This article was downloaded by: [Chinese University of Hong Kong]On: 19 December 2014, At: 00:22Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Social Work in Public HealthPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/whsp20

Beyond Access: Extending Our Thinkingon Health PolicyThomas C. Shaw aa Department of Political Science and Criminal Justice , University ofSouth Alabama , Mobile , Alabama , USAPublished online: 10 Sep 2012.

To cite this article: Thomas C. Shaw (2012) Beyond Access: Extending Our Thinking on Health Policy,Social Work in Public Health, 27:6, 554-566, DOI: 10.1080/19371910903183128

To link to this article: http://dx.doi.org/10.1080/19371910903183128

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Social Work in Public Health, 27:554–566, 2012

Copyright © Taylor & Francis Group, LLC

ISSN: 1937-1918 print/1937-190X online

DOI: 10.1080/19371910903183128

Beyond Access: Extending Our Thinkingon Health Policy

THOMAS C. SHAWDepartment of Political Science and Criminal Justice, University of South Alabama,

Mobile, Alabama, USA

Expanding access is often seen as a panacea for health problems.

Although access is a necessary step, it is also important that policy

analysts do not fail to consider postaccess issues. Increased ac-

cess to health is often assumed to be synonymous with improved

health outcomes; however, just because access exists does not mean(1) that everyone will take advantage of access to resources or

(2) that those taking advantage of access will necessarily see im-

proved outcomes. This article focuses on three aspects of health

policy, (1) the types of postaccess issues that exist, (2) the ‘‘if

you build it, they will come’’ syndrome, and (3) updating the

Anderson/Aday model of health care access to better theoretically

understand postaccess issues.

KEYWORDS Access, barriers, evaluation, health, healthcare,

policy

INTRODUCTION

The aim of this article is to examine the idea of access as it relates to under-standing health policy and health outcomes. In particular, it is a reformulationof Aday and Anderson’s (1974) and Anderson’s (1995) model of health careaccess. The reason for this reformulation is that policy makers tend to possessan ‘‘if you build it, they will come’’ mentality with regards to health care. Thismentality precipitates a focus on infrastructure and program development. Inother words, policy makers tend to focus on expanding access either via newfacilities or new programs. Although access remains a key area of concern inAmerican health care (Center for Health Economics Research, 1993; Instituteof Medicine, 2001a, 2001b; U.S. Department of Health and Human Services,

Address correspondence to Thomas C. Shaw, Department of Political Science and

Criminal Justice, University of South Alabama, 221 Humanities Building, Mobile, AL 36688.

E-mail: tshaw@usouthal.edu

554

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

Beyond Access 555

2000), the focus on access draws attention away from postaccess issues suchas why some individuals do not to make use of available services? Or why,even when individuals access health care services, their outcomes do notnecessarily improve?

The article begins by defining access and then enumerates the differentconditions of access and nonaccess. Next, it identifies the ‘‘if you build it,they will come’’ syndrome. Related to this problem, the article provides abrief example of a program, MedShare, that was able to expand access butthat was unable to produce much change in terms of health care outcomes.Last, it updates the Aday and Anderson (1974) model of health access toincorporate the ideas presented herein.

In terms of revising Aday and Anderson’s (1974) model of health careaccess, the article more clearly defines the access domain. It adds a newsubstantive aspect related to health care outcomes and, finally, revises themodel’s connections to capture more information regarding the nature of therelationships between the various dimensions.

Finally, the following caveat is warranted. The title and focus of thearticle, looking beyond access, is not meant to imply that access is nota relevant problem or that sufficient access has generally been obtained.Rather, access remains a high priority issue and is an antecedent conditionto the issues that are discussed. One of the goals of this article though is toremind policy makers that there are a host of issues beyond access that maylimit the success of access oriented policies.

DEFINING ACCESS

Access is a precondition for utilization. Therefore, access can exist regardlessof whether there is utilization. Also, there should be no serious financial ob-stacles that could prevent someone from using available services. Therefore,health care access is defined as ‘‘A condition in which health care serviceslocally exist and for which there is no significant financial impediment fortheir use.’’

