Access to Care

The number of Americans who do not have health insurance continues to increase. The National Health Interview Survey found that from January to June 2009, 45.4 million people (15.1%) were uninsured at the time of interview, 58.4 million people (19.4%) were uninsured for a portion of the year prior to the interview, and 8.2% of children were uninsured at the time of interview.[2]

Additionally, there are disparities in access to care based on race/ethnicity, employment, gender, and income level. Ethnic minorities are more likely to be uninsured than non-Hispanic whites. The 2008 National Health Interview Survey reported that 30.7% of Hispanics, 16% of African Americans and 10.4% of non-Hispanic white individuals had no health insurance at the time of interview.[3] Employment-based coverage is the largest source of health coverage in the U.S., and many unskilled, low paying, and part-time jobs do not offer health coverage benefits.[4] In 2008, one-third of the uninsured were in families with a household income less than $20,000.[4] In general, employment status is the most important predictor of health care coverage in the U.S. Within the employer framework, racial disparities exist: in 2008, approximately 70% of non-Hispanic whites had employment-based coverage, whereas only 50% of African Americans and 41% of Hispanics had employment-based coverage.[4] Disparities in health care coverage also exist based on gender and age. Men are more likely to be uninsured than women in all age groups.

 Evidence shows that uninsured individuals experience more adverse outcomes (physically, mentally, and financially) compared to insured individuals.[4] The uninsured are less likely to receive preventive and diagnostic health care services, are more often diagnosed at a later disease stage, and on average receive less treatment for their condition compared to insured individuals.[4] At the individual level, self-reported health status and overall productivity are lower for the uninsured.[4] The Institute of Medicine reports that the uninsured population has a 25% higher mortality rate than the insured population.[5]

The multiple data inputs and modeling procedure that SAHIE uses allow for the estimation of uninsured rates for all U.S. counties and provide a more stable estimate. Health insurance status can change throughout the year for individuals depending on the employment environment, among other factors. Combining survey responses from multiple dates throughout the year gives a more representative account of the average health insurance status.

National household surveys are the standard method for health insurance estimates.[12] These estimates are not always consistent with each other, although SAHIE incorporates numerous household surveys to try to account for the variation.[13] Estimates of the uninsured population will vary depending on the survey design, implementation, and data adjustment.[13] Survey estimates can also differ depending on how “uninsured” is defined. Some surveys only record insurance status at the time of the interview, others take into account the year prior to the survey.[13] 

Evidence suggests that access to effective and timely primary care has the potential to improve the overall quality of care and help reduce costs.[9,10] One analysis found that primary care physician supply was associated with improved health outcomes ranging from reduced all-cause, cancer, heart disease, stroke, and infant mortality; a lower prevalence of low birth weight; greater life expectancy; and improved self-rated health.[8] The same analysis also found that each increase of one primary care physician per 10,000 population is associated with a reduction in the average mortality by 5.3%.[8] Another study found that states with a higher ratio of primary care physicians compared to specialists had improved quality and effectiveness of care, as well as lower health care spending than states with a higher ratio of specialists.[10] Interestingly, increasing the supply of specialist physicians does not show lower mortality rates and does not improve the population health of the United States.[11] The County Health Rankings follows the findings in the literature by reporting only the population per primary care provider and not the overall provider rate for each county.

Although the relationship between primary care providers and improved health outcomes is supported in the literature, this measure has a number of limitations. First, primary care providers are classified by county, but providers living on the edge of counties or who practice in multiple locations may see patient populations that reside in surrounding counties. Therefore, this measure may either over- or underestimate patient access to primary care in some situations since patient-provider interaction is not restricted by county boundaries. Second, having an adequate supply of primary care providers does not ensure that people will use them in an efficient way. The measure does not report patient satisfaction with the care they receive, how often they make use of primary care services, if the primary care provider in their area accepts their type of insurance, or how long they have to wait to see a provider. Third, even with an adequate primary care supply, the way care is organized and coordinated may be just as important as the overall number of primary care providers in an area.[14] In health care systems that are primary care-oriented, Medicare beneficiaries have fewer hospitalization days and lower health care costs.[14] This suggests that while the measure provides an estimate of primary care access at the county level, it does not account for all of the barriers to access that individuals may encounter.

[1] Hall A, Harris Lemak C, Steingraber H, et al. Expanding the definition of access: It isn't just about health insurance. J Health Care Poor Underserved. 2008;19:625-638.

[2] Martinez M, Cohen RA. Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January-September 2008. Atlanta, GA: Centers for Disease Control and Prevention;2009.

[3] Centers for Disease Control and Prevention. Early release of selected estimates based on data from the 2008 National Health Interview Survey. Centers for Disease Contro l and Prevention Web Site. www.cdc.gov/nchs/nhis/released200906.htm. Updated July 1, 2009. Accessed January 18, 2010.

[4] Fronstin P. Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2009 Current Population Survey. Employee Benefit Research Institute; 2009. EBRI Issue Brief no. 334.

[5] Institute of Medicine. Hidden Costs, Value Lost: Uninsurance in America. Washington, DC: Institute of Medicine;2003.

[6] Berk ML, Schur CL. Measuring access to care: Improving information for policymakers. Health Aff. 1998;17:180-186.

[7] Robert Wood Johnson Foundation. SHADAC state health access profile. Robert Wood Johnson Foundation Web Site. www.rwjf.org/newsroom/interactive.jsp?id=35. Accessed January 20, 2010.

[8] Macinko J, Starfield B, Shi L. Is primary care effective? Quantifying the health benefits of primary care physican supply in the United States. Intl J Health Serv. 2007;37:111-126.

[9] Steinbrook R. Easing the shortage in adult primary care -- Is it all about money? N Engl J Med. 2009;360:2696-2699.

[10] Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries' quality of care. Health Aff. April 7, 2004: w4.184-197.

[11] Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations' health: Assessing the evidence. Health Aff. March 15, 2005: w5.97-107.

[12] Fisher R, Turner J. Health Insurance Estimates for Counties. Washington, DC: U.S. Census Bureau; 2003.

[13] Lewis K, Ellwood M, Czajka J. Counting the Uninsured: A Review of the Literature. Washington, DC: The Urban Institute; 1998. Occasional Paper No. 8.

[14] Goodman DC, Grumbach K. Does having more physicians lead to better health system performance? JAMA.