ABSTRACT
Access to health care in the United States involves longstanding inequities rooted in socioeconomic class (Institute of Medicine [IOM], 1993; Mechanic, 1994), and the recent emergence of the managed care industry as the dominant form of health insurance has raised new concerns about access, even among the insured. A majority of Americans now are covered by managed care plans and thus are subject to an array of demand-limiting tactics aimed at controlling health care utilization and costs. The ascendance of for-profit managed care organizations (MCOs) in the health care market has occurred in part because the United States has been unwilling to formulate explicit rationing policies to distribute limited health care resources across the population. The U.S. health care system, with its eclectic mix of private and public payers and providers, has no explicit rationing policy, but has a de facto one based on ability to pay and, to a lesser extent, on geographic variations in access to care. For example, the uninsured who are ineligible for Medicaid (e.g., the working poor) exemplify the operation of implicit rationing based on insurance coverage (Feldman, 1994). Among the insured, another form of rationing occurs when MCOs deny or delay approval of reimbursement for treatment, and the decision rules that govern such actions remain ambiguous at best and suspect at worst. Inequity in the national distribution of health care professionals and provider organizations, which favor urban over rural areas, is another form of rationing.