In elaborating on this definition, locally existing means that basic formsof health care services such as physicians, clinics, hospitals, and so onare geographically proximate to a given population. No significant financialimpediments entails that individuals whether by using their own resources(e.g., independently wealthy), possession of health insurance (whether pub-lic or private), or by using other available programs/funds are able to usehealth care services with only nominal or no financial obligations. Thus,someone could possess health insurance that reimbursed at a rate such thatthere would still be a financial impediment to using health care services;consequently, just possessing health insurance is not a sufficient condition toensure access. By including spatial as well as resource factors, this definition

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

556 T. C. Shaw

fits within the framework established by Aday and Anderson (1974) and asupdated by Anderson (1995).

This definition then allows one to identify six major categories of indi-viduals relative to access:

1. Individuals that do not possess access: services are not available or theycannot afford to make use of available services.

2. Individuals that possess access: services are available and mechanismsexist such that cost is not an overriding factor.

Among those that possess access, the categories can be refined to the fol-lowing:

2a. Individuals that do not utilize services:i. These are individuals that are unaware of the existence or their eligi-

bility for existing programs or funding mechanisms,ii. These are individuals that are aware of services and/or their eligibility

but for any number of reasons generally choose not to make use ofthe services.

2b. Individuals that utilize services:i. These are individuals that benefit from the services they receive, that

is, they experience improved health outcomes,ii. These are individuals that do not benefit from the services they re-

ceive, for example, MedShare participants (see section on MedShare).

Of these various categories, there are reported to be between 45 and 50million (Clemmitt, 2007; Graig, 1998; Shi & Singh, 2004) in Group 1. Theseindividuals will benefit the most from new policies and programs orientedaround expanding access.

The focus of this article however is on those individuals in Group 2.Individuals in Group 2bi are clearly the success stories and generally describethe majority of health-related cases.

Individuals in Group 2ai are problematic but likely the easiest groupto affect. Strategies to assist individuals in this group relate to traditionaleducation efforts, that is, getting the word out, and making sure the publicis aware of existing programs.

Individuals in Group 2aii are highly problematic. These individuals arein some way fearful or distrustful of the health care system. Beliefs ofthese individuals vary considerably. On the fearful side, individuals maybe intimidated either by the size and scope of health care institutions or byhealth care authorities. On the distrustful side attitudes may range from a lackof faith in the efficacy of medicine to an outright distrust of medical motives(Institute of Medicine, 2002). Ultimately, these individuals will likely be thehardest to affect because they require a change in perspective or attitude.

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

Beyond Access 557

The most problematic group though is 2bii. Individuals in this groupshould be success stories but are not. Individuals in this group possess accessand have utilized the services available to them but have not seen a changein their health care outcomes, which may ultimately affect future utilization.At one extreme, this group contains compliance issues. However, at theother end are programs that are ineffectual at achieving the ultimate goalof improving health outcomes. These failures may be related to the logic orrationale of the program or to the implementation of the program. In thefirst case it is likely advisable that the program needs termination whereas inthe second case the program may only need adjusting. A prime example ofthis type of problem comes from the MedShare program in Cincinnati. Theresearch suggests that though outwardly quite successful, MedShare is nothaving the anticipated impact on its participants (Shaw & Carrozza, 2008).The article later elaborates on this program as an example of the problemsrelated to individuals in Group 2bii.

‘‘IF YOU BUILD IT, THEY WILL COME’’

Kevin Costner’s character Ray Kinsella in the 1989 film Field of Dreams istold that if he will build a baseball field in his cornfield that they will come.The they refers not only to the ghosts of the banned Chicago White Soxplayers from the 1919 World Series and other baseball greats who want toplay again, but also to the hundreds maybe thousands of people who willwant to watch them play to recapture memories of their youth. Kinsellafaces the economic dilemma of destroying part of his cornfield on a farmthat already has mounting debt to build the baseball field. In the interestsof good moviemaking, the fans show up and Kinsella’s faith is rewarded bythe fact that not only do these fans want to watch but they are also willingto pay (Robinson, 1989).

The dilemma in the realm of health care is somewhat different but theexample remains relevant. There is an almost implicit faith that by creatinga program or services, people will use them and, further, that they will reapthe intended/hoped for benefits of the program. To be fair, this mentality isnot restricted to the domain of health care and could likely be applied toalmost any policy-making area. Yet it is more acute in health care due to theinherent incentives of improved health. Unfortunately, there are a numberof problems associated with this mentality.

