CHAPTER IV- DATA AND ANALYSISIntroductionBased on the collec

CHAPTER IV- DATA AND ANALYSIS
Introduction
Based on the collected data from the previous chapter, the
information supports the first hypothesis that: The introduction
of healthcare under the Affordable Care Act (Obamacare)
increased the percentage of low-income American households
with health insurance by 70%. The data also support the second
hypothesis that: The introduction of healthcare under the
Affordable Care Act (Obamacare) increased the percentage of
ethnic and racial minority households in the United States with
health increased by 20%. Finally, the data support the last
hypothesis of the study that: The introduction of healthcare
under the Affordable Care Act (Obamacare) increased the
percentage of ethnic and racial minority households in the
United States with health insurance by 20%.
The paper examines the difference in health care coverage in
the underrepresented American households before and after the
implementation of the Affordable Care by analyzing the data
from six different sources. The policy was enacted to primarily
expand American’s access to insurance and improve the quality
of health care services that American citizens get access to. As
such, the reform has resulted in a significant impact regarding
the health status of different groups living in America,
especially among the minorities. Besides, the introduction of
the reform has, over the years, been associated with a reduction
in disparities in the U.S health care system.
Notably, before A.C.A, various groups of color had limited
access to health insurance coverage which adversely affected
their health care conditions. Similarly, individuals from low -
income families also experienced this effect. In this regard, the
paper aims at answering a question that: Has the introduction of
healthcare under the Affordable Care Act (Obamacare)
increased the percentages of minority and lower-and middle-

class households with health insurance significantly?
The paper implements the statistical procedure used in the
articles identified and whose data have been included in the
research. In this regard, the paper depends on more than one
method for analyzing data that will be used in answering the
research questions. Additionally, the chapter explores data
presented in all the articles and analyzed them to determine
whether they support, partially support, or reject the
hypotheses.
Hypothesis #1
The first hypothesis that the paper is focused on is: The
introduction of healthcare under the Affordable Care Act
(Obamacare) increased the percentage of low-income American
households with health insurance by 70%.
One of the research articles that the paper uses in testing the
hypothesis outlined above is the study by Sommers et al.
(2017). Based on the methods used by the researchers, the study
found that 72 percent of the respondents living in Kentuc ky
were affected with chronic conditions, 69 percent in Arkansas,
and 55 percent in Texas. According to the results, the disease
prevalence between 2013 and 2016 decreased within the
expansion states with a P-value of 0.06. Sommers et al. (2017)
provided that the mean number of various conditions including
depression, hypertension, and diabetes ranged from 2.0 to 2.3.
According to the results of the study, the three states involved
in the research began the assessment when the uninsurance rate
was about 40 percent among the low-income individuals. At the
end of the research period, in 2014, the uninsurance rate was at
7.4 percent in Kentucky, 11.7 percent in Arkansas, and 28.2
percent in Texas. The study realized an increase in insurance
coverage, access, affordability, and prevention with a p-value of
0.05 while that of quality was at p<0.010.
Figure 1: Percentage of the uninsured Low-income adults
between 2013 and 2016

The second article used in testing the hypothesis is by Sommers
et al. (2016) and it addresses changes in utilization and health
among low-income adults after the expansion of Medicaid. The
study found that the expansion regarding health uninsurance
rate reduced by 22.7 percent as of 2015 with a p-value less than
0.001. The expansion rate of insurance cover was associated
with an increased rate of 12.1 percent and a p-value of less than
0.001. The results indicate that there was a reduced level of out-
of-pocket spending for the respondents during the research
period. The quality of care rating indicated significant
improvement with a -7.1 percentage point indicating “fair/poor”
care quality and a p-value of 0.03.
Considering the states, Sommers et al. (2016) found that
Arkansas realized an increased level of private insurance
coverage while Kentucky showed an increased Medicaid of 1.3
percent. The uninsurance rate reduced from 41.1 to 14.2 percent
in Arkansas, from 40.2 to 8.6 percent in Kentucky, and from
38.5 to 31.8 percent in Texas. During the research period,
private coverage gains showed greater values in Kentucky and
Arkansas. However, the two states showed the lowest Medicaid
gains. Besides, the minority experienced a significant increase
in insurance coverage which showed a p-value of 0.004.
Both the two studies that address the first hypothesis realized an
increase in the rate of insurance coverage expansion while the
rate of uninsurance greatly reduced. The studies indicate high
number of insurance rates for most respondents in the three
cities between the starting and ending period of the research.
The increase in health insurance coverage led to a reduced level
of income spending on health care services and out-of-pocket
spending among low-income individuals. In this regard, the two
studies support the first hypothesis. They both realized an
increase in the insurance coverage among the low-income
individuals after the implementation of A.C.A thus supporting
the hypothesis that: The introduction of healthcare under the
Affordable Care Act (Obamacare) increased the percentage of
low-income American households with health insurance by

70%.
Hypothesis 2
The second hypothesis is: The introduction of healthcare under
the Affordable Care Acct (Obamacare) increased the percentage
of middle-class American households with health insurance by
20%.
The first study that relates to the above hypothesis is by
Dickman et al. (2016) and it addresses low-, middle- and high-
class individuals’ spending on health. The results of the study
indicate that the per capita health expenditure grew between
1963 and 2012. The researchers found that the health
expenditure for the high-class income groups outpaced those of
the middle-class individuals. Notably, individuals from low -
class indicated the worst health status before the
implementation of A.C.A. The study found an increase in
prescription drug spending for the income groups after 2004.
However, the high-income group showed an increased inpatient
and outpatient expenditures while the middle-class indicated a
flat growth and a declining growth for the low-class.
Based on the research study, the researchers found that the
participants from the high-class made 40 percent more
outpatient visits per capita than the remaining groups with a
higher spending per visit approximately $303 compared to $241
for the remaining groups by2012 (Dickman et al., 2016). The
results indicate that private insurance expenditures for the three
income groups became different after 2004. In this regard, the
expenditures rose rapidly for the wealthiest groups while it fell
for the low-income group. Concerning the per capita Medicare
expenditure growth, the low-class individuals realized a slower
growth than the middle- and high-class groups. Private
insurance expenditures per enrollee for individuals younger than
65 years fluctuated for the low-class group indicated a modest
growth for the middle-class and sharply increased for the
wealthiest individuals.
According to Dickman et al. (2016), the Medicaid spending for
every nonelderly recipient significantly declined during the

research period. However, the study did not realize any trend
associated with the proportion of the total spending for the low -
income group. Besides, the faster growth of expenditures
realized among the poor before 2004 was driven by the
costliest. However, the expenditur es for both low-cost and high-
cost after year surged.
Figure 2: Diagram showing spending per capita
The second study related to the hypothesis is “The Effects of
Household Medical Expenditure on Income inequality in the
United States.” From the study, Christopher et al. (2018)
indicated that the Gini index was 46.77 at the start of the
research in 2010. However, subtracting medical outlays led to
an increase in the index to 48.22. The researchers realized a
Gini index of 47.84 in 2014 which increased to 49.21 after
subtracting medical outlays. When premium contributions of
employers were treated as additions to employee income, the
research realized outlays redistribution of about 1.7 percent for
all income groups, the poor, middle class, and wealthier
individuals.
The results indicate that the medical outlays in 2013 led to a
decrease in income for the low-income individuals by 49.2
percent, 10.7 percent for the middle-income population, and 2.5
percent for the wealthiest group. This indicates unequal pattern
that slightly improved in 2014 based on the research findings.
Additionally, the medical outlays reduced for the median
income individuals by 47.6 percent and 2.7 percent for the same
group in the top decile. According to Christopher et al. (2018),
about nine million American citizens whose incomes before
subtracting their medical outlays for their family income were
above the poverty level were pushed into the 150 percent
federal poverty level in 2014.
The two studies provide data on medical expenditures and
income inequality regarding a section of the American
population. Based on the data, there was a significant decrease

after the implementation of Medicaid under Obamacare for all
the income groups involved in the two studies. As such, the
introduction of A.C.A among the Americans realized positive
results, especially for the low- and middle-class individuals.
Therefore, the data from the studies support the hypothesis that:
The introduction of healthcare under the Affordable Care Act
(Obamacare) increased the percentage of middle-class American
households with insurance by 20%.
Hypothesis 3
The third hypothesis that the paper focuses on is: The
introduction of healthcare under the Affordable Care Act
(Obamacare) increased the percentage of ethnic and racial
minority households in the United States with health insurance
by 205.
The first study that is related to the hypothesis is “The Effect of
the Affordable Care Act on Racial and Ethnic Disparities in
Health Insurance Coverage.” The results of the study indicate
that the percentage of adults in various groups, White, Black,
and Hispanic of the uninsured individuals increased between
2008 and 2010. However, the values significantly declined
between 2010 and 2013. Buchmueller et al. (2016) found an
average coverage gap between Blacks and whites to be 11
percentage points while the average gap between Hispanics and
whites was about 27 percentage points. The study found that the
percentage of the uninsured reduced by 7.1 percent among
Hispanic, 5.1 percent among Blacks, and 3 percent among
whites in 2014.
The results indicate a decline in public insurance coverage for
all the three groups between 2008 and 2013 before realizing an
increase between 2013 and 2014. During the period in which
public insurance increased, the percentage point and gain were
greater for the two minority groups than the Whites. In this
regard, Buchmueller et al. (2016) indicated that private
coverage for Hispanics increased by 4.3 percentage points, 3
percentage points for the Blacks, and 1.5 percentage points for
the Whites. The public coverage between 2013 and 2014

