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Access to health care and community social capital

Health Services Research, Feb, 2002 by Michael S. Hendryx, Melissa M. Ahern, Nicholas P. Lovrich, Arthur H. McCurdy

This study examines variability in access to health care across 22 major U.S. cities. We examine how reported experience with access to health care is related to two types of community characteristics: (1) health care system variables, including managed care penetration and competition and physician supply, and (2) measures of social capital. By addressing these relationships, the study explores whether access to care may be potentially improved through public health collaborations, general social capital interventions, or health care system interventions.

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During the 1990s, managed care came to dominate the health care financing and delivery market. As health costs increased in the 1990s, employers moved employees into HMO plans and offered fewer employees insurance benefits (Institute for the Future 1998). Greater managed care penetration has resulted in downward pressure on health care prices, costs, and rate of utilization for insured persons, at least initially and for some types of services. It has also resulted in less revenue to care for the growing number of uninsured.

However, the increase in managed care has also resulted in a new focus on the health of communities, a focus that is coincident with the emerging understanding of the broad determinants of health and the healthier community movement. The determinants of health are now understood to include social and community characteristics such as income distribution, sense of community, and social networks that operate through their impact on individual stress (Ahern, Hendryx, and Siddharthan 1996; Evans, Barer, and Marmor 1994; Hendryx and Ahern 1997; House, Landis, and Umberson 1988; Patrick and Wickizer 1995). As our understanding of the social aspects of human health has deepened, communities are assuming more responsibility for improving the health status of citizens by initiating new collaborative institutions such as community care networks, which combine available assets in more efficient and effective ways.

A recent study by Cunningham and Kemper (1998) showed significant community variation in reported access to health care for the uninsured after accounting for need and a set of sociodemographic variables. The authors speculated that certain community-level variables such as physician supply may account for some of this variation but did not empirically examine community variables. Our study extends the Cunningham and Kemper research by including measures of (1) community health care characteristics such as managed care penetration and competition and (2) general community social capital indicators. Furthermore, we investigate citizen perceptions of access to health care for both uninsured and insured persons.

We hypothesize that reported access to care is positively associated with community social capital. The concept of social capital reflects the belief that levels of interpersonal trust, engagement in civic affairs, and reciprocity norms among citizens in a community determine the extent of cooperative and mutually beneficial behaviors occurring within the community. We explore in more detail in the Discussion section of this article the mechanism by which social capital may achieve this outcome, but our position, in brief, is that social capital improves the likelihood and impact of community accountability mechanisms, and accountability mechanisms help protect and improve access to care. This hypothesis is derived from Putnam's (1993) findings, beginning with the study of Italian postwar local governments and extending to the study of local government performance in the United States, that the level of social capital is a powerful predictor of the effective functioning of democratic government institutions. We extend the application of Putnam's social capital concepts to the functioning of the health care institutions in 22 major U.S. cities.

With respect to the other independent variables investigated, we expect physician supply will not be related to access because of the more than adequate supply of these resources in virtually all large metropolitan areas. The expected impact of HMO penetration and HMO competition on people's reports of health care access is less clear. Although managed care may improve access to outpatient and preventive services for those covered by insurance, it may also reduce access to hospitalizations and specialty services.

METHODS

Sources of Data

The data for this multicity study are from four principal sources: the CommunityTracking Study (CTS) Household Survey, the National Institute for Health Care Management (NIHCM) Data Source, the National Association for City and County Health Officials 1997 National Profile of Local Health Departments, and a multicity broadcast media marketing database.

The CTS is the result of an initiative of the Robert Wood Johnson Foundation. Survey data collection focuses on 60 metropolitan statistical areas (MSAs) nationwide, randomly selected with probability in proportion to population to insure representation of the U.S. population. In this study, we limit the analysis to 22 of the 48 MSAs with populations of 200,000 or more persons because of data availability from the other sources (the media marketing database included 24 of the 48 CTS MSAs, and 2 MSAs were lost because of missing data from the NIHCM). (1)

Health Care Industry

Access to health care and community social capital

Health Services Research, Feb, 2002 by Michael S. Hendryx, Melissa M. Ahern, Nicholas P. Lovrich, Arthur H. McCurdy

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