First, there is a belief in the rationality of individuals to seek out a serviceonce it is available. For many aspects of health care this is reasonable (e.g.,acute problems), but for nonacute problems it is a less viable assumption.Unfortunately, as identified earlier, there are many individuals that are appre-hensive, fearful, or distrustful of health care and its institutions. Particularlywhen faced with nonacute symptoms these individuals are often reluctant

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

558 T. C. Shaw

to make use of health care services. Although for non-health-related policiesit may even be economically preferable to hope that utilization is less thanoptimal at times, from a health care perspective the costs of underutilizationcan be high. Not only are there the health risks borne by the individualbut there are also the increased social costs of health spending related totreating more acute conditions as opposed to engaging in preventive care.This problem leads to individuals in Groups 2ai and 2aii (those with accessbut who are unaware and those with access but who choose not to utilize).

Second, this mentality tends to assume that the application of the process(i.e., utilization) implies an improvement in outcome. However, this is notnecessarily the case. Just as having a student in a classroom does not ensurelearning (Illich, 1972, p. 1), merely applying the outward manifestationsof health care such as tests and X-rays does not ensure improved healthoutcomes (Scott, 2003, pp. 334–336). Avedis Donabedian (2005) identifiedthis tendency in his discussion of the quality of health care as measuredby structure, process and outcomes (Wolper, 2004, p. 817). Structure andprocess are more easily measured than outcomes. Thus, particularly in thecase of process measures, there is an assumption that running tests equatesto improved health outcomes; though this is not an unfounded assumption,it is also one that cannot be accepted out-of-hand but that often is whenpolicy makers see high utilization rates. This problem leads to individuals inGroup 2bii (those utilizing but who receive no benefit from utilization).

Third, it is difficult to identify nonusers. Thus, once utilization begins tooccur the two previous problems contribute to a feeling of accomplishmentthat may lead to complacency in identifying nonusers. This problem leadsto individuals in Groups 2ai, 2aii, and 2bii.

The very success then of programs in enrolling and processing individu-als builds confidence in the program. Although this certainly does not applyto all, many policy makers and administrators are able to quickly quantifythe achievements of the program in terms of people served which pleasessponsors, donors, supporters, and constituents. The nexus between use andoutcomes is assumed because who wants to pay (particularly in difficulteconomic times) for additional evaluation research that will only reiteratewhat everyone can implicitly see in the number of enrollees/clients. Thus,because we build it and many come, we lose sight of (1) those who do notcome and (2) whether it actually works.

MEDSHARE: A PRACTICAL EXAMPLE OF AN

INEFFECTIVE PROGRAM

MedShare is a program in the Greater Cincinnati Area. It provides a subsidyfor qualifying indigent patients that allows them to purchase prescriptiondrugs at a considerably discounted rate. The program has been a huge

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

Beyond Access 559

success from an enrollment standpoint. However an evaluation of the pro-gram focused on its impact on participants’ quality of life found little to noeffect (Shaw & Carrozza, 2008). The logic behind the program was that byreducing financial impediments to prescription drugs (i.e., expanding access)individuals would experience an improvement in health care outcomes thatwould result in improved quality of life.

The SF12 was used as the quality of life measure in the MedShareevaluation. The SF12 is composed of a series of questions that ask about anindividual’s physical and mental well-being. The responses to these questionsare used to calculate physical and mental well-being sub-scores that rangefrom 0 (poor health) to 100 (good health) (Bowling, 1997, pp. 60–61). Al-though it is a somewhat blunt tool for investigating quality of life via physicaland mental functioning, the SF12 was necessary to make comparisons witha demographically similar non-MedShare group forming a postonly quasi-experimental design (Bingham & Felbinger, 2002). The SF12 was necessarybecause the data on the comparison group had already been collected inthe Greater Cincinnati Health Status Survey (GCHSS) and the only measurepertaining to quality of life in the GCHSS was the SF12. Thus, the SF12 wasthe only quality-of-life measure that could be used to make comparisonsbetween MedShare participants and a demographically similar subset fromthe GCHSS. The results of this postonly quasi-experimental design and awithin-program pre-post design failed to show any statistically significantimpact on program participants’ SF12 scores (Shaw & Carrozza, 2008). Com-pliance issues related to following physician orders and failing to acquiremedications due to economic issues were identified as having at best a mildeffect on the outcomes. However, accounting for compliance still did notshow a dramatic improvement in participants’ SF12 scores.

