| dc.description.abstract | Background: The Affordable Care Act (ACA) aimed to enhance access to
health care in the United States, particularly for those without comprehensive
insurance. This thesis examines the impacts of the ACA on equity of access by
investigating its effect on Federally Qualified Health Centers (FQHCs). FQHCs
provide essential primary care to low-income people. Their experiences of
providing primary care during the period of the ACA’s implementation can
provide valuable information about the challenges of addressing inequities of
access in the context of a dual insurance market.
Aim: To examine the ACA’s impact on the ability of FQHCs in Arizona,
California, and Texas to provide essential primary care to people with limited
health care access.
Methods: Using a case study approach, the thesis draws on two data sources
to contextualize and explore how the ACA was perceived to impact on FQHCs in
Arizona, California, and Texas, and how senior FQHC staff responded to these
impacts. Data from Uniform Data System (UDS) were analyzed to ascertain
trends in overall population insurance coverage and in FQHCs’ patient
coverage, provided services, and funding sources in Arizona, California, and
Texas from 2008 to 2015. The main body of the research focused on
administrators’ experiences of the ACA’s impact on FQHCs and their ability to
meet the needs of their patients. This was explored via 23 interviews with
executive directors and mid-level managers from 10 FQHCs in the three states,
which took place between July and September 2015.
Results: Impact on FQHCs: FQHCs in Arizona and California experienced an
increase in the proportion of their patients covered by Medicaid following
implementation of the ACA. Interviews confirmed that Medicaid expansion in
Arizona and California enabled many uninsured patients to obtain coverage and
access to care, with FQHCs experiencing increases in demand and revenue. In
contrast, FQHC administrators in Texas believed the ACA had minimal impact
on both patient coverage and revenues, as the state had not expanded Medicaid.
FQHCs in Texas experienced a minimal increase in the proportion of patients
with insurance coverage, with most newly insured patients gaining coverage via
the private market. UDS data from 2008-2015 showed that FQHCs in all three
states experienced an increase in real income from federal grants under the
ACA. Response of FQHCs: The majority of key informants in Arizona and
California stated the ACA had enhanced their ability to serve their patients,
primarily due to increased revenue from Medicaid which enabled FQHCs to
increase their capacity and better respond to the needs of their patients. In
contrast, there was no consensus among administrators in Texas regarding the
impact of the ACA on their ability to serve their patients. The absence of
Medicaid expansion and weaknesses of private insurance meant patients in
Texas faced particular difficulty in accessing care due to high deductibles, the
limited depth of coverage and a small pool of willing providers.
Discussion and conclusions: The experience of FQHC administrators
provides a valuable lens through which to evaluate the effectiveness of the ACA
in terms of one of its core objectives: addressing inequities of health care
coverage and access in the U.S. After the legislation took effect, FQHCs in
Arizona and California experienced considerable improvements in their ability
to meet patient needs, especially due to the expansion of Medicaid in these
states. In contrast, FQHCs in Texas did not experience a notable improvement in
their ability to serve their patients. The FQHCs in all three states continued to
face challenges in securing their patients’ access to specialist health services.
The findings of this thesis highlight the scale of challenge faced by policymakers
that seek to expand health care access within a context of mixed public/private
insurance. While the ACA aimed to improve health care access by expanding
coverage, its ability to do so was compromised by: i) regulatory barriers to the
expansion of public health insurance (a legal challenge and Supreme Court
ruling meant half of all US states opted out of Medicaid expansion); ii)
limitations in coverage and access associated with private health insurance; and
iii) reluctance on the part of some healthcare providers to accept patients with
public or more limited private insurance. | en |
