MPH 560 Week 3 Access to Health Services Analysis Example

Insured on Paper, Waiting in Practice: Using the Behavioral Model to Analyze Access to Care in a Southern Colorado County

[Student Name]

University of Phoenix

MPH/560: Public Health Systems and Services Administration

Week 3 Assignment

[Instructor Name]

[Date]

The county, its clinics, wait times, programs and residents' stories are composites written for a model paper; county estimates come from CDC PLACES, and research findings come from the sources cited.

A community health worker at the county health department described a client to her supervisor: a 52-year-old woman who had enrolled in Medicaid in March after losing her job, then called five clinics before finding one accepting new Medicaid patients, with a first appointment seven weeks away. She had diabetes and had run out of medication. She was insured, but she did not yet have access. This paper analyzes access to care in the county.

Defining Access

Access means more than coverage. It includes whether people can afford care, reach it, get an appointment in time, communicate with clinicians and trust them enough to return. A person can be insured and still unable to use care, and uninsured people sometimes find care through safety-net clinics.

Andersen's Behavioral Model

Andersen's behavioral model explains health services use through three groups of factors: predisposing characteristics, such as age, education and beliefs; enabling resources, such as income, insurance and a regular source of care; and need, both perceived by people and evaluated by clinicians. In revisiting the model, Andersen expanded it to include the health care system and external environment and to treat health outcomes and satisfaction as results that feed back into later use (Andersen, 1995).

County Data

CDC's PLACES estimates for 2023 put uninsurance among working-age county adults, 18 to 64, at 16.3%, with a confidence interval of 13.2% to 19.6%, and 72.9% had a routine checkup in the past year (Centers for Disease Control and Prevention [CDC], 2025). Only 10 of Colorado's 64 counties had a higher or equal estimate, and it concentrates among working-age adults in low-wage jobs.

Predisposing Factors

County residents skew older than Colorado as a whole and include a large Hispanic community, some of whom speak Spanish as their primary language. Educational attainment is lower than the state average. Some residents distrust health systems after past experiences with discrimination or medical debt.

Enabling Factors: Coverage and Income

Colorado expanded Medicaid in 2014, and many low-income adults gained coverage. Others remain uninsured: people with incomes just above Medicaid limits who find marketplace plans unaffordable, some immigrants who are ineligible and people who lost coverage during renewals after the pandemic.

Enabling Factors: Supply

The county's supply of primary care is thin, especially for Medicaid patients. The community health center, which runs four clinics, carries much of the load, and its new-patient waits run five to eight weeks. Several private practices limit new Medicaid patients. Behavioral health and dental care are scarcer still.

Enabling Factors: Geography and Transportation

Rural residents may drive 40 minutes or more to a clinic. In the city, bus routes do not reach some clinics directly, and service ends early in the evening. For people without a car, a single appointment can take half a day.

Enabling Factors: Hours and Work

Most clinics operate during weekday business hours. Workers paid by the hour lose wages to attend appointments, and many cannot take time off without risking their jobs.

Enabling Factors: Language and Culture

Spanish-speaking patients often wait longer for appointments with bilingual clinicians or interpreters, and some clinics rely on family members to interpret, which compromises privacy and accuracy. Health materials are not always available in Spanish, and forms for Medicaid renewal can confuse even fluent English readers.

The Health System as a Factor

Andersen's revised model counts the health system itself as a factor. The county's clinics are organized around scheduled visits, which works poorly for people whose lives do not allow advance planning. Referral processes differ by clinic, and there is no shared system for finding an open appointment, which is why the client called five clinics.

Need

Need is high. The county's diabetes, high blood pressure and obesity estimates rank among the higher Colorado counties. Many residents perceive need only when symptoms become severe, which pushes care toward emergency departments.

What Coverage Changes: Mortality

Coverage matters. A study comparing three states that expanded Medicaid for adults before 2014 with neighboring states found that expansions were associated with a 6.1% relative reduction in adjusted all-cause mortality, about 19.6 deaths per 100,000 adults, along with more coverage, less delayed care because of cost and better self-reported health; reductions were greatest among older adults, nonwhite adults and residents of poorer counties (Sommers et al., 2012). Coverage saves lives, most of all in the places with the fewest resources.

What Coverage Changes: The Oregon Experiment

A lottery in Oregon offered a rare randomized test. About two years after the lottery, Medicaid coverage increased diabetes diagnosis and treatment, increased preventive care, lowered the probability of screening positive for depression by 9.15 percentage points and nearly eliminated catastrophic out-of-pocket spending, yet two years in, blood pressure, cholesterol and blood sugar readings showed no significant difference (Baicker et al., 2013).

Reading the Evidence Together

The two studies are consistent with the behavioral model. Coverage is a powerful enabling resource that reduces financial harm, increases use and, over time and across populations, is linked to lower mortality. But coverage alone may not change clinical measures quickly, especially when other barriers, such as supply and follow-up, remain.

Who Remains Outside

Even with expansion, some residents cannot gain coverage. Undocumented immigrants are ineligible for most federal coverage and depend on the health center's sliding fee scale and state programs for emergency care. People experiencing homelessness may be eligible but struggle with paperwork and mail. For these groups, access depends on safety-net providers rather than coverage.

Coming Changes

Federal law enacted in 2025 adds work reporting requirements and more frequent eligibility checks for adults covered through Medicaid expansion. Experience with renewals after the pandemic suggests many eligible people could lose coverage for paperwork reasons, which would fall hardest on residents with unstable jobs or housing.

Recommendation One: Enrollment and Renewal Help

The health department should expand its enrollment assistance, adding help with renewals and future work reporting, at libraries, food pantries and the community college.

Recommendation Two: Community Health Workers

Community health workers can bridge predisposing and enabling barriers: finding appointments, arranging transportation, interpreting and following up. The department should add two positions focused on the east side.

Recommendation Three: Clinic Capacity

The department should convene the health center, hospital and private practices to expand evening hours, open same-day slots for people out of medication and share a referral system.

Recommendation Four: Transportation

The department should work with the transit agency on a route serving the health center and with Medicaid's transportation benefit to raise awareness among members.

Measuring Progress

Indicators include uninsurance and checkup rates, days to a new-patient appointment at the health center, emergency visits that a timely primary care appointment could have prevented and the share of members lost at renewal.

Conclusion

The woman who waited seven weeks shows the gap between coverage and access. Andersen's model reveals barriers beyond insurance: supply, geography, hours, language and trust. Evidence shows coverage is linked to lower mortality and reduced financial strain, while a randomized test shows its limits on short-term clinical measures. The health department can close part of the gap by protecting coverage and removing the barriers that stand between an insurance card and a clinician.

References

Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), 1-10. https://doi.org/10.2307/2137284

Baicker, K., Taubman, S. L., Allen, H. L., Bernstein, M., Gruber, J. H., Newhouse, J. P., Schneider, E. C., Wright, B. J., Zaslavsky, A. M., & Finkelstein, A. N. (2013). The Oregon experiment: Effects of Medicaid on clinical outcomes. New England Journal of Medicine, 368(18), 1713-1722. https://doi.org/10.1056/NEJMsa1212321

Centers for Disease Control and Prevention. (2025). PLACES: Local data for better health, county data, 2025 release [Data set]. https://data.cdc.gov/d/swc5-untb

Sommers, B. D., Baicker, K., & Epstein, A. M. (2012). Mortality and access to care among adults after state Medicaid expansions. New England Journal of Medicine, 367(11), 1025-1034. https://doi.org/10.1056/NEJMsa1202099