How many Americans do not have a usual place to go for health care? How does a regular source of care affect access to preventive care?

In 2005, 13 percent of Americans did not have a usual source of care. Young adults, men, and the uninsured—both poor and nonpoor—were more likely than their counterparts to lack a usual source of care. Those without a usual source of care are less likely to receive recommended preventive care and are more likely to have other unmet needs and adverse outcomes.

Why is this important?

Those without a usual source of health care are more likely to have unmet needs for care, more hospitalizations, and higher costs of care, and they are less likely to keep doctor appointments and receive preventive care services (Starfield 1998).

Findings

In 2005, one of every eight Americans—an estimated 38.5 million people—lacked a usual source of health care. The rate varied widely by sex and age group (NCHS 2006a).

• The proportion without a usual source of care was lowest among children (4%) and the elderly (5%) and highest among young adults (20% to 31%).
• Across all nonelderly age groups, men were more likely than women to lack a usual source of care (absolute difference of 5 to 17 percentage points).

Analysis of 2003–2004 data shows that those who lacked health insurance for part of a year or longer—whether poor or nonpoor—were much more likely to lack a usual source of care than those who were continuously insured during the year (NCHS 2006b).

• Among nonelderly adults, for example, more than one-half (53% to 56%) of those who were uninsured longer than a year versus only about one of 10 continuously insured adults (9% to 11%) did not have a usual source of care.
• Higher family income made some difference in having a usual provider among uninsured children (e.g., 27% of nonpoor versus 44% of nonpoor long-term uninsured) but made very little difference among uninsured nonelderly adults.

Adults were less likely to receive cervical, breast, and colorectal cancer screening at recommended ages if they lacked a usual source of care (absolute difference 26 to 38 percentage points compared with those with a usual source of care) (Swan et al. 2003).

Implications

The importance of having a regular health care provider can be seen in the fact that a doctor's recommendation greatly influences whether people receive preventive care (Hawley et al. 2000).

The relatively high rate of young adult women who lack a usual source of care is of concern given their need for routine gynecological exams. Younger men (and other adults) can also benefit from a usual source of care to facilitate cardiovascular health checks at appropriate ages (Xu 2002). The relatively higher rate of middle-age adults lacking a usual care source also puts them at risk of not receiving recommended cancer screening and flu shots (Breen et al. 2001; Doescher et al. 2004).

Improvement Ideas and Resources

The main reason people cite for not having a usual source of care is that they are seldom sick (Pancholi 2004). This suggests the need for consumer education on the benefits of establishing an ongoing relationship with a primary care physician who can promote preventive health and appropriate use of the health care system.

The most important benefit of health insurance is to facilitate having a regular source of care (Starfield 2000). Sixty-two percent of uninsured children and 67 percent of uninsured, poor parents qualify for Medicaid or the State Children's Health Insurance Program. More effort is needed to enroll these individuals through outreach and simplified enrollment procedures (Dorn and Kenney 2006; Ross and Hill 2003).

Measure:

The denominator is community-dwelling children or adults of specified ages. A randomly selected adult respondent in each household was asked, "Is there a place that you usually go to when you are sick or need advice about your health?" In households with children, adult respondents were asked, "Is there a place that [a randomly selected child] usually goes when he/she is sick or you need advice about his/her health?" Those who responded "yes" to these questions were asked what kind of place they (or their child) went to most often. The numerator includes those who responded that they (or their child) had no usual place, or that they (or their child) usually went to an emergency department. Unknown responses were excluded from both denominator and numerator. The rates for all ages combined, and all nonelderly adults combined, were age-adjusted to the 2000 U.S. standard population.

A separate analysis (not shown) found that adults with a usual source of care were 3.5 to 5.2 times more likely to receive recommended cancer screenings after controlling for differences in patients' age, race, education, and insurance coverage (Breen et al. 2001).

Limitations:

These data do not distinguish between a usual place of care and a regular doctor and do not indicate the length of the relationship. Interpersonal continuity of care is an equally important concept for measurement (Saultz and Lochner 2005).

Source:

Data on usual source of care were compiled by the National Center for Health Statistics using the National Health Interview Survey, a nationally representative household interview survey of the civilian, noninstitutionalized population of the United States (NCHS 2006a, 2006b). Data on cancer screening were compiled by researchers at the National Cancer Institute and the Centers for Disease Control and Prevention using the National Health Interview Survey (Swan et al. 2003).

References:

* Indicates source of data used in the chart(s).

Breen, N., D. K. Wagener, M. L. Brown et al. 2001. Progress in Cancer Screening over a Decade: Results of Cancer Screening from the 1987, 1992, and 1998 National Health Interview Surveys. Journal of the National Cancer Institute 93 (22): 1704–13.

Doescher, M. P., B. G. Saver, K. Fiscella et al. 2004. Preventive Care: Does Continuity Count? Journal of General Internal Medicine 19 (6): 632–7.

Dorn, S., and G. M. Kenney. 2006. Automatically Enrolling Eligible Children and Families into Medicaid and SCHIP: Opportunities, Obstacles, and Options for Federal Policymakers. New York: The Commonwealth Fund.

Hawley, S. T., J. A. Earp, M. O'Malley et al. 2000. The Role of Physician Recommendation in Women's Mammography Use: Is It a 2-Stage Process? Medical Care 38 (4): 392–403.

* NCHS (National Center for Health Statistics). 2005. Health United States, 2005. Hyattsville, Md.: Centers for Disease Control and Prevention.

* NCHS (National Center for Health Statistics). 2006a. Early Release of Selected Estimates Based on Data from the 2005 National Health Interview Survey. Hyattsville, Md.: Centers for Disease Control and Prevention.

* NCHS (National Center for Health Statistics). 2006b. Health United States, 2006. Hyattsville, Md.: Centers for Disease Control and Prevention.

Pancholi, M. 2004. Reasons for Lacking a Usual Source of Care: 2001 Estimates for the U.S. Civilian Noninstitutionalized Population. MEPS Statistical Brief #32. Rockville, Md.: Agency for Healthcare Research and Quality.

Ross, D. C., and I. T. Hill. 2003. Enrolling Eligible Children and Keeping Them Enrolled. The Future of Children 13 (1): 81–97.

Saultz, J. W. and J. Lochner. 2005. Interpersonal Continuity of Care and Care Outcomes: A Critical Review. Annals of Family Medicine 3 (2): 159–66.

Starfield, B. 1998. Primary Care: Balancing Health Needs, Services, and Technology. New York, N.Y.: Oxford University Press.

Starfield, B. 2000. Evaluating the State Children's Health Insurance Program: Critical Considerations. Annual Review of Public Health 21: 569–85.

* Swan, J., N. Breen, R. J. Coates et al. 2003. Progress in Cancer Screening Practices in the United States: Results from the 2000 National Health Interview Survey. Cancer 97 (6): 1528–40.

Xu, K. T. 2002. Usual Source of Care in Preventive Service Use: A Regular Doctor Versus a Regular Site. Health Services Research 37 (6): 1509–29.