https://orcid.org/0000-0002-8105-6780
Figures
Abstract
Background
In the United States, the Affordable Care Act (ACA) expanded public and private health coverage, increased health insurance affordability, reduced healthcare costs, and improved healthcare quality for many. Despite ACA provisions, lack of insurance and other factors continue to affect working-age women’s access to primary care services.
Methods
We conducted a mixed-method systematic review to identify factors that affect women’s access to primary care services since the ACA. In January 2021, MEDLINE, CINAHL, PsycINFO, and Web of Science were searched from 2010 to 2021 and an updated search was conducted in October 2023. We included 26 quantitative and qualitative studies reporting determinants, barriers and facilitators of women’s primary care access for women (18 to 64 years). Studies reporting measures of potential access, such as health insurance, and measures of realized access—healthcare service utilization, were included. The Mixed-Methods Appraisal Tool (2018) was used to rate the quality of studies. Andersen’s Behavioral Model of Health Services Use guided the narrative synthesis.
Findings
We found consistent evidence that ACA provisions expanding state Medicaid eligibility led to improved insurance coverage, especially for lower-income groups. We found mixed evidence of associations between individual-level determinants, such as age, education, race/ethnicity, income, and different measures of access. Limited qualitative evidence suggests that insurance coverage, low-cost care, positive patient-provider relationships, social support, and translation services enhance access for immigrants and refugees. Barriers include lack of coverage, high healthcare costs, culturally unresponsive healthcare services, poor patient-provider relationships, and transportation issues.
Conclusion
Adoption of ACA’s expanded Medicaid eligibility criteria would expand insurance coverage to women living in non-expansion states. Innovative healthcare policies, programs, and interventions at the federal, state, and local levels are needed. Suggested strategies include interventions expanding primary healthcare service availability and patient navigation services, and promotion of health literacy, culturally sensitive services, and provider bias education/training.
Citation: Gilchrist A, Fernando GVMC, Holland P, Ahmed F (2024) Factors affecting women’s access to primary care in the United States since the Affordable Care Act: A mixed-methods systematic review. PLoS ONE 19(12): e0314620. https://doi.org/10.1371/journal.pone.0314620
Editor: Don Mathew, University of Pittsburgh Medical Centre, UNITED STATES OF AMERICA
Received: February 4, 2024; Accepted: November 13, 2024; Published: December 19, 2024
Copyright: © 2024 Gilchrist et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The data has been placed in a public repository. A preview of the data can be accessed at the following URL: https://zenodo.org/records/13958823?preview=1&token=eyJhbGciOiJIUzUxMiIsImlhdCI6MTcyOTU0Mjc0MywiZXhwIjoxNzM1NjAzMTk5fQ.eyJpZCI6IjFlODRiY2YzLTI2NzYtNGYxMi1hMGI2LTkwNzcwNTdhNTQwNCIsImRhdGEiOnt9LCJyYW5kb20iOiJiNGZhNDNjN2UwMGY3NDI3YmJiYjYyMjVlOWIyODQzZiJ9.9g3EABbKZeHK-OEqHspCtQ2-uYwfpJYf8rAcdZJE924KOCWw7g0tkwhcD76rgzmXq8xcvpy8DaZbW4qwbiqGzw The information will only be available after acceptance.
Funding: The author(s) received no specific funding for this work.
Competing interests: he authors have declared that no competing interests exist.
Introduction
Women living in the United States (U.S.) face significant challenges accessing healthcare and experience poorer health outcomes compared to women living in other high-income countries [1, 2]. U.S. women have the worst access to healthcare and insurance, the highest rates of delayed or missed healthcare due to cost or affordability issues, the most avoidable deaths, and the poorest life expectancy compared to women living in 13 other high-income countries [2]. The Affordable Care Act (ACA) provisions significantly improved women’s access to healthcare services by expanding coverage, making healthcare more affordable, and ensuring that women are no longer denied coverage due to pre-existing conditions such as pregnancy and are covered for essential services such as preventive or reproductive healthcare. Nevertheless, barriers to access, coverage and affordability persist for women [3, 4]. Despite gains made by the ACA, 10% (9.5 million) of all women (19–64 years) were uninsured in 2022 [5]. U.S. women continue to be disproportionately impacted by issues related to health coverage, affordability and financial costs [6, 7]. A systematic review of factors that affect U.S. working-age women’s access to primary care services since the implementation of the ACA is vital to highlight current research gaps, and to inform directions for the future healthcare policies and practices needed to expand healthcare access for women.
Adult women face many unique sex and gender-specific barriers to accessing primary care services in the U.S. [8]. Women in the U.S. are less likely to be uninsured than men, and are more likely to face barriers to obtaining healthcare, due to affordability or delays in receiving care [7]. In 2021, men were more likely to be uninsured compared to non-elderly women (14% versus 11%), however, more women were covered by the federal-state Medicaid program for low-income individuals compared to men (18% versus 14%) [9]. Women are more likely to qualify for Medicaid as they earn less than men and are more likely to meet Medicaid’s eligibility criteria which include having a disability, being a parent of children under 18, being pregnant, or being more than 65 years [9]. Women were also more likely to have multiple chronic diseases compared to men (28.4% and 25.9% respectively) in 2018 [10]. In 2020, more working-age women reported visiting a provider in the past two years and having a usual source of care compared to men [11]. However, more women (27%) (18 to 64 years) in 2022 reported difficulties paying medical bills compared to men (23%) in the past year [6]. In 2020, U.S. women earned 84% of men as measured by the median hourly earnings of both full-time and part-time workers [12]. This persistent gender wage gap indicates women are less likely than men to be able to pay healthcare costs. Many other non-financial barriers also affect working-age women’s access to primary care, including age, disability status, geographic location, income, racial or ethnic group, geographic location, sexual orientation, and socioeconomic status [8].
Previous systematic reviews suggest that insurance coverage is associated with improved access to health services and better health outcomes in adult U.S. populations [13–15]. Few U.S.-based systematic reviews have examined factors that impact adult women’s access to healthcare before or during the ACA era. Most focus on sub-groups such as immigrant women [16–19], the effect of ACA provisions on women’s access to reproductive care [17, 20–22], and breast or cervical cancer screening [23–29]. A recent literature review suggests that while the ACA may have led to an overall improvement in health insurance coverage, healthcare access, affordability, contraceptive use, mental health care, perinatal outcomes, and use of preventive services for women, multiple barriers to access still exist, placing women at higher risk of poor health outcomes [30]. The authors cite methodological limitations as a systematic review was not conducted, and the review only included a few studies [30].
Despite the gains of the ACA, working-age women continue to experience barriers to healthcare access. A search of the literature revealed the lack of a synthesis of current empirical evidence about factors that impact working-age women’s access to primary care following the ACA. To address this gap, we conducted a mixed-method systematic review to provide a synthesis of evidence about what is known about individual and contextual factors that impact women’s access to primary care after implementation of the ACA, applying Andersen’s Behavioral Model of Health Service Utilization [31] as a framework. Study objectives included: i) identifying individual and contextual factors that impact access to primary care services among adult working-age women in the ACA era, and assessing the consistency of and quality of evidence supporting associations between each factor and measures of access; ii) exploring barriers and facilitators that adult working-age women experience accessing and using primary care services.
Materials and methods
We adopted a Mixed-method systematic review (MMSR) design as findings from various quantitative, qualitative, or mixed-methods studies can provide a more in-depth understanding of evidence [32, 33]. A narrative synthesis approach was chosen as an appropriate method for synthesizing diverse evidence applying a theoretical framework [34]. Mixed evidence enhances the relevance of findings for different stakeholders.
Protocol and registration
This mixed-method systematic review was performed and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines [35] (S1 File). The protocol was registered with Prospero with registration number CRD42021265314 [36]. Ethical approval was not required as this was a mixed-method systematic review of published literature.
Search strategy and eligibility criteria
Data sources and searches.
We searched MEDLINE, CINAHL, and PsycINFO via EBSCOHost and Web of Science for peer-reviewed studies published in English from 2010 to January 2021. Search strategies were developed in consultation with a library information specialist. For search terms, the main subject domains, Medical Subject Heading (MeSH) or free text terms for “women,” “primary care,” “access and utilization,” and “United States” were combined with the Boolean operator ‘AND’ in final searches. The search strategy was initially developed in MEDLINE and corresponding searches were conducted in CINAHL, PsycINFO and Web of Science databases (S2 File). We conducted database searches on 25 and 26 January 2021. An updated search in MEDLINE, CINAHL, PsycINFO and Web of Science using the same search strategies was conducted on 10 October 2023.