The paradox in this situation is that MedShare appears highly successfulaccording to most outward signs (e.g., enrollment, testimonials); yet to date,it does not seem to have produced much of an impact on enrollee’s health.From a policy perspective, the program is a clear mechanism for expandingaccess via subsidies that allow for greater access to medications. There is uti-lization/compliance in that numerous individuals are enrolling and qualifyingand are therefore taking advantage of the program. Yet closer examinationreveals that in terms of the underlying final objective, improved participanthealth, the program is not as successful.

MedShare is a clear example that expanded access and utilization do notguarantee the success of health policies in terms of improving health careoutcomes. As a result of such programs, individuals may well find themselvesin Group 2bii (those utilizing but who receive no benefit from utilization)and may eventually move into Group 2aii (those with access but who choosenot to utilize). However, we should not be satisfied with this outcome. Akey update this article makes to Aday and Anderson’s (1974) model is theaddition of health care outcomes as a factor in utilization.

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

560 T. C. Shaw

From a policy-making standpoint, one should be concerned about hav-ing health care outcomes incorporated into the model for two reasons. First,one should be absolutely concerned about programs that are not producingdesired outcomes. This concern is not restricted to the domain of healthpolicy but is particularly relevant within the health policy area given thepotential individual and social costs. Whether programs require terminationor reformulation is a contextual matter related to individual programs, butfrom a theoretical standpoint, it is essential to identify the evaluation phaseof the process. Second, the lack of improved outcomes due to programexposure could well lead to dissatisfaction among health care consumerswho may then join the ranks of Group 2aii (those with access but whochoose not utilize). Such defections may range from a matter of apathy, thatis, seeking out health care doesn’t help, so why do it; to probably the worst, amatter of cynicism in which individuals feel that the health care infrastructureis intentionally designed to produce poor outcomes and high profits.

ADJUSTING ADAY AND ANDERSON’S MODEL

The following changes are made to Aday and Anderson’s (1974) model toaccount for the issues discussed herein (see Figures 1 and 2). First, a financingmechanism box has been added to account for the fact that many healthpolicies are not aimed at structural characteristics but rather at reducingfinancial impediments to utilization. In the original model this aspect wasassumed under enabling factors. Enabling factors are still relevant to themodel because these may refer to characteristics such as transportation ortime-off work.

Next, the existing linkage between characteristics of the population andutilization has been highlighted to show the significance of this relationship.This is an area that needs attention beyond the access layer. That is, onceaccess is available, how does one increase the utilization of services amongmembers of Groups 2ai and 2aii?

Although there are difficulties associated with increasing utilization, par-ticularly acute among members of Group 2aii, the model is most seriouslydeficient in that it does not include any reference to outcomes. Here is wherethe ‘‘if you build it, they will come’’ syndrome fits into the model: because ac-cess is provided and utilization occurs, there is seemingly no need to evaluatefor outcomes as those are assumed to follow by virtue of individuals makinguse of the services. In the original model there was no accounting for theidea that outcomes may also affect utilization. The updated model includesa reciprocal mechanism such that utilization may affect customer satisfactionwhich may (or may not) in turn reaffect utilization. Also, outcomes mayaffect future utilization depending on the actual or perceived result of theoutcome.

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

Beyond Access 561

FIGURE 1 Aday and Anderson’s expanded behavioral access model.

These changes help to highlight the issues related to the various cat-egories of individuals identified and more fully elaborate the model. Indi-viduals in Group 1 (those without access) clearly benefit from new accesspolicies. Individuals in Groups 2ai and 2aii (those with access but who areunaware and those with access but who choose not to utilize) are accountedfor in the characteristics of the population at risk and its linkage to utilization.Individuals in Groups 2bi and 2bii (those utilizing who receive a benefit andthose utilizing but who receive no benefit from utilization) are accountedfor in the outcomes area and the linkage back to consumer satisfaction andfrom there to utilization.