increased by 2.8 percentage points for Hispanics, 1.9 percentage
points for the Blacks and the whites realized an increase of 1.5
percentage points.
Before A.C.A insurance expansions, about 60 percent of the
Hispanic noncitizens were uninsured while only 28 percent of
the Hispanic citizens were uninsured. Between 2013 and 2014,
the percentage point change was 7.0 for Hispanic noncitizens
and 6.7 for Hispanic citizens. In regards to the adults from
families whose income was below 138 %, the results indicate
more decline for Hispanics (9.3 percentage points) than for the
non-Hispanics (6.1 percentage points). The percentage of
Blacks without health insurance reduced by 5.6 percentage
points in 2013 considering the expansion states while the group
realized a decrease of 4 percentage points in the non-expansion
states.
Figure 3: Uninsured percentage of the Nonelderly between 2008
and 2014
The second study that is related to the hypothesis is “Racial and
Ethnic Disparities in Health Care Access and utilization under
the Affordable Care Act.” According to Chen et al. (2016), the
study found that the implementation of A.C.A significantly
reduced the rate of uninsured for all ethnicities and races. Based
on the research study, the uninsured rate decreased by 7 percent
for the African Americans and Latinos, 3 percent for the
Whites, and 5 percent for the remaining racial and ethnic groups
in 2014 compared to 2011. Additionally, the results show that 5
percent of the Latinos were likely to visit physicians, 3 percent
for African Americans, and 2 percent for whites in 2014
compared to 2011.
The implementation of Obamacare led to a significant reduction
of the likelihood of an individual getting uninsured with a
coefficient value of -0.03 and p-value <0.01. The delay in any
necessary care was reduced with a coefficient value of -0.03 and
a p-value <0.001. The reduction in the uninsured rates was more
pronounced in 2014. Besides, the possibility of being uninsured

in 2014 was 3 percentage points for the whites and 4 percentage
points for the African Americans and Latinos. However, the
likelihood of delayed or forgone care decreased by 2 percentage
points for the Latinos. On the other hand, Chen et al. (2016)
indicated that there was no significant difference for the African
Americas compared to the Whites in regards to forgone care or
physician visits in 2014.
The data from the two studies indicate an increase in health care
access among the ethnic and racial groups after the
implementation of the A.C.A relativee to the periods before the
reform. Based on the data, the rate of uninsured also reduced
significantly over the years after A.C.A implementation. As
such, the data support the hypothesis that: The introduction of
healthcare under the Affordable Care Act (Obamacare)
increased the percentage of ethnic and racial minority
households in the United States with health insurance by 20%.
References
Buchmueller, T. C., Levinson, Z. M., Levy, H. G., & Wolfe, B.
L. (2016). Effect of the Affordable Care Act on racial and
ethnic disparities in health insurance coverage. American
journal of public health, 106(8), 1416-1421.
Chen, J., Vargas-Bustamante, A., Mortensen, K., & Ortega, A.
N. (2016). Racial and ethnic disparities in health care access
and utilization under the Affordable Care Act. Medical
care, 54(2), 140.
Christopher, A. S., Himmelstein, D. U., Woolhandler, S., &

McCormick, D. (2018). The effects of household medical
expenditures on income inequality in the United
States. American Journal of Public Health, 108(3), 351-354.
Dickman, S. L., Woolhandler, S., Bor, J., McCormick, D., Bor,
D. H., & Himmelstein, D. U. (2016). Health spending for low -,
middle-, and high-income Americans, 1963–2012. Health
Affairs, 35(7), 1189-1196.
Sommers, B. D., Blendon, R. J., Orav, E. J., & Epstein, A. M.
(2016). Changes in utilization and health among low-income
adults after Medicaid expansion or expanded private
insurance. JAMA internal medicine, 176(10), 1501-1509.
Sommers, B. D., Maylone, B., Blendon, R. J., Orav, E. J., &
Epstein, A. M. (2017). Three-year impacts of the Affordable
Care Act: improved medical care and health among low -income
adults. Health Affairs, 36(6), 1119-1128.
CHAPTER I- INTRODUCTION
Introduction
This paper will examine the difference in health
care coverage in underrepresented American households before
and after the introduction of healthcare under the Affordable
Care Act. Chapter two will be a literature review; chapter three
will describe in detail studies that will later be used to test the
hypotheses in chapter four. Then chapter five will describe the
results, the conclusion and the recommendation.
Affordable Care Act (A.C.A.) is one of the
federal health reforms signed on March 31, 2010, under the
administration of former President Barack Obama. A.C.A. was
primarily enacted to expand Americans' access to insurance, put
more effort into disease prevention and wellness, improve
quality and system performance and reduce health care costs

(Blewett et al., 2018). As described in the A.C.A. itself, it aims
to extend insured Americans' health coverage to around 32
million, including those with private and public insurance.
Some of the guidelines related to expanding insurance access
coverage include ensuring that employers offer insurance
coverage to their workers, providing a tax credit to cover
specified costs of health insurance of small business employees,
and ensuring that individuals have insurance.
Before introducing A.C.A., most Americans were not
under any insurance health policy, especially the low -income
individuals, since they could not afford the cost of insurance.
Various insurance companies used individual's underwriting to
protect a healthy risk pool by ensuring that Americans pay
premiums that significantly reflected their medical plans
(Grogan, 2017). In 2009, a year before the A.C.A. passage, only
about 15% of the American population had health insurance.
The introduction of the Act in the subsequent year significantly
reduced the rate of uninsured individuals as it lowered to about
9%, indicating that almost 20 million Americans got insurance
coverage in the first year of A.C.A. introduction.
More than 31 million people are currently enrolled for health
coverage through A.C.A., implying that the Act has
significantly reduced the rate of insurance in every state. As of
February 2021, about 11 million people enrolled in the A.C.A.
Marketplace plans, while about 15 million enrolled in Medicaid
through the Act's expansion of eligibility to adults by December
2020 (Kavanagh et al., 2021). Therefore, A.C.A. has benefited
individuals from low-class and middle class and ethnic and
minority households.
Problem Statement
The introduction of A.C.A. has significantly affected
disparities in health insurance coverage among different racial
and ethnic groups. Based on the U.S. Census Bureau's
nationally representative American Community Survey, the
increase in the rate of nonelderly adults enrolling for insurance
coverage, which increased from 12.3% in 2013 to about 40% in

2017, led to a significant reduction in racial gaps. Notably, the
insurance rates of underrepresented American households
declined from 11% to about 6% (Christopher et al., 2018).
Before introducing the Act, people of color, the
underrepresented, were at higher risk of being uninsured than
whites. This, as a result, reflected the limited access of the
minority towards the health coverage options.
Before A.C.A., the eligibility for various groups of
color was limited to those with very low income. However, it
helped in filling some of the gaps. The introduction of A.C.A.
significantly improved health insurance coverage which l ed to
increased Medicaid to nearly all adults with incomes below the
poverty level. For instance, the groups of color experienced an
increased percentage in the coverage compared to whites
between 2010 and 2016 (Sommers et al., 2017). As such, the
trend continues to significantly impact the health status of the
underrepresented individuals making A.C.A. one of the primary
aspects that reduce health care access disparities among
Americans.
Pointing out the difference in health care access
coverage between before and after the introduction of A.C.A.
will provide more insights into the importance of the Act on the
well-being of the minorities. Policymakers can use the
information to adjust policy, thus improving the coverage in
underrepresented groups of Americans. The research analyzes
the differences between the underrepresented American
households before and after the introduction of A.C.A. We will
identify the differences by performing a literature review to
measure the impact of the Act.
Research Questions
The research question asked in this study is:
Has the introduction of healthcare under the Affordable Care
Act (Obamacare) increased the percentages of minority and
lower-and middle-class households with health insurance
significantly? Peer-reviewed data and studies from health
organizations will be used to answer the research question and

produce high quality research, other relevant information
necessary that will help in addressing the topic.
Research Hypotheses
The first hypothesis tested in this study is that
the introduction of healthcare under the Affordable Care Act
increased the percentage of low-income American households
with health insurance by 70%.
The second hypothesis tested in this study is
that the introduction of A.C.A. increased the rate of middle-
class American households with health insurance by 20%.
The third hypothesis tested in this study is that
the introduction of A.C.A. has increased the percentage of
ethnic and racial minority households in the United States with
health insurance by 20%.
The next chapter will offer a literary review, a
summary of research on the thesis of this study and provide the
readers with sufficient background and understanding of the
research topic.
Reference
Blewett, L. A., Planalp, C., & Alarcon, G. (2018). Affordable
Care Act impact in Kentucky: increasing access, reducing
disparities. American journal of public health, 108(7), 924-929.
Grogan, C. M. (2017). How the ACA addressed health equity
and what repeal would mean. Journal of health politics, policy
and law, 42(5), 985-993.
Kavanagh, M. M., Norato, L. F., Friedman, E. A., & Armbrister,
A. N. (2021). Planning for health equity in the Americas: an
analysis of national health plans. Revista Panamericana de
Salud Publica, 45, e29.
expenditures on income inequality in the United States.