Study selection.
We applied several inclusion criteria in selecting studies. First, empirical studies had to include findings relating to adult working-age (18 to 64 years) women. Second, U.S.-based studies that examined factors associated with providing formal, face-to-face primary health services to women were included. Third, studies had to report outcome measures of potential or realized access, including 1) health insurance; 2) usual source of care/regular primary care provider; 3) healthcare service utilization; 4) routine preventive health screenings and well visits; and 5) unmet healthcare needs. Fourth, empirical studies had to employ a quantitative, qualitative, or mixed methods design and be published in English between 2010 and 2023. We excluded studies conducted in institutional settings, studies that reported outcome measures for specialist or tertiary health services or disease-specific care, and studies reporting utilization of reproductive, sexual health services, or breast, cervical, or colorectal cancer screening services for women. Book chapters, conference abstracts, editorial commentary or opinion papers, or gray literature reporting non-peer-reviewed empirical research were excluded. A detailed summary of inclusion/exclusion criteria is outlined in S1 Table.
Database search results were uploaded to Endnote -software and then screened for duplicates, which were removed according to PRISMA guidelines [35]. The first reviewer (AG) independently screened all the titles, reviewed abstracts of potentially eligible studies and reviewed all studies eligible for a full-text review. The second reviewer (CF) independently screened a 10% random sample of abstracts and titles, and a 10% random sample of full-text studies to ensure study criteria were applied consistently. Disagreements were resolved between the first and second reviewers. The third reviewer (FA) arbitrated disagreements if the first and second reviewers (AG, CF) could not reach a consensus. Searches were supplemented with backwards and forward searches of all references of included studies.
Data extraction and quality assessment
An extraction tool was developed by adapting the Joanna Briggs Institute (JBI) Mixed Methods data extraction tool [37], and the extraction tool was piloted with ten studies. We extracted primary data about the authors, title, journal, study design, study aims/objectives, conceptual model or framework, population characteristics, sample size, sample characteristics such as year data collected and data sources, geographic setting, inclusion/exclusion criteria, data collection methods, measurement tools, relevant statistical findings of associations between determinants (independent variables) and outcome measures (dependent variables) of interest for quantitative studies or themes developed in qualitative studies. The first reviewer (AG) extracted data for all eligible studies using the revised data extraction form and summarized the data, and the second reviewer (CF) independently reviewed 25% of the data extraction forms for accuracy. The completed data extraction form is available in S3 File.
The quality of quantitative and qualitative studies was assessed using the Mixed Methods Appraisal Tool (MMAT) (2018) [38]. The MMAT (2018) was considered a suitable tool, as the content validity of the MMAT has been substantiated; each domain was developed from consultations, relevant literature and workshops and evidence suggests the tool has ecological validity with transferability of findings to real-world settings [39, 40]. The tool applied the following scoring: 100% (5), 80% (4), 60% (3), 40% (2), or 20% (1) quality criteria met. We evaluated quantitative non-randomized designs based on several criteria, including sample representativeness, appropriate exposure and outcomes measurements, complete outcome data, whether confounders were accounted for, and whether the intervention or exposure was administered as intended. Qualitative studies were evaluated based on the qualitative approach, data collection methods, findings, interpretation, and coherence of findings. Two reviewers (AG and CF) independently assessed the methodological quality of all eligible empirical studies using the MMAT (2018) and assigned an overall score for quality criteria met for each study [38]. Any disagreements in ratings were resolved after discussion. No studies were excluded based on study quality, as the mixed-method systematic review was exploratory.
Conceptual model
This review used Andersen’s Behavioral Model of Health Services Use [31] as a framework to guide the synthesis of findings. Andersen’s model has been applied extensively in empirical studies to examine determinants, barriers, and facilitators that influence healthcare access in different populations [41]. The model incorporates individual and contextual determinants of healthcare access. These include predisposing factors such as sociodemographic characteristics, enabling factors such as income, insurance or public policies, and healthcare financing, and need characteristics such as individual perceived need and evaluated need for healthcare or population health indices. These determinants predict personal health practices, patterns of healthcare utilization, perceived and evaluated health status, and perceived satisfaction with care. Outcomes in Andersen’s model include perceived health status, evaluated health status, and consumer satisfaction. Access is defined as either potential access (for example, insurance coverage, usual source of care) or utilization of health care services (for example, ambulatory care services for acute, chronic problems, or preventive health care) [31].
Data synthesis and analysis
We adopted a narrative synthesis approach because of the heterogeneity of research methodologies, focal populations, and variability of outcomes reported in the studies [34]. Andersen’s model [31] was used to organize and report the findings. In the first step, we applied an iterative process and, narratively summarized, synthesized, and presented findings from 23 quantitative studies. Patterns, similarities, differences, and relationships between studies were explored, and the robustness of the synthesis was assessed [34]. Statistically significant results were identified, categorized as positive, negative, or no relationship, and grouped under the Andersen model domains in a tabular format. In the second step, we conducted a thematic analysis of the findings and discussion sections of the included qualitative studies. Major themes relating to facilitators and barriers to access were identified and grouped according to Andersen’s domains. Data from three eligible qualitative studies were extracted, coded then organized into themes using NVivo 12, a Computer-assisted qualitative data analysis software program. In the final step, to address the study objectives, findings from quantitative and qualitative studies were integrated and synthesized to map the current evidence base regarding determinants, facilitators, and barriers to women’s access to health care. Relationships within and between studies and differences across studies were explored.
Results
Our search strategy resulted in 4901 abstracts after the removal of duplicates. We identified 391 studies for full review, and 16 were eligible for inclusion. Backwards and forward searching of included studies and relevant systematic reviews identified ten additional papers. Twenty-six studies were included in the review [42–67]. Search results are summarized in the PRISMA flowchart diagram of the systematic review search process (Fig 1). This mixed-method review is reported according to the PRISMA 2020 Checklist (S1 File) [35].
Study characteristics
Most studies were quantitative (23/26, 88%) [42–49, 51–56, 58–60, 62–67], and used a cross-sectional design (11/23, 48%), a panel or interrupted time series without a control group design (2/23, 9%), or a difference-in-difference (panel or repeated cross-sectional survey data) design (10/23, 43%). The majority were secondary analyses of national household survey datasets (16/23, 70%). Three studies (3/26, 12%) applied a qualitative design [50, 57, 61]. Most studies were nationally based, or conducted in selected Medicaid expansion and non-expansion states (18/26, 69%), occurred in mixed urban and rural settings (20/26, 77%), and targeted women (19/26, 73%) between 18 to 64 years. Studies were published between 2014–2021, with the majority (24/26, 92%) published between 2016–2021. The quality score of studies assessed using the MMAT [38] was 5/5 (13/26, 50%), 4/5 (9/26, 35%), and 3/5 (4/26, 15%) respectively (S4 File). Studies were not excluded based on an assessment of poor quality. Table 1 reports the study design, sample characteristics, data sources, and quality assessment scores of all included studies.
Overall synthesis of quantitative evidence
Outcome measures.
Table 2 summarizes the main outcomes reported in the 23 included quantitative studies. The outcomes reported in quantitative studies relate to measures of potential access (such as health insurance, usual source of care, and other barriers such as cost of health care) and measures of realized access (such as utilization of primary care services and preventive health screenings). Most quantitative studies (20/23, 87%) reported measures of potential access. Measures included insurance coverage and type (14/23, 61%), usual source of care/regular healthcare provider (9/23, 39%), cost or affordability (9/23, 39%), and delayed or foregone care (5/23, 22%). In comparison, fewer studies (11/23, 48%) examined measures of realized access or utilization of healthcare services, such as visits to a doctor or other healthcare professional for a routine checkup or health concerns (10/23, 43%), or receipt of preventive screenings in the past year (6/23, 26%). The operationalized definitions of outcome measures used to measure potential and realized access varied considerably, making it difficult to compare findings across studies.
Determinants associated with primary care access and health service utilization.
