What does ‘access to healthcare’ mean?

Access to healthcare is a growing problem, and as the gap between healthcare accessibility and the need for those services widens, so does public consensus over the root causes. 

Since research is our forte, we'll attempt a non-partisan analysis of the economic trends that shaped healthcare access throughout Medicare's history. In the process, we'll show how a solid definition of the problem can guide efforts toward equally cohesive solutions.

"Healthcare access" is a broad term that describes how easy or difficult it is for people to obtain suitable healthcare when needed. You may wonder what kind of care is considered accessible or inaccessible.

Generally, "healthcare" covers any professional medical or health service one can purchase on the open market, although it's also possible for the term to be qualified differently, depending on who defines it. Starting with the most inclusive definition used in American discourse, any combination of the following may fall under the healthcare umbrella:

• Doctor's offices (including primary care providers or PCPs)

• Urgent care

• Hospitalizations & emergency services (such as first responders)

• Surgery

• Medical specialists (e.g., endocrinologists, neurologists, doctors of osteopathy, OBGYNs, etc.)

• Nutritionists & naturopaths

• Health education centers

• Rehabilitation services (including physical therapy, occupational therapy, and speech therapy)

• Massage therapy

• Chiropractic care

• Dentistry

• Mental health providers & institutions

• Traditional Chinese medicine & reiki

• Hospice

• Birthing centers, midwifery, and pregnancy classes

Even though this is just a partial list, be aware that "healthcare" may mean different things in different contexts, especially in legal definitions (which themselves often change between states).

Attempting to improve access to healthcare requires some qualification. Not only do 44% of American adults lack sufficient access to healthcare, but 93% feel that what they do receive isn't worth the costs. That's according to a joint Gallup and West Health poll, which succinctly summed up the main issues within the healthcare industry: (1) high prices and (2) low value.

Good research should maintain context, showing which measurable trends resulted in the current problem—in this case, rising costs and diminishing returns. How almost all American adults began losing access to not only healthcare but good healthcare is (dare we say it) a vital question!

Framing the problem: high prices, low value

Researchers can get more done faster by analyzing the metrics most relevant to the main problem—in this case, barriers to healthcare access in terms of costs and quality. While rife for lively debate, we'll consider the issue as summarized in the Gallup poll mentioned above:

1. Rising healthcare costs

2. Reduced healthcare quality

We'll state from the outset that we certainly won't be solving this problem right here, but we can frame it as an exercise in defining the problem—a keystone research skill for maintaining context when wading through an unwieldy amount of data. 

Consider a well-defined problem like a bull’s eye. Without it, an organization risks scattering its efforts across multiple targets of lesser importance.

In this case, the main target could be framed in this way: when and how did healthcare costs start rising, and how have these trends correlated with lower healthcare quality?

Investigating the problem

We'll compare healthcare costs with quality starting in 1965 when data became abundant and the first Medicaid bill was passed. 

According to Kaiser Permanente, the total national health expenditure (NHE) rose from $147 per capita in 1960 to around $5,000 by 2000. NHE then rose past $8,000 by 2010—and in 2021, it reached almost $13,000.

It seems like quality should have also increased, but as already mentioned, it's lowered miserably. What happened? Assuming we've defined the problem correctly, a particular breadcrumb trail emerges:

• While some are quick to blame rising healthcare costs on inflation, Kaiser's data also showed rising insurance rates far outpaced inflation, so it's far from the full picture.

• By the 1980s, NHE rose ten times over 1960 levels (or, to put it technically, "went kaflooey"). This period coincided with increased healthcare spending and price markups, but a marked decline in healthcare accessibility and public health outcomes was the result.

• By 1990, NHE underwent the second-largest increase in thirty years, just as legislation granted insurance companies greater means of directly influencing healthcare costs. NHE then rose much higher than consumer demand, and by 2000, NHE tripled over 1990 levels.

• Between 2000 and 2020, insurance companies and legislators accelerated those trends, and healthcare costs more than doubled. Perceived healthcare quality further declined as healthcare costs increasingly shifted to employees, who put healthcare services off due to costs.

• In 2022, healthcare spending decreased for the first time since 1960, even though costs were still expected to rise—underlining the disconnect between supply and demand mentioned just above.

• Predictably, a 2023 Gallup poll placed perceived healthcare quality at an all-time low across virtually every category.

