SOCIAL CONDITIONS AND SELF-MANAGEMENT ARE MORE POWERFUL DETERMINANTS OF HEALTH THAN ACCESS TO CARE

Professional organizations advocate universal access to medical care a s a primary approach to improving health in the population. Access to medical services is critical to outcomes of acute processes managed in an inpatient hospital, the setting of most medical education, researc h, and training, but seems to be limited in its capacity to affect out comes of outpatient care, the setting of most medical activities. Pers istent and widening disparities in health according to socioeconomic s tatus provide evidence of limitations of access to care. First, job cl assification, a measure of socioeconomic status, was a better predicto r of cardiovascular death than cholesterol level, blood pressure, and smoking combined in employed London civil servants with universal acce ss to the National Health Service. Second, disparities in health accor ding to socioeconomic status widened between 1970 and 1980 in the Unit ed Kingdom despite universal access (similar trends were seen in the U nited States). Third, in the United States, noncompletion of high scho ol is a greater risk factor than biological factors for development of many diseases, an association that is explained only in part by age, ethnicity, sex, or smoking status. Fourth, level of formal education p redicted cardiovascular mortality better than random assignment to act ive drug or placebo over 3 years in a clinical trial that provides opt imal access to care. Increased recognition of limitations of universal access by physicians and their professional societies may enhance eff orts to improve the health of the population.