THINKING BEYOND ACCESS

Although access is a key factor and one that cannot be ignored in thinkingabout health care, there is a tendency to turn to other problems the momentaccess is achieved for a given population or group. Indeed, this is often thehighpoint of the policy process. Something, a program or maybe a building,has been created. Elected leaders, policy makers, and administrators canpoint to their accomplishment. Many of these same individuals then tend toassume rational actor behavior. That is, that people will automatically seek

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

562 T. C. Shaw

FIGURE 2 Updated behavioral access model incorporating outcomes.

out health relief or in other words, ‘‘If you build it, they will come.’’ Littlethought is given to those that do not utilize, and probably even less is givento the outcomes associated with those that do utilize because utilization isso closely correlated with improvement in people’s minds.

The overarching theme for this article is that to be more fully successfulin terms of health policy, we need to think beyond access and consider(a) how to increase utilization among both groups 2ai and 2aii, and (b) howto ensure that utilization leads to improved outcomes so that we can mini-mize individuals in Group 2bii.

Like most research, this article is long on problems and short on answers.However, the following paragraphs attempt to (a) open the door to possibleavenues for further exploration, (b) outline the difficulty in addressing the

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

Beyond Access 563

issue, and (c) discuss the implications for policy making. Table 1 presents asummary of the key points.

From the utilization standpoint and those that are unaware of programsor their eligibility, this seems to be a relatively straightforward case of in-creasing education and efforts aimed at raising community awareness. Froma policy standpoint, this suggests a low to moderate level of difficulty inaddressing the problem. On the positive side, these are common types ofpolicy initiatives that are familiar to most decision makers; therefore, they arelikely to be well received provided that funding is available. Unfortunately,the big money is typically in establishing new programs such that education-oriented efforts are often somewhat less attractive.

There may be many reasons for those individuals that are aware ofprograms and possess access but who still choose not to participate: attitudestoward health care or assistance, cultural/ethnic issues, or just plain fear andsuspicion of physicians, health care in general, or bureaucracy. These aretypically more difficult and far-reaching issues and to use Anderson’s (1995)terminology are considerably less mutable to health policy. However, foraccess policies to achieve efficiency, that is to maximize the utilization ofservices and programs, more consideration needs to be given to overcomingthese barriers. These issues pose moderate to highly difficult problems interms of policy. Because responses to these issues will involve changingdeeply set belief systems (that may be culturally related and reinforced),they will involve a very long-term timeline for change and will be difficult toevaluate. Consequently, policy makers will tend avoid these issues becausethey are costly and complex with little immediate payoff for elected officials.

In many ways, the most serious problem may be the situation in whichindividuals utilize the system but do not realize improvements in healthoutcomes (2bii). These cases have the potential to further undermine thedesire to utilize services. A good first step in addressing this problem is toincrease the emphasis on program evaluation (Bingham & Felbinger, 2002).Due to the ‘‘if you build it, they will come,’’ syndrome, it is too easy ifutilization numbers are good to assume that outcomes are being improved.Thus, program evaluation is a necessary step in identifying whether policiesare working. Unfortunately, it is again the case that the real money is inestablishing programs not in evaluating them. Indeed evaluation is usuallybest avoided from an administrative standpoint as the potential results usuallyhold more pitfalls than blessings. Certainly, evaluation is a trend that has beencontinuing since at least the 1970s (Poland et al., 1974); however, it mayhave reached its contemporary zenith in the public sector in the mid-1990swith Vice President Al Gore’s efforts at reinventing government. Despite theattention it receives, evaluation often seems to be treated as an afterthoughtliterally and from an economic standpoint.

Compliance is a potential issue when considering the ineffectiveness ofutilization. Is it that the program itself is not successful? Or, are the patients

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

TA

BLE

1The

Cat

egories

of

Acc

ess

and

Policy

Implica

tions

Cat

egories

rela

tive

toac

cess

Difficu

lty

Policy

implica

tions

1In

div

idual

sth

atdo

notposs

ess

acce

ss—

serv

ices

are

notav

aila

ble

or

they

cannotaf

ford

tom

ake

use

ofav

aila

ble

serv

ices.

Low

tom

odera

tedifficu

lty.

Fin

dm

ore

reso

urc

es

toexpan

dac

cess

tom

ore

gro

ups.

