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Research Letter
October 2016

Trends in Access to Primary Care for Children in the United States, 2002-2013

Author Affiliations
  • 1Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 2Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
JAMA Pediatr. 2016;170(10):1023-1025. doi:10.1001/jamapediatrics.2016.0985

To benefit from health care, children must be able to access it. One framework for access includes 5 domains: availability (adequacy of supply and resources), accessibility (geographic), accommodation (office hours, telephone access, and same-day access), acceptability (comfort with physician or other nonphysician professional), and affordability.1 In many of these domains, the United States ranks poorly compared with other developed nations.2 Over the last decade, there have been efforts to improve access, including patient-centered medical home initiatives and the passage of the Affordable Care Act. Using 2002-2013 Medical Expenditure Panel Survey (MEPS) data, we describe how access to primary care has changed over the last decade for children.


Administered by the Agency for Healthcare Research and Quality, MEPS sampled between 8965 to 11 576 children younger than 18 years old per year from 2002 to 2013, for a total of 121 924 sampled over the 12-year period.3 We examined items related to availability, accessibility, accommodation, acceptability, and affordability of the child’s usual source of care (USC) (Table). We compared 3-year blocks (2002-2004 vs 2011-2013), primarily focusing on respondents who reported a USC. To better understand changes over time, we examined annual trends for a subset of measures in each domain. All analyses in Stata SE version 13.1 (StataCorp) accounted for survey design and weighting. The University of Pittsburgh institutional review board approved this study as exempt, and consent was not required for this secondary analysis of MEPS data.

Table.  Access to Care for Children, 2002-2004 vs 2011-2013a
Access to Care for Children, 2002-2004 vs 2011-2013a


There was no significant change in the proportion of children with a USC (90.7% in 2002-2004 vs 91.6% in 2011-2013; Δ = 0.9%; P = .10) and no meaningful change in perceived availability of specific types of care at the USC (Table).

Accessibility (<15 minutes of travel time) and all 5 measures of acceptability (eg, “provider explains options”) improved significantly. Accommodation, measured by the ability to contact the USC by telephone during office hours, improved significantly (“Not at all difficult”: 58.2% vs 64%; Δ = 5.8%; P < .001). However, evening/weekend appointment availability (55.2% vs 52.2%; Δ = −3.0%; P = .04) and ease of telephone contact after hours (“Not at all difficult”: 44.3% vs 40.0%; Δ = −4.3%; P = .001) declined. Affordability, measured by the percentage of children with insurance, improved. However, among privately insured children, average annual out-of-pocket costs increased from $92.50 to $115.70 (Δ = $23.2; P = .009). Consistent with these findings, annual trends for selected measures demonstrated gradual improvement in selected accessibility and acceptability measures, worsening after-hours accommodation and increasing out-of-pocket costs for privately insured children during the study period (Figure).

Figure.  Annual Trends for Selected Measures of Access, 2002-2013
Annual Trends for Selected Measures of Access, 2002-2013

Annual trends for a subset of measures within each domain. Gray shaded area indicates 95% CIs for each value. Out-of-pocket costs are adjusted for inflation using the Bureau of Labor Statistics consumer price index and stratified by insurance type. USC indicates usual source of care.


Using nationally representative data over 12 years, we found mixed trends in access to primary care. Availability appears stable, consistent with prior work,4 and accessibility improved.

Accommodation measures demonstrated improved ease of telephone contact during office hours, but decreased telephone contact after hours and decreased availability of weekend/evening appointments. The decrease in after-hours accommodation is concerning as children with better after-hours access have decreased emergency department use.5 Potential reasons for this decline include inadequate reimbursement, changes in physician lifestyle expectations, or increased availability of alternative after-hour options (eg, urgent care clinics). While the etiology is unclear, our results suggest that after-hours accommodation within the USC is worsening rather than improving for children, despite the promotion of greater accommodation in patient-centered medical home initiatives. In contrast, all measures of acceptability improved, in keeping with growing focus on family-centeredness of care.6

Finally, affordability measures showed decreased uninsured rates, but significantly increased out-of-pocket costs among privately insured children. While insurance coverage has increased, it is important to monitor other trends in affordability as rising out-of-pocket costs could deter necessary care.

Our analysis is limited by data available in MEPS, which did not address certain aspects of the studied domains (eg, ease of same-day appointments). However, MEPS includes components of each access domain across a large, nationally weighted sample over 12 years, providing a unique opportunity to study national change in these domains over time. Overall, our analysis found stable availability, improved accessibility and acceptability, and improved insurance rates but worsening private insurance out-of-pocket costs and worsening after-hours accommodation, with important implications for future efforts to improve access to pediatric care and to improve child health.

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Article Information

Corresponding Author: Kristin N. Ray, MD, MS, Department of Pediatrics, University of Pittsburgh School of Medicine, 3414 Fifth Ave, 3rd Floor, Pittsburgh, PA 15213 (

Published Online: August 22, 2016. doi:10.1001/jamapediatrics.2016.0985.

Author Contributions: Dr Ray had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Both authors.

Acquisition, analysis, or interpretation of data: Ray.

Drafting of the manuscript: Ray.

Critical revision of the manuscript for important intellectual content: Both authors.

Statistical analysis: Ray.

Administrative, technical, or material support: Mehrotra.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported in part by grant K12HS022989 from the Agency for Healthcare Research and Quality (Dr Ray) and a grant from the Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center Health System (Dr Ray).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.

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