In Reply: Drs Prasad and Klingner make a critically important point that health insurance is not the only determinant of health care access. Penchansky and Thomas,1 building on the work of Donabedian and others, summarize the “five As of access to care” as affordability, availability, accessibility, accommodation, and acceptability.
The studies we reviewed reported that some patients did report the ED as their usual source of care.2 Uninsured patients were less likely to have a usual source of care than insured patients, but the best studies also showed that these patients were less likely to use EDs,3,4 supporting Prasad and Klingner's point that past use predicts future use, as well as our concern that uninsured patients may delay ED use even when clearly medically indicated.
Keirns CC, Newton MF. Uninsured Patients and Emergency Department Use in the United States—Reply. JAMA. 2009;301(11):1124-1125. doi:10.1001/jama.2009.275