In 2001, the District of Columbia (DC) fundamentally changed its system of safety-net healthcare. The District closed its public hospital; created an insurance program for low-income residents, the DC Healthcare Alliance; shifted control of its publicly-run clinics to nonprofits; expanded Medicaid coverage; and invested in safety-net providers. DC shifted from directly providing healthcare to providing coverage and promoting care through private providers.

This shift in priorities and structure offers an opportunity to examine the effects of increasing coverage and promoting primary care on access to healthcare. Using annual cross-sectional data from the Center for Disease Control's Behavioral Risk Factor Surveillance System from 1998 to 2006, I conduct multivariate regression analysis controlling for individual demographics, socioeconomic status, and health status, as well as pre-reform trends in DC and pre- and post-reform trends among a comparison group of eleven metropolitans in the region.

Analysis finds that DC's reforms are associated with improved access to healthcare in three of four outcomes and improved access trends in all four outcomes. Among non-elderly adults in DC, the reforms reduced the uninsured population by 5.7 percentage points; reduced the population delaying care due to cost by 17.3 percentage points; reduced the population without a personal doctor by 6.4 percentage points; and increased the population without an annual checkup by 2 percentage points. The effectiveness of DC's reforms suggests that policymakers seeking to improve access can do so by increasing coverage and promoting safety-net providers.