One in ten children among this low-income Oregon population lacked a current USC, mirroring national trends. Not surprisingly, children in our study without a USC had significantly higher rates of unmet healthcare need, compared with children who had a stable USC. These findings contribute to the large body of literature about the importance of having a USC.23-35
More importantly, this study found that one in four children had to change their USC for health insurance reasons. After controlling for several potentially confounding factors, the rates of unmet need for children with an unstable USC were similar to the needs of children without a USC. These findings suggest that simply having a current USC is not enough, children do better when they are able to develop a stable relationship with the same USC over time. The continuity of care that results when maintaining a stable USC not only matters for adults but also for children.
This study has important research implications. Increasingly, health services researchers are incorporating USC variables—sometimes dependent, other times independent—in models studying access to care. As we have learned to avoid assumptions that consider health insurance to be a static phenomenon, we also need to develop new methods that can accurately reflect the fluidity of having a USC one day and changing it the next. The USC changes described in this paper will have an impact on current models, and future research must account for this important variance in seeking a better understanding of health care access and utilization.
This study also has profound implications in the policy realm. Much of the current debate about health care reform has been focused on providing a medical home for everyone. Medical home advocates argue that having a USC can offer children uninterrupted access, despite potential insurance discontinuities.19, 21
In fact, a USC has proven more important than health insurance under certain circumstances.26, 28
Our study highlights the importance of ensuring stability with a USC provider or facility, which may be more important than shifting business towards more robust medical homes and away from others. In fact, attempts to move patients from one USC to another as insurance plans change may actually result in a health care system that merely provides “temporary housing,” defeating the purpose of creating medical homes in the first place.
This study contributes to global discussions about the attributes of an ideal medical home and the need to ensure stability with a USC. Most countries in the developed world can participate in these discussions without worrying about universal access to these services. In the US, however, insurance and a USC cannot be considered in isolation. A lack of health insurance was the most significant predictor for a child not having a USC, and having a parent who was uninsured was highly predictive of whether or not a child had changed his or her USC. While this study confirms the importance of a stable USC, our findings do warn against developing medical homes in the US as a substitute for expanding SCHIP and other models that are needed to stabilize the insurance system.
Interpreting data presented here requires consideration of several important factors. First, families enrolled in the food stamp program may be more resourceful when compared to a general low-income population; therefore, their children may be more likely to maintain a stable USC. Second, while a four-wave survey methodology was employed, the survey was only administered in English, Spanish and Russian; and telephone follow-up was not possible; thus, the response rate was 31%. Although this rate is comparable to the response rates of other similar studies of Medicaid-eligible populations, even some that employed telephone follow-up and personal interviews, response bias remains a concern. Some of the same factors influencing the likelihood that a family was enrolled in food stamps, such as higher literacy levels, better knowledge of available benefits, stable housing, and more secure sources of income, also influenced the likelihood of response. While responders and non-responders differed only slightly in demographic comparisons and statistical adjustments were made to control for non-response, we recognize the potential for selection and response bias even in the results that have been weighted back to the total food stamp population.
Third, as with any self-reported data, there is always the potential for recall bias. To minimize bias, respondents were asked to recall events and occurrences only in the past 12 months, and several questions pertained to similar topics in order to verify consistency in responses. Fourth, for the usual source of care predictor variable, it was possible to determine if the child had a site for usual care but not an individual provider. There may have also been subtle differences attributed to different types of usual source of care sites that were not measured in this study. We also focused on only those children who had a USC change for insurance reasons, so we did not capture all children who had changed USC for other reasons.
Finally, another factor that may vary across regions is the willingness of providers to care for underserved populations or the availability of safety net services versus how these services are delivered in other states.(Recent Graham Center Access Study) Our findings do, however, capture how a USC change can compromise access to health care services, putting children at a disadvantage similar to those who lack a USC. This study also draws strength from its focus on low-income children, a population of particular concern in the current debate about health care reform, and its relevance to current state policy discussions in Oregon. Studies such as this one are crucial to informing future state policy directions. Further studies are also needed to examine nationally-representative populations and children of all incomes.
This study not only highlights the importance of having a USC but also the need to ensure stability with a USC. A continuity relationship with a USC may, in fact, serve to buffer vulnerable populations from some of the current access disparities. We cannot build strong medical homes in isolation, however. As we build medical homes to improve the delivery of health care services, we must be wary of creating financing structures that require patients to move away from their current medical homes. In fact, shifting patients away from one USC to another, in search of the best medical home, may actually result in a health care system that merely provides “temporary housing.”