American Journal of Public Health, 108(3), 351-354.
CHAPTER V-DISCUSSION, CONCLUSION AND
RECOMMENDATIONS
Discussion
Various countries continue to debate on better ways of
expanding insurance coverage among minority and low -income
Americans. The data provides vital evidence on the benefits that
Americans have realized since the Affordable Care Act (A.C.A.)
was introduced. The data analysis indicates that the insurance
coverage in various states has been increasing over time, with a
small impact realized during the first two years of its
implementation. The study realized a pattern that indicates that
the increase in health insurance coverage under Obamacare
significantly reduced the cost-related barriers to care, outpatient
visits, and an increase in the number of yearly checkups.
The study realized a slower spending growth among the poor
and middle-income individuals before A.C.A. and during the
first year of its implementation. This pattern is associated with
the increased disparity in health care spending within different
income groups during the period. However, the data do not
provide adequate insights into whether the current acceleration
in health expenditure has the potential of reversing the trend.
The sharp increase in health expenditures among the high-
income Americans and slow growth for the rest of the American
population widen the income-based medical care receipt gap.
Besides, there are increased chances that the gap might signify
increased disparities in health care.

Notably, the low-income individuals had the lowest healthcare
expenditure before A.C.A., besides their increased need for
healthcare services. However, the expenditure for the healthy
was twice that of the poor. Several factors might have
contributed to this occurrence. One of the factors the study
realized from the data is that most wealthy individuals enrolled
for Medicaid when the program was first implemented. Another
factor that might have contributed to the pattern is a reduced
number of health care facilities and professionals in areas
occupied by low-income groups, thus the increased spending to
access the services (Manchikanti et al., 2017).
Since the implementation of A.C.A., various countries have
reported significant improvement in the quality of care and
health (Stefanacci, 2017). The improvement is associated with
the Medicaid expansion under Obamacare, which is consistent
with findings from some of the earlier evidence on the impact of
the legislation on the health care system in the United States.
The collected data indicate the increased quality of care even in
areas of care shortages. As a result, this suggests that expansion
in insurance services has demonstrated a positive impact in the
areas regardless of the capacity of the clinicians.
The analysis of the data provides key contributions to the
growing research on the Affordable Care Act. An increase in
insurance coverage under the legislation resulted in increased
access to primary care and medications and affordability of care
services. Most of the changes were realized during the first
three years of A.C.A. implementation. In this regard, the
Americans who gained insurance coverage during the period
realized larger policy-relevant changes, including reduced out-
of-pocket medical expenditure, increased likelihood of
accessing the source of care, and increased chances of
experiencing excellent health. Prior research indicates that poor
health rating increases the mortality risk among low-income
groups than the remaining population (Alcalá et al., 2017).
Based on the finding of this study, the effect can be eliminated
through the policy interest of A.C.A. on health status.

Most uninsured American families spend on premiums,
deductibles copayments that are not subjected to their income.
Due to this, the medical care expenses increase their poverty
and income inequality level, which are some of the primary
social determinants of health. In most cases, the techniques that
the individuals use in care payment, especially when the
insurance programs fail to scale premiums, can widen health
disparities among a group regardless of their family status.
The pattern realized from examining the data related to the Gini
index is attributable to the medical outlays. The values before
the introduction of the A.C.A. suggest a modest improvement in
the health care financing system. Based on this, it is possible to
deduct that the individuals from low-income families increased
their care utilization while ensuring that their medical outlays
remain constant. The study findings indicate that most private
insurance coverage offered under the legislation exchanges tend
to lead to high deductibles. As a result, this can drive several
families into extreme poverty despite the cost-sharing
subsidies.
The data analysis indicates that various ethnic and racial
minority groups experiencing disparities in health care access
and coverage before the introduction of A.C.A. have realized
improved measures under the legislation. In this regard, the
African American minority group has realized the highest
benefit as several individuals have had access to insurance
coverage. For instance, African Americans are more likely to
gain insurance coverage through Medicaid and Marketplace
under A.C.A. than whites or other minority groups (Rosenkrantz
et al., 2017). The findings also indicate a slower rate regarding
the decline of the insurance rates among the Latino. This could
be attributed to the individuals being more likely to live in
American states that do not participate in the Medicaid
expansion.
The study provides a snapshot of various ways in which the
provisions of A.C.A. have significantly increased the insurance
coverage among the minorities in American. The data

demonstrate that the reform has increased America's overall
insurance coverage rate and eliminated insurance coverage
disparities associated with ethnicity and race. The introduction
of the legislation increased the number of insured Americans
even though about 30 million individuals remain uninsured.
Among the uninsured population, the number of racial and
ethnic minorities remains the highest in the population size.
This is because most minority groups experience low income.
Considering that health expenditures account for a similar
income share for the poor and rich, the difference in health care
access exists.
The above results reflect the theoretical frameworks that
support the study. Health and health care quality tend to differ
greatly from one group to another. For instance, the results
indicate increased access to health care services among black
Americans than Latinos or whites after A.C.A. As a result,
health care inequalities occur along with social class, race, and
ethnicity (Alcalá et al., 2017). Notably, individuals from
disadvantaged social backgrounds are most likely to experience
limited access to health care services which negatively impacts
their health status. Besides, the increased cost of healthcare
services is likely to affect a portion of the population, with the
highest impact felt among the minorities and low-income
individuals.
The findings allow the demonstration of health care disparity as
a social construction due to its existence as a result of human
interactions. In this regard, the disparity is shaped by both
historical and cultural contexts (Courtemanche et al., 2018).
Based on this, society has a significant influence on the
definition of the health status of individuals. For instance, the
study results indicate that the low-class is associated with the
minority groups. As such, society has a label for the position
that such individuals hold. Thus they are often associated with
increased levels of poverty and poor health conditions.
Additionally, society and its members associate low -class
families with reduced access to health care services, which

explains health care disparities. Therefore, the results reflect
the theoretical framework, conflict theory, and interactionism
theory related to the causes of health care disparities in
American society.
Limitations
The study has several limitations. First, the study used peer
review as the data collection method, which might have affected
the data used in answering the research question. It is possible
that the data collected from various research studies have
changed due to time, and many people have benefited from
A.C.A. Therefore, our results might not reflect the current
impact of Obamacare regarding the number of uninsured
Americans. However, the information provides a broad
overview of the state of health care among Americans.
Additionally, the study provides a great understanding of
different American groups and their access levels to health care
services regardless of when the actual data collection occurred.
This provides great ground for developing effective policies for
reducing health care disparities among the American
population.
Second, the study results may be prone to bias which might
have occurred from the previous studies that have been used in
the research. There are high chances that during the review of
the article, the individuals reviewing them may misinterpret the
data collected, and as a result, this distorts the findings. The
occurrence of biases due to the methodology might have
reduced the validity and reliability of the research findings.
However, researchers can implement various strategies such as
ensuring sufficient depth and relevance of data and ensuring
different perspectives in future research to improve the validity
and reliability of their findings.
Conclusions
A.C.A has significantly impacted the health care system of the
United States since its implementation. The implementation of
the legislation led to the expansion of health insurance coverage
which provides increased opportunity to the Americans to enroll

in the programs, thus saving thousands of lives. Its
implementation reduced the number of uninsured individuals to
historically low levels regardless of ethnic or racial groups of
the individuals. Due to the complexity of the United States'
health system, it is difficult to measure the effects that the
legislation has had on the cost and quality of the services
offered within the system. However, based on other factors such
as health status and health spending of various American
families, it is safe to conclude that A.C.A has improved the
quality and reduced the cost of health care services.
More Americans have been covered through the expansion of
Medicaid under A.C.A. Historically, Medicaid has been used to
insuring low-income adults, children, and disabled people.
However, the introduction of Obamacare has expanded the
insurance cover of adults living below 138 percent of the
federal poverty level. Additionally, its expansion has improved
the number of newly eligible low and middle-income families to
insurance coverage. The various changes that have resulted
from the legislation make it easier for children to get enrolled
and stay covered at a lower cost. Besides, A.C.A has opened
new opportunities for the development and promotions of
systems that allow Medicaid beneficiaries to enroll online for
the services, thus increasing the coverage.
The disparity in health care is one of the major social issues
that have been prevalent in the history of the American
healthcare system. Among the ethnic and racial groups which
have continued to show an increased number of uninsurance
rates are Hispanic, Blacks and Latinos. The introduction of
Obamacare has increased the ability of individuals to access
quality health care services through the expansion of insurance
coverage. Therefore, the Medicaid expansion under A.C.A has
played a significant role in reducing disparities among the
ethnic and racial minority groups in the United States.
Various efforts have been put in place in the United States to
reduce disparities in health care. However, A.C.A is the only
effective effort that has shown the potential for reducing the

