in Medicine and Biomedicine and Behavioral Science Research, 1983, p. 4). As the commission pointed out, however, transforming this moral obligation into reality is difficult because it involves deciding what constitutes an adequate level of care, what should be considered an excessive burden, and how to know when these standards have been reached or even exceeded.

As the IOM committee considered ways to resolve these conceptual problems, it became clear that health outcomes are as integral to the concept of access as is the use of services. Certain questions assumed central importance—for example, who is not receiving preventive services or medical treatment that would make a difference for health status? Who is not receiving care that eases pain, improves functioning, or alleviates anxiety? With equity of access to health services, the answers to these questions should not be affected by race, ethnic origin, income, geographical location, or insurance status.

Based on these considerations, the committee defined access as follows: the timely use of personal health services to achieve the best possible health outcomes. Importantly, this definition relies on both the use of health services and on health outcomes to provide yardsticks for judging whether access has been achieved. The test of equity of access involves determining whether there are systematic differences in use and outcome among groups in society and whether these differences are the result of financial or other barriers to care.

A standard of "the best possible health outcome" is admittedly an ideal goal. Particularly in a society that limits the resources devoted to health care, all that medical science can offer is an optimistic target, unattainable for every patient. Social critics commenting on the health care scene have reminded us from time to time that, even if we could afford it, more medical services are not necessarily a good thing, nor are more services frequently the best road to good health for a society faced with tradeoffs about the best social investments it could make (Evans and Stoddart, 1990; Illich, 1975).

In applying its definition of access the committee sought to occupy a practical middle ground between all care that people might want or believe they needed and the view that medical care can make an important difference in people's lives. The definition forces us to identify those areas of medical care in which services influence health status and then to ask whether the relatively poorer outcomes of some population groups can be explained by problems related to access. The definition also emphasizes the need to move beyond standard approaches that rely mainly on enumerating the presence of health care providers, the number of uninsured, or encounters with health care providers to detect access problems.

For a health outcome to be a useful indicator of access problems, one

Front Matter (R1-R10)

Summary (1-18)

1. Introduction (19-30)

2. A Model for Monitoring Access (31-45)

3. Using Indicators to Monitor National Objectives for Health Care (46-129)

4. Future Indicators (130-136)

5. Recommendations (137-144)

Appendix A: Developing Indicators of Access to Care: The Case for HIV Disease (145-180)

Appendix B: Developing Indicators of Access to Care: Waiting Lists for Drug Abuse Treatment (181-198)

Appendix C: Developing Indicators of Access to Care: The Case for Migrants and the Homeless (199-218)

Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries (219-222)

Index (223-230)