Access to Care

Studies examine the impact of both health insurance and a usual source of care on access to health care

Medicaid and the State Children's Health Insurance Program (SCHIP) have expanded health insurance coverage to millions of low-income U.S. children. Beyond expansions in health insurance coverage, recent efforts to improve children's access to care have focused on securing a "medical home" (usual source of care) for all children. A usual source of care has proven more important than health insurance under certain circumstances. Nevertheless, both health insurance and a usual source of care are needed to provide children with optimal access to needed care, concludes a new study.

For low-income parents, insurance coverage was their primary concern, with care access and costs secondary, according to a second study. A third study found that adults with a usual source of care were more likely to perceive interactions with their health care provider as positive. The three studies were led by Jennifer E. DeVoe, M.D., D.Phil., of Oregon Health & Science University, and supported by the Agency for Healthcare Research and Quality (HS16181 and HS14645). They are summarized here.

DeVoe, J. E., Petering, R., and Krois, L. (2008, October). "A usual source of care: Supplement or substitute for health insurance among low-income children?" Medical Care 46(10), pp. 1041-1048.

Several policies are being proposed to improve children's access to care. Some policies, such as expanding the number of community health centers, aim to bolster the capacity of the safety net to deliver more services to improve access to a usual source of care, but still leaving thousands of children without health insurance. Other proposals expand eligibility for SCHIP, or mandate statewide individual health insurance coverage, without a mechanism to ensure adequate provider capacity. However, this study demonstrates that these efforts must be simultaneous. It found that each approach added to the likelihood of children's improved access to needed care. The researchers analyzed responses to 2,681 surveys of Oregon's food stamp program members to determine if insurance coverage or a usual source of care was superior for ensuring better access of children to necessary care services. Low-income Oregon children with health insurance and a usual source of care reported the best access to health care. After adjusting for multiple factors, insured children without a usual source of care had double the rate of unmet medical need, nearly seven times the likelihood of no doctor visits in 12 months, and four times the likelihood of problems obtaining specialty care. Similarly, having a usual source of care but no health insurance was associated with over four times the likelihood of unmet medical needs, nearly three times the odds of unmet prescription needs, and nearly five times the likelihood of problems obtaining dental care. In nearly every case, uninsured children without a usual source of care were at the highest risk of not receiving services.

DeVoe, J. E., Graham, A. S., Angier, H., and others (2008, November). "Obtaining health care services for low-income children: A hierarchy of needs." Journal of Health Care for the Poor and Underserved 19, pp. 1192-1211.

In this survey of a random sample of families from Oregon's food stamp population with children eligible for public insurance, low-income parents revealed barriers to obtaining health care services for their children. The researchers examined data from 2,681 completed surveys and written narratives from 722 parents. Parents of insured children were less likely than parents of uninsured children to report unmet health care needs. Health insurance coverage for both parents and children mattered greatly to this group. Parents were most concerned about health insurance instability, lack of access to services despite having insurance, and unaffordable medical costs. Once a family had secured insurance for the family, they then worried about accessing services (provider acceptance of insurance and insurance coverage of services) and costs. Insurance coverage, while important, may not provide unfettered access to quality health care for low-income children. This study confirms that parents are aware of this.

DeVoe, J. E., Wallace, L. S., Pandhi, N., and others (2008, September/October). "Comprehending care in a medical home: A usual source of care and patient perceptions about healthcare communication." Journal of the American Board of Family Medicine 21, pp. 441-450.

The ability to understand professional recommendations and to communicate with clinicians is important to the receipt of good quality health care services and patient satisfaction. For adults, having a usual source of care is associated with positive perceptions of health care communications, concludes this study. The research team analyzed nationally representative data from the 2002 Medical Expenditure Panel Survey to determine patient perceptions about health care communication. About 78 percent of U.S. adults reported having a usual source of care. Those who did were more likely to report that care providers always listened to them, always explained things clearly, always showed respect, and always spent enough time with them. Among survey respondents with a usual source of care, patients who perceived themselves to have more decisionmaking autonomy were non-Hispanic, had health insurance coverage, lived in rural areas, and had higher incomes. The researchers recommend that once patients are provided with a usual source of care, educational programs need to target individual practices to increase awareness among clinicians about how to actively involve all patients' participation, to the extent that they desire, in decisions about their health.

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