disparity. Based on the research findings, dealing with
differences in health care access requires strategies that
consider the socioeconomic status of individuals. The research
deepens the understanding of individuals on the impact of the
Affordable Care Act on Americans' lives. Also, it demonstrates
effective strategies that various groups can implement in their
programs to eliminate disparities in healthcare in the United
States.
Recommendations
Considering that the introduction of A.C.A has not fully
eliminated health care disparities, it is important for the
government to initiate additional programs that raise public and
provider awareness and expand health insurance coverage
among the American population, especially among the minority
groups. Additionally, there is a great need for the government
and other private organizations to ensure an improved capacity
of health care facilities and the number of providers in the
underrepresented communities. It is vital to integrate
information from different research to increase the knowledge
base on the cause of healthcare disparities and interventions to
reduce them.
There is a great need for different changes in the current health
policies in America. It is essential for policymakers to assess
the current health policies and determine ways to reduce the
yearly increase in health care expenditure for the general
population and increase access of the individuals to care despite
the number of uninsured. The policies should also ensure
improved quality and eliminate inequalities in healthcare.
Achieving this will require the policymakers to stage a
constructive policy debate that focuses on the coverage and
spending of Americans on health care services.
Future research should explore healthcare utilization under
A.C.A for specific racial and ethnic groups to provide detailed
information on the impacts of the legislation on the health care
system. Different states experience variations in health care
reforms and strategies that include Medicaid expansion and

health insurance coverage. Therefore, future research needs to
evaluate the variation across different states to measure the
impacts of the policies and identify the changes. Besides, the
studies should incorporate other methodologies to explore the
impacts further.
References
Alcalá, H. E., Chen, J., Langellier, B. A., Roby, D. H., &
Ortega, A. N. (2017). Impact of the Affordable Care Act on
Health Care Access and Utilization among Latinos. The Journal
of the American Board of Family Medicine, 30(1), 52-62.
Courtemanche, C., Marton, J., Ukert, B., Yelowitz, A., &
Zapata, D. (2018). Effects of the Affordable Care Act on Health
Care Access and Self-Assessed Health after 3 Years. INQUIRY:
The Journal of Health Care Organization, Provision, and
Financing, 55, 0046958018796361.
Manchikanti, L., Benyamin, R. M., & Hirsch, J. A. (2017).
Evolution of US Health Care Reform. Pain physician, 20(3),
107-110.
Rosenkrantz, A. B., Nicola, G. N., & Hirsch, J. A. (2017).
Anticipated impact of the 2016 Federal Election on Federal

Health Care Legislation. Journal of the American College of
Radiology, 14(4), 490-493.
Stefanacci, R. G. (2017). The Impact of Federal Health Care
Reform on LTC. Annals of Long-Term Care.
CHAPTER II-LITERATURE REVIEW
Generally, the U.S health care system is unique
considering all the advanced industrialized countries because it
does not have a uniform health care coverage for all its
population (Williams, 2017). However, it recently enacted
legislation that mandates health care coverage for almost
everyone regardless of gender or ethnicity. Joseph and Marrow
(2017) suggests that high cost is the primary reason that leads
to challenges that Americans face in accessing health care. In
2013, about 31 percent of the uninsured adults reported facing
challenges like delayed medical care while accessing health care
services (Williams, 2017). The paper provides a literature
review by examining the disparities in health care in the U.S.
Literature Review
Disparities in healthcare in the U.S
Health care disparity is socially constructed, and it results in
tangible effects on the health status of individuals. Health care
disparity is differences in the healthcare coverage, access to,
and quality care that various groups receive. Wheeler and
Bryant (2017) mentioned that racial and ethnic disparities are
arguably the most form of inequalities in the U.S health care
system. However, they become the most silent factors while
examining health inequity. The report released by the Institute
of Medicine (IOM) reveals that racial and ethnic minorities,
especially blacks, are more likely to receive a low valued
medical care which leads to increasingly poor health outcomes
among the population (Dickman et al., 2017). Over the years,

efforts have been made to eliminate various disparities in health
care to achieve health equity
Root causes of Disparities in Health Care.
According to Kelley et al. (2015), health disparities often result
from system conflict, inadequate resources, and the distribution
of the resources. The American government is responsible for
ensuring control of the distribution of health services and
resources to various individuals in need. For instance, the
government should ensure that people living in extreme poverty
are provided with medical care at a low cost (Travers et al.,
2017). However, the government may not offer the required
resources to every person in need due to the increased
population. As such, some patients may not be in a position to
receive the care that they require. Notably, these individuals
tend to be from poverty-stricken regions because they cannot
afford the required cost.
Poverty.
Grubbs (2019) defines poverty as a state in which individuals
lack the socially acceptable material possession such as income
and productive resources that promote sustainable livelihood.
Based on a 2018 report, more than 41 million Americans live in
poverty (Grubbs, 2019). Regarding the information, the
individuals experience detrimental health impacts due to their
socioeconomic status and environmental conditions (Sanyal et
al., 2010). As a result, the persons experience various health
conditions and health risk behaviors. About 30 communities in
the U.S are dominantly minority communities with lower
socioeconomic status, barriers to healthcare access, and
increased risk of health conditions compared to the remaining
population. Environmental Risks.
Health care disparities result when specific communities get
exposed to a combination of poor environmental quality and
social inequities. This makes people living in these areas to be

at high risk of diseases. (Artiga et al., 2020) asserts that some
communities reside in areas with adequate health care facilities.
Whereas, some communities have reduced health care facilities,
which reduces their ability to access health care services that
match their needs. Unequal Access to Health Care.
Notably, the increasing economic inequality in the U.S is
accompanied by increased level of disparities in health
outcomes. Byrd and Clayton (2013) assert that the wealthy
Americans' life expectancy exceeds that of the poor individuals
by about 15 years. This indicates that the wealthy get access to
high-quality care while those with low-income access
inadequate health care services. Grogan (2017) attributes
unequal access to health care services because America relies
on Private health insurance. In this regard, individuals with
corporate-sponsored plans have better access to healthcare
services than the remaining population. This results in disparity
in health care.
Irregular Source of Care.
Individuals from ethnic or racial minority groups are, in most
cases, less likely to get access to health care services from the
same doctor regularly than the whites. Additionally, Lee et al.
(2010) add that individuals rely more on clinics and emergency
rooms. As such, they do not access regular health care services,
thus more difficulty in obtaining prescriptions according to
their needs. Another factor that leads to the irregular source of
care is structural barriers like lack of transport to the available
healthcare providers and lengthy waiting times (Clouston and
Link, 2021). The factors reduce the likelihood of the individuals
to access health care services based on their health conditions
successfully.
Health Care Disparities Drivers
Multiple potential aspects could promote health care disparities;
however, there is no single factor that can be pointed out as the
cause. The following are some of the driving factors associated
with disparities in the U.S’s health care.

Socioeconomic inequality
According to Joseph and Marrow (2017), racial groups are more
likely to be employed in lower-paying jobs with less or no
access to comprehensive insurance packages. Additionally, they
experience high rates of unemployment which as a result hinder
them from accessing high-quality health care. High numbers of
minorities have less access to health insurance. Williams (2017)
mentioned that people from lower socioeconomic families have
limited access to education, resulting from the fact that more
than 24% of the minority groups live below the national poverty
line, thus poor health outcomes. Notably, financial status
directly impacts health. This is one of the major problems
leading to disparities in health care coverage in the U.S.
Bias from Care Providers
Grubbs (2019) explains that the difference in health care
coverage between the minority and non-minority results from
the persistence in racial bias and discrimination against the
minorities within the health care system. There is implicit bias
in how non-Hispanic white care providers offer treatment
services to minority racial groups (Griffith et al., 2017). This as
a result significantly influence and determine the extent of
health care access among the minorities.
Forms of Disparities in the U.S Healthcare
There are several forms of disparities that exist in the U.S
health care system. Various social determinants such as age and
sexual identity greatly impact the health outcome of indivi duals
in a specific risk population (Artiga et al., 2020).
Race and Ethnicity
Kelley et al. (2015) refer to racial and ethnic inequality as
advantages and disadvantages that the different groups
experience and how the socially constructed groups impact
individuals. Despite the improvements in healthcare, education,
and social mobility, Clouston and Link (2021) provides that
health care disparities originating from race and ethnicity have
remained a great problem in the United States. Racial and ethnic
discrimination in health care contributes to increased morbidity

and mortality levels among minorities. Some of the sources of
the racial and ethnic disparities in health care include factors
such as differences in location, inadequate health coverage,
difficulties in communication between the providers and
patients, and reduced access to providers (Kavanagh et al.,
2021).
Gender
While women tend to have a longer life expectancy in most
countries than men, the difference is not significant in America
(Gonzalez et al., 2010). The average life expectancy of males in
the U.S is 75, while that of females is 80. The difference results
from cultural, biological, and environmental factors that
combine to create gender behaviors differences (Byrd and
Clayton, 2013). Women tend to rate their health worse and visit
health care facilities more often than men of the same group.
The disparities are not always based on biology but rather
developed through the various experiences over the life course.
Geographic Area
While several views provide that genetic code significantly
determines the health status of a group of people, Travers et al.
(2017) provide that zip code is a better health outcome
predictor. In minority communities, the quality of health care is
lower. Communities in urban or suburban areas have increased
income levels, increasing the quality of health care services
they receive. According to Blewett et al. (2018), communities in
rural setup experience a high level of healthcare access
challenges. Also, the areas have fewer job opportunities which
significantly affect their income level. Williams (2017) found
that people living in rural areas had poor health conditions due
to reduced healthcare facilities and the number of providers.
The study also provides that areas populated by minority groups
have a high risk of certain conditions that adversely affect their
health status. Efforts towards Addressing Healthcare Disparities
in the U.S
In the past years, numerous interventions have been developed

