Insurance plus Access Does not Equal Health Care: Typology of Barriers to Health Care Access for Low-Income Families

Jennifer E. DeVoe, MD, DPhil; Alia Baez, BA; Heather Angier, BA; Lisa Krois, MPH; Christine Edlund, MSc; Patricia A. Carney, PhD


Ann Fam Med. 2007;5(6):511-518. 

In This Article

Abstract and Introduction

Purpose: Public health insurance programs have expanded coverage for the poor, and family physicians provide essential services to these vulnerable populations. Despite these efforts, many Americans do not have access to basic medical care. This study was designed to identify barriers faced by low-income parents when accessing health care for their children and how insurance status affects their reporting of these barriers.
Methods: A mixed methods analysis was undertaken using 722 responses to an open-ended question on a health care access survey instrument that asked low-income Oregon families, "Is there anything else you would like to tell us?" Themes were identified using immersion/crystallization techniques. Pertinent demographic attributes were used to conduct matrix coded queries.
Results: Families reported 3 major barriers: lack of insurance coverage, poor access to services, and unaffordable costs. Disproportionate reporting of these themes was most notable based on insurance status. A higher percentage of uninsured parents (87%) reported experiencing difficulties obtaining insurance coverage compared with 40% of those with insurance. Few of the uninsured expressed concerns about access to services or health care costs (19%). Access concerns were the most common among publicly insured families, and costs were more often mentioned by families with private insurance. Families made a clear distinction between insurance and access, and having one or both elements did not assure care. Our analyses uncovered a 3-part typology of barriers to health care for low-income families.
Conclusions: Barriers to health care can be insurmountable for low-income families, even those with insurance coverage. Patients who do not seek care in a family medicine clinic are not necessarily getting their care elsewhere.

Children from lower socioeconomic backgrounds have poorer health outcomes.[1,2] These health disparities are due, in part, to barriers in accessing medical care and utilizing primary care services.[3,4,5] Recent expansions in insurance coverage have improved access to health care for this population,[3,6,7,8] and the presence of family physicians in underserved communities has made primary care services more widely available.[9] Yet, even with the services of family physicians and expanded health insurance, children from low-income families are not guaranteed access to health care services.[5,10,11,12,13,14,15] Among the poor, who visits a family physician and who does not? What barriers persist? Family physicians caring for vulnerable populations must understand differences in access to care and utilization of services in their communities.

Recent efforts to better understand these disparities have queried physicians and patients about differing practices based on a patient's health insurance status and type of insurance.[12,13,14,16] Other analyses have used vital statistics and Medicaid data to study utilization and coverage patterns.[6,17] Secondary analyses of administrative data are often several steps removed from the real-life experiences of vulnerable families, and studies conducted in physicians' offices miss the invisible families who are unable to visit health care facilities. To our knowledge, limited information has been collected directly from families living in poverty about factors affecting access to medical care and how insurance status affects their situations. This study was designed to add richness and depth to the current research by directly capturing the experiences of low-income families as they navigate the health care system and to determine how insurance coverage affects their concerns.

In collaboration with state policy makers, we designed a cross-sectional survey to collect statewide primary data. More than 25% of the survey respondents provided additional written comments to a concluding open-ended survey question that asked, "Is there anything else you would like to tell us?" We report findings from a mixed methods analysis of this subset of respondents.


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