Most quantitative studies examined associations between individual predisposing, enabling, or contextual enabling factors, such as the ACA Medicaid expansion’s impact on access measures. Few studies assessed contextual predisposing factors, individual or contextual need factors, or behaviors. Identified determinants were classified according to Andersen’s framework, however, the following determinants—English proficiency, having children or dependents, immigration status/nativity, the number of births, or family size are not included in the applied Andersen’s model [31]. Several other studies have categorized these determinants as individual predisposing factors according to Andersen’s model [41]. The findings for associations between individual and contextual factors described in the Andersen model and different measures of access and healthcare utilization are reported in S2 Table.
Individual predisposing factors.
While certain trends were noted with individual predisposing factors such as age, race/ethnicity, and educational level, findings were not consistent across all studies. Several studies reported ACA’s Medicaid expansion was associated with significantly increased insurance coverage rates in uninsured women [53, 55, 67] and Medicaid-insured women [67], across all age groups. Relative to younger women (18–24 years), older women (25–34 years) were more likely to be insured in Medicaid expansion states [53]. One cross-sectional survey conducted in Utah found older age was associated with having a regular provider [42], while another California-based cross-sectional survey found a significant increase in a younger age group (18 to 34 years) having access to a usual source of care by study year (change between 2013 and 2016) [48]. Age was not associated with a routine check-up in the past year post-Medicaid expansion [47], a Nurse Practitioner or Physician’s assistant visit in the past year [54], or with one or more doctor’s visits in the past year [62] or avoidance of a doctor because of concerns about discrimination [66] in working-age women.
Several studies reported associations between race and ethnicity and various measures of access [53–55, 62, 66, 67]. One study of low-educated adults (19–64 years) found significant decreases in uninsurance rates and increased Medicaid coverage across all racial and ethnic groups, with Hispanic women experiencing the highest gains in health coverage and Medicaid in expansion states [67]. Similarly, Lee et al. (2018) found that all groups of adult women experienced decreases in uninsurance, with low-income (≤ 138% FPL) Hispanic women reporting the largest decreases. Another study of reproductive-age women found that while uninsured rates decreased across all groups, both U.S.-born Hispanic and foreign-born Hispanic women had significantly increased odds of being uninsured compared to white women post-Medicaid expansion [53]. In adult women (18–64 years) Hispanic and Native American ethnicity were associated with avoidance of doctors because of concerns about discrimination [66]. Compared to adult non-Hispanic white women, women from other racial/ethnic groups had significantly fewer family physician or nurse practitioner/physician assistant visits in the last year [54, 62].
Evidence regarding the association between educational level, employment, marital status, family dependents, and access measures was mixed. Several studies reported some associations between educational level and various measures of access [42, 48, 49, 53, 54, 62, 66], however, other studies found no such association [43, 47]. Full-time employment status post-Medicaid expansion was associated with lower levels of uninsurance [53]. Other studies failed to find an association between employment status and various measures of access [42, 47, 54, 62]. Two studies reported married status was associated with increased health insurance coverage [53, 58], checkups in the last year [58], and decreased avoidance of seeking healthcare because of cost [58] compared to non-married status post-Medicaid expansion. Other studies found no association between marital status and measures of access [42, 47, 54, 58, 62]. Low-income reproductive-age women without dependent children were more likely to have health insurance coverage [52, 58], have a personal doctor [52], have a check-up in the last year [58], and less likely to avoid seeking care because of cost compared to those with dependent children post-Medicaid expansion [58].
Limited evidence was available regarding associations between other individual predisposing factors, including health literacy [42], immigrant status [42, 48, 62], sexual orientation/gender identity status [45, 66], discrimination [66]; English proficiency [62], information sources [42], or family size and the number of births [53, 54] and various measures of access. Higher levels of health literacy were associated with significantly increased odds of having a regular healthcare provider [42]. Immigrants were less likely to have a regular healthcare provider compared to those born in the U.S. [42] or to have visited a doctor at least once in the past year [62]. None of the included studies examined associations between health beliefs, occupation, religion, or social networks and measures of access.
Individual enabling factors.
Most studies found insurance coverage was associated with higher rates of healthcare utilization, such as visiting a doctor in the last year [54, 62], or receipt of a blood pressure check or influenza vaccination in the last year [60]. Women without insurance or Medicaid/Medi-Cal coverage were less likely to have a regular healthcare provider [42]. We found mixed evidence of an association between income and different access measures. One study found that uninsurance in low-income women declined significantly post-Medicaid expansion, primarily due to increased Medicaid coverage [53]. Another study reported that women in lower income groups (≤138% and 139% −399% FPL) reported improved health insurance affordability and increased doctor’s visits in the past 12 months, and receipt of preventive services increased across all income groups [56]. Other studies found no association between income levels and different measures of access [48, 54, 62, 66]. In reproductive-aged women, higher income levels were associated with increased utilization of preventive health services such as blood pressure checks or influenza vaccinations. There was limited evidence assessing associations between a usual source of care [62], access to public transit [42], geographic residence [54], and measures of access. Women with a usual source of care were more likely to have seen a physician at least once in the past year [62].
Individual need factors.
The few studies that explored associations between need factors and measures of access found mixed evidence [42, 51, 54, 59, 62]. Women with chronic diseases were more likely to have seen a doctor in the past year [62], and women with hypertension had significantly higher odds of having a regular healthcare provider [42]. Women with mental health problems were less likely to have had a routine health check-up in the last two years (79.5% versus 82.2%) [59]. Evidence was mixed regarding associations between perceived health status and measures of access [42, 54, 62]. Only one study assessed individual health behaviors (tobacco use) and measures of access [42] and found no association.
Contextual level factors.
None of the included studies examined contextual predisposing factors such as community levels of education, employment, or crime rates or contextual need factors such as environmental health-related measures such as air, housing, or water quality, death, or injury rates with measures of access. One study found that while rural areas had lower per-capital county supplies of nurse practitioners/physician assistants compared to urban areas, urban-rural differences were not significant for per-capital county supplies of family medicine physicians [54].
Several studies examined contextual enabling factors such as ACA’s healthcare policy enacted into law in 2010. Medicaid expansion in designated states was associated with decreased uninsured rates in adult women [55]; women of reproductive age [46, 53], low-income women of reproductive age [43, 52], low-income childless women [64], low-income women [65] and low‐educated adults [67], compared to non-expansion states. For example, the odds of being uninsured were two times higher for women of reproductive age residing in Medicaid non-expansion states compared to expansion states [53]. Increased levels of overall insurance coverage were associated with Medicaid expansion in adult women [44], women of reproductive age [46], low-income childless women [64], and low‐educated women compared to non-expansion states. In several studies, Medicaid expansion was associated with significantly increased rates of coverage in working-age women [43, 44, 46, 55, 64, 67]. One study of low-income reproductive-age women found 38.7% of uninsured women in 2013 acquired Medicaid in 2014 in expansion states compared to 19.5% in non-expansion states [43].
There was mixed evidence of an association between Medicaid expansion and other measures of potential access. Two studies found that Medicaid expansion was significantly associated with increased access to a usual source of care in reproductive-age women [46] and access to a personal doctor in low-income women [65]. A California-based study of low-income reproductive-age women, found those insured with Medi-Cal, other public insurance, or private insurance, compared to women with no insurance, were significantly more likely to have a usual source of care post-expansion [48]. In contrast, other studies found no association between Medicaid expansion and improved access to a usual source of care in adult women [55] or low-income women [49]; having a personal doctor [52, 63], or needing to see a doctor but unable to because of cost [52] in low-income women.
Several studies found Medicaid expansion led to a reduction in delayed or non-receipt of medical care in the past year for both adult women [55] and reproductive-age women [46], the increased ability of low-income women to afford healthcare [65], decreased problems paying medical bills for adult women [55], increased ability to see a doctor due to lower cost for low-income reproductive-age women [52] and decreased avoidance of healthcare due to cost for low-income reproductive-age women [58].
Few included studies examined the impact of Medicaid expansion on women’s healthcare utilization. Medicaid expansion was associated with increased doctor’s visits in women in lower-income brackets (≤138% and 139% −399% FPL), preventive health screenings in all adult women [56], and increased checkup visits in low-income reproductive-age women [58]. However, the majority of studies found no association between Medicaid expansion and provider visits [49, 52], cholesterol checks [58], routine check-ups [63], or a flu shot [63] in the past year in low-income women.
Overall synthesis of qualitative evidence
A thematic analysis of three qualitative studies examining the experiences of Latina immigrants [50, 57] and Iraqi refugee women [61] was conducted to identify facilitators and barriers to primary care access. Two thematic areas of interest included 1) facilitators and 2) barriers to healthcare access. Themes were grouped according to domains from the Andersen model [31].