to address disparities in healthcare services and the quality of
health care. However, most of the interventions have not been
successful regardless of the improvements that have resulted
from them (Wheeler and Bryant, 2017). The interventions
reflect important gaps that have been in existence and continue
to exist in the U.S health care system. For instance, the Centers
for Population Health and Health Disparities established in
2003 to primarily eliminate disparities in access, and the quality
of health care services developed various interventions focused
on cardiovascular disease and cancer (Gonzalez et al., 2010).
Based on the results that the group achieved, it is evident that
reducing health care disparities does not only deal with one
aspect like access or quality, but rather includes numerous
aspects that should be taken into account to effectively
eliminate such disparities (Lee et al., 2010).
Decades of surveillance and research in the U.S estimated the
cost of health inequalities and premature death between 2003
and 2006 to be about $2 trillion (Kavanagh et al., 2021). In
response to the claim on health inequity, there have been
various national initiatives, including Healthy People 2020 and
National Partnership for Action to End Health Disparities,
which have taken various strategies of providing health care
services to individuals, especially among the minorities and
people with low socioeconomic status (Clouston and Link,
2021). Based on the findings provided by Healthy People 2020,
a solution that can be effective in addressing the persistent
disparities in health care among the minorities should target an
improvement in the various social determinants of health such
as health care access, quality, and utilization (Kavanagh et al.,
2021).
Another effort towards addressing healthcare disparities has
been put by Public Health Accreditation Board which ensures
that public health agencies meet national standards based on the
essential health services (Travers et al., 2017). The provision of
accreditation standards ensures improvement in community-
driven health plans and emergency operations plans, which help

address health equity and cultural competency among
vulnerable populations (Artiga et al., 2020). According to
Griffith et al. (2017), the accreditation process and national
standards enacted in various healthcare facilities have in the
past drove the focus towards vital actions which not only
encourage preparedness and response of various communities to
the health impacts but also improve efforts focused on
addressing threats that minorities and other vulnerable
communities’ experience.
Notably, non-profit organizations have also participated in
ensuring local strategies to improve health equity. For instance,
NACCHO, an organization representing local public health
department in the United States, has been working to protect
and promote the health and well-being of all people (Kavanagh
et al., 2021). The organization coordinates different services
and programs that ensure that individuals are healthy and safe
from health emergencies. ASTHO is another non-profit
organization that directs its efforts towards ensuring healthy
equity while also improving social determinants of health
(Blewett et al., 2018). Since health inequalities result due to
gender, sexual orientation, race, and geographical location, the
vision of the organization, as Grubbs (2019) mentioned, is to
support the state of health agencies to ensure health equity
advancement and health care access to health care
everyone. A.C.A on Healthcare Disparities in the U.S
Notably, disparities in health insurance coverage that regards
ethnicity and race are some of the long-standing features in the
health care system of the United States. Joseph et al. (2017)
assert that reducing the level of exposure to broad medical
coverage can lead to better financial outcomes, reducing
disparities in health insurance coverage and economic
inequality. In this regard, Dickman et al. (2017) provides that
among the legislations that have shown a great improvement in
addressing health care disparities is A.C.A. However, the
legislation has not fully addressed the difference in health care.

According to Grogan (2017), millions of Americans who are
disabled rely on the A.C.A for health insurance coverage. As
such, increased healthcare coverage provided under the
legislation has helped several disabled individuals access care
based on income level. Clouston and Link (2021) provides that
not all disabled people qualified for the traditional Medicaid
disability before A.C.A. However, Medicaid expansion with
A.C.A allows the individuals to join the workforce without
putting their benefits in any danger and also allows low -income
workers to access employer-sponsored insurance. Besides,
Travers et al. (2017) indicate that the implementatio n of the
legislation significantly reduced unmet needs that the
population report due to the cost of health care.
No doubt, since the passage of the law, most seniors have
benefited from it and the non-cost preventive services. Kelley et
al. (2015) provides that A.C.A has significantly lowered out-of-
pocket coststhrough “donut hole” for prescription drugs. Before
implementing the legislation, the individuals who reached
certain levels of prescription drug cost faced the donut hole,
under which they had to incur the full cost of the prescription
drugs. Before A.C.A covered the hole, most five million senior
individuals on Medicare experienced it (Dickman et al., 2018).
Major primary care organizations and legislation have led to the
endorsement of PCMH as a model with the potential to ensure
reforms in the health care system and eliminate health care
disparity. Griffith et al. (2017) provide that the model has
primarily improved access to health care services while
reducing the cost. However, Shakir et al. (2018) mentioned that
the model should include equity dimensions that address
different social determinants of a specific population. Many
stakeholders regarding the PCMH initiatives provide and
believe that a primary care system promoting preventive care
and also offers services based on a community has an increased
chance of reducing health disparities (Joseph and Marrow,
2017).
According to the study conducted by Griffith et al. (2017), the

implementation of A.C.A made healthcare costs to become more
affordable to several Americans despite their color, sex, or
ethnicity. Under the legislation, most states have expanded
Medicaid to millions of eligible low-and middle-income
Americans. The various changes regarding enrollment and
eligibility have ensured easier enrolment of children, with
coverage requiring little to no cost-sharing. As mentioned in
one study, better affordability improves access (Wheele and
Bryant, 2017). Under A.C.A, there has been a significant
reduction in the probability of individuals not receiving medical
care due to the cost. As such, this dramatically increased the
number of individuals who report their satisfaction with the care
they receive. Health Care Coverage among Minorities
Before A.C.A., there was a growing pattern of limited health
care access among racial groups in America. Gonzalez et al.
(2010) provide more insights into the various challenges that
few Americans, the minorities, including the lowest rates of
access and use of major depression therapies among Mexican
and African American individuals. Based on the study, the
authors provide that few Americans were able to access
standard care. As such, ethnicity and race significantly
impacted the nature of care individuals received before 2010. In
addition to the information, Lee et al. (2010) further provide
that underrepresented communities reported unique additional
barriers to accessing health care in America. Based on their
research to obtain in-depth information on health care access
among Asian Americans, Lee et al. (2010) assert that the
barriers occur due to limited opportunities and resources to the
communities.
Sanyal et al. (2010) provided in their study that there existed a
gap in the risk types that individuals belonging to different
communities experience. After performing a database search,
the authors claimed that treatment options in clinical setups
favor some communities over others. Thus, there is a need to
provide healthcare awareness and education to the communities

at risk. Travers et al. (2017), based on their study to examine
the various changes in racial disparities in forgone care before
and after the Great Recession between 2006 and 2013, found
that African-Americans were disproportionately after the
Recession as they experienced financial constraints, compared
to the whites, in obtaining medical care. This information adds
to what Sanyal et al. (2010) demonstrate in their study on the
risk gaps of various communities regarding access to health care
services.
Before implementing A.C.A., the U.S. had a heavily privatized
health care system that resulted in more than 42 million
Americans with limited access to affordable health care.
According to Joseph and Marrow (2017), the majority of this
population was made of immigrants and minorities. The authors
assert that most migrants are poor and are mainly people of
color, and as such, they experience reduced treatment options.
Dickman et al. (2017) provided through their research that
economic inequality in America was responsible for increased
disparities in health outcomes of individuals in various
communities. Additionally, like others who have addressed the
topic, poor Americans have worse healthcare access than
wealthy individuals.
The implementation and spread of A.C.A. have significantly
eliminated health care coverage disparities among minorities.
Blewett et al. (2018) assess health insurance disparities since
the implementation of A.C.A. found that insurance rates
reduced from 16.7% to 5.5% among racial groups. Based on the
implementation, the authors conclude their research by
mentioning that the extensive outreach and enrollment campaign
among various communities in America played a significant role
in eliminating coverage disparities among Blacks, the most
overrepresented among the uninsured communities. In another
study that analyzes the national health plan, Kavanagh et al.
(2021) provide that A.C.A. has a guideline that countries use to
ensure physical accessibility of health care facilities and
policies for increasing affordable access to medicines.

