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Objectives: This study examined the association between type of health insurance coverage and quality of primary care as measured by its distinguishing attributes--first contact, longitudinality, comprehensiveness, and coordination., Methods: The household component of the 1996 Medical Expenditure Panel Survey was used for this study. The analysis primarily focused on subjects aged younger than 65 years who identified a usual source of care. Logistic regressions were used to examine the independent effects of insurance status on primary care attributes while individual sociodemographic characteristics were controlled for., Results: The experience of primary care varies according to insurance status. The insured are able to obtain better primary care than the uninsured, and the privately insured are able to obtain better primary care than the publicly insured. Those insured through fee-for-service coverage experience better longitudinal care and less of a barrier to access than those insured through health maintenance organizations (HMOs)., Conclusions: While expanding insurance coverage is important for establishing access to care, efforts are needed to enhance the quality of primary health care, particularly for the publicly insured. Policymakers should closely monitor the quality of primary care provided by HMOs.

Objectives: In national and local discussions of health care reform, there is disagreement about whether a national health insurance plan should be mandatory or voluntary. This study describes characteristics of low- income people who were more likely or less likely to be covered by a voluntary plan., Methods: Survey data were available from an evaluation of Washington State's Basic Health Plan, which offered subsidized health insurance to low-income residents. For those subjects who were eligible and uninsured at baseline, those who joined were compared with those who did not join on a variety of demographic and health-related characteristics., Results: There were substantial differences between those who did and did not join the Basic Health Plan. Those who did not enroll were generally less well-off, with less education, lower income, and worse health. Many had never had health insurance., Conclusions: If health care reform results in a voluntary plan, additional measures may be needed to ensure that less advantaged citizens have adequate access to health care.

Objectives: Our objective was to evaluate whether referral to primary care settings would be clinically appropriate for and acceptable to patients waiting for emergency department care for nonemergency conditions., Methods: We studied 700 patients waiting for emergency department care at a public hospital. Access to alternative sources of medical care, clinical appropriateness of emergency department use, and patients' willingness to use nonemergency services were measured and compared between patients with and without a regular source of care., Results: Nearly half (45%) of the patients cited access barriers to primary care as their reason for using the emergency department. Only 13% of the patients waiting for care had conditions that were clinically appropriate for emergency department services. Patients with a regular source of care used the emergency department more appropriately than did patients without a regular source of care. Thirty-eight percent of the patients expressed a willingness to trade their emergency department visit for an appointment with a physician within 3 days., Conclusions: Public emergency departments could refer large numbers of patients to appointments at primary care facilities. This alternative would be viable only if the availability and coordination of primary care services were enhanced for low-income populations.