In 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law by President Obama. Despite polarized attitudes toward health care reform as a whole, one provision of the ACA was notably popular and quickly implemented: the dependent coverage expansion, which requires all insurance plans with dependent coverage to include children up to age 26 (Chen, 2018). Although a substantial effort was made to find literature which may explain the difference in attitudes towards the ACA and the dependent coverage expansion, none of the discovered studies directly addressed this topic. The most relevant literature discovered either related to: (1) the impact of the expansion provision on young adults’ health and coverage rates (n=3), or (2) influencing factors towards attitudes towards the ACA (n=5).
A systematic approach was followed in order to utilize published works that are relevant to the research topic. Specifically, the articles were limited to peer-reviewed, full-text, scholarly articles published in academic journals within the last 10 years, and found within the SocINDEX with Full Text and Academic Search Complete databases. The search criteria was refined by searching a combination of the following keywords: perception, attitudes, health care, affordable care act, age, socioeconomic, and race. In addition, the reference pages of notable articles were used to identify other relevant articles.
Lastly, the article title, subject, and abstract was then used to further refine the search results, ultimately leaving the most substantial and relevant articles to the research question at hand. Study Characteristics The majority of articles were conducted quantitatively using surveys (Benson et al., 2011; Carlson, Lennox, Lynch, & Dreher, 2014; Dahlen, 2015; Gelman, Lee, & Ghitza, 2010; Legerski & Berg, 2016; VanGarde, Yoon, Luck, & Mendez-Luck, 2018). Of these quantitative studies, only one study developed their own survey (Benson et al., 2011), while the remaining used data previously collected and made available by various government/educational organizations.
McCabe (2016) provided the only mixed-method study, using surveys and interviews to capture how personal experiences with health care impact attitudes towards the ACA. Lastly, Hensley (2012) applied a qualitative approach using focus groups to determine the impact of the ACA on persons within the mental health community. Participant Characteristics and Variables The studies reviewed varied greatly in sample size and population. Several of the quantitative studies had large sample sizes, the most substantial being VanGarde et al. (2018) with approximately 400,000 research participants, followed by Carlson et al. (2014) with approximately 210,000 participants, and Gelman et al. (2010) who used approximately 100,000 participants.
However, the quantitative study by Benson et al. (2011) only had 362 participants, which was due to focusing only on Einstein College medical students. The qualitative studies had understandably smaller sample sizes, the smallest being 46 participants included in the Hensley (2012) study. Samples were random, except in the few studies that studied specific groups such as Benson et al. (2011) which studied medical students at Einstein College, Hensley (2012) which studied the mental health community in the mid-West region, and Dhalen (2015) who only considered unmarried persons due to the impact of marriage on health care choices and access. A common variable used in the studies was age, however, the method of organizing/grouping the ages differs slightly.
Noteworthy is the Carlson et al. (2014) study, which uses age to group participants as either directly benefiting (ages 19-26) or not benefiting (ages 27-34) from the ACA expansion provision. Another common variable used was political views, which was categorized as either Republican or Democratic (Benson et al., 2011, Gelman et al 2010; Legerski & Berg, 2016; McCabe, 2016). The most extensive use of variables can be found in the VanGarde et al. (2018) study, which mapped health care coverage and access by race/ethnicity, employment status, education, income, gender, perceived health, time since last care received, chronic health conditions, and ability to pay for services.
Findings Impact of Expansion Provision on Young Adults
All of the articles referencing the impact of the ACA on coverage rates reflect a similar 3-6 percentage point increase in young adult coverage (Carlson, et al., 2014; Dahlen, 2015; VanGarde et al., 2018). Dahlen (2015) reveals a notable increase in young men, which they attributed to an increased willingness for men to leave employment due to the ability to get dependent insurance. VanGarde et al. (2018) further researched coverage rates according to race and ethnicity, and found that certain groups had higher increases in coverage than others. Their research showed the largest increase was among Alaska Natives/American Indians (8.4 percentage points), followed by non-Hispanic Whites (7.05 percentage points), and Hispanic (6.1 percentage points), while the lowest increase was non-Hispanic Blacks (1.2 percentage points).
In addition to improved coverage rates for young adults, Carlson et al. (2014) also found an increase in the self reported health of young adults following the ACA. They determined this was because the increase in access to dependent coverage lessened stress and anxiety, which were main detractors of overall health. Race and ethnicity were also factors in the health of young adults, according to VanGarde et al. (2018), whose research found that while all categories had increases in coverage, physician access did not universally increase.
Sadly, their study found that non-Hispanic Blacks had no significant improvement in physician access due to the associated cost issues, while non-Hispanic Whites saw a 3.2 percentage point increase in access, showing a persistent disparity in health care coverage and access across different race and ethnicities. Influencing Factors of Attitudes Towards the ACA Among the studies which examine attitudes towards health care reform, there is a clear consensus that political party identification substantially shapes public opinion on the ACA (Benson et al., 2011; Gelman et al., 2010; Legerski & Berg, 2016; McCabe, 2016). Some authors attribute the strong influence to partisan beliefs about the type of impact the ACA will have on health care. Specifically, while Republicans share a belief the ACA will have an overall negative impact on health care, Democrats believe the ACA provides a positive impact overall (Gelman at al., 2010).