Even though A.C.A.'s future is not clear, the program remains
one of the policies that will reduce various challenges that the
U.S. health system faces. A study conducted by Shakir et al.
(2018) to determine the different effects of P4P (Pay-for-
performance) indicates that financial risks contribute to
disparities among races and classes and across hospitals. The
authors found that safety hospitals under the program
experience increased penalties. However, it improves health
outcomes among minority individuals. A.C.A.'s introduction led
to coverage gains among groups facing challenges like
disparities (Artiga et al., 2020). However, the plan puts some
groups at higher risk of increased health conditions and poor
health outcomes than others.
The health system of Americans still has a long way to go in
achieving health equity. Grogan (2017) provided that A.C.A.
has been one of the significant steps the U.S. has taken in
creating new programs and different regulations that have
shown potential in improving health care equity. Based on one
research that examined the extent to which A.C.A. reduced
disparities in healthcare across socioeconomic groups, Griffith
et al. (2017) assert that lower socioeconomic individuals in
America made a substantial gain in the first two years of the
act's implementation. Besides, the authors claim that the policy
significantly improved health insurance coverage and access to
care for the poor. As a result, this led to a reduced
socioeconomic gap, which most minority communities do
experience.
Health care disparities can be taken to mean "avoidable health
differences that adversely affects various socially disadvantaged
groups" (Clouston and Link, 2021). Based on the conflict theory
that provides structural conditions regarding competition
between communities, the study focuses on the various social
needs leading to the creation of groups based on classes, thus
inequality. As such, different changes are the primary causes
that create varying outcomes. Health disparities among
underrepresented communities result from unique conditions

that affect the population more than the remaining individuals,
thus leading to significant differences. The various factors that
the minorities experience impact the multiple outcomes that can
either be similar for such communities or different. Health Care
Coverage of Middle Class
The middle class in America refers to individuals with income
ranging from $ 44 000 to 88 000 for a family consisting of four
people (Shakir et al., 2018). Considering that most individuals
within the group have jobs, they depend on their employer's
insurance coverage to access high-quality care. Clouston and
Link (2021) provide that lack of employer-based coverage and
limited access to public coverage leaves close to 15 percent of
Americans uninsured. Besides, the most uninsured middle-class
individuals come from full-time workers. Even though the
members of the population are employed, the insurance
coverage is unaffordable, thus the increased insurance level.
Kelley et al. (2015) provide that the availability of employer-
sponsored coverage has been declining over the years. The firms
that offered health coverage between 2000 and 2008 reduced
from 69 percent to 63 percent. Notably, the nature of a job
makes a difference in whether one is offered health insurance
coverage or not (Dickman et al., 2017). For instance, most firms
with a high percentage of low-wage workers in America are less
likely to offer health benefits than high-wage firms. As Travers
et al. (2017) mentioned, insurance becomes increasingly
unaffordable for many when it is offered. This makes workers
spend a large portion of their income annually to cater for their
health care needs.
While A.C.A. has been described as resulting in devastating
cuts to lower-income families and vulnerable American
communities, it has improved middle-class individuals' health
coverage. However, Grubbs (2019) indicates that the legislation
provides less attention to the middle class. Thus, they may not
benefit from it as such. Importantly, most of the population
groups get their coverage through the A.C.A. marketplace. This

is one of the benefits that the legislation provides to middle-
class individuals since, before its introduction, the individuals
could easily lose their security of employer-based coverage
(Joseph and Marrow, 2017). The legislation has made it possible
to easily secure health insurance coverage.
Williams (2017) mentions that the middle-class is one of the
vulnerable groups to high insurance costs A.C.A., which is
based on the changes that former President Trump and his
government pushed for. Based on the recommended changes,
pulling the premium tax credits will create a large and stable
market for individuals' insurance. Defunding the cost-sharing
reduction payments and the 2019 repeal would have adversely
affected health care access among middle-class families as this
would have increased the cost of health care access. Making the
population realize the full benefits of the legislation requires
the government to recognize that the individuals experience
unaffordable insurance costs with less or no financial assistance
(Kavanagh et al., 2021).
Theories
The study will apply two social theories to support the results
of the study. First, the conflict theory. In regards to the theory,
issues associated with health care systems are rooted in
capitalist society. As such, health care services have become a
commodity that individuals must buy because they need them.
In this view, people with money and power in different
American communities decide how the healthcare system should
run (Penner et al., 2013). Therefore, the dominant groups ensure
adequate healthcare coverage while simultaneously ensuring
that the underrepresented groups experience reduced access to
the services. This, as a result, leads to disparities regarding
various social services, including healthcare.
The second theory that the research will be based on is
interaction theory. The theory tries to provide specific insights
regarding the relationship of various individuals to certain
illnesses. It attributes health and illness to social constructions
(Penner et al., 2013). A group of people who frequently

experience a specific health condition, based on the theory, are
associated with the conditions. The theory supports the fact that
most American minorities are associated with various kinds of
illness. They appear to be more vulnerable and in need of health
care services. As a result, their needs exceed what is available,
thus disparities in healthcare.
Terms and Concepts
Health care disparity refers to the differences that exist in the
access and availability of health care services. Also, it indicates
variation in disease occurrence within population groups with
different characteristics. Healthcare inequality describes unjust
and avoidable differences existing in the nature of health care
across a given population and between specific groups.
Addressing healthcare disparities as “socially constructed”
means that the disparities result from human interaction, and
they exist because individuals agree that they exist. A capitalist
society describes a society with different classes, hierarchies of
power, and privileges.
Chapter three will describe how the data were collected that
answer the research question and its component parts and
studies that will be used to test the hypotheses in chapter four.

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CHAPTER III- METHODOLOGY
The chapter describes the research methodology used in
collecting data for answering the research question. Essentially,
the study relies on previously published studies that relate to
the hypotheses of the research. In this regard, the study will
offer a detailed analysis of the concepts presented in the

documents and data from health organizations. Besides, it will
outline the setting, subjects, research instruments, procedures,
and limitations to each study included in testing the outlined
hypotheses.
Setting
The first article is, “Three-year impacts of the Affordable Care
Act: improved medical care and health among low-
income adults” and it is authored by Sommers et al. It was
published online in 2017 by Chan School of Public Health. The
study was conducted between 2013 and 2016, and it included
three states, Kentucky, Arkansas, and Texas. Texas was selected
as a control for the remaining two states. The second
article, “Health Spending for Low-, Middle-, and high-Income
Americans, 1963-2012,” is authored by Dickman et al. and was
published in 2016. The study involved details regarding the
health expenditures of representatives of the American
population over fifty years.
The third article is “The Effect of the Affordable Care Act on
racial and ethnic disparities in Health Insurance coverage.” Its
authors are Buchmueller et al. The study was published in 2016.
It provides the extent of health insurance coverage for groups
such as Whites, Blacks, and Hispanic adults under A.C.A.
implementation. The fourth study that this research will use
is “Change in Utilization and Health among Low-income Adults
After Medicaid Expansion or Expanded Private Insurance.”
Its authors are Sommers et al., and the study was published in
2016 in JAMA. The study was conducted in three different
states, Kentucky, Arkansas, and Texas. Additionally, the
research was occurred between 2013 and 2015.
Another study whose data is to be used in testing the hypotheses
is “The Effects of Household Medical Expenditure on Income
inequality in the United States.” Its authors are Christopher et
al., and the article was published in 2018. The study was based
on the information regarding the United States’ population. The
last study related to the hypotheses of the research is “Racial
and Ethnic Disparities in Health Care Access and Utilization

under the Affordable Care Act.” The authors of the study are
Chen et al. and it was published in 2016. The research is based
on a previous study that covers information regarding the
United States’ population.
Description of the Subjects
The participants involved in the study included United States
citizens whose ages range between 19 and 64 years. According
to Sommers et al. (2017), the population composed of
individuals with household earnings below the federal poverty
level percentage. The authors recruited the participants within
the selected states every year from 2013 up to 2016. The yearly
sample-sized that was used during the research period was
between 2,209 individuals and 3 011. Thus, 10 885 people
participated in the research during the four years. The study
included the three states because they all covered various
elements of private marketplace insurance expansion and
Medicaid expansion under the Affordable Care Act (A.C.A.).
According to Dickman et al. (2016), the research implemented
document review as the data collection method, and it involved
22 nationally representative surveys. It involved data from
Health Services Utilization and Expenditure survey, National
Medical Care Utilization and expenditure surveys, National
Medical Expenditure Survey, and Medical Expenditure Panel
Surveys. The authors provided that the surveys collected
demographic information that includes details regarding income
and family size. The research by Buchmueller et al. (2016), on
the other hand, used data from a previously conducted survey
that contains details of different minority groups living in the
United States and are affected by the implementation of the
Affordable Care Act. The informatio n included respondents
whose ages range from 19 to 64 years. Additionally, the
researchers observed the characteristics that led to differences
among the White, Black, and Hispanic such as income and
education levels.
The research by Sommers et al. (2016) included 8676
participants who were citizens of the United States. According

