Table 2.
Theme Categories From Analysis of Semi-Structured Interviews with Virginia AIDS Drug Assistance Program Clients Regarding Affordable Care Act Qualified Health Plan Enrollment/Re-Enrollment with Representative Participant Quote Examples and Frequencies
| Theme | ||
|---|---|---|
| A. Belief systems | Representative quote | n (%) |
| Value of insurance: Describes beliefs of value of health insurance | ||
| Necessary/beneficial: Describes value of health insurance. Often describes benefits such as lower hospital bills, medication coverage, ability to see physicians, increased general well-being, less stress | “Bills–oh my god, bills will drive you crazy, especially if you can't afford them. Health care, bills are the highest bills.” | 51 (96.2) |
| Available alternatives: Describes that health insurance is unnecessary due to availability of alternatives | “I'm not too sure. I know because the clinic here is Ryan White Program. If you qualify for that, they pay for that. As far as medical insurance, it's used outside the [HIV] clinic.” | 37 (69.8) |
| Unnecessary/limited impact: Describes that health insurance is unnecessary or that it will not have an impact on health, costs, or coverage | “They didn't cover anything. I had to pay a lot of out of pocket stuff. I mean, they would only cover just a little bit and most of it was out of pocket costs. So they really didn't cover nothing.” | 20 (37.7) |
| Role of government: Describes beliefs of what government should/should not provide to citizens, or mandate that they do | “I knew they were talking that you were going to need to have to have insurance or you were going to have a penalty, but I really wasn't too keen on all that.” | 15 (28.2) |
| Understanding of ACA: Describes sources of information that led to understanding of ACA and/or enrollment | ||
| HIV Clinic: Describes how clinic/health department/case manager impacted participant understanding; can also report that someone in one of these settings handled all forms/completely guided process for enrollment | “Case managers, medical case managers, um explained stuff to me, um I even received a booklet that, from the health insurance and so that helped me along.” | 36 (67.9) |
| Personal research: Describes how participant individually researched the legislation, marketplace, insurance options, etc., and may include describing resources, such as the newspaper or the internet | “I had so much access to much more information. People who maybe have read up on it and people writing things, not just like the format of forms or papers, but people's opinions and views on it. Maybe it's worded a little differently that made it easier for me to understand. A whole lot more information having the Internet.” | 26 (49.1) |
| Social relationships: Describes how participant contacts (such as family/friends) impacted participant understanding | “I think they get turned off because it's difficult and they're not good with computers and you have to go online a lot. So unless they get someone to help them, they don't understand it.” | 20 (37.7) |
| B. Barriers to enrollment and/or re-enrollment | ||
| Privacy: Describes concerns that enrollment or mailed medications will result in loss of privacy or disclosure of HIV positive status | “Somebody took it [mailed medications] and spread it all through my neighborhood…yeah. It was devastating.” | 45 (84.9) |
| Computer and internet access and literacy: Describes lack of experience or challenges with computer and/or internet access, which then impacted ability to enroll and/or knowledge of ACA | “People who don't understand computers as well or, whatever not computer savvy they would have a hard time with dealing with websites in general but have a hard time signing up and they would need someone to help them.” | 36 (67.9) |
| Insufficient assistance: Describes a challenging experience with clinic/case manager on getting assistance to enroll; can also describe poor relationships with clinic/provider/case manager (participant does not need to describe that poor relationship with clinic/provider/case manager directly impacted enrollment likelihood/experience, only that the relationship is poor) | “I think a lot of times if you are left to your own devices, it can sometimes be overwhelming or just, you know, a little intimidating, so it was a lot easier and a much better experience having someone that knew what was going on and the best thing to offer as far as coverage was concerned.” | 33 (62.3) |
| Difficulty understanding information: Challenges with understanding information; can describe that the process is complicated or that they aren't able to understand the information given | “By me not having the full education, and I have a reading disorder. I don't understand a lot. When I read something, I don't understand it. Yeah, it was pretty rough.” | 33 (62.3) |
| Mental health: Describes difficulties with enrollment due to mental health problems | “I mean if you can't get out of bed because you're so depressed, you're not going to go and get health insurance.” | 33 (62.3) |
| Substance misuse: Describes challenges with enrollment due to substance misuse | “I guess, if you're drunk all the time. You can't get your mind together to get the stuff.” | 31 (58.5) |
| Physical barriers: Describes difficulties with physically getting to clinic or health department (e.g., transportation or living in a rural area) | “Not as many outlets and places to go, especially of transportation is an issue or if Internet is an issue. Also, living in a very rural area–whether or not maybe you can't access or it's a far drive or it's hard to get to a place to sign up. It just adds another factor.” | 29 (54.7) |
| Other priorities: Describes challenges with enrollment due to other concerns in their life, such as problems with substances or housing | “You're not going if you're a drug addict. You're going to have a hard time prioritizing whether you need to take care of your HIV or even get health insurance.” | 24 (45.3) |
| Costs: Describes costs of enrollment/continued enrollment in health insurance, added costs, unexpected costs | “Just some of the insurance you just have to watch what you're getting because after the fees and stuff you know, you just have to be careful.” | 23 (43.4) |
