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Health Insurance Challenges in the Post-Affordable Care Act (ACA) Era: a Qualitative Study of the Perspective of Low-Income People of Color in Metropolitan Detroit

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Low-income people of color are at risk of remaining uninsured due to a variety of factors. This study examined Affordable Care Act (ACA)-related and other health insurance enrollment experiences, observations, navigation needs, and experiences maintaining health insurance coverage among low-income communities of color in an economically disadvantaged community (Metropolitan Detroit). We conducted nine focus groups (n = 87) between May and June 2015. Participants were recruited through community-based organizations serving our key populations of interest. Using an inductive thematic analysis approach, codes and themes were generated. Findings from six themes demonstrated that although health insurance is perceived as important, confusion and frustration persist around health plan benefits and coverage, eligibility requirements and key provisions of the ACA, and enrollment. Individuals face difficulties justifying the cost of health insurance. More focused insurance outreach efforts are needed to achieve the ultimate goal of improving the health of low-income communities of color.

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  1. Chaudry A, Fortuny K, Pedroza J. Improving access of low-income immigrant families to health and human services: the role of community-based organizations. Urban Institute. 2014. Accessed 8 July 2016.

  2. Centers for Disease Control and Prevention. FastStats: health insurance coverage. 2015. Accessed 8 July 2016.

  3. Enroll America. Enroll America. Michigan: State Snapshot; 2016 . Accessed 18 January 2017

    Google Scholar 

  4. Michigan Department of Community Health. Healthy Michigan Plan. 2016.,5668,7-326-67957---,00.html. Accessed 18 January 2017.

  5. Sommers BD, Gourevitch R, Maylone B, Blendon RJ, Epstein AM. Insurance churning rates for low-income adults under health reform: lower than expected but still harmful for many. Health Aff (Millwood). 2016;35(10):1816–24.

    Article  PubMed  Google Scholar 

  6. Desan MH. Bankrupted Detroit. Thesis Eleven. 2014;121(1):122–30.

    Article  Google Scholar 

  7. Center for Healthcare Research & Transformation. Federally Qualified Health Centers. 2013. Accessed 8 July 2016.

  8. Barcellos SH, Wuppermann AC, Carman KG, Bauhoff S, McFadden DL, Kapteyn A, Winter JK, Goldman D. Preparedness of Americans for the affordable care act. Proc Natl Acad Sci U S A. 2014;111(15):5497–502.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Sommers BD. Health care Reform’s unfinished work—remaining barriers to coverage and access. N Engl J Med. 2015;373(25):2395–7.

    Article  CAS  PubMed  Google Scholar 

  10. Delgado G. Breaking barriers: improving health insurance enrollment and access to healthcare. Alliance for a Just Society. 2015. Accessed 8 July 2016.

  11. Chandrasekar E, Kim KE, Song S, Paintal R, Quinn MT, Vallina H. First year open enrollment findings: health insurance coverage for Asian Americans and the role of navigators. J Racial Ethn Health Disparities. 2016;3(3):537–45.

    Article  PubMed  Google Scholar 

  12. Vargas R. How health navigators legitimize the affordable care act to the uninsured poor. Soc Sci Med. 2016;165:263–70.

    Article  PubMed  Google Scholar 

  13. Stewart DW, Shamdasani PN. Focus groups: theory and practice. Sage Publications; 1990.

  14. Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches. Sage Publications; 2008.

  15. Baicker K, Taubman SL, Allen HL, Bernstein M, Gruber JH, Newhouse JP, Schneider EC, Wright BJ, Zaslavsky AM, Finkelstein AN. Oregon health study group.. The Oregon experiment—effects of Medicaid on clinical outcomes. N Engl J Med. 2013;368(18):1713–22.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Kamimura A, Tabler J, Chernenko A, Aguilera G, Nourian MM, Prudencio L, Ashby J. Why uninsured free clinic patients don’t apply for Affordable Care Act Health Insurance in a non expanding Medicaid state. J Community Health. 2016;41(1):119–26.

    Article  PubMed  Google Scholar 

  17. Rae M, Damico A, Cox C, et al. The cost of the individual mandate penalty for the remaining uninsured. The Henry J. Kaiser Family Foundation. 2015. Accessed 8 July 2016.

  18. Goodnough A. Many see IRS penalties as more affordable than insurance. The New York Times. 2016. Accessed 8 July 2016.

  19. Kaiser Family Foundation. The requirement to buy coverage under the Affordable Care Act. The Henry J. Kaiser Family Foundation. 2015. Accessed 8 July 2016.

  20. Claxton G, Rae M, Panchal N, Whitmore H, Damico A, Kenward K, Long M. Health benefits in 2015: stable trends in the employer market. Health Aff (Millwood). 2015;34(10):1779–88.

    Article  Google Scholar 

  21. Manning WG, Newhouse JP, Duan N, Keeler EB, Leibowitz A, Marquis MS. Health insurance and the demand for medical care: evidence from a randomized experiment. Am Econ Rev. 1987;77(3):251–77.

    CAS  PubMed  Google Scholar 

  22. Ubel PA, Comerford DA, Johnson E. Healthcare.Gov 3.0—behavioral economics and insurance exchanges. N Engl J Med. 2015;372(8):695–8.

    Article  CAS  PubMed  Google Scholar 

  23. Pollitz K, Tolbert J, Ma R. Survey of health insurance marketplace assister programs. The Henry J. Kaiser Family Foundation. 2014. Accessed 8 July 2016.

  24. Enroll America. Detroit: uninsured population & enrollment assisters. 2014. Accessed 8 July 2016.

  25. Stern S. A framework on health insurance literacy for the outreach and enrollment community. 2015. Accessed 8 July 2016.

  26. Centers for Medicare and Medicaid Services. From coverage to care: a roadmap to better care and a healthier you. 2014. Accessed 8 July 2016.

  27. Choi K, Fabian L, Mottey N, Corbett A, Forster J. Young adults’ favorable perceptions of snus, dissolvable tobacco products, and electronic cigarettes: findings from a focus group study. Am J Public Health. 2012;102(11):2088–93.

    Article  PubMed  PubMed Central  Google Scholar 

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Correspondence to Minal R. Patel.

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This study was funded through the National Institute for Health Care Reform (UM#N019071).

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All authors declare that they have no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the University of Michigan Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Patel, M.R., Jensen, A., Ramirez, E. et al. Health Insurance Challenges in the Post-Affordable Care Act (ACA) Era: a Qualitative Study of the Perspective of Low-Income People of Color in Metropolitan Detroit. J. Racial and Ethnic Health Disparities 5, 78–85 (2018).

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