These

polici

es

are

stan

dar

dpro

gra

mefforts

aim

ed

atpro

vid

ing

insu

rance

or

mak

ing

serv

ices

avai

lable

and

are

usu

ally

well

supported

by

deci

sion-m

akers

.2

Indiv

idual

sth

atposs

ess

acce

ss—

serv

ices

are

avai

lable

and

mech

anis

ms

exis

tsu

chth

atco

stis

notan

overr

idin

gfa

ctor.

2a

Indiv

idual

sth

atdo

notutilize

serv

ices.

2ai

These

are

indiv

idual

sth

atar

eunaw

are

of

the

exis

tence

or

their

eligib

ility

for

exis

ting

pro

gra

ms

or

fundin

gm

ech

anis

ms.

Low

tom

odera

tedifficu

lty.

These

indiv

idual

sneed

tobe

mad

eaw

are

ofth

eav

aila

bility

of

serv

ices

and/o

rth

eir

eligib

ility

for

serv

ices.

These

polici

es

are

fairly

stan

dar

dtrad

itio

nal

educa

tion

efforts

and

are

usu

ally

well

supported

by

deci

sion-m

akers

.2ai

iThese

are

indiv

idual

sth

atar

eaw

are

of

serv

ices

and/o

rth

eir

eligib

ility

butfo

ran

ynum

ber

ofre

asons

genera

lly

choose

notto

mak

euse

of

the

serv

ices.

Modera

teto

hig

hly

difficu

lt.

These

indiv

idual

sw

illre

quire

ach

ange

inth

eir

bas

icunderlyin

gbeliefst

ruct

ure

s;as

such

,policy

efforts

tore

ach

these

indiv

idual

sw

illbe

long

term

innat

ure

.B

eca

use

there

willbe

little

short

term

pay

off

and

difficu

lty

ineval

uat

ing

succ

ess

these

polici

es

are

notlikely

tobe

well

supported

by

deci

sion-m

akers

.2b

Indiv

idual

sth

atutilize

serv

ices.

2bi

These

are

indiv

idual

sth

atbenefitfr

om

the

serv

ices

they

rece

ive,i.e.,

they

experience

impro

ved

heal

thoutc

om

es.

No

real

difficu

lty.

These

indiv

idual

sposs

ess

acce

ssan

dar

ere

apin

gits

benefits

;as

such

,th

ere

isno

need

toad

dre

ssth

isgro

up

with

additio

nal

polici

es.

2bii

These

are

indiv

idual

sth

atdo

notbenefit

from

the

serv

ices

they

rece

ive,e.g

.,M

edSh

are

par

tici

pan

ts(s

ee

sect

ion

on

MedSh

are).

Modera

teto

hig

hly

difficu

lt.

These

indiv

idual

sm

ayor

may

notbeco

me

dis

satisf

ied

with

heal

thse

rvic

es

dependin

gon

wheth

er

they

real

ize

the

lack

ofbenefitth

ey

are

rece

ivin

g.There

are

thre

edifficu

ltie

sw

ith

this

gro

up.First

,eval

uat

ion

efforts

are

nece

ssar

yto

est

ablish

pro

gra

mm

atic

succ

ess

and

eval

uat

ion

isgenera

lly

less

well

supported

by

deci

sion-m

akers

.Se

cond,th

e‘‘i

fyou

build

it,th

ey

willco

me’’

syndro

me

mitig

ates

agai

nst

both

the

need

for

eval

uat

ion

and

negat

ive

eval

uat

ion

resu

lts.

Third,deci

sion

mak

ers

are

less

likely

tosu

pport

efforts

inth

isar

ea

beca

use

they

repre

sentpre

vio

us

failure

s.

564

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

Beyond Access 565

not following through on specified treatment plans? Either situation or acombination of both may be to blame (Gochman, 1997). There are a numberof potential reasons for a lack of compliance: (a) intentional disregard,(b) lack of understanding, or (c) lack of means to carry out the treatment plan(e.g., costs associated with being healthy). There may however be more ofan effort on the part of physicians to address compliance issues with creativesolutions now that physicians are bearing more of the risk associated withpatients’ health under managed care (Bodenheimer & Grumbach, 2009, pp.31–37; Wolper, 2004, p. 419). However, despite the impact and complexityof compliance issues, there is still evidence that some health programs lackeffectiveness. The MedShare example is a case in point.