to the authors, the minimum age for the participants was 19
years, while the maximum was 64 years, with an income level
below the federal poverty level. The researchers surveyed a bout
1000 different people in each of the three states annually.
Christopher et al. (2018) used existing data from the Annual
Social and Economic Supplement of 2011 up to 2015 as the
source of data for their research. According to the authors, the
Current Population Surveys required the respondents to provide
information on their income and expenditures for 2010 through
2014 to ensure a broad view of the impacts of household
medical expenditures.
The subjects to the study conducted by Chen et al. (2016)
involved various American groups, including Whites, African
Americans, and Latinos. The researchers focused on the groups
regarding their health care access and utilization before the
implementation of A.C.A. and after its implementation.
Description of Research instruments
The researchers used different instruments in their studies.
Sommers et al. (2017) implemented a survey that they
conducted through random-digit dialing over the telephone. The
method automatically generates telephone numbers of
individuals to participate in a given study at random. It included
both English and Spanish languages for contacting the selected
individuals. The method is beneficial since it captures
respondents with unlisted numbers which could be missed while
using a phone book. Additionally, the method limits challenges
associated with the telephone directory as the sampling frame.
Dickman et al. (2016) used a document review based on the
survey information from different organizations. This gave the
researchers a broad view of the American’s health expenditure.
Besides, the method is beneficial in collecting detailed
information over a large coverage within a short period, making
it possible to reduce research biases resulting from the sample
included in a study.
The research by Buchmueller et al. (2016) used document
analysis as the research instrument for data collection. Based on

the data from the survey, the researchers examine the
percentage of individuals with health insurance coverage and
those without. The analysis provided a broad view of the impact
of A.C.A. on the minority groups in the U.S. The research by
Sommers et al. (2016) implemented a random-digit telephone
survey that involved the use of landlines and cellphones to
select and contact the respondents. The researchers used survey
questions that were taken from national surveys such as Oregon
Health Insurance Experiment and government surveys.
Christopher et al. (2018) reviewed existing data as the research
instrument for their study. The method is beneficial as it
provides adequate background information and broad coverage
of data that the researchers might not have collected using the
other data collection methods. Additionally, the method allows
researchers to study subjects to which they may not have easy
physical access. Chen et al. (2016) also used existing data to
answer their research question. This broadens their
understanding based on the data that they can access.
Description of Variables
Regarding the research, the independent variable is the
implementation of the Affordable Care Act whiles the
dependent variable is health care coverage. Based on the
information provided by the authors, the level of health
coverage is measured in terms of the number of people with
insurance coverage since it directly affects access to health care
services. In this regard, the level of health care coverage has
been operationalized. Based on the information that
Buchmueller et al. (2016) provided in their research, they
operationalized access to health insurance coverage for different
groups. As such, the study measured the effect that the
implementation of A.C.A. resulted in among the minority
groups.
Chen et al. (2016) in their research to determine the racial and
ethnic disparities in health care access and utilizatio n under

A.C.A. defined the measured outcome variables in three main
aspects that included the probability of insurance, probability of
having medical care delay, and the probability of having
foregone medical care. Through the defined aspects, the
researchers measured the changes in the dependent variable
which is the health care coverage among the racial and ethnic
groups.
Definition of Terms
The Federal Poverty Level (F.P.L.) indicates the lowest amount
of yearly income of a household which provides that they are
eligible for receiving certain welfare benefits. Random-digit
dialing is a probability sampling technique that uses randomly
generated telephone numbers in statistical surveys. Nonresponse
bias is an error that occurs when participants of a study are
unwilling to respond to a survey due to an aspect that makes
them differ from those who respond.
Procedures
The research uses document review to collect appropriate data
to accept or reject the hypotheses of the study. This allows the
study to obtain results quickly and at a low cost. By using six
different studies, it is possible to provide accurate information
and also eliminates errors that might result due to data
collection from primary subjects. The statistical procedure used
in testing the hypotheses of the study relates to techniques that
the researchers, whose data have been included in the research,
used in answering their research questions or testing hypothesis.
As such, this study does not depend on a single technique but
rather draws conclusions based on different techniques. The
following are procedures that the researchers used in their
studies.
Sommers et al. (2017) used a survey to collect data from
various participants that they selected through the random-digit
dialing method. The study then implemented a linear regression
model on the data they collected during the four years and from
different states. The data was then taken through an

instrumental variable analysis that included a two-stage least
squares regression. In the first step, the researchers predicted
the probability of an individual having health insurance, and the
second stage involved the provision of an estimate of the impact
of A.C.A.
Based on data presented from different surveys used in the
study, Dickman et al. (2016) examined the trends related to per
capita health spending. The analysis method that the authors
used explored trends related to income according to data of
individuals on payment, service type, and self-reported health
status. The researchers then divided the population represented
in the survey into equal quintiles and used the federal poverty
level to categorize income from different families as a
percentage of poverty. Additionally, Dickman et al. (2016)
categorized health services into groups including inpatient care,
outpatient care, dental care, and prescription medicines to
accurately calculate the total health expenditure.
Buchmueller et al. (2016) used the data from the American
Community Survey to examine the differences in healthcare
coverage in terms of health insurance cover of the individuals.
The researcher implemented three approaches in evaluating
disparities. The approaches included comparing unadjusted
differences in means, calculating means after controlling health
needs and preferences of the individuals, and lastly, getting
differences in mean for various variables that significantly
affect the health status of individuals like socioeconomic status.
Regarding the study conducted by Sommers et al. (2016), the
researchers used multivariable linear regression which is a
statistical technique for predicting an outcome based on the
response of a given variable. The study used the technique to
analyze the outcomes before the expansion of Medicare under
A.C.A. and after its expansion. The researchers then compared
the outcome from Arkansas and Kentucky with the control state,
Texas, to assess the impact of health insurance coverage
expansion.
Based on the data from Annual Social and Economic

Supplement, Christopher et al. (2016) used the Gini index, a
technique for measuring income distribution across a
population, to evaluate income inequality. First, the researchers
calculated the Gini index based on the total income of a family
and then subtracted medical outlays. Additionally, the
researchers further explored the data by calculating the net
income changes that are attributable to the outlays to explore
the difference existing for groups.
Chen et al. (2016) used survey weights to adjust sample
characteristics thus preventing the occurrence of nonresponse
bias. The authors implemented linear probability models for the
estimation of trends in health care access and utilization for the
groups after the introduction of A.C.A. The models took into
account factors such as predisposing factors, enabling factors
like family income, and the need factors for the population.
Additionally, the researchers examined the different exposures
of Obamacare for specific ethnic and racial groups to determine
the relation between A.C.A. indicator and racial or minority
groups.
Limitations
The research on the impacts of the Affordable Care Act:
improved medical care and health among low-income adults
may be limited by the sample since it uses a sample from only
three states and therefore might not apply to the general
American population. This may affect the research due to the
sampling method. Additionally, using the random-dialing digit
may make it difficult to recruit targeted respondents thus
affecting the outcome of the research. Some of the limiting
factors to the research on Health Spending For Low-Middle-
And High-Income Americans regard the method of data
collection as it might not cover all the necessary information
that addresses the aspects of the study.
The study conducted by Buchmueller et al. (2016) might be
limited by the accuracy of the information presented in the
existing data sources. As such, this might also limit this
research since the information is due to dependence on the

already presented data where there is no control over data
included in the research. The various potential limitations to the
study conducted by Sommers et al. (2016) include nonresponse
bias which might result from the data collection method,
random-digit dialing survey. This results in low response rates,
below the federal government surveys. However, using
weighting for the population features has the potential of
mitigating nonresponse bias. Another potential limitation to the
study regards the states involved in the research. This may not
adequately reflect the situation of the general population in
American. As such, this will limit the application of the
research’s findings.
Various limitations that might affect the outcomes of research
conducted by Christopher et al. (2018) on the medical
expenditures on Income inequality include the method of data
collection the researchers implemented. In this regard, they
have no control of the data that should be included and the ones
to be excluded in the research and as a result, it might
significantly affect the results of the study. Another limitation
to the study relates to the scope provided by the data that was
implemented in the study. According to the authors, the data
provides a scope that is beyond their study.
Some of the factors that might limit the use of Chen et al .'s
(2016) findings include being too much dependent on the
existing data which affects the outcome of the research.
However, this might result in the wrong prediction. The study
investigated a portion of the aspects that regards the changes in
health care quality and outcomes under the implementation of
A.CA. Besides, the data might not provide specific information
on the various racial and ethnic subgroups that significantly
impact the outcome of the research.

