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Access encompasses both the ease and timeliness with which health services can be obtained (Office of Health Care Access, 1999; Millman, 1993). Metrics of measuring access to health services include:

* Having health insurance,
* Adequate income, and
* A regular primary care provider or
* Other regular source of care (U.S. Department of Health and Human Services, 2000).
* Utilization of certain clinical preventive services, such as, early prenatal care, mammography, and Pap tests, can also indicate better access to services.
* Rate of avoidable hospital admission

Health care models:

* Purely private enterprise: Exist in poorer countries with sub standard health care dominated by private clinics for wealthier population.
* In almost all the countries, a private system exists in addition to Government health care system (such as Medicare and Medicaid in U.S). This is sometimes referred to as Two-tier health care.
* The other major models are public insurance systems:

o Social Security Health Care model where workers and their families are insured by the State.
o Publicly funded health care model, where the residents of the country are insured by the State.
o Social Health Insurance, where the whole population or most of the population is a member of a sickness insurance company.

Models for access: access to health services can be impeded broadly by:

* Affordability: Economic barriers (no insurance, poverty),
* Availability: Supply and distribution barriers (inadequate or inappropriate services or primary care providers, geographic unavailability due to difficult infrastructure);
* Unavailability of services, lack of transportation and other infrastructure), and

Language and cultural barriers.

Discussion:
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A. Insurance coverage:
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* Approximately 85% of Americans have health insurance.
* Approximately 60% obtain health insurance through their place of employment or as individuals,
* Various government agencies provide health insurance to 25% of Americans.[3].
* In 2004, 45.8 million (15.7%) Americans were without health insurance [1].
* According to 2000 U.S. census data [2], the percentage of large firms (200 employees or more) offering health benefits to its retirees fell between 1988 and 2001 (excepting a spike in 1995).
* Although most types of health insurance cover common treatment services and screening and diagnostic tests, many preventive services and interventions are not covered. For example, while most health insurers will pay to treat emphysema, lung cancer, and other tobacco-related diseases, for example, few will reimburse for smoking cessation programs or medications.

B. Economic condition:

Cost is a barrier. Cost is more likely to affect persons:

* Of Hispanic ethnicity,
* To affect unmarried persons,
* Those who did not graduate from high school, were four times more likely than college graduates to experience cost barriers to health care,
* People with income under $25,000

C. Availability:

Access barrier is intense in areas where the need is high but capacity of existing providers is insufficient.

* Hispanic is less likely than non-Hispanic respondents to have health-care coverage (76.2% versus 90.6%),
* They have one or more regular personal health-care providers (68.5% versus 84.1%), or
* They have a regular place of care (93.4% versus 96.2%).
* Hispanic has needs of medical care, but can not obtain it (6.5% versus 5.0%).
* Hispanics also are significantly less likely to be screened for blood cholesterol and for breast, cervical, and colorectal cancers and to receive a influenza / pneumococcal vaccination.

D. Language factor:

Language can be an obstacle to health care access for:

* People who do not speak English and
* For the deaf and hearing impaired.

According to the 1990 U.S. Census, about nine percent of Connecticut's population was foreign born and 15% of children and older spoke a language other than English at home. Of this group, 39% did not speak English 'very well'. . According to U.S. Census Bureau, 2001, 6 percent of population is hard of hearing, and 25,500 residents are considered profoundly deaf (Connecticut Commission on the Deaf and Hearing Impaired, 2001).

The ability of Connecticut's health care providers to communicate with non-English speaking people and is very limited. In 2001, 35 percent of total physicians and surgeons practicing medicine in Connecticut indicated that a language other than English was spoken at their practice location (Connecticut Department of Public Health, Bureau of Regulatory Services, 2001). Spanish was the most frequently spoken language.

E. Cultural factor:

Cultural differences between Hispanics and other minorities and health care providers affect health-related behaviors in certain minority groups:

* lack of knowledge about Western medicine,
* fear of public institutions (based on experiences with discrimination),
* modesty about their bodies, and
* The belief in minority women that their own needs are secondary to those of their husbands and children (True and Guillermo, 1996).
* Hispanics have less knowledge about cancer. Cancer is increasing among Hispanics [4], and cancer screening, an essential component of early detection and treatment.
* Many non-Western women do not go directly to a physician when they are ill. Instead, they first attempt to treat themselves, and if that fails, they follow the recommendations of friends, family, and in some cases, alternative or folk healers (Bayne-Smith, 1996).
* Many health problems of minority women thus go unreported and unrecognized, in part because the women do not communicate the problems, but also because providers cannot relate to the women's cultural norms (Bayne-Smith, 1996).
* Lesbians are less likely than heterosexual women to seek health care and more likely to encounter barriers in access to care and preventive services. For example, many women who have sex only with women believe they do not need Pap tests, and confusion even exists in clinical practices about whether lesbians should be offered cervical smears routinely (Bailey et al., 2000).