Facilitators.
Five themes were developed relating to facilitators. Three themes aligned with individual predisposing characteristics included 1) positive health beliefs, 2) health-affirming behaviors, and 3) social support. Belief in the efficacy of biomedical options resulted in timely healthcare-seeking behaviors [61]. Women were often motivated to seek healthcare because they wanted to stay healthy so they could take care of their families [57]. Health-affirming behaviors included recognizing the importance of health, applying relevant health-related knowledge, health literacy, and knowledge about community resources such as where to access free, low-cost healthcare [50]. Social support such as family members acting as translators at doctor’s visits or access to social networks including faith communities [57], religious beliefs, and informal networks that assisted women in navigating difficult life circumstances [50] were important coping mechanisms that often facilitated access to care.
Two themes were linked to individual and contextual enabling factors, including 1) healthcare safety net and 2) healthcare organization and delivery. Access to insurance facilitated healthcare access [50]. Often low-income immigrant or refugee women did not have insurance coverage, so accessed free or low-cost healthcare or prescription medications [57]. Healthcare organization characteristics such as close geographic proximity, culturally appropriate healthcare, and the provision of translation services facilitated access to healthcare [50, 57].
Barriers.
Six themes related to barriers to access included: 1) immigrant status and linguistic barriers, 2) negative health beliefs, 3) inadequate healthcare safety net, 4) healthcare organization and delivery barriers, 5) delayed care, and 6) health service alternatives. Two themes, 1) immigrant status and linguistic barriers, and 2) negative health beliefs related to individual predisposing characteristics. Immigrant identity was linked to low-income status and a lack of English proficiency. Undocumented status was a significant barrier as these women often did not qualify for medical assistance or insurance coverage under federally funded Medicaid or Medicare programs, so could not afford care [50, 57]. Negative health beliefs, such as the perception of health as the absence of illness, also led to delayed health-seeking for preventive care services [50].
The two themes of inadequate healthcare safety net and healthcare organization and delivery barriers were linked to individual and contextual enabling characteristics. Lack of insurance and the high cost of healthcare services are significant barriers to access [50, 57, 61]. Often women are unable to enter the health insurance market if they are not eligible for Medicaid or other publicly funded health insurance and rely on free or low-cost clinics, same-day appointments at urgent care, or a visit to the emergency room as a last resort [57, 61]. Healthcare delivery system-related barriers such as discriminatory practices, difficulties making appointments, inadequate provider assessments or treatments, inexperienced providers, lack of follow-up regarding test results, lack of translators, language difficulties, unreliable public transportation, and long wait times often prevented access to or delivery of effective healthcare services [50, 57, 61].
Finally, two themes delayed care and health service alternatives related to Andersen’s domain of health behaviors. Women often delayed care because of financial constraints and fears about financial costs or competing needs (such as family, and work commitments) or a history of negative experiences with healthcare providers, such as not being listened to [61]. Immigrants felt undeserving of government assistance programs available to U.S. citizens [57]. Shopping around for health services or prescription drugs that were free or low-cost to avoid having to use the emergency room was common [57], which often delayed care or resulted in the receipt of low-quality or inappropriate care. These themes are outlined in the S3 Table with illustrative quotes or excerpts.
Methodological limitations of studies
Some of the quantitative studies used cross-sectional data so could not assess temporality, or whether causal relationships existed between variables of interest and outcome measures [42, 45, 47–49, 51, 53, 59, 60, 62, 66]. Many of the quantitative studies used secondary datasets from large national surveys such as the BRFSS, NHIS, or MEPS [43–46, 51, 52, 54–56, 58–60, 63, 64, 67], which often include standard self-reported healthcare survey variables, which may limit the applicability of findings to the review questions. Studies conducting secondary data analyses of cross-sectional surveys such as the MEPS and NHIS have higher response rates than the BRFSS [68]. The BRFSS uses random-digit dialed surveys, which may lower individual response rates and frame non-coverage, reducing representativeness [69].
While quantitative studies generally controlled for confounding variables, one study may have failed to control for all potential confounders [60]. In addition, considerable heterogeneity regarding the operationalization of access measures made it difficult to compare the findings of quantitative studies included in the review. For example, definitions of measures of affordability or costs often varied considerably across studies [45, 46, 51, 52, 55, 56, 58, 63, 65]. Additionally, comparison across studies was complicated by the fact that some studies examined associations between measures of potential access [42, 43, 49, 53, 58, 66] or measures of realized access [47, 49, 54, 58, 62] and variables such as education, employment, or marital status. Several studies employed difference-in-difference study designs to examine the effects of ACA [43, 44, 52, 55, 56, 58, 63–65, 67]; however, because of confounding from contemporaneous socio-economic or political changes, these estimates were unable to determine causality. Some difference-in-differences studies used logistic regression models, while others used linear regression models, which may make it easier to interpret the findings of difference-in-difference studies [70].
Discussion
This systematic review advances our understanding by synthesizing evidence about major determinants, facilitators, and barriers that impact working-age women’s access to primary care in the ACA era. Current gaps in knowledge about this topic are identified. Regarding the first objective, the review found moderate evidence that individual predisposing factors such as age, marital status, race/ethnicity, and enabling factors such as insurance and income were associated with various access measures in working-aged women. Evidence of an association between other individual predisposing, enabling, and need factors and measures of access was often mixed or not reported. Contextual enabling factors such as ACA’s Medicaid expansion were consistently associated with reduced uninsured rates and gains in coverage, particularly Medicaid, among women in low and moderate-income brackets. Evidence of association between Medicaid expansion and other measures of access, such as a source of usual care or regular provider or health service use was mixed.
Regarding the second objective, limited qualitative evidence from studies of low-income immigrant and refugee women suggests that facilitators of access include free or low-cost healthcare, health literacy, social support, and supportive relationships with providers. Barriers include lack of insurance coverage, high costs of health care, healthcare delivery system barriers such as lack of translation services, poor communications with providers, and transportation barriers. The synthesis of evidence in this review builds on findings from other studies that have examined the association of various socio-demographic characteristics with access measures in non-elderly U.S. adults.
The ACA led to some of the most significant advances in women’s access to primary care in recent decades. ACA provisions such as Medicaid expansion resulted in significant decreases in rates of uninsurance and gains in Medicaid coverage for women living in Medicaid expansion states, compared to non-expansion states. Despite these gains, some studies reported differential patterns in accessing health coverage by age, income, marital status, and race/ethnicity persist for women post-Medicaid expansion [53, 55, 58, 67, 71]. Similarly, previous studies of U.S.-based adults have found that while Medicaid expansion reduced inequalities in insurance coverage by age, income level, marital status, and race and ethnicity, substantial inequalities continue to persist among low-income minority adults [72–77]. The findings of our review highlight the need for additional research to identify how differential patterns of access intersect with gender and other determinants, such as age, income, marital status, and race/ethnicity in the ACA era. Research needs to focus on low-income women or women belonging to racial/ethnic or sexual minority groups who are most often impacted by healthcare inequalities.
In this review, we found few studies had assessed the effect of ACA provisions, such as Medicaid expansion on women’s coverage, access, and healthcare utilization [43, 44, 46, 48, 49, 52, 53, 55, 56, 58, 63–65, 67]. A recent literature review of 601 studies published between 2014 to 2021 examined the effect of Medicaid expansion on outcomes relating to access and coverage, affordability, and healthcare service use for working-age adults [78, 79]. This literature review revealed few studies have examined how the ACA has impacted working-age women’s access to care, and often studies failed to report subgroup gender analyzes [75, 80–83]. Studies about women’s access included in the review often focused on the impact of ACA provisions on access to reproductive care [3, 84–91].
Insurance coverage is the most commonly reported indicator of access in ACA-related literature, however, may not always lead to improvement in realized measures of access. There may be several reasons ACA provisions are not always associated with improved access, affordability, or health service use for women. A nationally representative survey conducted in 2022 with working-age women found that 68% of low-income women and 52% of all participating women experienced difficulties paying for medical bills and also found it difficult to pay for necessities like food, heat, or housing [6]. Under ACA provisions, insurance coverage may not sufficiently protect against high costs, or networks may be so limited that newly insured individuals cannot find care [92]. Women, especially if uninsured, underinsured, or low-income, may be more likely to delay or forego care if unable to afford health care costs or medical bills.
