Impact of the Affordable Care Act on the HIV Care Continuum

172 Pages·2017·1.17 MB·English

Walden University
ScholarWorks
Walden Dissertations and Doctoral Studies
Walden Dissertations and Doctoral Studies
Collection
2017
Impact of the Affordable Care Act on the HIV Care
Continuum
Ebere Erugo
Walden University
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Walden University

College of Health Sciences

This is to certify that the doctoral dissertation by

Ebere Erugo

has been found to be complete and satisfactory in all respects,
and that any and all revisions required by
the review committee have been made.

Review Committee
Dr. Ernest Ekong, Committee Chairperson, Public Health Faculty
Dr. Peter Anderson, Committee Member, Public Health Faculty
Dr. Lori Dewald, University Reviewer, Public Health Faculty

Chief Academic Officer
Eric Riedel, Ph.D.

Walden University
2017
Abstract
Impact of the Affordable Care Act on the HIV Care Continuum
by
Ebere N. Erugo

MPH, Kaplan University, 2013
BSN, Mountain State University, 2010

Dissertation Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Philosophy
Public Health—Epidemiology

Walden University
December 2017
Abstract
People living with human immunodeficiency virus (HIV) and acquired
immunodeficiency syndrome (AIDS; PLWHA) are at increased risk of insufficient
medical care due to lack of insurance. Inadequate medical care for PLWHA contributes
to increases in HIV transmission rates. The U.S. Surveillance Report noted that in 2015,
over 1.2 million people were living with HIV infection, and there were approximately
50,000 new infections every year. The report further stated that about 675,000 people
have died from HIV-related illnesses since its discovery in 1981. The implementation of
the Affordable Care Act (ACA) in 2014 was intended to provide Americans, including
people at risk of or living with HIV, options for health insurance coverage and better
access to health care. It was also designed to allow people with existing health conditions
such as HIV to reach for optimal health, irrespective of the severity of their condition.
Andersen’s behavioral model and economic theory provided the theoretical framework
and conceptual foundation for this study’s assessment of the impact of the ACA on the
HIV care continuum. This quantitative study used secondary data with a retrospective
correlational design. Data from the Health Resources Service Administration and the
Behavioral Risk Factor Surveillance System were analyzed. Overall, chi-square tests
indicated a steady increase in the number of PLWHA who achieved viral suppression (χ2
(1) = 105, p < .001) between 2010 and 2015. Future research should include the general
American population to assess the impact of the ACA. This study could lead to positive
social change as PLWHA are made more aware of the benefits of comprehensive health
care coverage and increase healthcare utilization, leading to improved health for those
infected and less transmission of the virus.
Impact of the Affordable Care Act on the HIV Care Continuum
by
Ebere N. Erugo

MPH, Kaplan University, 2013
BSN, Mountain State University, 2010

Dissertation Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Philosophy
Public Health—Epidemiology