Uniquely, Benson et al. (2011) discovered that attitudes towards the ACA were attributed more to support of the President than to actual political party affiliation. Gelman et al. (2010), while not including it as a variable researched in their study, suggests future studies consider presidential support in addition to political affiliation. In addition to political factors, Gelman et al. (2010) discovers that age and income can prevail over political affiliation as an influencing factors on attitudes toward the ACA.
The finding suggest that a younger and lower income person is more likely to view the ACA positively, while older and richer individuals are more likely to have a negative opinion, relative to their political party. For example, while it is true that Republicans are less likely to support the ACA, low income and/or young Republicans had higher rates of support than their Republican peers. This suggests that while political party carries substantial influence, age and income are ultimately the main influencing factors due to their ability to override party influence.
As could be expected, the quantitative studies appear to have approached their study using the Positivism paradigm, as they begin with an objective point of view and use a deductive strategy to find meaning in their data, ultimately looking for concrete answers to explain their revealed patterns (Carlson et al., 2014; Dahlen, 2015; Gelman et al., 2010; Legerski & Berg, 2016; McCabe, 2016). The majority of these Positivistic studies followed the Conflict Theory in trying to understand the differences in access to and attitudes towards the ACA (Carlson et al., 2014; Dahlen, 2015; Gelman et al., 2010).
However, McCabe (2016) employs the Structural Functionalism Theory to understand how negative or positive interactions in health care impact attitudes toward the ACA. Similarly, Legerski & Berg (2016) does not use the Conflict theory, but instead utilizes the Symbolic Interactionism Theory to explain how the ACA policy itself, and ones understanding of the policy, is related to their attitude towards the ACA. On the contrary, it appears the remaining studies used the Social Constructionism Paradigm by starting with the belief that realities and understandings are different depending on which group is studied. While Benson et al. (2011) wanted to understand the attitudes and beliefs of medical students, Hensley (2012) studied the mental health community, and VanGarde et al. (2018) sought to understand the reality of persons from different races and ethnicities.
A unique perspective worth noting is the use of the Conflict, Feminist, and Critical Race Theory in the VanGarde et al. (2018) study, which called attention to the disparity in health insurance and physician access, most notably for non-Hispanic Blacks. Limitations It was apparent rather quickly that the studies performed with the use of previously collected data were limited in terms of the data they could extrapolate. For example, Carlson et al. (2014) would have continued research with the participants over a longer period to truly assess long term health improvements, while Gelman et al. (2010) would have preferred to differentiate between political affiliation and support for the President, had they both not been limited in available data. Another repeat limitation among the studies was the lack of geographic data of the research participants, which either did not allow them to form conclusions on the greater population (Hensley, 2012) or did not allow them to control for the fact that states had adopted dependent coverage at different times (Dahlen, 2015).
Eight years after the passing of the ACA, health care reform remains a top concern for voters and continues to be a major talking point for political figures. Now, more than ever, when the fight for each individual vote is intense, having a better understanding of the factors that influence attitudes toward health care reform is of great importance. Unfortunately, there is a very limited number of studies that directly apply to attitudes toward the expansion provision of the ACA. By gleaming information from related topics on the ACA, there appears to be consensus on which areas to focus on (age, income, political affiliation) and which areas should be further explored (Presidential support). Finally, the related research provides valuable insight on the importance of collecting/refining geographic data.
- Benson, A. A., Mendelsohn, N., Gervits, M., Adeshuko, F., Garcia, C. S., & Smoller, S. (2011). Medical Student Views of Healthcare Reform in the United States, 2009. Einstein Journal Of Biology & Medicine, 27(1), 28-33.
- Carlson, D.L, Lennox Kail, B., Lynch, J.L., and Dreher, M. (2014). The Affordable Care Act, Dependent Health Insurance Coverage, and Young Adults’ Health. Sociological Inquiry, 84(2), 191-209. doi:10.1111/soin.12036
- Chen, W. (2018). Young Adults’ Selection and Use of Dependent Coverage under the Affordable Care Act. Frontiers in Public Health, 6, 3. doi:10.3389/fpubh.2018.00003
- Dahlen, H. M. (2015). ‘Aging Out’ of Dependent Coverage and the Effects on US Labor Market and Health Insurance Choices. American Journal Of Public Health, 105(5), 640-650. doi:10.2105/AJPH.2015.302791
- Gelman, A., Lee, D., & Ghitza, Y. (2010). Public opinion on health care reform. The Forum, 8(1), 1–13.
- Hensley, M. A. (2012). Perspectives of Mental Health Stakeholders on Health Care Reform. Journal of Policy Practice,11(3), 178-191. doi:10.1080/15588742.2012.655201
- Legerski, E. M., & Berg, J. A. (2016). Americans’ Approval of the 2010 Affordable Care Act: Self-interest and Symbolic Politics[*]. Sociological Inquiry, 86(3), 285–300. doi:10.1111/soin.12121
- McCabe, K. (2016). Attitude Responsiveness and Partisan Bias: Direct Experience with the Affordable Care Act. Political Behavior, 38(4), 861-882. doi:10.1007/s11109-016-9337-9 VanGarde, A., Yoon, J., Luck, J. and Mendez-Luck, C. (2018). Racial/Ethnic Variation in the Impact of the Affordable Care Act on Insurance Coverage and Access Among Young Adults. American Journal of Public Health, 108(4), 544-549.