Center for Studying Health System Change

Introduction

In a recent article in Journal of the American Medical Association (JAMA), researchers from the Health System Change showed that there was considerable variation across communities in the ability of uninsured persons to obtain medical care¹. While the exact reasons for these variations were not determined, it is likely that characteristics of the community-including the health system-are important factors. Therefore, where you live is an important factor in determining the amount of difficulty you have in getting medical care if you are uninsured.

Whether individuals reported that they experienced delays or were unable to obtain needed medical care is one of the most important, direct and often-used measures of access to care available in health care surveys². This measure essentially reflects a result, or outcome, of an attempt to obtain medical care. Other measures of access to care are also commonly used in research, such as having a usual source of care and the convenience of getting to the doctor, as well as measures that reflect both the frequency and pattern of health care use. These measures reflect somewhat different aspects of the care-seeking process, which involves a number of steps and potential barriers-both financial and nonfinancial-that could be encountered after the initial decision to seek care has been made. Researchers in the field of access to care generally agree that a thorough assessment of access should consider multiple measures that reflect these different aspects or steps of the care-seeking process³.

In the following sections of this report, we examine variations across communities on a number of additional measures of access to care for uninsured persons, augmenting the research published in JAMA. We also discuss how the pattern of variation on these other measures is consistent (or inconsistent) with the level of difficulty in getting care reported by uninsured persons. This analysis not only presents a more thorough assessment of which communities rate high or low on access to care, but it may permit some insight as to why levels of reported difficulty in obtaining care are higher in some communities than others.

Data Source

The data for this report are based on the Community Tracking Study Household Survey conducted in 1996-1997. The Community Tracking Study is a major initiative of The Robert Wood Johnson Foundation to track changes in the health care system over time and to gain a better understanding of how health system changes affect people⁴. The nationally representative data collection is based in 60 randomly selected communities-or sites-nationwide. Twelve of these communities were randomly selected to serve as case study sites, and the Household Survey included considerably larger sample sizes for these sites.

All site-specific estimates in this report were adjusted to control for differences across communities on the following set of factors: health status, age, gender, family income, family size, educational attainment, race/ethnicity and whether the interview was conducted in Spanish. Community-specific estimates are reported only for the 12 case study sites (where the sample sizes are large enough to permit separate reporting), while correlations between measures (using Pearson correlation coefficients) are computed based on all 60 sites⁵.

¹Cunningham, PJ, Kemper, P. "Ability to Obtain Medical Care for the Uninsured: How Much Does it Vary Across Communities?" Journal of the American Medical Association; Vol. 280: 921-927 (1998).

² Donelan K, Blendon RJ, Hill CA, Hoffman C, Rowland D, Frankel M, Altman D. "Whatever Happened to the Health Insurance Crisis in the United States?" Journal of the American Medical Association, Vol. 276: 1346-1350 (1996); Berk ML, Schur CL, Cantor JC. "Ability to Obtain Health Care: Recent Estimates from The Robert Wood Johnson Foundation Access to Care Survey." Health Affairs, Vol. 14: 139-146 (1995).

³ Gold MR, Stevens B. "Synopsis and Priorities for Future Efforts." Health Services Research, Vol. 33, No. 3, Part II: 611-624 (1998).

⁴ For a more detailed description of the Community Tracking Study, see Kemper P, Blumenthal D, Corrigan JM, et al., "The Design of the Community Tracking Study." Inquiry. Vol. 33: 195-206 (1996). For a detailed discussion of site definition and sample design, see Metcalf CE, Kemper P, Kohn LT, Pickreign JD. Site Definition and Sample Design for the Community Tracking Study. Technical Publication No. 1. Center for Studying Health System Change, 1996.

⁵ More detail on the data and analytic methods is contained Cunningham and Kemper, "Ability to Obtain Medical Care."