Low-income women with Medicaid coverage are more likely to report health insurance coverage with limitations compared to those with private insurance (individual or employer-sponsored) [6]. Women may also be subject to coverage exclusions for certain types of conditions, health maintenance services, or preventive services not mandated by law [93]. There is a need for quantitative research that evaluates the longer-term impact of the ACA on women’s access, coverage, and use of primary care services. Highlighted research gaps include the effect of certain ACA provisions such as Marketplace subsidies or the Individual Mandate on coverage, affordability, and utilization for women [30].
In the context of the ACA, limited qualitative or mixed-methods research has also been conducted on women’s experiences accessing primary care, factors that act as facilitators or barriers to access, satisfaction with care received, and health outcomes. We found limited qualitative research on women’s experiences of accessing primary care. Qualitative studies included in this review focused on immigrant and refugee women’s experiences [50, 57, 61]. In the ACA era, qualitative research has often focused on facilitators and barriers to access in broad adult populations [94–98]. Other studies of immigrant and refugee women since ACA have focused on specific sub-groups such as East African-born women (18–85 years) [99], undocumented African immigrant women’s experiences with ambulatory care visits, emergency room and hospital admission [100], homeless women [101], and women receiving reproductive health services [102–105].
Our findings are consistent with those of other U.S.-based qualitative studies of working-age women and their experiences accessing cancer screening or sexual and reproductive health services in the ACA era. Several studies reported facilitators of access included health coverage, good health literacy [99, 105, 106], social support [102, 104, 106], and positive interactions with providers [103, 105]; while common barriers included no health coverage or high costs [99, 102, 104, 107], low health literacy [99, 104–106] healthcare delivery barriers such as inadequate provider communication or mistrust [99, 102, 105], lack of culturally appropriate services [99, 107], and transportation issues [102, 104, 105, 107]. Several of these studies also found that difficulties navigating providers or clinics were a significant barrier [102, 104]. Similarly, an Oregon-based qualitative study found new Medicaid adult enrollees often failed to access care regularly because of barriers, including poor interactions with providers, confusion about coverage, or a lack of perception about the need for medical care [94]. Myriad other facilitators and barriers may impact working-age women’s access to primary care in the ACA era and warrant further investigation.
This review identified there is a need for additional research to explore the experiences of broader heterogeneous populations of women, to ascertain the complex factors that deter working-age women’s access to primary care despite ACA provisions that have expanded coverage. Quantitative studies rarely considered individual predisposing or enabling factors, such as health literacy, information sources, language barriers, social support networks, or means of transportation. Qualitative or mixed methods research focusing on vulnerable groups of women can provide valuable insights to inform health-related policies, programs, and interventions aimed at improving women’s access to primary care in U.S.-based settings and beyond.
Implications
Health policy initiatives.
To address contextual enabling factors such as lack of insurance coverage, expanding Medicaid eligibility to the remaining ten states that have not adopted Medicaid expansion would provide essential insurance coverage to eligible low-income women. There is a need to increase federal and state outreach to uninsured women who are eligible but not yet enrolled in Medicaid or marketplace coverage [4, 108]. The American Rescue Plan (ARP) of 2021 has enabled many Americans to access affordable coverage, qualifies those previously eligible for Premium Tax Credits for increased subsidies, and reduces premiums [109]. Under the ARP, approximately 2.6 million uninsured Hispanics may qualify for zero-dollar insurance plans, and an additional 3 million may qualify for low-cost premiums [110]. Continued support for the ARP will help to address healthcare coverage inequities, especially in uninsured or underinsured Hispanic populations. National reform of immigration policies with provisions that reduce restrictions for undocumented immigrant eligibility for Medicaid and marketplace insurance plans would help reduce the much higher rates of uninsurance in Latinas [111].
Other measures such as redesigning eligibility requirements for cost-sharing and premium tax credits to promote affordable insurance for individuals, instituting federal and state regulations limiting the availability of individual market plans that are non-compliant with ACA regulation, funding programs offering consumer assistance, education, and outreach promoting open enrolment, and general assistance with enrolment, and federal legislation authorizing a public insurance plan that provides various options for coverage as a stepping stone to universal coverage should be considered [108].
Navigating healthcare access.
Many women without coverage would benefit from assistance with navigating access to insurance coverage. In 2021, the Centers for Medicare and Medicaid Services announced it would provide $80 million to fund navigators ahead of and during 2022 open enrollment for health insurance to support educational outreach and assistance with navigation, with a focus on culturally responsive strategies to redress budget cuts to the navigator program beginning in 2019 [112]. More culturally tailored navigation programs initiated by federal, state and local governments could help to identify and assist low-income or otherwise vulnerable groups of women who are eligible for Medicaid, tax credits, or marketplace schemes with signing up for Medicaid coverage or other provisions of the ACA.
Delivery of culturally appropriate care.
To promote healthcare access, individual-level interventions that provide more culturally appropriate care for immigrant groups of women including linguistic and/or cultural matching of providers with patients, incorporation of culturally specific components within individual encounters, provision of culturally/linguistic appropriate materials, family involvement, and continuity of care are needed [113]. Healthcare delivery organizations can provide training in cultural competency, integrate interpreter services into the delivery of services, employ community health workers to provide culturally appropriate care, provide telemedicine services, and conduct outreach [113].
Strengths and limitations
This review provides insights into multitudinous factors that can impact women’s access to primary care during the ACA and provides suggestions for future research, policy, and practice. Adopting a mixed-methods approach allowed for the inclusion of heterogeneous study designs, analytic methods, measures, and outcomes to meet the broad and diverse research questions. Applying Anderson’s model as a framework to examine determinants and factors associated with access may contribute to the generalizability of findings to women living in other settings. While this review only includes U.S.-based studies, these findings may be relevant to other countries, especially high or middle-income countries, who have not adopted universal healthcare coverage and have significant uninsured or underinsured populations. Despite a systematic search of several databases, as the research questions were broad, selective use of MeSH headings and key terms and exclusion of non-English studies may have excluded potentially eligible studies. Despite this limitation, it is unlikely that the review findings would be significantly altered as key relevant studies conducted with women were included.
Future directions
This review provides additional insights into factors that may impact women’s access to health care during the ACA and provides suggestions for future research, policy, and practice. This review is relevant to policymakers, healthcare administrators, public health professionals, and healthcare providers in the U.S. and other countries experiencing similar challenges to healthcare access because of a lack of universal healthcare coverage. More longitudinal studies using time-series or repeated measures analysis would be helpful to explore trends relating to individual or social determinants of health such as available types of insurance coverage, to capture any changes that have occurred following the implementation of major ACA provisions relating to women’s access to healthcare including reproductive services. Strategies to improve women’s access to care should first focus on assisting women who may be eligible under ACA provisions to obtain health coverage and developing tailored, culturally sensitive programs. Second, more innovative interventions and strategies need to be developed to assist women in navigating access to health insurance and promoting women’s regular engagement with primary care services for acute, chronic and preventive healthcare needs.
Further work needs to be done to promote healthcare-related immigration policies at the federal, state, and local levels to address inequities around access in vulnerable, often marginalized immigrant and refugee groups of women. The engagement of federal and state-level health policymakers in developing relevant policies and federal and state funding is essential for any necessary reforms. Other stakeholders, including public health professionals, frontline providers such as primary care providers and nurses, and women, should be included in the planning design, and implementation of programs and interventions to improve women’s access to primary care. Policymakers, healthcare system administrators, researchers, and healthcare providers must work together to fund, design, and develop equitable healthcare policies, programs, and interventions aimed at improving healthcare access for all working-age women.
Supporting information
S4 File. Quality appraisal of studies applying Mixed Methods Appraisal Tool (MMAT) version 2018.
https://doi.org/10.1371/journal.pone.0314620.s004
(PDF)
S2 Table. Determinants of access and utilization of healthcare services for working-age women.
https://doi.org/10.1371/journal.pone.0314620.s006
(PDF)
S3 Table. Andersen’s model domains and themes relating to facilitators and barriers to access.
https://doi.org/10.1371/journal.pone.0314620.s007
(PDF)
Acknowledgments
The authors would like to thank John Barbrook, information specialist for his help in developing search strategies for this systematic review.
References
- 1. Gunja MZ, Tikkanen R, Seerval S, Collin SR. What is the Status of Women’s Health and Health Care in the U.S. Compared to Ten other countries? 2018; (December 19, 2018). Available from: https://doi.org/10.26099/wy8a-7w13.
