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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One of the key objectives of accountability mechanisms is to protect access to care for vulnerable populations (Steinberg and Baxter 1998). Accountability initiatives to protect access are designed to ensure that institutions are providing high-quality care to all segments of the population. For example, in one CTS site, a study of the burden of indigent care revealed that one institution was not providing its share. This institution came under close scrutiny, and community initiatives were prompted to improve access and explore financing models for the uninsured. In another site, a hospital association that provides a leadership role in community health included representation from physicians and business leaders on its governing body. Our view is accountability mechanisms are more likely to arise and be successful when the three theoretical components of social capital--trust, civic engagement, and reciprocity norms--are in place.

Even though the magnitude of the observed effects was modest, the findings reported here are important because they are shown to be independent of individual-level predictors known to be powerful correlates of access and because they are independent of health system characteristics. In addition, the results cannot be attributed to common method variance but represent completely separate sources of information. The measure of access from the Household Survey represents self-reported perceptions, whereas the measures of social capital are collected from independent surveys and data sources unconnected to the Household Survey.

It is intriguing that although the measure of general social capital was related to access as hypothesized, a measure specific to public health-community collaborations was significant in the opposite direction--collaboration was negatively associated with access. This may be a function of the inclusion of specific communities where public health officials are striving to engage in collaborations because access problems are known to exist. However, if social capital in general improves access, but public health collaborations--which might reasonably be viewed as a manifestation of social capital--show the opposite effect, it might be the case that social capital operates in ways the public health collaboration variable does not represent. What these other ways may be is an important question for further research. One possibility is public health collaborations affect a relatively small proportion of the population when it comes to access and that access for the population in general is more dependent on broa der community functioning.

The reporting of fewer access to care problems was related to one other health system variable: more HMO plans in the MSA. This community feature is in contrast to individual HMO enrollment, which was associated with more access problems. The presence of more HMO plans in a community may represent greater competition for customers, resulting in downward price pressure and more effective control of health insurance premiums and out-of-pocket costs. In other analyses not shown here, more HMO plans were associated with reduced out-of-pocket costs. More HMO plans also increases the probability that plans are locally owned, and locally owned plans may be more committed to providing better access to their enrollees.