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Access to Primary Care

The Healthy People 2020 Social Determinants of Health topic area is organized into 5 place-based domains:

  1. Economic Stability
  2. Education
  3. Health and Health Care
  4. Neighborhood and Built Environment
  5. Social and Community Context

Access to Primary Care is a key issue in the Health and Health Care domain.

The National Academies of Sciences, Engineering, and Medicine (formerly known as the Institute of Medicine) define primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”1 A primary care provider is usually an internist, family physician, pediatrician, or non-physician provider (e.g., family nurse practitioner, physician assistant).23 Research shows that access to primary care is associated with positive health outcomes.24

Primary care providers offer a usual source of care,3 early detection and treatment of disease,4 chronic disease management, and preventive care.2 Patients with a usual source of care are more likely to receive recommended preventive services such as flu shots, blood pressure screenings, and cancer screenings.356 However, disparities in access to primary health care exist, and many people face barriers that decrease access to services and increase the risk of poor health outcomes.7 Some of these obstacles include lack of health insurance,7, 8, 9 language-related barriers,10 disabilities,11 inability to take time off work to attend appointments,12 geographic and transportation-related barriers,13 and a shortage of primary care providers.14 These barriers may intersect to further reduce access to primary care.

Lack of health insurance decreases the use of preventive and primary care services and is associated with poor health outcomes.7, 8, 91516 Individuals without health insurance may delay seeking care when they are ill or injured, and they are more likely to be hospitalized for chronic conditions such as diabetes or hypertension.47, 8, 9 In addition, children without health insurance are less likely to get vaccinations, a routine primary care service.17 Overall, having health insurance increases the use of health services and improves health outcomes.1819

Speaking a language other than English at home can negatively impact access to primary care and screening programs.10 For example, a study found that Hispanic individuals who did not speak English at home were less likely to receive recommended preventive health care services for which they were eligible.10 Another study examined women of various racial and ethnic groups whose primary language was not English (they spoke Spanish, Cantonese, or Japanese) and found that they were less likely to be screened for breast or cervical cancer.20 Similarly, older adults with limited English proficiency were less likely to have a usual source of care compared to those who only spoke English.21

People may experience reduced access to primary care due to limited provider office hours and availability.2223 Many primary care providers do not offer services during typical off-work hours, posing barriers to workers without sick leave benefits.12 One study found that even when workers were provided with sick leave, some did not take time off to receive primary care because they still feared they would lose wages.12

Factors such as travel distance and the supply of primary care providers can also limit people’s ability to get primary care.13 For example, rural residents may need to travel long distances to get primary care and thus may be less likely to seek preventive care such as vaccinations.13 In addition, rural communities tend to have fewer providers than urban communities;1 this relative shortage of providers may make it harder for rural residents to access primary care.13

Primary care is critical for improving population health and reducing health disparities.4 Further research is needed to better understand barriers to primary care, offer support to primary care providers, and develop interventions that expand primary care access. This additional evidence will facilitate public health efforts to address access to primary care as a social determinant of health.

For additional information, please see the Access to Health Services literature summary.

Disclaimer: This summary of the literature on access to primary care as a social determinant of health is a narrowly defined review that may not address all dimensions of the issue.i, ii Please keep in mind that the summary is likely to evolve as new evidence emerges or as additional research is conducted.

Endnotes

i Terminology used in the summary is consistent with the respective references. As a result, there may be variability in the use of terms, for example, black versus African American.

ii The term minority, when used in a summary, refers to racial/ethnic minority, unless otherwise specified.

References

1 Institute of Medicine (US) Committee on the Future of Primary Care; Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, editors. Primary care: America's health in a new era. Washington (DC): National Academies Press (US): 1996.

2 Shi L. The impact of primary care: a focused review. Scientifica (Cairo). 2012;2012:22 p.

3 Freidberg MW, Hussey PS, Schneider EC. Primary care: a critical review of the evidence on quality and costs of health care. Health Aff (Millwood). 2010;29(5):766-72.

4 Starfield B, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502.

5 Xu K. Usual source of care in preventive service use: a regular doctor versus a regular site. Health Serv Res. 2002 Dec;37(6):1509-29.

6 Blewett LA, Johnson PJ, Lee B, Scal PB. When a usual source of care and usual provider matter: adult prevention and screening services. J Gen Intern Med. 2008;23(9):1354-60.

7 American College of Physicians-American Society of Internal Medicine. No health insurance? It's enough to make you sick [Internet]. Philadelphia: American College of Physicians-American Society of Internal Medicine; 1999 [cited 2018 Jan 4]. 22 p. Available from: https://www.acponline.org/acp_policy/policies/no_health_insurance_scientific_research_linking_lack_of_health_coverage_to_poor_health_1999.pdf [PDF – 451 KB]

8 Kaiser Family Foundation. Key facts about the uninsured population. Washington (DC): Kaiser Family Foundation; 2016 Sep 29. 11 p.

9 Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA, Zaslavsky AM. Unmet health needs of uninsured adults in the United States. JAMA. 2000;284(16):2061-69.

10 Cheng EM, Chen A, Cunningham W. Primary language and receipt of recommended health care among Hispanics in the United States. J Gen Intern Med. 2007;22(2):283-8.

11 Krahn GL, Hammond L, Turner A. A cascade of disparities: health and health care access for people with intellectual disabilities. Dev Disabil Res Rev. 2006;12(1):70-82.

12 Gleason RP, Kneipp SM. Employment-related constraints: determinants of primary health care access. Policy Polit Nurs Pract. 2004;5(2):73-83. doi:10.1177/1527154404263265

13 Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public Health. 2015;129(6):611-20. doi:10.1016/j.puhe.2015.04.001

14 Bodenheimer T, Pham HH. Primary care: current problems and proposed solutions. Health Aff (Millwood). 2010 May;29(5):799-805.

15 Brown ER, Ojeda VD, Wyn R, Levan R. Racial and ethnic disparities in access to health insurance and health care. Los Angeles: UCLA Center for Health Policy Research; 2000. 82 p.

16 Zuvekas SH, Taliaferro GS. Pathways to access: health insurance, the health care delivery system, and racial/ethnic disparities, 1996-1999. Health Aff (Millwood). 2003;22(2):139-53.

17 Becton JL, Cheng L, Nieman LZ. The effect of lack of insurance, poverty and paediatrician supply on immunization rates among children 19-35 months of age in the United States. J Eval Clin Practi. 2008;14(2):248-53.

18 Freeman JD, Kadiyala S, Bell JF, Martin DP. The causal effect of health insurance on utilization and outcomes in adults: a systematic review of U.S. studies. Med Care. 2008;46(10):1023-32.

19 Hadley J. Sicker and poorer-the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income. Med Care Res Rev. 2003;60(2 suppl):3S-75S.

20 Jacobs EA, Karavolos K, Rathouz PJ, Ferris TG, Powell LH. Limited English proficiency and breast and cervical cancer screening in a multiethnic population. Am J Public Health. 2005;95(8):1410-6.

21 Ponce NA, Hays RD, Cunningham WE. Linguistic disparities in health care access and health status among older adults. J Gen Intern Med. 2006;21(7):786-91.

22 O'Malley AS, Samuel D, Bond AM, Carrier E. After-hours care and its coordination with primary care in the U.S. J Gen Intern Med. 2012;27(11):1406-15.

23 Schoen C, Osborn R, Doty MM, Squires D, Peugh J, Applebaum S. A survey of primary care physicians in 11 countries: perspectives on care, costs, and experiences. Health Aff (Millwood). 2009 Nov-Dec;28(6):w1171-83.