Do Rural Georgians Experience Disparities in Access to Healthcare? An Assessment of the Impact of the Patient Protection and Affordable Care Act for Individuals in Rural Georgia

This study examines the relationships between (a) having insurance, (b) foregoing care due to cost, and (c) having a usual source of care, and location and/or passage of the Patient Protection and Affordable Care Act (ACA) for residents in Georgia. Data for these variables were taken from the years 2005–2009 (years preceding the ACA reform) and 2011–2017 (years after the ACA reform). Relationships between the variables were assessed for statistical significance using Pearson’s chi squared (χ2) test and a multivariable regression analysis. The study used publicly available secondary data from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System. The quantitative data sets analyzed for this study provided insights into healthcare accessibility and affordability for Georgia’s rural and urban populations. Stata statistical software was used to analyze the data and test statistical significance. Pre-ACA percentages for having insurance for rural Georgians ranged from a mean value and standard deviation of 79.6% ± 1.67%, dropped to 69.3% in 2011, and returned to pre-ACA values after 2014. Foregoing care pre-ACA values of 19.0% ± 1.45% increased to 26.9% in 2011 and dropped to pre-ACA values after 2014. In contrast, usual source of care results showed pre-ACA values of 82.1% ± 0.97% with post-ACA values of 72.1% ± 1.25%. The 10% decrease is a permanent change. This study showed that disparities affected all demographic characteristics, such as age, race, marital status, education, and gender, which may be determinants for health-related behaviors for both rural and urban communities. Keywords: Affordable Care Act, Healthcare, Insurance, Health-related behavior, Rural, MedicaidAbstract i -- Table of Contents ii -- List of Tables vi -- List of Figures vii -- Chapter 1: Introduction 1 -- Overview 1 -- Data and Methods 1 -- Statement of the Problem 2 -- Research Questions 3 -- Theoretical Framework of the Study 5 -- A Behavioral-Ecological Framework for Healthcare Access and Navigation Model 6 -- Health Belief Model 6 -- Data and Methods Analysis 8 -- Significance of the Study 8 -- Organization of the Study 10 -- Chapter 2—Review of the Literature 10 -- Chapter 3—Data & Methods Analysis 11 -- Chapter 4—Results 11 -- Chapter 5—Discussion 11 -- Summary 12 -- Chapter 2: Review of the Literature 13 -- Overview 13 -- Georgia and Medicaid 14 -- Theories of Environmental Factors and Individual Perceptions for Accessing Healthcare 14 -- Health Behaviors: Realized Access to Care 16 -- Health Behaviors: Personal Health Practices 19 -- Health Behaviors: Healthcare Navigation 20 -- Control Variables in the Environmental/Individual Context 24 -- Rural and Urban Characteristics for the State of Georgia 25 -- Social and Environmental Healthcare Factors 25 -- Distance and Transportation 26 -- Physicians and Hospitals 27 -- Experiences with Personal Healthcare 28 -- Content Searched 31 -- Summary 32 -- Chapter 3: Methodology 34 -- Overview 34 -- Research Questions 34 -- First Question—Insurance 36 -- Second Question—Foregoing Care Due to Cost 37 -- Third Question—Usual Source of Care 37 -- Data Source 38 -- Interview Protocol for Behavioral Risk Factor Surveillance System Questions 38 -- Protocol Question #1 38 -- Protocol Question #2 39 -- Protocol Question #3 39 -- Data Collection 40 -- Research Design 41 -- Survey Sample 41 -- Rural and Urban Characteristics 41 -- Demographics 42 -- Stata and Behavioral Risk Factor Surveillance System Techniques 43 -- Limitations of the Behavioral Risk Factor Surveillance System. 44 -- Poststratification and Raking 44 -- Technical Support 45 -- Summary 45 -- Chapter 4: Results 46 -- Overview 46 -- Methods of Analysis 46 -- Demographic Characteristics 47 -- Results for Research Questions 49 -- Research Question #1 49 -- Research Question #2 56 -- Research Question #3 62 -- Discussion of Results 69 -- Chapter 5: Discussion 73 -- Overview 73 -- Data and Methods 73 -- Analysis and Implications of the Results 73 -- Health Insurance 73 -- Foregoing Care Due to Cost 76 -- A Usual Source of Care 77 -- Literature Support and Implications 80 -- The Affordable Care Act 83 -- Behavioral Theory 84 -- Limitations and Delimitations of the Study 86 -- Recommendations for Further Study 87 -- The Coronavirus – Covid-19 88 -- Summary 89 -- References 91 -- Appendix A: Question #1 Interview Protocol for BRFSS Survey Participants—Health -- Insurance 101 -- Appendix B: Question #2 Interview Protocol for BRFSS Survey Participants—Foregoing Care Due to Cost 103 -- Appendix C: Question #3 Interview Protocol for BRFSS Survey Participants—Usual Source of Care 105 -- Appendix D: IRB Protocol Exemption Report 107Peterson, James W.Moore, MirandaPeterson, BonnieD.P.A.Public Administratio