- 2.
Gunja MZ, Masitha R, Zephyrin LC. Health Care for Women: How the U.S. Compares Internationally Commonwealth Fund; 2024.
- 3. Johnston EM, McMorrow S, Thomas TW, Kenney GM. ACA Medicaid Expansion and Insurance Coverage Among New Mothers Living in Poverty. Pediatrics. 2020;145(5). pmid:32295817
- 4. Gunja MZ, Collins SR, Doty MM, Beutel S. How the Affordable Care Act Has Helped Women Gain Insurance and Improved Their Ability to Get Health Care: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016.2017. Available from: https://www.commonwealthfund.org/publications/issue-briefs/2017/aug/how-affordable-care-act-has-helped-women-gain-insurance-and.
- 5.
Kaiser Family Foundation. Women’s Health Insurance Coverage. Kaiser Family Foundation; 2023.
- 6.
Long M, Frederiksen B, Ranji U, Salganicoff A, Diep K. Experiences with Health Care Access, Cost, and Coverage: Findings from the 2022 KFF Women’s Health Survey. Kaiser Family Foundation 2022.
- 7. Daher M, Al Rifai M, Kherallah RY, Rodriguez F, Mahtta D, Michos ED, et al. Gender disparities in difficulty accessing healthcare and cost-related medication non-adherence: The CDC behavioral risk factor surveillance system (BRFSS) survey. Preventive Medicine. 2021;153:N.PAG–N.PAG. pmid:34487748
- 8. Daniel H, Erickson SM, Bornstein SS. Women’s Health Policy in the United States: An American College of Physicians Position Paper. Ann Intern Med. 2018;168(12):874–5. pmid:29809243
- 9. Kaiser Family Foundation. Women’s Health Insurance Coverage. 2022 Dec 21, 2022.
- 10. Boersma P, Black LI, Ward BW. Prevalence of Multiple Chronic Conditions Among US Adults, 2018. Prev Chronic Dis. 2020;17:E106. pmid:32945769
- 11.
Long M, Frederiksen B, Ranji U, Salganicoff A. Women’s Health Care Utilization and Costs: Findings from the 2020 KFF Women’s Health Survey. Kaiser Family Foundation; 2021 April 21, 2021.
- 12. Barroso A, Brown A. Gender pay gap in U.S. held steady in 2020. Pew Research Center; 2021 May 25, 2021.
- 13. Buchmueller TC, Grumbach K, Kronick R, Kahn JG. The effect of health insurance on medical care utilization and implications for insurance expansion: a review of the literature. Med Care Res Rev. 2005;62(1):3–30. pmid:15643027
- 14. Freeman JD, Kadiyala S, Bell JF, Martin DP. The causal effect of health insurance on utilization and outcomes in adults: a systematic review of US studies. Med Care. 2008;46(10):1023–32. pmid:18815523
- 15. Hadley J. Sicker and poorer—the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income. Med Care Res Rev. 2003;60(2 Suppl):3S–75S; discussion 6S-112S. pmid:12800687
- 16. Seo JY, Bae SH, Dickerson SS. Korean Immigrant Women’s Health Care Utilization in the United States: A Systematic Review of Literature. Asia Pac J Public Health. 2016;28(2):107–33. pmid:26769982
- 17. Winn A, Hetherington E, Tough S. Systematic Review of Immigrant Women’s Experiences With Perinatal Care in North America. Journal of obstetric, gynecologic, and neonatal nursing. 2017;46(5):764–75. pmid:28667831
- 18. Tefera GM, Yu M. Immigrant Women’s Access to Healthcare Services in the United States: A Qualitative Meta-Synthesis. Journal of social service research. 2022;48(2):285–99.
- 19. Omenka OI, Watson DP, Hendrie HC. Understanding the healthcare experiences and needs of African immigrants in the United States: a scoping review. BMC Public Health. 2020;20(1):27. pmid:31914960
- 20. Bossick AS, Brown J, Hanna A, Parrish C, Williams EC, Katon JG. Impact of State-Level Reproductive Health Legislation on Access to and Use of Reproductive Health Services and Reproductive Health Outcomes: A Systematic Scoping Review in the Affordable Care Act Era. Womens Health Issues. 2021;31(2):114–21. pmid:33303355
- 21. Sun EP, Guglielminotti J, Chihuri S, Li G. Association of Medicaid Expansion Under the Affordable Care Act With Perinatal Care Access and Utilization Among Low-Income Women: A Systematic Review and Meta-analysis. Obstet Gynecol. 2022;139(2):269–76. pmid:34991110
- 22. Bellerose M, Collin L, Daw JR. The ACA Medicaid Expansion And Perinatal Insurance, Health Care Use, And Health Outcomes: A Systematic Review. Health Aff (Millwood). 2022;41(1):60–8. pmid:34982621
- 23. Oh KM, Taylor KL, Jacobsen KH. Breast Cancer Screening Among Korean Americans: A Systematic Review. J Community Health. 2017;42(2):324–32. pmid:27678390
- 24. Adunlin G, Cyrus JW, Asare M, Sabik LM. Barriers and Facilitators to Breast and Cervical Cancer Screening Among Immigrants in the United States. J Immigr Minor Health. 2019;21(3):606–58. pmid:30117005
- 25. Ahmed AT, Welch BT, Brinjikji W, Farah WH, Henrichsen TL, Murad MH, et al. Racial Disparities in Screening Mammography in the United States: A Systematic Review and Meta-analysis. J Am Coll Radiol. 2017;14(2):157–65.e9.
- 26. Jerome-D’Emilia B. A systematic review of barriers and facilitators to mammography in Hispanic women. J Transcult Nurs. 2015;26(1):73–82. pmid:24797255
- 27. Jerome-D’Emilia B, Gachupin FC, Suplee PD. A Systematic Review of Barriers and Facilitators to Mammography in American Indian/Alaska Native Women. J Transcult Nurs. 2019;30(2):173–86. pmid:30122121
- 28. Khan-Gates JA, Ersek JL, Eberth JM, Adams SA, Pruitt SL. Geographic Access to Mammography and Its Relationship to Breast Cancer Screening and Stage at Diagnosis: A Systematic Review. Womens Health Issues. 2015;25(5):482–93. pmid:26219677
- 29. Nelson HD, Cantor A, Wagner J, Jungbauer R, Quiñones A, Stillman L, et al. Achieving Health Equity in Preventive Services: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2020;172(4):258–71. pmid:31931527
- 30. Lee LK, Chien A, Stewart A, Truschel L, Hoffmann J, Portillo E, et al. Women’s Coverage, Utilization, Affordability, And Health After The ACA: A Review Of The Literature. Health Aff (Millwood). 2020a;39(3):387–94. pmid:32119612
- 31.
Andersen RM, Davidson PL, Baumeister SE. Improving Access to Care. In: Kominski GF, editor. Changing the US health care system: key issues in health services policy and management. Fourth edition. ed. San Francisco: Jossey-Bass; 2013.
- 32. Hong QN, Pluye P, Bujold M, Wassef M. Convergent and sequential synthesis designs: implications for conducting and reporting systematic reviews of qualitative and quantitative evidence. Systematic Reviews. 2017;6(1):61. pmid:28335799
- 33. Pace R, Pluye P, Bartlett G, Macaulay AC, Salsberg J, Jagosh J, et al. Testing the reliability and efficiency of the pilot Mixed Methods Appraisal Tool (MMAT) for systematic mixed studies review. Int J Nurs Stud. 2012;49(1):47–53. pmid:21835406
- 34. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the conduct of narrative synthesis in systematic reviews: A product from the ESRC Methods Programme.2006.
- 35. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Bmj. 2021;372:n71. pmid:33782057
- 36. Gilchrist A, Fernando GVMC, Ahmed F, Holland P. Individual and contextual factors impacting access to primary care in women of working age in the United States in the Affordable Care Act (ACA) era: a mixed-methods systematic review. PROSPERO: International prospective register of systematic reviews. 2021;CRD42021265314.
- 37.
Lizarondo L, Stern C, J C, Godfrey C , Rieger K, Salmond S, et al. Chapter 8: Mixed methods systematic reviews. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis: JBI; 2020.
- 38. Hong QN, Fàbregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, et al. The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Education for Information. 2018a;34:285–91.
