This study addressed the separate and combined association between insurance and/or a USC and access to health care for adults in the US. The uninsured without a USC were at highest risk for not receiving needed services. In many cases, having only insurance or only a USC was associated with higher rates of unmet needs as compared to having both. In addition to the differences noted among the INS/USC subgroups, there were consistent patterns of increased vulnerability among those in all income categories below 400% FPL and among those reporting less than “excellent” health status. Those over age 65 were less likely to experience unmet medical needs, problems getting care and delayed care, than those in the reference age group between 18–24 years of age. This confirms previous work which has found that receipt of unmet health care needs, and many disparities in basic cardiovascular risk measures, decline for those over age 65.32–37
It has been reported that these declines are largely due to many uninsured adults obtaining Medicare at age 65. However, we controlled for insurance status, so there may be an additional protective effect from Medicare insurance as compared to another type of insurance. In addition, perhaps, those in this age group may be more proficient at navigating the health care system to get their needs met or they may be less likely to report an unmet need.
As shown in Table , those without insurance were more likely to not have a USC and vice versa; however, Table shows that 15% of adults have either insurance or a USC but not both, highlighting that access to one does not guarantee access to the other. This suggests that covering millions more with stable health insurance will not ensure that everyone has a USC. In fact, some studies propose that expanding eligibility for public insurance programs or mandating individual coverage, without a mechanism to ensure adequate provider capacity, will merely result in more covered Americans with nowhere to go for care.13,38–40
Alternatively, expanding the number of community health centers may bolster the capacity of the safety net in order to improve access to a USC, but leave thousands without insurance to cover necessary prescription medications, tests, referrals and ancillary services.41
Concurrent with health insurance reforms, there is a separate need to focus on bolstering the US health system’s capacity to provide a stable usual source of care.
Further, even individuals with financial access (i.e. insurance) and structural access (i.e. a USC) do not always receive care.5,8,12
For example, in this study, 5.4% to 37.1% of adults in the Yes INS/Yes USC group reported having at least one of the unmet health care needs. This suggests that having insurance and a USC provides potential access
, but the degree of synergy between them dictates whether realized access
is achieved (Fig. ).
Potential and realized access to health care services.
Figure illustrates the difference between the potential for care and the reality of care. An individual can have insurance, which provides potential financial access; but if he or she cannot find a primary care physician within the insurance network, care cannot be realized. Alternatively, if structural access is available but the care is unaffordable (i.e. lack of financial access), then the care is not realized. In either case, potential access is not real access until both financing and delivery are coordinated and consistently available. Figure demonstrates the important overlap that must exist to make access a reality—only at the confluence of the two circles. Thus, unmet need does not mean having no access; rather, unmet need is the difference between having potential and realized access (the outer, non-overlapping areas of each circle in Figure ). This model might help to explain why over one-third of adults with insurance and a USC reported at least one unmet need in this study. If someone has financial and structural access (potentially) but the circles in Figure have little or no overlap, then they are likely to experience unmet needs.
There are exceptions. Some individuals who lack potential access or who have minimal overlap do realize care. For example, a patient’s USC might agree to continue seeing her even though she has lost insurance and no longer has financial access. Or, a patient who has changed insurance carriers may pay out-of-pocket to continue receiving services from a trusted USC outside of his network (although this is rare and usually results in patient’s reducing contact with their USC).19
“Patient-centered medical homes” might help to improve synergistic relationships between the financing and delivery of primary health care, especially if payment mechanisms are transformed to facilitate comprehensive and integrated care.42–49
Innovators have made headway in defining and demonstrating medical home models.44,45,50–53
However, the number of US medical school graduates entering primary care professions has been in a rapid decline, which casts doubt on the US health care system’s ability to provide a basic USC, whether a medical home or not, to all newly insured persons.54
Thus, it remains to be seen whether medical home efforts to improve quality and performance will increase capacity and ensure continuous access to a USC.
Secondary data analyses are limited to existing data. For example, MEPS-HC data are available through 2007, so we were not able to ascertain the effects of the recent economic downturn. We reported on cross-sectional measures for both insurance and a USC because we did not have data to capture longitudinal USC status; therefore, we could not capture the effects of duration of insurance and/or continuity with a USC.55–57
We also did not account for the type of USC provider, which might contribute to subtle differences that were not measured in this study.58
Also, we did not include a full analysis of the specific reasons people reported a lack of a USC; however, upon review of the main reasons we found the top reported to be that respondents were seldom or never sick and the second most common was that the cost of medical care was too high. Since we used a subgroup that included people who had seen a clinician at least once in the past year and who reported that they had a need for care, it is unlikely that these reasons for a lack of USC would change our results. As with all studies that rely on self-report, response bias remains a possibility.
Although the MEPS-HC is representative of the civilian, non-institutionalized US population, the observational nature of the data limits causal inferences. We aimed to achieve consistency in our examination; thus, we included the same covariates across all logistic regression models. We secondarily assessed associations with other covariates, but did not build individual models for a comprehensive examination of each covariate.
Finally, we recognize that every state has unique insurance programs, and the availability of services varies widely by region. While we could not account for the willingness of providers to care for underserved populations or the availability of safety net services in every region, the multivariable analyses did include a MEPS-HC geographic region variable, which would be considered a crude proxy for some of these variations.