The Case for Synergy Between a Usual Source of Care and Health
Jennifer E. DeVoe, MD
, Carrie J. Tillotson, MPH
, Sarah E. Lesko, MD, MPH
Lorraine S. Wallace, PhD
, and Heather Angier, MPH
Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA;
Center for Researching Health Outcomes, Mercer
Island, WA, USA;
Department of Family Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA.
BACKGROUND: In 2010, the United States (US) passed
health insurance reforms aimed at expanding coverage
to the uninsured. Yet, disparities persist in access to
health care services, even among the insured.
OBJECTIVE: To examine the separate and combined
association between having health insurance and/or a
usual source of care (USC) and self-reported receipt of
health care services.
DESIGN/SETTING: Two-tailed, chi-square analyses
and logistic regression models were used to analyze
nationally representative pooled 2002–2007 data from
the Medical Expenditure Panel Survey (MEPS).
PARTICIPANTS: US adults (≥18 years of age) in the
MEPS population who had at least one health care visit
and who needed any care, tests, or treatment in the
past year (n=62,067).
MAIN OUTCOME MEASURES: We assessed the likelihood
scription needs; a problem getting care, tests, or treatment;
and delayed care based on whether each individual had
health insurance, a USC, both, or neither one.
KEY RESULTS: Among adults who reported a doctor visit
and a need for services in the past year, having both health
insurance and a USC was associated with the lowest
percentage of unmet medical needs, problems and delays
in getting care while having neither one was associated
with the highest unmet medical needs, problems and
delays in care. After adjusting for potentially confounding
covariates (age, race, ethnicity, employment, geographic
residence, education, household income as a percent of
federal poverty level, health status, and marital status ),
compared with insured adults who also had a USC,
insured adults without a USC were more likely to have
problems getting care, tests or treatment (adjusted relative
risk [aRR] 1.27; 95% confidence interval [CI] 1.18–1.37);
and also had a higher likelihood of experiencing a delay in
urgent care (aRR 1.12; 95% CI 1.05–1.20).
CONCLUSIONS: Amidst ongoing health care reform, these
findings suggest the important role that both health
insurance coverage and a usual source of care may play
in facilitating individuals’ access to care.
KEY WORDS: health insurance; usual source of care; access to health
care; health policy; health care reform.
J Gen Intern Med 26(9):1059–66
© Society of General Internal Medicine 2011
With the recent passage of one of the most monumental health
insurance reform policies in US history, energies are now
focused on expanding health insurance coverage to millions of
Americans. These efforts are important due to the overwhelm-
ing evidence that stable health insurance coverage is associ-
ated with more consistent access to health care services,
which contributes to better outcomes.
Yet, even among
insured persons, there are disparities in access to care and
the quality of care received.
necessary to access care, but not always sufficient,
especially if insured individuals have no place to obtain
Approximately 19% of all US adults are without a
usual source of care (USC), and 53% of uninsured adults
have no USC.
Safety net services are oversubscribed and
the supply of primary care services is widely disparate across
leaving many Americans with few options to
find and maintain a stable USC. This is further challenged by
the amount of influence payers exert over the choices
available to their clients, often creating restrictive provider
networks and financial penalties for patients seeking a USC
outside the network.
The emphasis on insurance coverage in recent policies
coupled with primary care workforce shortages prompted us
to revisit the question of how much influence insurance and
a USC have on receipt of needed health care services. Past
ually, usually controlling for the other factor. The few
focused exclusively on a single outcome or a specific
The primary objectives of this study were
(1) to describe the prevalence of and characteristics associ-
ated with having insurance coverage and/or a USC; and (2)
to ascertain the separate and combined association between
having health insurance and/or a USC and self-reported
access to health care services for a nationally representative
Received August 1, 2010
Revised January 10, 2011
Accepted February 9, 2011
Published online March 16, 2011