We'll let you take a breath and reflect on the overall trend behind the data. In our brief sample, spikes in actual healthcare spending coincided with a marked reduction in quality at three separate times (about every other decade). While we didn't prove causation over correlation, whatever correlation is there was consistent. The problem, stated mathematically, is:

Between 1960 and 2023, rising US healthcare expenses were inversely correlated with quality.

Managing the symptoms of modern healthcare-access challenges

How to improve access to healthcare while reducing costs is the trillion-dollar question—and in light of the above, improvement through brute-force spending (at least through the usual channels) is unlikely to raise healthcare quality.

The following is a small sample of commonly cited barriers to healthcare access. Armed with the greater context of the problem, reflect on how each point is a mere symptom of the inverse relationship (even if not causal) between modern healthcare spending and quality. 

To maintain a focused approach, we'll label each of the following accessibility barriers as (A) a cost burden, (B) a quality issue, or both.

• Rising insurance premiums (costs and quality, as patients pay more while receiving less)

• Limited office hours and appointment availability (this is a quality concern, as what healthcare is still available disrupts people's schedules)

• Geographical clinician shortages (this is a quality concern since some populations are forced to go without healthcare services)

• Transportation barriers (costs and quality, as time and financial expenses increase even before reaching the clinic)

• Limited education about care sites (this is a quality concern since many people don’t know about their options )

• Social determinants to healthcare barriers (costs and quality, where unmet needs for preventative care often lead to major cost burdens in the future)

• Insufficient insurance coverage (costs and quality, as out-of-pocket expenses increase and patients go without certain healthcare services)

• Stigma and bias among the medical community (this is a quality concern that causes diagnoses and prognoses to become less objectively accurate)

• Patient language barriers (this is a quality concern that can lead to complete ineffectiveness in some cases)

• Tighter limitations on healthcare services covered (quality—and potentially costs, if more effective healthcare options are excluded, and vice versa)

• Collective insurance-rate hikes independent of individual health measures (costs, which disproportionately affect, or even punish, those who depend on fewer healthcare resources)

Improving healthcare access requires new solutions, and they'll likely be as counterintuitive as the results of the problem-framing exercise above. The good news is the diminishing returns of healthcare spending must eventually give way to wiser, more creative uses of available healthcare resources.

This may be happening already, even if just at the private level (e.g., greater spending on nutritious foods), which holds the potential for reducing public healthcare expenses and burdens. However, the population chooses to secure greater health outcomes, some commonly promoted healthcare-access solutions include:

• Incentivize private health insurance accessibility by tying rates to actual market demand

• Expand public health programs in lockstep with inflation to keep healthcare purchasing power even

• Extend telehealth services to reduce clinic overhead and appointment costs (for both patients and insurance providers)

• Invest in mobile clinics that offer essential services and educate the public about local healthcare options, which improves accessibility and patient choice

• Make healthcare services culturally relevant based logically on the demographics of a given jurisdiction

• Improve independent health education resources to empower private individuals to reduce demand on an already overburdened healthcare system

The issue of healthcare access is complex and relates to many other issues that can quickly become overwhelming (e.g., financial, political, and medical industry changes). Yet by asking the most fundamental questions first and not deviating from the information it leads you to, you’ll be able to clarify the issue tightly and concisely. Ultimately, you know you’ve done well when the data speaks for itself.

Healthcare access refers to the ease or difficulty of securing necessary healthcare, considering potential barriers such as costs, transportation, and available resources. Healthcare coverage, on the other hand, refers to private or public insurance coverage, as opposed to "out-of-pocket" expenses (those not covered by any insurance).

Access and coverage go hand in hand, where poor healthcare coverage can easily be a barrier to healthcare access—but strictly speaking, access refers to the physical, financial, and other factors impacting an individual's ability to obtain healthcare. Coverage refers solely to levels of healthcare insurance.

As of mid-2023, the states with the highest healthcare accessibility are (starting with the highest):

1. Hawaii

2. Iowa

3. Colorado

4. Minnesota

5. Rhode Island

6. Maryland

7. New Hampshire

8. Massachusetts

9. Utah

10. Washington

Note that accessibility doesn't always mean low costs or high quality. For example, Rhode Island and Massachusetts—ranked 5th and 8th for accessibility—are among the top 10 costliest states for healthcare (per capita). Not surprisingly, Massachusetts' cost of living is 49% higher than the national average, while Rhode Island manages just 13% higher.

Colorado and Utah, ranked 3rd and 9th for accessibility, are among the top 10 lowest-cost-per-capita states, achieving high accessibility and low expenses.