THE SIGNIFICANCE OF AFFORDABLE CARE ACT (ACA) ON HEALTHCARE BEHAVIORS OF PERSONS OF LATINO AND AFRICAN AMERICAN ETHNICITY WITHIN THE MIDDLE CLASS IN AMERICA

THE SIGNIFICANCE OF AFFORDABLE CARE ACT (ACA) ON HEALTHCARE BEHAVIORS OF PERSONS OF LATINO AND AFRICAN AMERICAN ETHNICITY WITHIN THE MIDDLE CLASS IN AMERICA

Dissertation Proposal

Chapter 1: Introduction

The United States has a unique health care system amongst the developed countries. It lacks uniform and universal health care coverage. However, the American government recently endorsed the Affordable Care Act (ACA)as an optionalhealth care provision to all citizens. McIntyre and Song (2019) argue that ACA supplemented insurance coverage by creating health insurance markets at the state level on the premise of choice and competition. It also offered Americans up to 400% of the poverty line with subsidies to assist them to acquire insurance.

Rather than running a national health service or a multi-payer or single-payer universal health insurance fund, the American health care system is hybrid. Reports indicate that 48% of health care expenditure comes from private funds, 28% from families, and 20% from private businesses (The Commonwealth Fund, n. d). Other spending includes 28% of the federal government and 17% from local and state administrations.

The majority of Americans expect health care providers to treat and attend to them successfully during an illness. In reality, the existing system benefits as well as hurt them. Some patients often find physicians’ recommendations difficult and confusing to follow. Furthermore, the costs are unforeseen and devastating most of the time, especially when conditions are. Over 40 million American adults experienced severe diseases in the last three years (The Commonwealth Fund, n. d). Those with serious ailments suffered immense losses of abilities, time, independence, and control over their lives, an aspect that many people take for granted. The economic, psychological, and physical toll tends to be life-changing. Even as the system helps Americans, it harms them in the process (Boudreau, 2017).

The cost of drugs in the U. S. has increased health care expenditure for ordinary Americans. According to Waxman, Corr, Martin, and Duong (2017), the creation of Medicare Part D by Congress deprived Medicare of its rights to negotiate drug prices, leaving only Medicaid and the Veterans Administration with such bargaining power. Although health care lacks a legitimate cost because stakeholders price their services depending on the payer, several factors contribute to the growing prices of drugs. These factors include high launching prices for patented brand-name drugs, manufacturers who capitalize on the natural monopolies in the industry, and the lack of strong competition amongst generic drug manufacturers (Waxman et al., 2017). As a result, players in the health care business create brands and demand the highest payments. As the cost of medicines soars, even Americans willing to finance their medical needs are adversely affected.

Although the U.S. government has pledged to avail health care to every American, some citizens opt to pay for it themselves. According to Amadeo (2019), most citizens are pleased with the current private health care system and not ready to accept a drastic change in the form of universal healthcare system.  Out of the 283.3 million Americans, 89.3% possess some form of health insurance, while 66% of workers have a private health insurance plan. Amongst those insured, 36.5% (115.4 citizens) obtain medical attention through the American administration via Veteran Administration/military care (14.14 million), Medicare (50.5 million), and Medicaid (61.65 million) (The Commonwealth Fund, n. d).

Research done previously about the topic indicates that American healthcare is a multi-trillion-dollar industry that encompasses government watchdogs, insurers, and providers who command the pricing and procedures involved in the distribution of healthcare resources. However, the government does not entirely pay for Medicare. The burden is shifted to the Middle-class to pay additional premiums to close the gap (Collins, Bhupal, & Doty, 2019).

Despite being a huge industry, the healthcare sector forces some people in the middle class to go without services due to financial hardship, while others within the same socioeconomic class can afford comprehensive personalized care (Boudreau, 2017). This is especially true of minority persons, especially Latino and African American individuals, who remain underrepresented within many healthcare systems throughout the United States(Chen, Vargas-Bustamante, Mortensen, &Ortega, 2016).  According to a study completed by Chen et al. (2016), minorities, especially Latino and African Americans remain underrepresented within many healthcare systems and are often less insured that Caucasian counterparts. Similarly, findings of a study completed by Buchmueller,Levinson, Levy, and Wolfe (2016) indicated that although coverage of minority persons has increased under ACA, Latino and African Americans still remain less insured than White contemporaries, and less likely to take advantage of medical care services due to economic hardship and historic mistrust of healthcare systems. To compound these issues, in recent years the shift of healthcare institutions from focus on consumers or the compassionate care of patients to creating profits can compromise quality of care, especially for underrepresented ethnic minority groups (Boudreau, 2017).

