The Reality of the Affordable Care Act Implementation among the Chronically Uninsured: A Qualitative Study

Millions of Americans remain uninsured even after implementation of the Affordable Care Act (ACA), representing a major concern for public health. Uninsured people are more likely to have more serious health problems. The uninsured are more concentrated in Medicaid nonexpansion states and the South, as well as more likely to be Spanish speaking, unmarried, and have less than a high school education. Previous research has not addressed why the chronically uninsured choose not to enroll in health insurance. This paper focuses on chronic uninsurance and decisions to sign-up for health insurance. Six focus groups were conducted with fifty-two participants during the first year of implementation of the ACA. Participants were recruited through churches, free clinics, and community centers. Seven themes emerged: immediacy, instability, personal cost, discouragement, “us vs. them”, Mistrust and health insurance literacy. Themes were described through levels of the Social- Ecological model. The chronically uninsured weigh multiple factors in their decision to sign up for health insurance. Cost is a major barrier, though it is important to examine in the realm of instability and immediate needs. Future interventions should target health insurance literacy, overcoming multiple cost considerations, and skepticism toward the ACA.