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Improving Access to
Directions for the 21st Century
Chapter 1 - Introduction: The Crises in Health Care Delivery and Physician Workforce Supply
In 1988, when COGME issued its first report to the Secretary and Congress, it expressed concern that physician specialty
and geographic maldistribution was growing despite an increasing aggregate supply of physicians. At that time, concerns about access to health care and rising health care costs had not yet been so prominently thrust into the national spotlight. Similarly physician workforce policy was not high on the national agenda.
The historical context of this report is vastly different. Today the health care system is acknowledged to be in crises. While health care expenditures exceeded $650 billion in 1990 and are projected to reach $1 trillion in 1995, 37 million Americans remain medically uninsured, and millions more face barriers to basic health care. Furthermore, the Nation's basic health status indicators, which are in some measure influenced by access to health care, lag behind most economically developed countries. There is now recognition that health care reform to ensure access to basic care for all Americans is not possible without physician workforce reform. It is in this context that COGME has been examining physician workforce supply and distribution and its impact on ensuring access to care for all Americans.
The Crisis in Health Care Delivery
Within the community of nations, The United States leads in biomedical research, technology development, and some aspects of health care delivery. The United States produces excellent physicians and leads in the development, application, and diffusion of new technologies for disease diagnosis and treatment. The United States also is recognized for innovations in health care delivery systems such as HMOs and other managed care systems.
Nevertheless, the health care system has notable flaws. Although the United States spends far more per capita on health care than any other nation, millions of Americans face significant barriers trying to obtain basic health services. The United States pioneers in biomedical research and sophisticated medical technology funded through the National Institutes of Health (NIH), but basic health status indicators lag far behind other developed countries. Although the Centers for Disease Control has led advances in epidemiology and disease prevention and control, the actual performance of the health care system in providing basic screening, counseling, and immunization services is considered to be far below target levels.
Today, public concern about the health care crises is expressed through the sheer number of national health care reform proposals that have been introduced. The major elements of the health care crisis include:
Inadequate Access to Health Care
The problems associated with access to health care have deeply rooted social, economic, and educational implications. Significant numbers of people do not have access to affordable and quality health care, and the numbers continue to increase, Availability of insurance or other third-party coverage is a necessary means of access for preventive and medical services. Yet 37 million Americans lack health insurance, three-fourths of them are fulltime workers and their families, and another 16 million have inadequate coverage. In 1990, 17 percent of the nonelderly U. S. population did not have private or public coverage. In 1988, two-thirds of the uninsured population were in families of full-year steadily employed workers. These individuals and their families face barriers in obtaining medical care and are less likely to get preventive care or adequate care when faced with serious illness.
Studies have shown that lack of insurance coverage is the major barrier to health care. Without insurance coverage, many individuals and their families forgo medical care or opt for reduced care. One recent study showed data indicating that lack of access to basic care in Washington, D.C., and the United States resulted in excess needless premature deaths among African Americans from common treatable conditions such as asthma, pneumonia, hypertension, and tuberculosis. Similarly, studies in New York City indicate that residents in low-income census tracts were significantly more likely to be hospitalized for common conditions that can be treated with access to basic health care.
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