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INTRODUCTION

This fundamental question is at the basis of healthcare access. It implies the opportunity of gaining appropriate healthcare when needed, where needed, and at the level needed. It involves utilization of healthcare services and provision of appropriate services. Toward this end, health systems must achieve health(care) of all individuals and populations by delivering healthcare services to those who need them and benefit from them.

Local and national resources as well as personal resources must be available for the materialization of healthcare access. First, health policies set the stage for various approaches to healthcare delivery. Secondly, health personnel, facilities, and/or technology must be available where people live, work, or pursue their education. Thirdly, people must have the means and know‐how to obtain the services. Thus, healthcare access in all its dimensions impacts all levels of the healthcare system, including people, processes, providers, organizations, and policy makers (Rouse and Serban 2015). This book is intended to present a synthesis of concepts, principles, models, and methods for addressing healthcare access within a system rife with complexity coming from all its levels.

This chapter proceeds as follows: I will first discuss the complexity of the concept of healthcare access, a multidimensional construct, going beyond its (mis)interpretation as a financial barrier in the existing political discourse on healthcare in the United States and beyond. I will address the relevance of understanding access in the context of public health, expanding on the system levelers for change and potential approaches to drive change. Then, I will proceed by pointing out that access is not an end in itself; it moderates healthcare utilization, with both intended consequences, such as improving health outcomes through appropriate utilization, and unintended consequences, such as over‐utilization and potentially higher costs. I will subsequently consider methodological approaches to addressing healthcare access problems, focusing on the use of quantitative approaches to explore a wide range of solutions. Finally, this chapter provides an overview of the remaining chapters in this book and how they address the framework presented in this chapter.

ACCESS AS A MULTIDIMENSIONAL CONSTRUCT

The current political discourse around healthcare access primarily focuses on financial barriers; it has been taken as synonymous with the availability of financial and health system resources. Limiting the access discussion to affordability or provider availability is understandable. It is however a simplistic approach for regulatory agencies charged with advancing access (Khan and Bhardwaj 1994). Simply measuring affordability or provider availability is neither adequate nor appropriate to understand healthcare access. Construing the conceptual framework for access requires a richer perspective.

There is a very large literature on the conceptual construct of healthcare access. Many organizations have been promoting and publishing on this topic (Healthy People 2020 2010; RAND Corporation 2010; www.kff.org). To distil this entire literature would not serve the reader of this book well, but several references to the existing proposed conceptual approaches will be provided.

One of the earliest access frameworks is the behavioral model by Ronald Andersen (Andersen 1968), initially developed in the late 1960s. In the early literature, access has also been differentiated between realized and potential, where realized access refers to the direct utilization of the services and potential access refers to the opportunity to utilize services (Khan 1992; Guagliardo 2004; McGrail and Humphreys 2009). Guagliardo (2004) stages first the potential for care delivery, followed by realized delivery of care. Potential access exists when a population in need for specific healthcare services lives in a community with access to “a willing and able healthcare delivery system.” Realized care follows when all barriers to provision of healthcare are overcome. Guagliardo (2004) fundamentally describes “access” as both a noun referring to potential for healthcare use, and a verb referring to the act of using or receiving healthcare.

When Andersen revisited the behavioral access model, he introduced the concepts of effective access, established when utilization improves health status, and efficient access, established when the level of health status increases relative to the amount of healthcare services consumed (Andersen 1995). More generally, access can be placed under the framework of the 3 E's: Efficiency, Effectiveness, and Equity (Aday et al. 2004), discussed further in Chapters 2 and 3.

Penchansky and Thomas (1981) have usefully grouped access barriers into five dimensions: availability, accessibility, affordability, acceptability, and accommodation. Healthy People 2020 redefines the five dimensions of access, including insurance coverage, health services, and timeliness of care. Access as a multidimensional construct has been defined within multiple other frameworks as reviewed by Ansari (2007) and the Rural Policy Research Institute (MacKinney et al. 2014), among others. Further references to other multidimensional constructs will be provided in Chapter 2, however this book will primarily employ the simple but relevant framework provided by Penchansky and Thomas (1981). The diagram in Figure 1.1 shows the five dimensions of access within a service science framework for a broader understanding of service access. This access framework can apply to other fundamental services, for example, education, financial services, and healthy food stores, among others.

Figure 1.1 The access framework as a five‐dimensional construct following the model by Penchansky and Thomas (1981).

ACCESS FOR PUBLIC HEALTH

Urban and rural communities face many challenges to improving public health. Economic initiatives, changing demographics, and growth at the community level have resulted in changes that offer new opportunities for improving health while requiring that health systems be adapted to residents' health needs. One important integration of the community health needs into the directions of the healthcare system transformation is redesigning public healthcare delivery to achieve equitable, efficient, and effective access to healthcare.

Materialization of healthcare access in public health can take many forms, including prevention of emergency department visits and hospitalizations; quality of life of those with unmet health needs and with delays in receiving appropriate care; a cumulative decline in mortality and disability; and an overall improvement in mental health status, life expectancy, and general sense of wellbeing, among others.

While it is well understood that healthcare access is an actionable approach to improving public health, its conceptualization suggests the type of actions that need to be taken. For example, the current understanding of access as a financial barrier (affordability dimension) has brought forward national and state policies with a focus on coverage of healthcare benefits and insurance. As highlighted in the conceptualization of access as a multidimensional construct in this chapter, there are multiple dimensions of access that are interrelated; affordability is one of them but other dimensions are equally relevant to public health.

Importantly, access dimensions also have different relevance depending on the sub‐population in need for care. For example, children in the United States are generally insured through commercial or public insurance, with only about 3.2% of children being uninsured (National Center for Health Statistics 2016). Thus, for the child population, affordability is not the primary dimension of relevance. Since children access the healthcare system with the effort and time commitment of their parents, accessibility and availability of the services may have a higher priority over other dimensions. Parents need to take time away from work and the children may miss school days. Timeliness through reducing travel and wait time may be essential to the decision as to whether to seek care.

There is also a wide variation in the relevance of access dimensions by healthcare services sought and/or needed. Mental and behavioral health services present challenges in access across all five dimensions for the majority of the population in the United States. In contrast, dental care is viewed as an axillary service for most health benefits programs hence insurance coverage is low. In many cases, dental care is an out‐of‐pocket expense; however, for children from low‐income families, it is covered by Medicaid. But Medicaid participation by dentists is low (Serban and Tomar 2018). In one of my recent studies for Georgia, USA, my collaborators and I showed that there is a very large gap in accessibility and availability of dental care services between children with public insurance and those whose parents have other forms of affordability (Cao et al. 2017).

Compared with specialized care, primary care has become more available due to comprehensive coverage across all healthcare insurance programs, with a...