Insurance is not enough: Access barriers, usual source of care, and reliance on the emergency department

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.

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.

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).

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.