes (Health Status,
Satisfaction) from Health Services Use
5.
5.
Effective Access
To Minimize the Costs of Improving Outcomes from
Health Services Use
Efficient Access
6.
23
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
24
Improving Dimensions of Access to Care
Dimension Intended Improvement
To Increase or Decrease Health Services Use
To Monitor and Evaluate Policies to Influence
Health Services Use
Realized Access (Use of Services)
2.
To Insure Health Services Distribution is
Determined by Need
To Insure Health Services Distribution is
Determined by Need
Equitable Access
3.
To Reduce the Influence of Social Characteristics
and Enabling Resources on Health Services
Distribution
To Reduce the Influence of Social Characteristics
and Enabling Resources on Health Services
Distribution
4.
Inequitable Access
5.
To Minimize the Costs of Improving Outcomes from
Health Services Use
Efficient Access
6.
25
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
26
Improving Dimensions of Access to Care
Dimension Intended Improvement
To Increase or Decrease Health Services Use
To Monitor and Evaluate Policies to Influence
Health Services Use
Realized Access (Use of Services)
2.
To Insure Health Services Distribution is
Determined by Need
To Insure Health Services Distribution is
Determined by Need
Equitable Access
3.
To Reduce the Influence of Social Characteristics
and Enabling Resources on Health Services
Distribution
To Reduce the Influence of Social Characteristics
and Enabling Resources on Health Services
Distribution
4.
Inequitable Access
To improve the Outcomes (Health Status,
Satisfaction) from Health Services Use
5.
5.
Effective Access
6.
27
A Behavioral Model of Health Services Use
Health
Contextual Characteristics Individual
Characteristics Behaviors Outcomes

Personal Health Practices Process of
Medical Care Use of Personal Health Services
Perceived Health Evaluated
Health Consumer Satisfaction
PREDISPOSING ENABLING NEED Demographic
Financing Perceived Social
Organization Evaluated Beliefs
PREDISPOSING ENABLING NEED Demographic Healt
h Policy Environmental Social
Financing Population Health Indices
Beliefs Organization
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TABLE 1.1.  HEALTH INSURANCE COVERAGE FOR
PERSONS UNDER SIXTY-FIVE, BY AGE, RACE AND
ETHNICITY, AND POVERTY LEVEL
Notes aAge adjusted to the year 2000 United
States Standard populations.bPersons of Hispanic
origin may be white, black, or Asian or Pacific
Islander. cIncludes persons of Hispanic and
non-Hispanic origin. dPoverty level is based on
family income and family size, using Bureau of
the Census poverty thresholds. eThe sum of
percentages for private insurance, Medicaid, and
not covered may not sum to 100 percent because
other types of health insurance (Medicare,
military) do not appear in the table and because
persons with both private insurance and Medicaid
are counted in both columns. fIncludes other
public assistance. gIncludes state sponsored
plans and State Childrens Health Insurance
Program (SCHIP). Source National Center for
Health Statistics. Health United States, 2004.
Hyattsville, Md. National Center for Health
Statistics, 2004, pp. 345, 348, 350.
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TABLE 1.2.  PERSONAL HEALTH CARE USE BY INCOME.
Notes aVarious national surveys reported in
Andersen, R., and Anderson, O. Trends in the Use
of Health Services. In H. E. Freeman, S. Levine,
and L. G. Reeder (eds.), Handbook of Medical
Sociology. (3rd ed.).Upper Saddle River, N.J.
Prentice Hall, 1979, pp. 374, 378, 379. bNational
Center for Health Statistics. Health United
States, 2004. Hyattsville, Md. National Center
for Health Statistics, 2004, pp. 289, 247, 265.
cLowest 1527 percent of family income
distribution for 19281931, 19521953, 19631964,
1974. Below poverty for 1997, 2002. dMiddle
5173 percent of family income distribution for
19281931, 19521953, 19631964, 1974. 100
percent to less than 200 percent of poverty
threshold for 1997, 2002. eHighest 1232 percent
of family income distribution for 19281931,
19521953, 19631964, 1974. 200 percent or
greater of the poverty threshold for 1997,
2002. fEstimates only for persons 2 years of age
and older, 1997, 2002.
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TABLE 1.3.  PERSONAL HEALTH CARE USE BY RACE OR
ETHNICITY
Notes aNational Center for Health Statistics.
Health United States, 1993. Hyattsville, Md.
National Center for Health Statistics, 1994, pp.
174, 179, 180. bFor hospital admissions and
percentage seeing a doctor National Center for
Health Statistics. Health United States, 1988.
Hyattsville, Md. National Center for Health
Statistics, 1989, pp. 107, 111. cFor percentage
seeing a dentist National Center for Health
Statistics. Health United States, 1999.
Hyattsville, Md. National Center for Health
Statistics, 1999, p. 242. dNational Center for
Health Statistics. Health United States, 2004.
Hyattsville, Md. National Center for Health
Statistics, 2004, pp. 289, 247, 265. e1964
includes all other races. f1964 includes white
Hispanics. g1964 includes black
Hispanics. hPersons of Hispanic origin may be of
any race. iFor percentage seeing a dentist,
includes only persons 2 years of age and older.
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Conclusions

• There is nothing more practical than a good
  model to understand and promote access to care
• Low income and some minority populations appear
  to have achieved equity of access according to
  gross measures of hospital and physician use (not
  adjusting for need) but not dental care
• Equity has not been achieved according to health
  insurance coverage (and regular care,
  prevention,delay,morbidity, mortality)
• A first step toward equitable access is coverage
  for all