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INTRODUCTION

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Access to health care is the ability to obtain health services when needed. Lack of adequate access for millions of people is a crisis in the United States.

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Access to health care has two major components. First and most frequently discussed is the ability to pay. Second is the availability of health care personnel and facilities that are close to where people live, accessible by transportation, culturally acceptable, and capable of providing appropriate care in a timely manner and in a compatible language. The first and longest portion of this chapter dwells on financial barriers to care. The second portion touches on nonfinancial barriers. The final segment explores the influences other than health care (in particular, socioeconomic status and race/ethnicity) that are important determinants of the health status of a population.

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FINANCIAL BARRIERS TO HEALTH CARE

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Lack of Insurance

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In 1990, Ernestine Newsome was born into a low-income working family living in South Central Los Angeles. As a young child, she rarely saw a physician or nurse and was behind on her childhood immunizations. When Ernestine was 7 years old, her mother began working for the telephone company, and this provided the family with health insurance. Ernestine went to a neighborhood physician for regular checkups. When she reached 19 in 2009, she left home and began work as a part-time secretary. She was no longer eligible for her family’s health insurance coverage, and her new job did not provide insurance. She has not seen a physician since starting her job.

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Health insurance coverage, whether public or private, is a key factor in making health care accessible.

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Historically, trends in health insurance coverage in the United States in the modern era can be divided into three phases. The first phase, occurring between the 1930s and mid-1970s, saw a large increase in the proportion of Americans with health insurance due to the growth of employment-based private health insurance and the 1965 passage of Medicare and Medicaid (Table 3–1). The second phase, starting in the late 1970s, marks a reversal of this trend; between 1980 and 2010, the number of uninsured people in the United States grew from 25 to 50 million. The single most important factor explaining the growing number of uninsured in this period was a decrease in private insurance coverage. The number of uninsured peaked in 2010—the year the ACA was signed into law–signifying the onset of the third phase in this historical trend as the number of uninsured decreased from 50 to 41 million between 2010 and 2013 (Fig. 3-1). Because the major coverage expansion policies legislated by the ACA did not take effect until 2014, the decrease in the number of uninsured between 2010 and 2013 was largely explained by states more actively enrolling individuals and families eligible for Medicaid under the traditional eligibility criteria. In 2014, ...

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