This paper, “Equity of Access to Medical Care: A Conceptual and Empirical Overview,” was co-authored by Lu Ann Aday, Ph.D., and Ronald M. Andersen, Ph.D.. It was published as a supplement in Medical Care, Vol. 19, No. 12, in December 1981, under the broader theme of “Access to Medical Care: Progress, Problems and Prospects”. Dr. Aday’s primary affiliation was the Center for Health Administration Studies, Graduate School of Business, The University of Chicago, Chicago, Illinois. The paper itself was prepared for the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical Behavioral Research, and some of the original research presented was supported by grants from The Robert Wood Johnson Foundation and a contract from the National Center for Health Services Research.
The report primarily focuses on several key aspects related to the concept of equity of access to medical care in the United States:
- It summarizes the major ethical considerations pertinent to conceptualizing and measuring equity of access.
- It presents national and community data to illustrate the current profile of access within the U.S..
- It discusses the implications of both the conceptual and empirical issues for future health policy.
- It explores changes in health care policy and considers the future trajectory of the “equity of access” objective in the U.S..
The authors begin by identifying three implicit assumptions that underpin the objective of equity and serve as a starting point for examining its ethical dimensions:
- Health care is a right. This distinction is further clarified by distinguishing the “right to health” (which factors in personal behavior and is largely beyond state control) from the “right to health care” (which specifically implies access to medical care services). The latter is considered a fundamental normative starting point for discussions of access.
- The resources for allocating health care are finite. The authors note that the finitude of resources is evident in the rising cost of medical care, which necessitates moral choices about distributive justice. This scarcity also implies potential trade-offs with other health care system goals like cost containment and quality.
- Health policy should be concerned with designing “just” mechanisms for allocating scarce health care resources. This forms the core of the conceptual and methodological interest in equity.
The paper introduces a framework for studying access to medical care, defining access as “those dimensions which describe the potential and actual entry of a given population group to the health care delivery system“. Within this framework, equity of access is achieved “when services are distributed on the basis of people’s need for them,” whereas inequity is suggested “if services are distributed on the basis of demographic variables, such as race, family income, or place of residence, rather than need“.
The authors explore various criteria of social justice relevant to the “equal access” objective, based on Outka’s work:
- Merit or desert: Generally deemed inappropriate for health care allocation, as health crises are often beyond individual control, though it may apply to health behaviors (e.g., smoking habits).
- Societal contributions: Based on a utilitarian concept of justice, this criterion considers contributions to the common good (e.g., occupational and educational statuses), but the authors point out that programs like Medicare and Medicaid were enacted to cover those who might contribute least (the poor and elderly).
- Supply and demand: This market-based principle is considered inappropriate for health care due to the consumer’s limited choice, knowledge, and influence when ill, and the significant role of providers and the insurance industry. While some economists advocate for free market forces, most contemporary medical economists suggest that society should assure a “basic minimum” care.
- Need: Emphasized as the most appropriate basis for allocating health care resources. Supported by Rawls’ concept of social justice, this criterion suggests that resources should be allocated to those with the greatest need. It can be operationalized by looking at observed morbidity or the fit between observed need and obtained services.
- Similar treatment for similar cases: This criterion ensures that socio-demographic factors like income or race do not determine the quality or type of medical care received by individuals with similar needs.
Empirically, the paper analyzes trends in access over a 25-year period (1953-1979) primarily using data from the Center for Health Administration Studies (CHAS-NORC) and the National Center for Health Statistics (NCHS-HIS). Key findings include:
- Significant improvements in equity of access for traditionally disadvantaged groups since the 1950s, largely attributed to public financing programs such as Medicare and Medicaid.
- However, persistent inequities remain in areas such as dental services, prenatal care, and adequate third-party insurance coverage for the poor. These gaps showed no signs of narrowing in recent years.
- While overall physician visit rates for the poor increased substantially after the mid-1960s, these gains appeared to be leveling off or even diminishing by the late 1970s. Similarly, hospital admissions showed a leveling off after dramatic gains.
- When adjusted for need (e.g., using symptoms-response ratios), low-income individuals showed improved appropriate contact for symptoms. However, complete parity for all age groups based on disability or chronic illness had not been fully achieved, and sustained gains were not evident in the late 1970s for all age groups.
- Pockets of inequity continued to exist based on the specific measure of access considered, the type of community (e.g., certain Western, low-income metropolitan, or non-metropolitan areas), and socio-demographic characteristics within the community.
The paper also discusses the impact of governmental programs:
- Medicare enrollment and reimbursements increased, but potential access barriers might be reflected in rising deductibles for hospitalization and supplementary medical insurance premiums.
- For Medicaid, while payments per recipient in constant dollars increased, the number of recipients declined in the late 1970s, suggesting increasing access barriers due to fiscal problems and service cuts in many states.
- Community Health Centers showed increased users and encounters, but appropriations in constant dollars did not keep pace with the services provided, indicating that they were securing revenues from various sources.
Ultimately, the report suggests that the U.S. is at a critical point where the positive trends in access over the past 30 years could slow or even reverse. This is attributed to the prevailing conservative political climate, concern over inflation (with medical care singled out as a major contributor), and an increasing emphasis on cost control and individual responsibility for health. The authors note that the concept of medical care as a right may be increasingly questioned, and the criteria for social justice might shift towards marketplace, merit, and societal contribution, moving away from need and similar treatment.
Reference: Aday, L. A., & Andersen, R. M. (1981). Equity of access to medical care: A conceptual and empirical overview. Medical Care, 19(12, Suppl.), 4–27. https://www.jstor.org/stable/3763937