? Do Medicare and Medicaid contribute to barriers to access so far we think about the delinquencies in reimbursement?
? Does it anyway refer to the question of availability of health care providers?

The U.S Health care ranking is very poor in relation to other industrialized nations in health care despite having

* the best trained health care providers and
* the best medical infrastructure

The ranking are as bellow:

* 23rd in infant mortality,
* 20th in life expectancy for women and 21st for men
* 67th in immunization, right behind Botswan
* Rank below Canada and a wide variety of industrialized nations on outcome studies on a variety of diseases, such as coronary artery disease, and renal failure.

The ranking is poor because, the access barrier is intense in U.S. Access to Health care. Difficulty in accessing to health care to 30% Americans is based on the ability to pay (disparity is directly related to income and race) [5].

Managed care organizations spend 20 % of their premium behind administration while it is only 3% in Medicare. Moreover, Managed care covers 60% of the population while Medicare and Medicaid cover 25%. About 17% of U.S population is uninsured of which, two-third has trouble accessing/paying for health care. As Medicaid covers mainly uninsured population, therefore, we may presume that high administrative cost of care providers and quickly decreasing reimbursement rate in Medicaid is a major cause of access barrier to minorities and disadvantaged so long we bark on 'availability' of care.

The bottom line:

Possible options to remove access barrier

* Reducing fundamental socio-economic inequities (almost absent in U.S),
* Expanding insurance coverage,
* Expanding access to Public health (preventive) services that reduce risk factors to chronic diseases and injuries.
* Prompt and effective primary care in a doctor's office or other outpatient setting, followed by proper management can reduce the need for hospitalization for many medical conditions, such as asthma, dehydration, urinary tract infections, and perforated or bleeding ulcers (Foland, 2000; Office of Health Care Access, 2000). These conditions are referred to as 'ambulatory care sensitive' hospital admissions.
* When early care is delayed or foregone, the result is often 'avoidable' or 'preventable' hospitalizations which can indicate:
o problems with access to primary health care services or
o Inadequate outpatient management and follow-up, because Three out of four 'avoidable' hospital admissions occur through emergency rooms (Foland, 2000).
* Health Literacy and removing cultural barrier by social services and public health programs: Many patients lack the reading and comprehension skills helpful for maintaining a healthy lifestyle and to function in the U.S. health care system. These deficits result not only from poverty and low educational attainment, but also from differences in language and culture. Because of the inability of patients to read and understand health-related information:
o infants are being born with birth defects,
o diseases are being diagnosed at advanced stages, and
o Medications are being taken improperly.
* Removing cultural barriers to lifestyle and medication that have proven effective for controlling weight, blood pressure, cholesterol, and blood sugar should help reduce the large inequities in chronic disease.
* Universal health care (single or multi payer).

Sources:

1. "Income, Poverty, and Health Insurance Coverage in the United States: 2004." U.S. Census Bureau. Issued August 2005.

2. Cunningham P, May J. "Medicaid patients increasingly concentrated among physicians." Track Rep. 2006 Aug;(16):1-5. PMID 16918046.

3. LS Balluz, ScD, CA Okoro, MS, TW Strine, MPH, National Center for Chronic Disease Prevention and Health Promotion, CDC 2002.

4. Villar HV, Menck HR. The National Cancer Data Base report on cancer in Hispanics: relationships between ethnicity, poverty, and the diagnosis of some cancers. Cancer 1994; 74:2386--95

5. The Case for Universal Health Care in the United States http://cthealth.server101.com/the_case_for_universal_health_care_in_the_united_states.htm, The Case For Single Payer, Universal Health Care For The United States Outline of Talk Given To The Association of State Green Parties, Moodus, Connecticut on June 4, 1999-By John R. Battista, M.D. and Justine McCabe, Ph.D.