Promoting Women’s Access to Primary Care

Despite the historic gains in insurance coverage following the Affordable Care Act (ACA), millions of women in the United States remain uninsured or underinsured, and continue to face persistent barriers to access. Evidence demonstrates that expanding insurance coverage alone does not always result in equitable access. Without targeted health policies, existing disparities, particularly among low-income women, women of color, immigrants, and women living in non-expansion states, persevere.

Access to primary care is essential to improve population health, manage healthcare costs, achieve better health outcomes, and promote longer, healthier lives. Women’s access to timely, affordable primary care advances preventive care and early detection of treatable diseases, which leads to improved health outcomes across the life course. When women are able to access primary care, families and communities benefit, which reduces avoidable downstream healthcare costs.

Research that my team and I have conducted demonstrates that policy-driven reforms reduce these gaps, but only when insurance coverage is combined with strategies that address financial, social, and structural barriers to access and care. Policymakers can build on the successes of the ACA to promote equitable access to primary care for women nationwide.

Barriers to Primary Care Access Among Women

The ACA led to a significant reduction in uninsured rates among women by expanding Medicaid eligibility among certain vulnerable populations such as low-income, minority, and reproductive-aged women, creating health insurance marketplaces, and prohibiting gender-based pricing. These reforms represent significant advances in equity relating to healthcare coverage.

Access to care remains uneven across the United States. In states that did not adopt Medicaid expansion, uninsured rates among women remain higher, and gaps in coverage persist. Among insured women, many report delaying or forgoing primary care due to cost, not having a source of usual care, transportation difficulties, or other logistical barriers.

Other systemic barriers exist, including unavailable primary care services, fragmented service delivery, and rising healthcare costs. These challenges undermine access to primary care services, including preventive care, contributing to higher use of emergency department services, delayed diagnosis, and increased long-term expenditures.

We conducted a review of studies that examined factors that impact women's access to primary care following the ACA. Key findings include the following:

• Access to insurance coverage is an essential component of access, but may not always be enough to ensure that women use primary care services. Uninsured women are significantly less likely to have a primary care provider, yet many insured women also lack consistent access due to availability, cost, or structural barriers.
• Medicaid expansion improved access, particularly for low-income women, but significant state-level inequities persist.
• Cost remains a major barrier for insured women due to copayments, deductibles, and gaps in covered services.
• Non-financial barriers prevent access, and include limited clinic availability, language barriers, lack of culturally responsive care, and transportation.
• Structural barriers and social determinants of health play a critical role, with compounded disadvantages affecting women experiencing poverty, discrimination, immigration-related barriers, or unstable employment.

Overall, these findings highlight that multiple individual as well as structural factors influence women’s ability to access primary health care, and access does not depend on health coverage alone.

Research-Based Policies That Promote Primary Care Access

These findings highlight the need for multi-level solutions that strengthen coverage while addressing healthcare delivery system weaknesses and non-financial barriers. Three major policy strategies emerged from the evidence:

• Ensure affordable insurance coverage that supports the use of healthcare services

Following the ACA, Medicaid expansion and affordable marketplace coverage led to gains in rates of insurance, access to a usual source of care, and reduced cost-related barriers, particularly for low-income women. Insurance coverage remains the most significant predictor of access in the context of affordable, available primary care services.

Closing the Medicaid coverage gap reduces inequities associated with geographic location. Continuous eligibility policies can reduce gaps in coverage that often result in disrupted access. Reducing out-of-pocket costs for women who use their insurance may promote the utilization of primary care services.

• Strengthen Primary Care Delivery Systems

Access to primary care is often constrained by provider shortages, fragmented services, and under-resourced primary care clinics. Community health centers and low-cost clinics are critical access points, particularly in underserved urban or rural areas, but often lack resources.

Investment in primary care health system infrastructure improves access in under-resourced communities. Training and retaining adequate numbers of community-based primary care providers is essential to ensure the availability of services. Mobile care units and telehealth services can address geographical and logistical barriers when implemented equitably.

• Address non-financial and structural barriers

Qualitative findings highlight how barriers such as limited clinic hours, language barriers, lack of culturally appropriate care, and transportation difficulties lead to delayed care and missed appointments. This increases the risk of late diagnoses and poorer health outcomes.

Providing culturally-responsive care improves engagement and continuity. Integrating care navigation, social support, and language services into care models promotes access and utilization of healthcare services.

What Policymakers Should Do to Improve Women’s Access to Primary Care

The following recommendations outline feasible, actionable steps that federal and state policymakers can take to improve women’s access to primary care:

Expand insurance coverage and reduce healthcare costs

• Adopt Medicaid expansion in all remaining states.
• Restructure eligibility standards for cost-sharing subsidies and premium tax credits to promote affordable insurance coverage.
• Reform healthcare-related immigration policies at the federal, state and local levels to expand Medicaid and marketplace eligibility for undocumented immigrants and refugees.
• Enhance outreach, education and navigation services to streamline enrollment and renewal process for Medicaid and marketplace coverage.

Build culturally responsive and patient-centered care delivery

• Fund healthcare navigation, transportation assistance, translation services, and extended clinic hours.
• Expand culturally and linguistically appropriate healthcare services for immigrant and refugee women. Match patients with providers who share their language and cultural background. Incorporate culturally specific components into individual clinical encounters. Provide culturally and linguistically appropriate educational and outreach materials.
• Mandate cultural-competency training within healthcare delivery system-based workforce development programs.

Strengthen policy evaluation and foster accountability

• Fund long-term studies that track changes in women’s insurance coverage and other individual factors and social determinants of health. Over time, this will allow researchers to evaluate how major ACA policies, including those related to reproductive healthcare, have affected women’s access to care.

Working-age women in the United States continue to face significant inequalities in primary care access. While the ACA expanded access to coverage to millions of Americans, our research demonstrates that additional policies are required to translate insurance coverage into meaningful access and utilization. By expanding access to affordable insurance, strengthening primary care service delivery systems, and addressing non-financial barriers, policymakers can take action to promote more equitable access to healthcare and improve health outcomes for women.