Walden University
December 2017
Dedication
This study is lovingly dedicated to my children, Unique, Jewel, Destiny, and
Joshua Erugo. You are my loudest cheerleaders. You continued to cheer me on and
propelled me to keep moving even when I thought I had reached my limit. You are truly
my inspiration, and you showed your faith in me when you expressed that when you
grow up, you would like to be just “like Mommy because she is getting her doctorate
degree even with all the challenges she is facing.” I thank you for believing in me; I thank
you for constantly praying for me; I thank you for allowing me have some time to myself
to complete my school work each time I requested it. I thank you for your support and
unconditional love, and most of all, I thank you for sharing your world with me. I love
you all more than words can ever express, and I believe in all of you to reach every goal
you set for yourselves.
Acknowledgments
First and foremost, I would like to acknowledge and give thanks and glory to
Almighty God, who has made it possible for me to go through this journey successfully.
Without Him, I can do nothing, but my strength is anchored in the knowledge that “I can
do all things through Christ which strengthens me.”
I would like to thank my committee chair, Dr. Ernest Ekong; committee member,
Dr. Peter Anderson; and URR representative, Dr. Lori L. Dewald, for agreeing to work
with me and working tirelessly to make sure that I completed this dissertation. I
especially want to express my deep appreciation to Dr. Peter Anderson for taking so
much time to correct my papers over and over without showing his frustration.
To my sisters and backbones, Ezioma and Ngozi; I say thank you for providing
the shoulders to lay my weary head on when I could not hold it up any longer. Thank you
for all the support and encouragement you have continually provided to me—you rock!
To my sister’s husband, Ike Onwukanjo, thank you so much for being there for my
children and me during the hardest season of our lives. You are more than a brother-in-
law. To my mother, my sister, Ijeoma, my brothers—Barrister Azubuike Okorie, the late
Anozie Okorie, and Chinedu Okorie and their families—I couldn’t ask for a better
family. To my church family at Calvary Gospel Church in Waldorf, MD, thank you for
providing spiritual covering for me. To my friends, Jewel Klass-Kendall, Dr. Ellis
Opusunju, Malaika Oliver, Lisa Adams, Uche Onyeka, Lydie Bianda, and Lesley
Morgan, thank you for providing me with support and encouragement. Last but not least,
thank you Dr. Elisabeth Johnson-Kallos for accepting to serve as my external editor.
Table of Contents
List of Tables ..................................................................................................................... vi
List of Figures ................................................................................................................... vii
Chapter 1: Introduction to the Study ....................................................................................1
Introduction ....................................................................................................................1
Background ....................................................................................................................6
The HIV/AIDS Epidemic in the United States ....................................................... 6
The Affordable Care Act ........................................................................................ 7
The Impact of the ACA on HIV Care in the United States .................................... 9
Problem Statement .......................................................................................................12
Purpose of the Study ....................................................................................................13
Research Questions and Hypotheses ...........................................................................14
Theoretical Foundation and Conceptual Framework ...................................................16
Theoretical Foundation ......................................................................................... 16
Conceptual Framework ......................................................................................... 17
Nature of the Study ......................................................................................................19
Definition of Terms......................................................................................................20
Assumptions .................................................................................................................22
Scope and Delimitations ..............................................................................................23
Scope ................................................................................................................... 23
Delimitations ......................................................................................................... 23
Limitations ...................................................................................................................24
i
Significance..................................................................................................................25
Summary ......................................................................................................................28
Chapter 2: Literature Review .............................................................................................30
Introduction ..................................................................................................................30
Literature Search Strategy............................................................................................32
Theoretical Foundation ................................................................................................33
Andersen’s Behavioral Model of Health Care Utilization .................................... 33
Application of Theory in Previous Studies ........................................................... 36
Economic Theory .................................................................................................. 36
Rationale for Choosing Andersen’s Model and Economic Theory ...................... 38
Conceptual Framework ................................................................................................39
Literature Review Related to Key Variables and Concepts .........................................40
Access to HIV Care .............................................................................................. 41
Out-of-Pocket Health Care Costs.......................................................................... 44
Adherence to HIV Care ........................................................................................ 46
Linkage to HIV Care ............................................................................................. 50
Retention in HIV Care .......................................................................................... 52
Treatment Outcome and Viral Suppression .......................................................... 56
Age, Gender, and Race ......................................................................................... 57
Summary ......................................................................................................................59
Conclusions Based on the Literature Review ..............................................................60
Chapter 3: Research Method ..............................................................................................61
ii
Research Design and Rationale ...................................................................................61
Independent Variable ............................................................................................ 65
Dependent Variables ............................................................................................. 65
Research Methods ........................................................................................................66
Population ............................................................................................................. 66
Sampling Procedures ............................................................................................ 66
Power Analysis ..................................................................................................... 69
Procedures for Recruitment, Participation, and Data Collection .......................... 69
Instrumentation and Operationalization of Constructs ......................................... 71
Operationalization of Variables ............................................................................ 75
Covariates ............................................................................................................. 77
Data Analysis Plan ................................................................................................ 78
Threats to Validity .......................................................................................................80
Ethical Procedures .......................................................................................................82
Summary ......................................................................................................................84
Chapter 4: Results ..............................................................................................................86
Research Questions and Hypotheses ...........................................................................86
Data Collection ............................................................................................................88
Data Collection in the HRSA ................................................................................ 88
Data Collection in the BRFSS .............................................................................. 89
Time Frame and Response Rates: Univariate Characteristics .............................. 93
Discrepancies in the BRFSS Data Sets ................................................................. 98
iii