Am Fam Physician. 2005 Nov 1;72(9):1664-1665.
In the United States, health care reform across the political spectrum has been focused on removing cost as a barrier to health care—principally by making insurance coverage more accessible. The U.S. Census Bureau recently reported that 45 million Americans, or nearly one in six, were uninsured in 2003.1 However, insurance and cost are only part of the story. Although having insurance facilitates health care use and should therefore be expanded, having a regular source of care (or a “medical home”) is in fact a greater predictor of receiving care than having insurance alone. This fact is underscored by the Robert Graham Center’s One-Pager published in American Family Physician2 that found that more primary care is received in an average month by people who have a usual source of care and no health insurance than by those who have insurance but no usual source of care; those who have both fare best of all.
A recent review of the literature on the benefits of having a medical home3 found that although insurance is an important “enabler” of health care, it does not guarantee receipt of appropriate, high-quality services. Having a medical home ensures better utilization, more effective care, and improved health outcomes. Moreover, having regular access to a particular physician is generally associated with earlier and more accurate diagnoses, reduced emergency department use, fewer hospitalizations, lower costs, fewer unmet medical needs, and increased patient satisfaction.3 Many studies conclude that having both health insurance and a medical home results in improved overall health for the entire population, thereby lowering the costs of care and effectively reducing health care disparities.4
It is disappointing, especially in light of these facts, that our health care system is plagued by an increasing shortage of available physicians, especially in the primary care disciplines. A lack of primary care physicians has been linked to increased mortality.5–7 Medical economics makes it difficult for private office-based physicians to locate in low-income (urban or rural) areas where health care services already are severely lacking. The National Association of Community Health Centers (NACHC) estimates that 36 million Americans, or about one in eight, are without a medical home because of a shortage of practicing primary care physicians.8
Exacerbating this trend is the fact that the number of primary care physicians per capita has been steadily shrinking relative to specialists,9 and that too many primary care physicians limit their participation in Medicaid or do not participate in the program at all,10–13 inhibiting access for the publicly insured even in areas that do not have physician shortages.
Family physicians and other primary care physicians play an essential role in improving access to primary care services and health outcomes. The Centers for Disease Control and Prevention recently reported that primary care physicians provide 90 percent of all preventive care visits in the United States, and that about one-fifth provide home visits (compared with 6 percent of specialists),14 thereby expanding their vital role in the delivery of primary care.
Moreover, family physicians are vital to their local safety-net systems. In order to effectively and equitably distribute the burden of reduced-cost care while ensuring that every person has a medical home, many communities across the country have built integrated health care systems funded through federal, local, or private dollars. These integrated care systems can pool resources to include transportation, case management, translation, and other specialized services to facilitate health care use among those less likely to have a medical home.
The problems of the rising number of people who are uninsured and the preservation of Medicaid and the State Children’s Health Insurance Program are among the most critical issues currently facing the primary care safety net. These programs help facilitate access to a medical home and the benefits associated with such access. NACHC has partnered with the American Academy of Family Physicians and other key safety-net health care provider organizations to fight for Medicaid’s future.
The combination of insurance and a regular source of care results in improved health and most effectively narrows health disparities. Family physicians and other primary care physicians already provide the bulk of preventive care, but millions of Americans are still without a medical home due to compounding access barriers. Any plan to improve access to health care on the national or local level must also include access to a medical home in order to most effectively achieve improved health outcomes for all.
MICHELLE PROSER, M.P.P., is a research and data analyst at the National Association of Community Health Centers, Washington D.C.
Address correspondence to Michelle Proser, M.P.P., National Association of Community Health Centers, 2001 L St. NW, 2nd Floor, Washington, DC 20036 (e-mail:email@example.com). Reprints are not available from the author.
1. DeNavas-Walt C, Proctor BD, Mills RJ. Income, poverty, and health insurance coverage in the United States: 2003. U.S. Census Bureau. Current population reports P60-226. August 2004. Accessed online August 1, 2005, at: http://www.census.gov/prod/2004pubs/p60-226.pdf.
2. The importance of having health insurance and a usual source of care [Graham Center One-Pager]. Am Fam Physician. 2004;70:1035.
3. Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. Pediatrics. 2004:113;1493–8.
4. National Association of Community Health Centers. A nation’s health at risk II: a front row seat in a changing health care system. Special Topics Issue Brief #7. August 2004. Accessed online August 1, 2005, at: http://www.nachc.com/press/files/nationshealthIIstib7.pdf.
5. Shi L, Macinko J, Starfield B, Wulu J, Regan J, Politzer R. The relationship between primary care, income inequality, and mortality in U.S. States, 1980–1995. J Am Board Fam Pract. 2003;16:412–22.
6. Shi L, Starfield B. Primary care, income inequality, and self-rated health in the United States: a mixed-level analysis. Int J Health Serv. 2000;30:541–55.
7. Shi L, Starfield B, Kennedy B, Kawachi I. Income inequality, primary care, and health indicators. J Fam Pract. 1999;48:275–84.
8. National Association of community Health Centers. A nation’s health at risk: a national and state report on America’s 36 million people without a regular health-care provider. Special Topics Issue Brief #5. March 2004. Accessed online August 1, 2005, at: http://www.nachc.com/press/files/UnservedReportSTIB5.pdf.
9. Biola H, Green LA, Phillips Rl, Guirguis-Blake J, Fryer GE. The U.S. primary care physician workforce: minimal growth 1980–1999. One-pager No. 22. Accessed online August 1, 2005, at: http://www.graham-center.org/x467.xml.
10. Cunningham PJ. Mounting pressures:physicians serving Medicaid patients and the uninsured, 1997–2001. Results from the Community Tracking Study, No. 6. Center for Studying Health System Change, December, 2002. Accessed online August 1, 2005, at: http://www.hschange.com/CONTENT/505/505.pdf.
11. Zuckerman S, McFeeters J, Cunningham P, Nichols L. Changes in medicaid physician fees, 1998–2003: implications for physician participation. Health Aff (Millwood) 2004;(suppl Web Exclusives):W4-374–84.
12. Berman S, Dolins J, Tang SF, Yudkowsky B. Factors that influence the willingness of private primary care pediatricians to accept more Medicaid patients. Pediatrics. 2002;110:239–48.
13. Perloff JD, Kletke PR, Fossett JW, Banks S. Medicaid participation among urban primary care physicians. Med Care. 1997;35:142–57.
14. Woodwell DA, Cherry DK. National Ambulatory Medical Care Survey: 2002 summary. Adv Data 2004:26:1–44. Accessed online August 1, 2005, at: http://www.cdc.gov/nchs/data/ad/ad346.pdf.
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