This paper considers the impact of community-level variables over and above the effects of individual characteristics on healthcare access of low-income children and adults residing in large metropolitan statistical areas (MSAs). Further, we rank MSAs' performance in promoting healthcare access for their low-income populations. The individual-level data come from the 1995 and 1996 National Health Interview Survey (NHIS). The community-level variables are derived from multiple public-use data sources. The outcome variable is whether low-income individuals received a physician visit in the past twelve months. The proportion receiving a visit by MSA varied from 63% to 99% for children and from 62% to 83% for adults. Access was better for individuals with health insurance and a regular source of care and for those living in communities with more federally-funded health centers. Children residing in MSA.
The framework presented in this article extends the Andersen behavioral model of health services utilization research to examine the effects of contextual determinants of access. A conceptual framework is suggested for selecting and constructing contextual (or community-level) variables representing the social, economic, structural, and public policy environment that influence low-income people's use of medical care. Contextual variables capture the characteristics of the population that disproportionately relies on the health care safety net, the public policy support for low-income and safety-net populations, and the structure of the health care market and safety-net services within that market. Until recently, the literature in this area has been largely qualitative and descriptive and few multivariate studies comprehensively investigated the contextual determinants of access. The comprehensive and systematic approach suggested by the framework will enable researchers to strengthen the external validity of results by accounting for the influence of a consistent set of contextual factors across locations and populations. A subsequent article in this issue of Inquiry applies the framework to examine access to ambulatory care for low-income adults, both insured and uninsured.
This study examines the effects of community-level and individual-level factors on access to ambulatory care for lower-income adults in 54 urban metropolitan statistical areas in the United States. Drawing on a conceptual behavioral and structural framework of access, the authors developed multivariate models for insured and uninsured lower-income adults to assess the adjusted effects of community-and individual-level factors on two indicators of access: having a usual source of care, and having at least one physician visit in the past year. Several community factors influenced access, but they did so differently for insured and uninsured adults and for the two measures of access used. The findings of this study confirm that public policies and community environment have measurable and substantial impacts on access to care, and that expanded public resources, such as Medicaid payments and safety-net clinics, can lead to measurable improvements in access for vulnerable populations residing in large urban areas.
Dentists who care for publicly insured patients appear to have practices that are different from those who do not, in terms of delivery of patient care and practice structure. Such differences have implications for the access to and quality of dental health care of publicly insured patients. The success of public programs and policies aimed at ensuring access to dental care depends on ability and willingness of dentists to accommodate public patients' needs.
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