Access to care as a component of health system reform.

THE PRESSING INTEREST AND CURRENT ACTIVITY SURrounding health care access and health system reform by physicians, other health care professionals, policy makers, and the public is well justified and increasingly urgent. Health care expenditures in the United States are at an all-time high and are projected to exceed $2 trillion in 2006, with Medicare and Medicaid accounting for more than $400 billion and more than $300 billion, respectively. At the same time, the number of individuals with inadequate health insurance coverage also has reached an all-time high: nearly 47 million are uninsured and at least 16 million more are underinsured. In addition, some companies that traditionally have provided employer-sponsored health insurance are eliminating this benefit or reducing coverage and benefit levels, and many more are shifting an increasing proportion of health care costs to their insured employees. As a result, many insured individuals are responsible for an increased share of health insurance premium costs, for increased out-ofpocket costs for some medical services due to reductions in first-dollar coverage and increased individual and family deductible levels, and for increased costs and copayments for medications, due to reductions in prescription drug benefit plans. Moreover, the time in which the baby boom generation will enter Medicare is rapidly approaching, potentially threatening the financial stability and longterm viability of this major health care funding institution. Along with these alarming trends in expenditures and health insurance coverage, there are several major problems at the clinical care delivery level in the US health care system. For instance, medical care has become increasingly fragmented, and patients are often left to navigate and negotiate through a bewildering and complex system. At the same time, advances in medical science more than ever offer the possibility of reducing the morbidity and mortality associated with serious diseases, yet access, availability, and cost prevent many patients from benefiting from these latest discoveries and from receiving the quality of care that should be available. Compared with outcomes in some other industrialized countries, some broad measures of health in the United States are mediocre at best, while only in the overhead costs of running this chaotic enterprise does the United States lead the world. Perhaps most concerning, physicians continue to be increasingly frustrated by insurance company administrators and legislators making decisions that directly affect patient care and medical practice, and dictating policies that govern determining and obtaining compensation for clinical care. These and other factors make achieving meaningful reform in the US health care system, and specifically addressing the issue of access to care, critical priorities. This issue of JAMA includes a collection of articles that provide new data and thoughtful perspectives on important issues involving various aspects of access to care, as a critical component of comprehensive health system reform. Perhaps the most important factors that must be considered in any discussion of access to health care are quality of care and health care outcomes. In general, forgoing or delaying necessary medical care, including preventive interventions, diagnostic testing, or medical or surgical treatment, is associated with worse health outcomes, as shown in 2 longitudinal observational studies reported in this issue. In their multicenter study of 2498 patients hospitalized for acute myocardial infarction, Rahimi and colleagues found that self-reported financial barriers to health care services (18.1% prevalence) or medication (12.9% prevalence) were common, even among the roughly 69% of patients with health insurance. At 1-year follow-up, financial barriers to health care or to medication were associated with significantly worse recovery after myocardial infarction, manifested as higher rates of angina, increased risk of rehospitalization, and poorer quality of life. In another study, Hadley used data from sequential interviews from the national Medical Expenditure Panel Survey (1997 through 2004) to compare medical care use and health changes among uninsured and insured nonelderly individuals who experienced a “health shock” caused by an unintentional injury (15 866 individuals) or onset of a chronic medical condition (7954 individuals). Following such a health shock, those who were uninsured reported that they received less medical care, had less medication use,