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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.

Access to health care has two major components. First and most frequently discussed is 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 language spoken by those who need assistance. 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) that are important determinants of the health status of a population.

Lack of Insurance

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 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, 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.

Health insurance coverage, whether public or private, is a key factor in making health care accessible. In 1980, 25 million people were uninsured, but by 2009 the number had increased to 51 million (Table 3–1 and Figure 3–1) (US Census Bureau, 2010). The particular pattern of uninsurance is related to the employment-based nature of health care financing. Most people, like Ernestine Newsome, obtain health insurance when employers voluntarily decide to offer group coverage to employees and their families and their employers help pay for the costs of health insurance. People whose employers choose not to provide health insurance, are self-employed, or are unemployed are left to fend for themselves outside of the employer-sponsored group health insurance market, with the result that many are uninsured. Often people without employment-based insurance are not eligible for public programs such as Medicare and Medicaid, and are unable to purchase individual private coverage because they cannot afford the premiums.

Table 3–1. Estimated Principal Source of Health Insurance, 2009

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