Access to Health Care, Socioeconomic Status, and Health
Authors: Marc A. Baltzan
Journal: Annals of Internal Medicine (1999)

Letters2 March 1999Access to Health Care, Socioeconomic Status, and HealthLeigh F. Callahan, PhD and Theodore Pincus, MDLeigh F. Callahan, PhDUniversity of North Carolina; Chapel Hill, NC 27599 (Callahan)Vanderbilt University; Nashville, TN 37232 (Pincus) and Theodore Pincus, MDUniversity of North Carolina; Chapel Hill, NC 27599 (Callahan)Vanderbilt University; Nashville, TN 37232 (Pincus)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-130-5-199903020-00022 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:We appreciate the comments of Dr. Baltzan, which provide us an opportunity to reemphasize our strong belief in the importance of access to medical care to improve health outcomes (1). Access to care is more critical to outcomes in acute diseases and acute events within chronic diseases but becomes less critical in outcomes of chronic diseases.We would broaden the meaning of the term "access" beyond its generally understood meaning, which involves removal of financial barriers to standard medical encounters. For example, might "access to care" not include such matters as transportation to a clinical site, provision for continuity with the same physician (if desired), patient education, programs to enhance self-management, and family therapy? Many additional approaches to "access" seem to be required if one is to take full advantage of scientific medical advances, particularly for persons of lower socioeconomic status.Although decreases in mortality during the 1970s "coincided with dramatic improvements in access to care," that phenomenon does not establish cause and effect. For example, the decrease in tuberculosis deaths in the first half of the 20th century, when antibiotics were not available, did not substantially differ from that seen in the second half of the century, when antibiotics were used (2, 3). Furthermore, concomitant increased longevity and increased unemployment are not inconsistent with associations of socioeconomic status and health and may be explained by evidence of widening disparities in mortality according to socioeconomic status (4). In addition, it can be argued that improvements in outcomes for stroke, myocardial infarction, and vehicular trauma and neonatal survival result from improved social conditions rather than from direct medical care; similar higher prevalences according to socioeconomic status are seen in all these conditions (5).We agree with Dr. Baltzan's conclusion that access, social conditions, and self-management are all relevant to care. All physicians have some patients whom they recognize will do very well and others whom they recognize will probably have poor outcomes. We suggest that primary determinants of this overall prognostic impression are variables identified with socioeconomic status, regardless of access to care. Access is certainly important as a necessary condition to improved health; however, it is sufficient in acute diseases but not sufficient in chronic diseases, in which self-management and social conditions may be as (if not more) important.References1. Pincus T, Esther R, DeWalt DA, Callahan LF. Social conditions and self-management are more powerful determinants of health than access to care. Ann Intern Med. 1998;129:406-11. LinkGoogle Scholar2. McKeown T. The Role of Medicine. Oxford: Blackwell; 1979. Google Scholar3. Sagan LA. The Health of Nations: True Causes of Sickness and Well-Being. New York: Basic Books; 1987. Google Scholar4. Marmot MG, McDowall ME. Mortality decline and widening social inequalities. Lancet. 1986;2:274-6. CrossrefMedlineGoogle Scholar5. Pincus T, Callahan LF, Burkhauser RV. Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18-64 United States population. J Chronic Dis. 1987;40:865-74. CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: University of North Carolina; Chapel Hill, NC 27599 (Callahan)Vanderbilt University; Nashville, TN 37232 (Pincus) PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoSocial Conditions and Self-Management Are More Powerful Determinants of Health Than Access to Care Theodore Pincus , Robert Esther , Darren A. DeWalt , and Leigh F. Callahan Access to Health Care, Socioeconomic Status, and Health Marc A. Baltzan Metrics 2 March 1999Volume 130, Issue 5Page: 453KeywordsAntibioticsHealth careMortalityMyocardial infarctionSocioeconomic status Issue Published: 2 March 1999 CopyrightCopyright © 1999 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...