Finally in terms of Group 2bii, they pose a moderate to high level ofdifficulty in terms of policy. Because the emphasis in addressing this group ison program evaluation, policy makers and elected officials are less likely tobe interested in these problems which are not as politically sexy. Also, the ‘‘ifyou build it, they will come,’’ syndrome can undermine efforts at increasingprogram evaluation. Last, because addressing these issues likely acknowl-edges earlier programmatic failures, policy makers and elected officials willtypically not want to be associated with them.

In conclusion, this article highlighted some key deficiencies in the cur-rent thinking on access and health policy. It reformulates Aday and Ander-son’s (1974) model to better conceptualize where access fits in the modeland to incorporate relevant but missing factors: health care outcomes aswell as important linkages between the concepts. In addition, it identifiesa series of categories of individuals that while possessing access are still atrisk either due to a lack of utilization or the ineffectiveness of utilizationand relates the policy implications to each of these categories. Finally, thepaper calls attention to the, ‘‘If you build it, they will come,’’ syndrome whichby (a) assuming rational behavior, (b) substituting utilization for outcomes,and (c) equating utilization with success, tends to blind policy makers topostaccess health issues.

REFERENCES

Aday, L. A., & Anderson, R. M. (1974). A framework for the study of access to medicalcare. Health Services Research, 9, 208–220.

Anderson, R. (1995). Revisiting the behavioral model and access to care: Does itmatter? Journal of Health and Social Behavior, 36(1), 1–10.

Bingham, R. D., & Felbinger, C. L. (2002). Evaluation in practice (2nd ed.). NewYork, NY: Seven Bridges Press.

Bodenheimer, T., & Grumbach, K. (2009). Understanding health policy: A clinical

approach (5th ed.). New York, NY: McGraw-Hill.Bowling, A. (1997). Measuring health, a review of quality of life measurement scales.

Philadelphia, PA: Open University Press.

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014

566 T. C. Shaw

Center for Health Economics Research. (1993). Access to health care: Key indicators

for policy. Chestnut Hill, MA: Center for Health Economics Research.Clemmitt, M. (2007). Universal coverage. CQ Researcher, 17(12), 265–288.Donabedian, A. (2005). Evaluating the quality of medical care. Milbank Quarterly,

83(4), 691–729.Gochman, D. S. (Ed.). (1997). Handbook of health behavior research II: Provider

determinants. New York, NY: Plenum Press.Graig, L. A. (1998). Health of nations. Washington, DC: Congressional Quarterly

Press.Illich, I. (1972). Deschooling society. New York, NY: Harper & Row.Institute of Medicine. (2001a). Crossing the chasm: A new health system for the

twenty-first century. Washington, DC: National Academies Press.Institute of Medicine. (2001b). Coverage matters, insurance and health care. Wash-

ington, DC: National Academies Press.Institute of Medicine. (2002). Unequal treatment: Confronting racial and ethnic

disparities in health. Washington, DC: National Academies Press.Poland, O. E., Horst, P., Nay, J. N., Scanlon, J. W., Wholey, J. S., Lewis, F. L., : : :

Hedrick, J. L. (1974, July/August). Program evaluation. Public Administration

Review, 34(4), 299–338.Robinson, P. A. (1989). Field of dreams. Universal Studios.Scott, R. W. (2003). Organizations: Rational, natural, and open systems (5th ed.).

Upper Saddle River, NJ: Prentice Hall.Shaw, T. C., & Carrozza, M. A. (2008). Is access sufficient? An examination of the

effects of the MedShare program to expand access to prescription drugs forindigent populations. Evaluation Review, 32(6), 526–546.

Shi, L., & Singh, D. A. (2004). Delivering health care in America, a systems approach.

Sudbury, MA: Jones and Bartlett.U.S. Department of Health and Human Services. (2000). Healthy people 2010: Un-

derstanding and improving health (2nd ed.). Washington, DC: GovernmentPrinting Office.

Wolper, L. F. (2004). Health administration (4th ed.). Sudbury, MA: Jones andBartlett.

Dow

nloa

ded

by [

Chi

nese

Uni

vers

ity o

f H

ong

Kon

g] a

t 00:

22 1

9 D

ecem

ber

2014