Field of Work: Assessing the influences on access to health care for low-income individuals.

Problem Synopsis: Since the 1960s, researchers have investigated the individual-level factors that predict whether or not a person will be likely to have access to health care. However, individual-level factors alone fail to fully account for variations in access or explain why residents of some geographic areas fare much better in accessing care than others.

Synopsis of the Work: Researchers affiliated with New York University, Robert F. Wagner Graduate School of Public Service , the UCLA Center for Health Policy Research and Rutgers Center for State Health Policy examined how individual- and community-level factors influence access to health care for low-income residents, and why their access varies in different metropolitan regions of the United States.

Key Findings: In a spring 2004 article, "Effects of Community Factors on Access to Ambulatory Care for Lower-Income Adults in Large Urban Communities," in the journal Inquiry, the researchers reported the following key findings:

• Several individual-level factors contributed to differences in access among residents of 54 metropolitan areas, including:
  • Insured and uninsured people were half as likely to have a usual source of care if they had immigrated in the last five years compared with those living in the United States longer.
  • Lower-income insured and uninsured residents who did not graduate from high school had a lower probability of visiting a physician than did those with a secondary education.
  • Uninsured residents with a usual source of care were two-and-a-half times more likely to visit a physician in the previous year, whereas insured residents with a usual source of care were three times more likely to do so.
• Several community-level factors influenced access for low-income residents, but, in many cases, they did so differently for insured and uninsured adults. For example:
  • Low-income residents fared slightly better when their state's Medicaid program paid providers more. Larger payments per beneficiary increased the likelihood that uninsured residents would have a usual source of care. For insured adults, the larger payments promoted use of physician services, but not whether they had a usual source of care.
  • Low-income insured adults in areas with a higher proportion of residents covered by HMOs were more likely to have a usual source of care, a finding consistent with the emphasis in managed care on coordination and "gate keeping" by a primary care provider.
  • Among low-income adults, living in a metropolitan area with a large population dependent on the health care safety net reduced the likelihood of having a usual source of care.

Key Conclusions:
In the Inquiry article the researchers concluded that:

• "Individual level factors exert a very strong and dominant effect on access to care; however, community factors modify that effect by promoting or discouraging the development of a connection to the health care system by low-income residents and their obtaining needed health services."
• "A number of community factors can be modified by policy and community intervention." For example, the size of the population that must depend on the safety net can be reduced by the federal and state government through expanding Medicaid and CHIP (Children's Health Insurance Program) coverage and by assisting noncitizens to become naturalized and qualify for Medicaid coverage.