- 39. Hong QN, Gonzalez-Reyes A, Pluye P. Improving the usefulness of a tool for appraising the quality of qualitative, quantitative and mixed methods studies, the Mixed Methods Appraisal Tool (MMAT). J Eval Clin Pract. 2018b;24(3):459–67. pmid:29464873
- 40. Souto RQ, Khanassov V, Hong QN, Bush PL, Vedel I, Pluye P. Systematic mixed studies reviews: updating results on the reliability and efficiency of the Mixed Methods Appraisal Tool. Int J Nurs Stud. 2015;52(1):500–1. pmid:25241931
- 41. Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen’s Behavioral Model of Health Services Use: a systematic review of studies from 1998–2011. Psychosoc Med. 2012;9:Doc11. pmid:23133505
- 42. Ahad FB, Zick CD, Simonsen SE, Mukundente V, Davis FA, Digre K. Assessing the Likelihood of Having a Regular Health Care Provider among African American and African Immigrant Women. Ethn Dis. 2019;29(2):253–60. pmid:31057310
- 43. Chen L, Frank RG, Huskamp HA. Overturning the ACA’s Medicaid Expansion Would Likely Decrease Low-Income, Reproductive-Age Women’s Healthcare Spending and Utilization. Inquiry. 2020;57:46958020981462. pmid:33305968
- 44. Courtemanche C, Marton J, Ukert B, Yelowitz A, Zapata D, Fazlul I. The three-year impact of the Affordable Care Act on disparities in insurance coverage. Health Serv Res. 2019;54 Suppl 1(Suppl 1):307–16. pmid:30378119
- 45. Dai H, Meyer IH. A Population Study of Health Status Among Sexual Minority Older Adults in Select U.S. Geographic Regions. Health Educ Behav. 2019;46(3):426–35. pmid:30606058
- 46. Daw JR, Sommers BD. The Affordable Care Act and Access to Care for Reproductive-Aged and Pregnant Women in the United States, 2010–2016. Am J Public Health. 2019;109(4):565–71. pmid:30789761
- 47. DiPietro Mager NA, Zollinger TW, Turman JE Jr, Zhang J, Dixon BE. Routine Healthcare Utilization Among Reproductive-Age Women Residing in a Rural Maternity Care Desert. J Community Health. 2021;46(1):108–16. pmid:32488525
- 48. Early DR, Dove MS, Thiel de Bocanegra H, Schwarz EB. Publicly Funded Family Planning: Lessons From California, Before And After The ACA’s Medicaid Expansion. Health Aff (Millwood). 2018;37(9):1475–83. pmid:30179554
- 49. Farietta TP, Lu B, Tumin R. Ohio’s Medicaid Expansion and Unmet Health Needs Among Low-Income Women of Reproductive Age. Matern Child Health J. 2018;22(12):1771–9. pmid:30006730
- 50. Greder K, Reina AS. Procuring Health: Experiences of Mexican Immigrant Women in Rural Midwestern Communities. Qual Health Res. 2019;29(9):1334–44. pmid:30556481
- 51. Johnson PJ, Jou J, Upchurch DM. Psychological Distress and Access to Care Among Midlife Women. J Aging Health. 2020;32(5–6):317–27. pmid:30614361
- 52. Johnston EM, Strahan AE, Joski P, Dunlop AL, Adams EK. Impacts of the Affordable Care Act’s Medicaid Expansion on Women of Reproductive Age: Differences by Parental Status and State Policies. Womens Health Issues. 2018;28(2):122–9. pmid:29275063
- 53. Jones RK, Sonfield A. Health insurance coverage among women of reproductive age before and after implementation of the affordable care act. Contraception. 2016;93(5):386–91. pmid:26802569
- 54. Lee H, Hirai AH, Lin CC, Snyder JE. Determinants of rural-urban differences in health care provider visits among women of reproductive age in the United States. PLoS One. 2020b;15(12):e0240700. pmid:33301492
- 55. Lee LK, Monuteaux MC, Everett W. Early Effects of the ACA on Women’s Health Measures. J Gen Intern Med. 2018;33(12):2034–6. pmid:30054883
- 56. Lee LK, Monuteaux MC, Galbraith AA. Women’s Affordability, Access, and Preventive Care After the Affordable Care Act. Am J Prev Med. 2019;56(5):631–8. pmid:30905480
- 57. Luque JS, Soulen G, Davila CB, Cartmell K. Access to health care for uninsured Latina immigrants in South Carolina. BMC Health Services Research. 2018;18(1):310. pmid:29716586
- 58. Margerison CE, MacCallum CL, Chen J, Zamani-Hank Y, Kaestner R. Impacts of Medicaid Expansion on Health Among Women of Reproductive Age. Am J Prev Med. 2020;58(1):1–11. pmid:31761513
- 59. Massetti GM, Thomas CC, King J, Ragan K, Buchanan Lunsford N. Mental Health Problems and Cancer Risk Factors Among Young Adults. Am J Prev Med. 2017;53(3s1):S30–s9. pmid:28818243
- 60. Pazol K, Robbins CL, Black LI, Ahrens KA, Daniels K, Chandra A, et al. Receipt of Selected Preventive Health Services for Women and Men of Reproductive Age—United States, 2011–2013. MMWR Surveill Summ. 2017;66(20):1–31. pmid:29073129
- 61. Ross Perfetti A, Abboud S, Behme M, Barg FK. Understanding wellness and barriers to care among Iraqi refugee women in the United States. Health Soc Care Community. 2019;27(6):1430–7. pmid:31338949
- 62. Seo JY, Kuerban A, Bae SH, Strauss SM. Disparities in Health Care Utilization Between Asian Immigrant Women and Non-Hispanic White Women in the United States. J Womens Health (Larchmt). 2019;28(10):1368–77. pmid:31264933
- 63. Simon K, Soni A, Cawley J. The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions. J Policy Anal Manage. 2017;36(2):390–417. pmid:28378959
- 64. Sommers BD, Kenney GM, Epstein AM. New evidence on the Affordable Care Act: coverage impacts of early medicaid expansions. Health Aff (Millwood). 2014;33(1):78–87. pmid:24395938
- 65. Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act. JAMA. 2015;314(4):366–74. pmid:26219054
- 66. SteelFisher GK, Findling MG, Bleich SN, Casey LS, Blendon RJ, Benson JM, et al. Gender discrimination in the United States: Experiences of women. Health Serv Res. 2019;54 Suppl 2(Suppl 2):1442–53. pmid:31663120
- 67. Wehby GL, Lyu W. The Impact of the ACA Medicaid Expansions on Health Insurance Coverage through 2015 and Coverage Disparities by Age, Race/Ethnicity, and Gender. Health Serv Res. 2018;53(2):1248–71. pmid:28517042
- 68.
Czajka JL, Beyler A. Declining Response Rates in Federal Surveys: Trends and Implications (Background Paper). Princeton: Mathematica Policy Research; 2016.
- 69. Rao R, Link M, Battaglia M, Frankel M, Giambo P, Mokdad A. Assessing Representativeness in RDD Surveys: Coverage and Nonresponse in the Behavioral Risk Factor Surveillance System. 2005.
- 70. Karaca-Mandic P, Norton EC, Dowd B. Interaction Terms in Nonlinear Models. Health services research. 2012;47(1pt1):255–74. pmid:22091735
- 71. Manuel JI. Racial/Ethnic and Gender Disparities in Health Care Use and Access. Health Serv Res. 2018;53(3):1407–29. pmid:28480588
- 72. Buchmueller TC, Levinson ZM, Levy HG, Wolfe BL. Effect of the Affordable Care Act on Racial and Ethnic Disparities in Health Insurance Coverage. Am J Public Health. 2016;106(8):1416–21. pmid:27196653
- 73.
Baumgartner JC, Collins SR,.Radley DC, Hayes SL. How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care. The Commonwealth Fund; 2020 January 2020.
- 74. Lee H, Porell FW. The Effect of the Affordable Care Act Medicaid Expansion on Disparities in Access to Care and Health Status. Medical care research and review. 2020;77(5):461–73. pmid:30362848
- 75. Yue D, Rasmussen PW, Ponce NA. Racial/Ethnic Differential Effects of Medicaid Expansion on Health Care Access. Health Serv Res. 2018;53(5):3640–56. pmid:29468669
- 76. Gonzales S, Sommers BD. Intra-Ethnic Coverage Disparities among Latinos and the Effects of Health Reform. Health Serv Res. 2018;53(3):1373–86. pmid:28660697
- 77. Angier H, Hoopes M, Gold R, Bailey SR, Cottrell EK, Heintzman J, et al. An early look at rates of uninsured safety net clinic visits after the Affordable Care Act. Ann Fam Med. 2015;13(1):10–6. pmid:25583886
- 78.