Despite the existing health insurance marketplace in the ACA, some Latinos and African Americans who are Middle-class earners still have insignificant healthcare behaviors than their Whites counterparts. Their healthcare behaviors include, but not limited to being uninsured, skip needed health care because of cost, and go without a regular source of care (Krogstad, 2016). In addition, many Latinos and African Americans middle-class earners cite the high cost of insurance as the main reason they lack coverage (Mathur, Srivastava, &Mehta, 2015).

In the regard to the best interests of the population, Latinos and African Americans in the Middle-class earners who go without having health insurance, can cause delays in treatment or access to health care. Those delays can make them sicker and potentially even leading to disability (Butler, 2016). Society as a whole will struggle because they will not be able to contribute as much as they did when they were healthy. If disability occurs because they did not gain access to health care, not only does society pay their disability payments, but it loses out on their current and future productive contributions to society (Waxman &Al, 2017).

Statement of the Problem

The problem to be addressed in this study is thatmiddle-class minorities (Latinos and African-Americans) enrolled in the ACA do not participate in preventive care because of high healthcare costs. According to Boudreau (2017), middle-class minority Americans cannot afford basic preventive; however, because they wait until they are sick to be assessed by a healthcare provider, their costs per visit go up almost 52%. These results are looking for alternative ways to prevent illness, including following shady internet sites and adhering to myths in illness preventive (Butler, 2016).

There is a tremendous need for affordable care in the United States, especially for minoritymiddle-class citizens. According to Collins et al. (2019), the health system used currently in America is expensive to citizens who cannot afford the high costs of private insurance.Hence, as the cost of care continues to rise, the private insurance actors burden the middle class with higher rates. Regardless of the situation, affordable healthcare is necessary for middle-class society in the U.S. In addition, the middle-income earners are people making somewhere between $40,500 and $122,000(American Community Survey, 2017).

Similarly, Schnake-Mahl, and Sommers (2017) believed that middle class persons, especially those that live in the suburbs, remain largely understudied within literature regarding healthcare coverage. Schnake-Mahl and Sommers (2017) opined that one of the main reasons that the middle class remain understudied in this type of scholarship, is that public perception of habitation within the suburbs implies that families have enough expendable income to afford comprehensive health insurance, however, that is often untrue. Additionally, Joseph and Marrow(2017), examined the healthcare behaviors of underrepresented groups, such as immigrants and persons of ethnic minorities. Joseph and Marrow (2017) indicated that a need existed to better understand the healthcare behaviors of minority persons that are granted coverage under the ACA.

ACA plays a pivotal role in enhancing access to health care among the low- and middle-income earners in the US. However, despite the numerous benefits associated with ACA, such as the availability of subsidies and cost-sharing, the concept is linked to unintended barriers. ACA supports the development of narrow networks where the available insurers have limited offers and policies to make the healthcare plans more competitive. Therefore, conducting this research will help in filling the above gap. Additionally, it is imperative to acknowledge that there is limited baseline data concerning the pre-ACA years. Thus, findings obtained from the research will contribute to knowledge development in the field.

Purpose of the Study

The purpose to be addressed in this quantitative study is to investigate the perceptions of middle-class Latino and African-Americans enrolled in the ACA regarding their participation in preventive care and the cost of healthcare. The study will embrace a quantitative descriptive design with a focus on the descriptive statistics on the target participants. The rationale for choosing the research design is the fact that it is a reliable approach, and findings obtained from the study can be generalized for the broader population. The study will also rely on a survey questionnaire to help in the data collection.

