Availability, accessibility, and acceptability in the evolving health care system for older adults un the United States]

OBJECTIVE: This study examined three dimensions of access to medical services that contribute to social equity in distribution--availability, accessibility, and acceptability--in order to examine the equity of two medical system arrangements in the United States of America: the traditional fee-for-services scheme and the newer, health maintenance organization (HMO) approach. Equity was compared among three racial/ethnic groups of older adults in the country: European-Americans (the majority in the United States), African-Americans, and Latin Americans (Latinos). METHODS: The data came from a representative national survey that included 858 Latinos, 970 African-Americans, and 8,622 European-Americans. All the survey participants were 65 years of age or older, living in urban areas, and using services through the United State Government's Medicare program for older persons. The three groups were compared through chi-square tests and logistic regression analysis. RESULTS: The data indicated that the older persons belonging to minority groups--who have fewer economic resources but a greater need for medical services--benefit more from HMOs, which provide them with greater availability and access to medical services than does the fee-for-services system. This difference is due to the fact that HMOs reduce the economic barriers for patients. However, the Latinos in HMOs reported lower satisfaction with their HMOs' primary-care physicians than did the European-Americans. CONCLUSIONS: The HMO approach increases access to medical care but does not necessarily improve the quality of the patient-physician interpersonal relationship for older minority persons in the United States. This study demonstrates that in health systems that are going through a reform process it is possible to monitor equity in medical care, and that an accurate assessment needs to focus on vulnerable populations as well as to distinguish between different dimensions of access.