| Ineligibility: Describes a participant's perceived or actual ineligibility to enroll and can include concerns about ineligibility, such as drug use or no stable housing (no address) | “Because drugs man…it says on the application ‘do you do drugs?’” | 22 (41.5) |
| Challenging process: Challenges with overall process; describes in a broader sense that the participant can understand information, but the entire process is difficult | “In trying to fill it out for my son, the Obamacare, it's been really, really complicated. And I've tried three or four times and still haven't gotten it complete.” | 16 (30.1) |
| Form of enrollment: Describes challenges with the form of enrollment (paper enrollment, online enrollment, unsure but recalls that it was challenging); can include challenges with internet/webpage | “It was complicated. I guess that was when they were having all the issues with the site and stuff, so kept messing up, or it wouldn't process through. We had to keep redoing stuff.” | 13 (24.5) |
| Concerns about medications being mailed: Describes concerns about medications not being delivered in time, being stolen, or being of poor quality | “I was doing good and then I started getting sick and the medicine tasted funny or tasted different and I was asking if I could go somewhere to get it analyzed and I thought well I'm not getting the right medication because I feel like it's a government controlled thing that they…would have my guarantee that I'm getting what I'm supposed to be getting. I questioned it and so now that made me sick so I'm still questioning the safety of it.” | 13 (24.5) |
| Alternate source for insurance: Describes that person did not have need to enroll because they were able to get insurance through other means | “I guess my friends have jobs so they have insurance through their jobs.” | 12 (22.6) |
| Time: Describes that the process took a long time (note: can overlap “form of enrollment” in event that with challenge internet was slow) | “It was on the computer. It took two hours. It was a very long process.” | 8 (15.1) |
| Taxes: Describes challenges with filing taxes, after enrolling | “When you go to fill out your taxes, you have to prove that you have Obama insurance, and then they have to look up if you're golden or if you're bronze or anything like that.” | 7 (13.2) |
| Inability/difficulty in gathering applicant information: Describes difficulties collecting information to enroll (e.g., previous taxes, bank statements) | “Proving my income was complicated because I haven't filed tax returns in a while. And they wanted to see a bunch of bank account statements and then a bunch of invoices from customers and stuff. So that was the only way I could prove it and they rejected me the first time. So I basically had to give them much more information, which is fine. I get it. It just was not clear exactly what I needed to show them” | 5 (9.4) |
| Lack of knowledge: Describes lack of knowledge of enrollment options | In response to “Why didn't you enroll in 2014?”: “I didn't know nobody that done it. Nobody told me about it.” | 5 (9.4) |
| Political barriers: Describes that political beliefs resulted in decreased interest or in complete disinterest in enrolling | “But because of their prejudice–and it's not just toward Obamacare, just because Obama was black–for where I live, that's all it takes…If I say Obamacare, all of a sudden it's a color thing. And they haven't even looked in it, know anything about it.” | 3 (5.7) |
| Lack of impact: Describes belief that insurance won't actually impact the participant's life, such as | “It's like the low income for example always–it's like this is somebody that's helping you. Okay, we're going to help you do this. But we're only going to give you this much.” | 2 (3.8) |
| Lack of health problems: Describes belief that insurance is not necessary due to lack of chronic illnesses | “I don't want that. I'm a healthy person. I don't get sick. You got those people. I've got a good immune system.” | 2 (3.8) |
| C. Impact to care after enrollment and/or re-enrollment | ||
| Medication access: Describes impact in delivery of medications | ||
| Positive: Describes improved delivery or easy transition to new system | “The change is good because it is coming to your house. If you don't want anybody to know anybody about you, you don't have to run into anybody. It's coming directly to you. You don't have to go through the health department and see Michael, Jody, or Susie there; and wondering if they know which are coming for. It's more personal when it comes to your house.” | 41 (77.4) |
| Neutral: Describes being neither satisfied nor dissatisfied with altered medication delivery; can also report no change in medication delivery | 31 (48.5) | |
| Negative: Describes frustration or challenging experience, distrust, concerns, or dislike of altered medication delivery | “One time I did when we had that bad snow storm. I had a little problem getting it because they couldn't get through because the roads were so bad. It took three weeks before I could get it.” | 27 (50.9) |
| Provider access: Describes change or addition of providers in HIV care and/or other medical care | ||
| Positive: Describes benefits of added providers and/or care; can also include continued ability to see a provider, if dependent on insurance | “Having insurance has changed my non-HIV medical care due to the fact that I'm more on top of that due to the fact that it could lead to other things if I'm not on top of it.” | 38 (71.7) |
| Neutral: Describes being neither satisfied nor dissatisfied with providers/care; can report no change to provider choice, availability, frequency of seeing providers, etc. | “No, I'm seeing them about the same.” | 36 (67.9) |
| Negative: Describes frustration or challenging experience, distrust, concerns, or dislike of providers/care | “Actually, I was going less because they cover nothing.” | 1 (1.9) |
Themes were assessed using an open coding strategy which is further described in methods. The themes were categorized into (A) belief systems, (B) barriers to ACA QHP enrollment and/or reenrollment, and (C) impact to care after Affordable Care Act (ACA) Qualified Health Plan (QHP) enrollment and/or re-enrollment. For each theme, a representative participant quote is included. For frequencies, participants contributed multiple statements. Totals can be >100%.