Guth M, Ammula M. Building on the Evidence Base: Studies on the Effects of Medicaid Expansion, February 2020 to March 2021. Kaiser Family Foundation; 2021.
- 79.
Guth M, Garfield R, Rudowitz R. The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. Kaiser Family Foundation; 2020.
- 80. Miller S, Wherry LR. Health and Access to Care during the First 2 Years of the ACA Medicaid Expansions. N Engl J Med. 2017;376(10):947–56. pmid:28273021
- 81. Sommers BD, Blendon RJ, Orav EJ, Epstein AM. Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance. JAMA Intern Med. 2016;176(10):1501–9. pmid:27532694
- 82. Sommers BD, Blendon RJ, Orav EJ. Both The ’Private Option’ And Traditional Medicaid Expansions Improved Access To Care For Low-Income Adults. Health Aff (Millwood). 2016a;35(1):96–105. pmid:26733706
- 83. Wherry LR, Miller S. Early Coverage, Access, Utilization, and Health Effects Associated With the Affordable Care Act Medicaid Expansions: A Quasi-experimental Study. Ann Intern Med. 2016;164(12):795–803. pmid:27088438
- 84. Snyder AH, Weisman CS, Liu G, Leslie D, Chuang CH. The Impact of the Affordable Care Act on Contraceptive Use and Costs among Privately Insured Women. Womens Health Issues. 2018;28(3):219–23. pmid:29544988
- 85. Daw JR, Winkelman TNA, Dalton VK, Kozhimannil KB, Admon LK. Medicaid Expansion Improved Perinatal Insurance Continuity For Low-Income Women. Health Aff (Millwood). 2020;39(9):1531–9. pmid:32897793
- 86. Dunlop AL, Joski P, Strahan AE, Sierra E, Adams EK. Postpartum Medicaid Coverage and Contraceptive Use Before and After Ohio’s Medicaid Expansion Under the Affordable Care Act. Womens Health Issues. 2020;30(6):426–35. pmid:32958368
- 87. Clapp MA, James KE, Kaimal AJ, Sommers BD, Daw JR. Association of Medicaid Expansion With Coverage and Access to Care for Pregnant Women. Obstet Gynecol. 2019;134(5):1066–74. pmid:31599841
- 88. Harvey SM, Gibbs SE, Oakley LP. Association of Medicaid Expansion With Access to Abortion Services for Women With Low Incomes in Oregon. Womens Health Issues. 2021;31(2):107–13. pmid:33168482
- 89. Gibbs SE, Harvey SM, Larson A, Yoon J, Luck J. Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program. J Womens Health (Larchmt). 2021;30(5):750–7. pmid:33085917
- 90. Gibbs S, Harvey SM, Bui L, Oakley L, Luck J, Yoon J. Evaluating the effect of Medicaid expansion on access to preventive reproductive care for women in Oregon. Prev Med. 2020;130:105899. pmid:31730946
- 91. Moniz MH, Kirch MA, Solway E, Goold SD, Ayanian JZ, Kieffer EC, et al. Association of Access to Family Planning Services With Medicaid Expansion Among Female Enrollees in Michigan. JAMA Netw Open. 2018;1(4):e181627. pmid:30646135
- 92. Dorner SC, Jacobs DB, Sommers BD. Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the Affordable Care Act. JAMA. 2015;314(16):1749–50. pmid:26505601
- 93.
Palanker D, Davenport K. Women’s Health Coverage Since the ACA: Improvements for Most, But Insurer Exclusions Put Many at Risk. The Commonwealth Fund and the National Women’s Law Center; 2016 August 2016. Contract No.: 1889.
- 94. Allen H, Wright BJ, Baicker K. New medicaid enrollees in Oregon report health care successes and challenges. Health Aff (Millwood). 2014;33(2):292–9. pmid:24493773
- 95. Brown EJ, Kangovi S, Sha C, Johnson S, Chanton C, Carter T, et al. Exploring the Patient and Staff Experience With the Process of Primary Care. Ann Fam Med. 2015;13(4):347–53. pmid:26195680
- 96. Brown EE, Schwartz M, Shi C, Carter T, Shea JA, Grande D, et al. Understanding Why Urban, Low-Income Patients Miss Primary Care Appointments: Insights From Qualitative Interviews of West Philadelphians. J Ambul Care Manage. 2020;43(1):30–40. pmid:31770184
- 97. Cross-Barnet C, Colligan EM, McNeely J, Strawbridge LM, Lloyd JT. Facilitators and barriers to optimal preventive service use among providers and older patients. Geriatr Nurs. 2019;40(1):72–7. pmid:30122404
- 98. Saluja S, McCormick D, Cousineau MR, Morrison J, Shue L, Joyner K, et al. Barriers to Primary Care After the Affordable Care Act: A Qualitative Study of Los Angeles Safety-Net Patients’ Experiences. Health Equity. 2019;3(1):423–30. pmid:31448352
- 99. Murray KE, Mohamed AS, Ndunduyenge G. Health and prevention among East African women in the U.S. J Health Care Poor Underserved. 2013;24(1):233–46. pmid:23377731
- 100. Olukotun O, Kako P, Dressel A, Mkandawire-Valhmu L. A qualitative exploration of the experiences of undocumented African immigrant women in the health care delivery system. Nurs Outlook. 2020;68(2):242–51. pmid:31526520
- 101. Biederman DJ, Nichols TR. Homeless women’s experiences of service provider encounters. J Community Health Nurs. 2014;31(1):34–48. pmid:24528122
- 102. Chor J, Garcia-Ricketts S, Young D, Hebert LE, Hasselbacher LA, Gilliam ML. Well-woman Care Barriers and Facilitators of Low-income Women Obtaining Induced Abortion after the Affordable Care Act. Womens Health Issues. 2018;28(5):387–92. pmid:29747908
- 103. Phillippi JC, Holley SL, Payne K, Schorn MN, Karp SM. Facilitators of prenatal care in an exemplar urban clinic. Women Birth. 2016;29(2):160–7. pmid:26530714
- 104. Mann L, Tanner AE, Sun CJ, Erausquin JT, Simán FM, Downs M, et al. Listening to the voices of Latina women: Sexual and reproductive health intervention needs and priorities in a new settlement state in the United States. Health Care Women Int. 2016;37(9):979–94. pmid:27050775
- 105. Roman LA, Raffo JE, Dertz K, Agee B, Evans D, Penninga K, et al. Understanding Perspectives of African American Medicaid-Insured Women on the Process of Perinatal Care: An Opportunity for Systems Improvement. Matern Child Health J. 2017;21(Suppl 1):81–92. pmid:28965183
- 106. Allen JD, Leyva B, Torres AI, Ospino H, Tom L, Rustan S, et al. Religious beliefs and cancer screening behaviors among Catholic Latinos: implications for faith-based interventions. J Health Care Poor Underserved. 2014;25(2):503–26. pmid:24858865
- 107. Hailemariam M, Felton JW, Key K, Greer D, Jefferson BL, Muhammad J, et al. Intersectionality, special populations, needs and suggestions: the Flint Women’s study. Int J Equity Health. 2020;19(1):18. pmid:32005120
- 108. Crowley RA, Bornstein SS. Improving the Patient Protection and Affordable Care Act’s Insurance Coverage Provisions: A Position Paper From the American College of Physicians. Ann Intern Med. 2019;170(9):651–3. pmid:30986852
- 109.
Office of the Assistant Secretary for Planning and Evaluation, DHSS. Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges. Issue Brief. Washington, DC; 2021. Report No.: HP-2021-2.
- 110. Department of Health and Human Services. HHS Announces Commitments from Partners to Encourage Latino Consumers to Enroll in Health Insurance Coverage through HealthCare.gov. 2021.
- 111. Doty MM, & Collins S. R. Millions More Latino Adults Are Insured Under the Affordable Care Act. 2017.
- 112. Keith K. Health Affairs. 2021. Available from: https://www.healthaffairs.org/do/10.1377/forefront.20210422.65513/full/.
- 113. Handtke O, Schilgen B, Mösko M. Culturally competent healthcare—A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision. PLoS One. 2019;14(7):e0219971. pmid:31361783