Gilchrist, Allison and Gilchrist and Ahmed, Faraz and Holland, Paula (2024) A qualitative exploration of low-income women’s access to primary care services and health-seeking behaviours in an urban setting in California in the Affordable Care Act era. PhD thesis, Lancaster University.
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Abstract
Introduction: Under the 2010 Affordable Care Act (ACA), Medicaid eligibility was expanded to low-income individuals at 138% of the federal poverty level. Medicaid is a United States (U.S.) federal programme that funds health insurance for low-income individuals. Despite ACA reform, many women continue to experience significant challenges in accessing primary care. A mixed-methods systematic review found limited research since the ACA on factors that impact working-age women’s access, particularly low-income women. Methods: A qualitative study explored low-income women’s experiences accessing primary care services in an urban setting in California. Eighteen semi-structured interviews were conducted with eligible women. A reflexive thematic analysis method was applied using a hybrid inductive and deductive approach. Results: Levesque’s conceptual framework of access to healthcare guided the deductive analysis (Levesque et al., 2013). Low-income women’s experiences with primary care access were influenced by several intersecting individual demand-side, health system supply-side factors, and structural determinants. The inductive analysis found health coverage, low healthcare costs, health-related knowledge, easy geographic access, convenient appointment scheduling mechanisms, and supportive, trusting relationships with providers facilitated primary care access. Major barriers to access included no health coverage, difficulties making appointments, healthcare setting discrimination, lengthy appointment wait times, limited health-related knowledge, poor provider communication, and difficulties navigating access to healthcare services. Analysis and Discussion: This study resulted in a better understanding of factors that impact low-income women’s access to primary care. The social-ecological model and the intersectionality framework were applied as a lens to better understand how the complex interplay of determinants influences access in low-income women in the ACA era. Conclusion: These findings provide a foundation for California and U.S. policymakers, practitioners, and researchers to develop and implement policies, programmes, and interventions at the policy, health system and clinic-level to address the significant barriers low-income women still face accessing primary care.