About This Literature Summary
This summary of the literature on Access to Primary Care as a social determinant of health is a narrowly defined examination that is not intended to be exhaustive and may not address all dimensions of the issue. Please note: The terminology used in each summary is consistent with the respective references. For additional information on cross-cutting topics, please see the Access to Health Services literature summary.
Related Objectives (4)
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Related Evidence-Based Resources (4)
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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).2,3 Research shows that access to primary care is associated with positive health outcomes.2,4
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.3,5,6 However, disparities in access to primary 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.7,8,9,15,16 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.4,7,8,9 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.18,19
Only offering primary care services in English can negatively impact access to primary care and screening programs for patients who speak a language other than English.10 For example, a study found that Hispanic children who do not primarily speak English and immigrant Hispanic children are more likely to lack a usual source of care compared to non-immigrant Hispanic individuals in English-speaking households.10 Similarly, a study examining health quality of life outcomes in older populations discovered that older immigrants with limited English proficiency had less access to health care than older adults who speak English fluently.20
Limited provider office hours and availability can be barriers to accessing primary care.21,22 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 Additionally, primary care provider shortages and extreme demand often make it challenging for patients to get an appointment.13
Factors such as access to transportation, 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 Therefore, addressing barriers to accessing primary care may help reduce disparities and reduce the risk of poor health outcomes. For example, the National Health Service Corps supports the work of primary health care clinicians in areas of the United States with limited access to care, also called health professional shortage areas (HPSAs).23 Digital solutions like telehealth can also improve access to primary care by reducing barriers related to transportation and expanding the ability to offer services in languages other than English.24
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.
Institute of Medicine (U.S.) Committee on the Future of Primary Care. (1996). Primary care: America’s health in a new era (M. S. Donaldson, K. D. Yordy, K. N. Lohr, & N. A. Vanselow, Eds.). National Academies Press.
Shi, L. (2012). The impact of primary care: A focused review. Scientifica, 2012.
Friedberg, M. W., Hussey, P. S., & Schneider, E. C. (2010). Primary care: A critical review of the evidence on quality and costs of health care. Health Affairs, 29(5), 766–772. doi: 10.1377/hlthaff.2010.0025
Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. Milbank Quarterly, 83(3), 457–502. doi: 10.1111/j.1468-0009.2005.00409.x
Xu, K. T. (2002). Usual source of care in preventive service use: A regular doctor versus a regular site. Health Services Research, 37(6), 1509–1529. doi: 10.1111/1475-6773.10524
Blewett, L. A., Johnson, P. J., Lee, B., & Scal, P. B. (2008). When a usual source of care and usual provider matter: Adult prevention and screening services. Journal of General Internal Medicine, 23(9), 1354–1360. doi: 10.1007/s11606-008-0659-0
American College of Physicians — American Society of Internal Medicine. (1999). No health insurance? It’s enough to make you sick — scientific research linking the lack of health coverage to poor health. https://www.acponline.org/acp_policy/policies/no_health_insurance_scientific_research_linking_lack_of_health_coverage_to_poor_health_1999.pdf [PDF – 462 KB]
Tolbert, J., Orgera, K., & Damico, A. (2020, November 12). Key facts about the uninsured population. KFF. https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/
Ayanian, J. Z., Weissman, J. S., Schneider, E. C., Ginsburg, J. A., & Zaslavsky, A. M. (2000). Unmet health needs of uninsured adults in the United States. JAMA, 284(16), 2061–2069.
Avila, R. M., & Bramlett, M. D. (2013). Language and immigrant status effects on disparities in Hispanic children’s health status and access to health care. Maternal and Child Health Journal, 17(3), 415–423.
Krahn, G. L., Hammond, L., & Turner, A. (2006). A cascade of disparities: health and health care access for people with intellectual disabilities. Mental Retardation and Developmental Disabilities Research Reviews, 12(1), 70–82.
Gleason, R. P., & Kneipp, S. M. (2004). Employment-related constraints: Determinants of primary health care access? Policy, Politics, & Nursing Practice, 5(2), 73–83.
Douthit, N., Kiv, S., Dwolatzky, T., & Biswas, S. (2015). Exposing some important barriers to health care access in the rural USA. Public Health, 129(6), 611–620.
Bodenheimer, T., & Pham, H. H. (2010). Primary care: Current problems and proposed solutions. Health Affairs, 29(5), 799–805.
Brown, E. R., Ojeda, V. D., Wyn, R., & Levan, R. (2000). Racial and ethnic disparities in access to health insurance and health care. https://www.kff.org/wp-content/uploads/2013/01/racial-and-ethnic-disparities-in-access-to-health-insurance-and-health-care-report.pdf [PDF – 1.9 MB]
Zuvekas, S. H., & Taliaferro, G. S. (2003). Pathways to access: Health insurance, the health care delivery system, and racial/ethnic disparities, 1996-1999. Health Affairs, 22(2), 139–153.
Hill, H. A., Singleton, J. A., Yankey, D., Elam-Evans, L. D., Pingali, S. C., & Kang, Y. (2019). Vaccination coverage by age 24 months among children born in 2015 and 2016 — National Immunization Survey-Child, United States, 2016-2018. Morbidity and Mortality Weekly Report, 68(41), 913.
Freeman, J. D., Kadiyala, S., Bell, J. F., & Martin, D. P. (2008). The causal effect of health insurance on utilization and outcomes in adults: A systematic review of U.S. studies. Medical Care, 46(10), 1023–1032.
Hadley, J. (2003). 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. Medical Care Research and Review, 60(2_suppl), 3S–75S.
Nguyen, D., & Reardon, L. J. (2013). The role of race and English proficiency on the health of older immigrants. Social Work in Health Care, 52(6), 599–617.
O’Malley, A. S., Samuel, D., Bond, A. M., & Carrier, E. (2012). After-hours care and its coordination with primary care in the U.S. Journal of General Internal Medicine, 27(11), 1406–1415.
Schoen, C., Osborn, R., Doty, M. M., Squires, D., Peugh, J., & Applebaum, S. (2009). A survey of primary care physicians in 11 countries, 2009: Perspectives on care, costs, and experiences: Doctors say problems exist across all 11 countries, although some nations are doing a better job than others. Health Affairs, 28(Suppl1), w1171–w1183.
National Health Service Corps. (2021, November). Mission, work, and impact. HRSA. https://nhsc.hrsa.gov/about-us
Rural Health Information Hub. (2022). Telehealth use in rural healthcare. https://www.ruralhealthinfo.org/topics/telehealth