Access to health care in North Dakota, a frontier state, has been a widely debated policy issue. Historically, the focus of North Dakota health policy efforts has been directed to issues pertaining to the provision of health care services. During the economic recession of the I 980s, an out-migration of North Dakota residents left the state with a smaller population in 1990 than it had in 1930, the only state to experience this population shift. In response to these demographic shifts, the North Dakota Health Task Force was formed to develop a health care reform strategy that addressed geographical and financial health care access issues. Over 2,000 North Dakota families were surveyed to provide the Task Force and other policy makers with information about North Dakota residents' health insurance coverage and health care utilization. The purpose of this research was to examine what variables impact access to health insurance coverage and utilization of health care services in North Dakota. Three access areas were addressed: financial, geographical and cultural. To examine financial access, health insurance coverage was examined. Among the non-institutionalized ND residents, the greatest proportion of uninsured were young adults; although, all North Dakotans were found to be at risk. The health insurance findings mirrored many other studies' findings in which males, part-time workers and rural dwellers were the most likely to go without insurance. In addition, health insurance appears to serve as a gatekeeper for obtaining health care services. A surprising finding was that geographic barriers were not a hindrance to obtaining health care. Yet, Native Americans covered by Indian Health Service were less likely to obtain health care than the uninsured indicating there may be some cultural barriers for this population. Other findings included: the uninsured go without health care and report lower health status more frequently than the insured; poverty level is positively correlated with health status; among those with no regular source of health care, the insured report they do not need health care while the uninsured report they cannot afford it. Comparisons of rural and urban dwellers also are included in the analyses.