Social determinants of disparities in primary care access

Disparities in health outcomes by social position, race and ethnicity and geographic space are a major focus of research and policy in the United States. Access to high quality primary care may diminish these disparities in health. This dissertation increases our understanding of primary care access by examining two rarely examined predictors: health insurance transitions and neighborhood effects on primary care access.;Research has consistently found that health insurance predicts primary care use. However, most research has only examined predictors of current health insurance coverage. Due to this cross-sectional approach, the social processes behind gaining and losing insurance coverage and the length of time spent in an uninsured or insured state are largely unknown. Using a two-year retrospective history from the Los Angeles Family and Neighborhood Survey (L.A. FANS), I used survival analysis to estimate how long adults remain uninsured or insured. I compared predictors of current health insurance coverage to predictors of health insurance transitions through multivariate logistic regression. Predictors of health insurance transitions generally match predictors of cross-sectional health insurance coverage and are associated with insurance eligibility. Yet, the lengths of uninsured and insured spells have been underestimated. The most effective policies to decrease uninsurance will focus on expanding insurance eligibility.;Past research has focused on individual level predictors of health care access, including health insurance, but has not considered how neighborhood environment might affect an individuals' primary care access. I examined whether neighborhood environment affects primary care access among adults in L.A. FANS using multi-level fixed and random effects logit models. Neighborhood environment affects primary care access even when controlling for individual characteristics. Neighborhood health behavior norms and social capital explain some of the effect of neighborhood environment on having a regular source of care. Neighborhood demand for health care resources significantly predicts receiving a check-up.;These analyses support the implementation of both micro and macro-level policies to address disparities in primary care access and provide new directions for future research.