Insurance is not enough
Access barriers, usual source of care, and reliance on the emergency department
Bibliographic Data
| ID | 24214233 |
|---|---|
| Authors | A Ma (0000-0002-6413-4935), Alison Sanchez (0000-0001-9746-5004) |
| Year | 2026 |
| Volume | 409 |
| Pages | 119875 |
| Publication date | 2026-11-01 |
| Open Access | Yes |
| Type | ARTICLE |
| Venue | Social Science & Medicine (JOURNAL) |
| Journal identifiers | ISSN: 0277-9536 • E-ISSN: 1873-5347 |
| Publisher | Elsevier BV (PUBLISHER) |
| DOI | 10.1016/j.socscimed.2026.119875 |
| PMID | 42801849 |
| OpenAlex | W7214216277 |
| Language | EN |
| References cited | 38 |
BACKGROUND: Emergency department (ED) overuse for non-urgent conditions is a persistent driver of rising health care costs in the United States. Federal and state policy has focused primarily on expanding insurance coverage as the principal lever for redirecting patients to primary care, yet coverage expansion may be insufficient when structural barriers, including provider shortages, network gaps, and insurance non-acceptance, constrain patients' ability to establish a usual source of care (USC). Racial and ethnic minority populations face these barriers disproportionately. METHODS: Using 2021-2022 California Health Interview Survey data (46,810 interviews; 8.6% response rate), we estimated survey-weighted multivariable logistic models guided by the Andersen-Newman Behavioral Model of Health Service Use. The analytic sample comprised adults self-identifying as Asian, Black, Hispanic, White, or other race/ethnic groups (up to 45,916 observations). Two outcomes were examined: using the ED as a USC and having no-USC. Key enabling variables included three measures of provider access barriers (provider not accepting new patients, difficulty finding a general physician, and provider not accepting insurance), insurance status, employment, and family income. FINDINGS: Approximately 1% of adults reported using the ED as their USC and 16% of adults reported having no-USC at all. All three measures of access barriers are associated with higher odds of using the ED as their USC or not having a USC. Difficulty finding a general doctor is associated with 3.13 times higher odds of ED as a USC (SE: .533). Having private insurance is negatively correlated with relying on the ED as a USC (OR: .22 to .41, SE: .083 to .101) and having no-USC (OR: .18 to .84, SE: .013 to .045). Poor self-reported health is associated with higher odds of ED reliance (OR: 1.82 to 2.50, SE: .509 to .851). CONCLUSIONS: Insurance coverage is an important but insufficient enabling resource. Structural barriers to primary care were associated with higher odds of ED reliance by an amount large enough to substantially offset coverage-related gains. Policy must extend beyond insurance expansion to address provider capacity, network adequacy, and continuity of care, particularly for Black and marginalized populations.
access barriers · emergency department utilization · health care access · health care utilization · Health insurance · usual source of care · Emergency and Acute Care Studies · Healthcare Policy and Management · Primary Care and Health Outcomes
Societal and Individual Determinants of Medical Care Utilization in the United States
Health Care Spending in the United States and Other High-Income Countries
The ACA’s Impact On Racial And Ethnic Disparities In Health Insurance Coverage And Access To Care
Predictors of Emergency Room Access and Not Urgent Emergency Room Access by the Frail Older Adults
Factors Associated With Emergency Department Use Among the Rural Elderly
Receipt of Preventive Care Among Adults
Insurance or a regular physician
Exploring Nonresponse Bias in a Health Survey Using Neighborhood Characteristics
Revisiting the Behavioral Model and Access to Medical Care
| Highly cited | No |
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