References
Buchmueller, T. C., Levinson, Z. M., Levy, H. G., & Wolfe, B.
L. (2016). Effect of the Affordable Care Act on racial and
ethnic disparities in health insurance coverage. American
journal of public health, 106(8), 1416-1421.
Chen, J., Vargas-Bustamante, A., Mortensen, K., & Ortega, A.
N. (2016). Racial and ethnic disparities in health care access
and utilization under the Affordable Care Act. Medical
care, 54(2), 140.
expenditures on income inequality in the United
States. American Journal of Public Health, 108(3), 351-354.
Dickman, S. L., Woolhandler, S., Bor, J., McCormick, D., Bor,
D. H., & Himmelstein, D. U. (2016). Health spending for low -,
middle-, and high-income Americans, 1963–2012. Health
Affairs, 35(7), 1189-1196.
Sommers, B. D., Blendon, R. J., Orav, E. J., & Epstein, A. M.
(2016). Changes in utilization and health among low-income
adults after Medicaid expansion or expanded private
insurance. JAMA internal medicine, 176(10), 1501-1509.
Running head: EDUCATIONAL OUTCOMES OF FOSTER
YOUTH
2

EDUCATIONAL OUTCOMES OF FOSTER YOUTH
Please note this is a sample, NOT an example.This paper is not
perfect. (Example: The contents page in the sample paper does
not have page numbers after every subheading in each chapter
and APA style has changed a bit since the paper was submitted
a few years ago.
Educational Outcomes of Foster Youth
A capstone submitted in partial fulfillment of the requirements
for the degree of
Bachelor of Arts in Sociology
DATE HERE
NAME HERE
National University
COPYRIGHT BY
NAME HERE
2015
TABLE OF CONTENTS
LIST OF
TABLES………………………………………………………………
………
4
ABSTRACT…………………………………………………………
…………………..
5
CHAPTER

I
INTRODUCTION……………………………………………………
Research Questions
Statement of the Problem
Hypotheses
6
II
REVIEW OF RELATED LITERATURE
..........................................
Research Questions
Hypotheses
Who Is Considered At-Risk?
The Educational System: Outcomes for Foster Youth
Family Systems: Outcomes for Foster Youth
Theoretical Framework
13
III
RESEARCH
METHODOLOGY.........................................................
Study 1
Study 2
Study 3
Definition of Terms
23
IV
RESULTS………………………………………………...................
..
Quantitative Data
Qualitative Data
29
V
DISCUSSION, CONCLUSIONS, AND

RECOMMENDATIONS....
Parental support
Negative Attitudes
Additional Factors
Need for Future Research
Call to Action
39
References
………………………………………………………………………....
........
47
List of Tables
Figure 1:1 Laws Pertaining to Foster
Youth……………………………………………..
8
Figure 4:1. Proficiency Score on CST English, Grade 11 in
2011……………….............
32
Figure 4:2. Proficiency Score on the CST Math, Grade 11 in
2011……………………...
33
Figure 4:3. Enrollment in Community Colleges Basic Skills
Courses…………………...
34
Figure 4:4. Enrollment in California State
Universities………………………………….
35
Abstract
The purpose of this study was to determine whether or not

foster youth have poorer educational outcomes than their peers
who are not in foster care and whether or not these outcomes
were related to lack of parental support and negative attitudes.
This study explored the educational outcomes of foster youth by
comparing data from several sources. Sources included a study
by the Stuart Foundation that compares foster youth to another
similar cohort of at-risk youth. Other sources included were
derived from state databases such as Dataquest, Datamart, and
the CSU Analytical Studies, all of which are published through
state websites. Additionally, this study used a case study to
determine the perspectives of youth regarding their educational
experiences. Ultimately the hypotheses were found to be true
and it was determined that an additional factor, lack of
collaboration and communication, was equally relevant to poor
educational outcomes as lack of parental support and negative
attitudes.
Keywords: foster care, stigma, deviance
CHAPTER 1: INTRODUCTION
Introduction
Foster youth deal with a much higher possibility of negative
outcomes in life, which are directly related to less education, a
lower quality education, or an incomplete education. This
concern is one that often gets lost in the difference between
stigma of adults with poor life outcomes and the children with
poor educational outcomes. In fact, an overwhelming body of
evidence indicates that these two populations are the same
people; children with poor educational outcomes often become
adults with poor life outcomes such as poverty, joblessness,
crime, substance abuse, and unwanted pregnancies. One
subgroup in our public schools that face the highest risk of
these problems is foster youth. This paper will explore
quantitative data that describes the educational outcomes of
foster youth as well as analyze qualitative data that describes
the sociological factors that contribute to a social stigma
surrounding foster youth.

What is foster care?
The National Adoption Center defines foster care as “a
temporary arrangement in which adults provide for the care of a
child or children whose birth parent is unable to care for them.
Foster care is not where juvenile delinquents go. It is where
children go when their parents cannot, for a variety of reasons,
care for them.” (National Adoption Center, n.d.) This definition
implies that the situations that warrant the need for foster care
are not attributed to the child. Ultimately, parents can have any
combination of physical, mental, or emotional issues that
prevent them from caring for their own children. Some of the
possible scenarios for children who enter the foster care system
are the following: placement with a foster parent who is
temporarily responsible for the child, placement in a kinship
care situation with a blood relative who is assuming temporary
or permanent responsibilities as guardian, or a facility that
offers group and residential care supported by the county or
state. (Child Welfare, n.d.)
In our current society, education is regarded as an important key
to success. (Center for Public Education, 2006) Therefore, as
Americans we are constantly concerned with improving our
educational opportunities for young people. Students’ success
postulates the ultimate success of our country as a whole. It is
estimated that as of 2012 there were about 397,000 children in
foster care. (U.S. Department of Health and Human Services,
2012, p.ii) Considering this is a large number of students
represented in our public school systems, it is important to
evaluate how our school systems are serving their needs. This
paper will compare the educational outcomes of foster youth to
that of their peers who live with parents. Additionally, this
paper will examine research studies that identify contributing
factors to these outcomes.
History & Context of Foster Youth in the United States
The ideology of foster youth has had a murky past, yet over
time has progressed immensely. Based on The National Foster
Parent Association (NFPA) (2015), the idea of a child without

parents lead primarily to indentured servitude initially in the
United States. This policy was based on the English Poor Law
in 1562. This perpetuated exploitation and abuse to poor
children without parents for centuries. The first foster home
movement described by the NFPA began with a minister named
Charles Loring Brace. Brace felt it was important to address the
needs of the growing number of immigrant children coming into
the New York that were ending up homeless. Though his efforts
were filled with good intentions, the efforts placed children
with families in the West or South who needed extra workers,
resulting in outcomes that were little better than the indentured
servitude of the past. In fact, it was not until the early 1900’s
that government social services really took on the responsibility
of overseeing the care for foster youth. (National Foster Parent
Association, 2015)
Today our country has a variety of social services and has
progressed to make many positive changes towards caring for
the needs of foster youth through our laws and policies. There
are several laws that affect foster youth and their educational
outcomes. Figure 1 below is a chart summarizing the most
influential laws that protect the rights of foster youth and in
turn affect their educational outcomes. (California Department
of Education, 2015)(Education Coordinating Council, n.d.)
Figure 1:1 Laws Pertaining to Foster Youth
AB408
Protects students right to participate in afterschool and
extracurricular activities
AB167
Allows foster youth to qualify for graduation based on the
California state requirements instead of the district
requirements to graduate
AB490
Protects students rights to the following: access to mainstream
schools, enrollment in school without all necessary
documentation, enrollment at their current school for the
remainder of the school year even if their placement changes,

access to a district liaison, grade protection from absences,
opportunity to receive partial credits towards graduation
requirements
AB12
Allows students who are working or in school to remain in
foster care placement until age 21
AB669
Exempts students from in-state residency requirements at
community colleges and state colleges
AB1393
Allows priority access to on campus, year round housing at all
CSUs
Although these laws and our social services do great work to
protect the interests of foster youth, as a country we must al so
continue to evaluate our progress in serving their needs to
determine if the laws, policies, and efforts we have in place
indeed work or need revision. The main reason for this
continuous evaluation is that if we do not adequately meet the
needs of at-risk youth through their education, they will more
than likely become adults that have negative life outcomes.
Research Questions
The following research questions will be investigated in this
paper:
1. What are educational outcomes of students in foster care
compared to their peers who are not in the foster care system?
2. What are possible contributing sociological factors?
This study will synthesize data on educational outcomes from
several sources such as government agencies, non-profit
organizations, and academic studies to compare results for both
foster youth and the general population. Data such as test
scores, graduation rates, acceptance to college, and completion
of college will be used to determine educational outcomes.
Additionally, this study will analyze several academic studies
on emancipated foster youth to see what social factors
contribute to their overall success or struggle in education, and

as a result life outcomes.
Statement of the Problem
Education acts as a foundation for many other social systems
that exist in America. The outcomes of education can dictate
our economy, quality of life, civic engagement, health, and
many other aspects of American life. The need to address issues
concerning foster youth extends beyond the simple obvious
moral of protecting children. In fact, the issues concerning
educational outcomes of foster youth have direct effects on
other problems in society such as crime, homelessness, teen
pregnancy and much more. These concerns are a drain on our
economy and our overall well-being as a country.
Unfortunately, foster youth are at a much higher risk of these
negative life outcomes after emancipation.
Shocking statistics concerning foster youth
Homelessness.
It is estimated that at least ⅓ of foster youth become homeless
immediately after emancipation. (Lifting the Veil, 2010) This
problem is one that grows for foster youth as they emancipate
and they are at risk of this even as adults. In fact, 40% of
people living in homeless shelters are former foster youth
(Children Uniting Nations, 2015) and 50% of foster youth will
be homeless during the first two years of emancipation.
(Promises 2 Kids, 2013)
Abuse.
Abuse is a cycle that plagues many foster youth throughout
their family experiences. Statistics show that this cycle repeats
with many victims of abuse. According to studies on abuse, 30%
of abused children will also abuse their own children. (Promises
2 Kids, 2013) This is a common reason for foster care
placement. In fact, 32.9% of children in foster care were
removed from an abusive home. (Children Uniting Nations,
2015) In the United States, a child abuse report is filed every 10
seconds. (Promises 2 Kids, 2013) Obviously this is a horrendous
problem that must be addressed.
Crime.

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