There are two ways to look at the issue of access to health care. The first is
legal and theoretical. For example, say a federal or state law mandates that
any family whose income is within 150 percent of the federal poverty level
qualifies for a particular public health insurance program. Having accom-
plished this, legislators claim that they have provided access to health care for
all these low-income people. The problem is resolved. The legislators feel
good, knowing that they have pushed through important legislation. Most
of the tax-paying public feels good, knowing that a portion of their taxes is
being spent for a legitimate humanitarian purpose, to help those not in a po-
sition to help themselves. Low-income families that can take full advantage
of the public health insurance feel good because they have access to health
care that otherwise would have been prohibitively expensive.

The second way to analyze the issue of access is to look past image, myth,
and ideology--to look beyond abstract laws and regulations that address ac-
cess. While the importance of these government programs cannot be denied,
the mere fact of their existence does not guarantee that the target population
will have access to health care and certainly does not guarantee access to
health care for those in need but outside the target population. The reality of
access to health care is that it is influenced not only by government programs
but also by a wide range of political, economic, cultural, and other social fac-
tors. For example, how many legally qualified applicants for a public health
insurance program cannot complete the initial application and interview
process because they are illiterate or have a poor grasp of the English lan-
guage because it is not their native tongue? How many cannot go to the of-
fice for the required interview because they lack money for transportation,
because they lack day care for their children, or because they cannot take
time off from their job for fear of losing it? Once enrolled in the public
health insurance program, how many families cannot use the benefits be-
cause they cannot afford required deductibles and copayments? How many
are forced to use emergency rooms because physicians will not give appoint-

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