摘要：Objectives. We evaluated self-perceived access to health care in a cohort of Medicare beneficiaries. Methods. We identified patterns of use and barriers to health care from self-administered questionnaires collected during the 1993–1994 annual examination of the Cardiovascular Health Study. Results. The questionnaires were completed by 4889 (91.1%) participants, with a mean age of 76.0 years. The most common barriers to seeing a physician were the doctor’s lack of responsiveness to patient concerns, medical bills, transportation, and street safety. Low income, no supplemental insurance, older age, and female gender were independently related to perceptions of barriers. Race was not significant after adjustment for other factors. Conclusions. Psychological and physical barriers affect access to care among the elderly; these may be influenced by poverty more than by race. Disparity in access to health care among nonelderly Americans has been well documented. The primary reason for this disparity is lack of health insurance, either employer-sponsored or public. 1– 5 Approximately 16% of Americans aged younger than 65 years were uninsured in 2000. 6 A large percentage of working-age Americans without coverage have histories of chronic conditions, including diabetes, heart disease, and depression. 2 The vast majority of these people delayed or did not receive needed care because of cost. Although the most important factor affecting the ability to use health services in the nonelderly is lack of insurance, other factors have also emerged. Factors highly correlated with lack of insurance, including race, income, and other sociodemographic characteristics, have been associated with lower health care use in younger populations. 7– 9 Although there is a perception of greater equality regarding access to health care in older Americans because of the provision of Medicare, recent studies have concluded otherwise. 10– 15 Cost appears to be one of the major factors associated with lack of access to care. Between 1995 and 1997, approximately 11% of Medicare beneficiaries reported delaying care because of cost or because they had no specific source of care. 13 Because out-of-pocket expenses are the greatest financial burden for Medicare recipients, issues of cost in the elderly are primarily related to insurance coverage supplemental to Medicare. Type of insurance has been reported to be independently related to both use of health services and medical outcomes. 11, 14 In addition to lack of complementary health insurance, evidence is accumulating that other sociodemographic factors may affect the health care services received by individuals aged 65 years and older, including race, education, age, and gender. 10, 12– 15 It is also becoming evident that satisfaction with provider services may impact perceptions of access to health care 16, 17 and clinical outcomes. 18, 19 Data regarding characteristics of Medicare recipients and perceptions of barriers to care are needed to better understand this complex issue. The Cardiovascular Health Study (CHS), with a longitudinal cohort drawn from Medicare enrollment files in 1989–1990 and 1992–1993, 20 included a self-administered questionnaire on access and barriers to health care at the annual examination completed in 1993–1994. Using these data, we were able to investigate the following questions: Where do the elderly receive their medical care, and how easily are they able to be seen by a physician? What are the self-perceived barriers affecting the ability of elderly patients to see a physician? Are socioeconomic characteristics associated with self-reported barriers to care?