• Once participants are selected for use within this study, an invitation email will be sent to respective individuals. Within the invitation email will be detailed information on participant rights, expectations of the researcher, informed consent and information about the data collection questionnaire. Once participants electronically grant consent, a link will be sent to the data collection questionnaire. Once the questionnaire is completed electronically, answers will electronically be sent to the researcher, and participants will be thanked for participation.
• With the study methodology, the researcher will be in a position to explore the significance of ACA among the middle-class minority population in the U.S.The independent variable in the study includeshealthcare under the ACA. The dependent variables, on the other hand, will include healthcare behaviors, including number of primary doctor visits, participation in preventative health care measuresand healthcare spending.
• The target population will consist of Latino and African Americanminorities in themiddle-class throughout the City of Baltimore, Maryland.The sample, which will be found using purposive sampling, will also consist of at least100middle-class citizensof ethnic minority who will answer questions aimed to collect information about the amount of money they spend on medical expenses on an annual basis and how they participate within the healthcare system.The estimated sample size will be determined by using linear multiple regression option (Fixed Model, R^2 deviation from zero), a statistical test method knowing as the G*Power3.1.9.4. The research will be conducted in the City of Baltimore, Maryland where there are large numbers of Latino and African American population.The Surveys will be targeting Universities, Hospitals, and Communities with large Latinos and African Americans population. Thesurveys will be completed online, using Survey Monkey, to ensure confidentiality and comfortability while answering questions. Additionally, data analysis will be completed through the use of SPSS.
• Failure to examine these issues could have detrimental effects on the middle class, both medically and financially. Without insurance, Kominski, Nonzee, and Sorensen (2017) allege that families will experience a monetary toll for lack of primary care, such as prescription medicine, or flu shot. Lack of affordable health care or insurance is costly for a majority of Americans. As such, they risk missing preventive care and likely to endure adverse health consequences. Therefore, living without affordable health care and insurance embodies living with the weight of being unable to receive primary care.

Theoretical or Conceptual Framework

The conceptual model recommended for this study merges two perspectives that will indicate how Americans can access healthcare at a cheaper cost. The first paradigm is the behavioral model of health services initially created by Ronald Andersen during the 1960s (Ryvicker, 2017). It concentrates on three areas of people’s individualities as forecasters of health service utilization and ensuing results: need, enabling, and predisposing aspects. The need category includes both the supplier’s appraisal of health care demands and patients’ perception of health care. Enabling forces, such as health insurance and income levels, either allow or obstruct service uptake (Ryvicker, 2017). Predisposing elements encompass ethnicity or race, sex, age, and other socio-demographic characteristics that depict an individual’s social standing and, in return, the capacity to command essential resources to solve health issues (Ryvicker, 2017). The behavioral view recognizes the potential implications of the economic, political, and physical environment for health service consumption.

An additional framework that could explain the lack of affordable health care within middle-class persons of ethnic minority is the equity of access model. The paradigm arrived in 1981 when Adey and Anderson argued that inequity exists when the administration distributes services based on people’s demand for them and recommended the distribution of the services based on demographic variables, such as place of residence, family income, and race instead of need. The availability of health services allows citizens to work and become productive in their lives. However, failure to offer them access to health care due to limited income, ethnicity, or place of residence denies them their right to equitable and quality healthcare.

The two models emphasize diverse but compatible and crucial considerations in healthcare provision and accessibility. The behavioral dimension underscores variations in the healthcare sector as a vital enablers of healthcare access. Thetwo models acknowledge the need for adopting affordable care among the public. The behavioral model for example focuses on the various attributes such as race or sex of a person that can influence access to care. Besides, a person’s behaviors can prevent him or her from accessing healthcare, as depicted in the behavioral model (Krogstad, 2016). Lack of income and factors, such as ethnicity or race, sex, and age, among other socio-demographic characteristics that determine the social standing of a person ascertain whether a person will receive health care or not. As this study will examine healthcare behaviors within persons of ethnic minority in the middle class, this framework is appropriate to underpin this study (Waxman &Al, 2017).

Nature of the Study

This study will adopt a descriptive quantitative approach to determine the healthcare behaviors as being insured,preventive care because of high cost, and go without a regular source of careof persons of ethnic minority within the middle class, especially personsthat receive healthcare coverage under the ACA.The quantitative research method will be considered the most appropriate since it allows the researcher to compile reliable, valid, and generalizable findings to a larger population. Descriptive research is a quantitative research approach that describes the characteristics of a phenomenon or population that is being studied. In other words, it entails observing and describing the behavior of study participants without influencing it in any manner. The descriptive research design will be considered the most suitable in this study since it allows research to be carried out in the natural setting of the participant or a phenomenon, hence, guarantees collection of quality and accurate data. Additionally, it is easy and cheap to conduct since it usually involves a large sample size(Chen, Vargas-Bustamante, Mortensen, &Ortega, 2016). The survey method will be used for several reasons. It is the most affordable means of gathering data. It is easier to place them on websites or email to respondents. Their use incurs little to no expense, although robust targeting is required to produce the highest possible rate of response and truthful results(Chen, Vargas-Bustamante, Mortensen, &Ortega, 2016).

Additionally, questionnaires are not only affordable but practical. It is easy to pick the questions to pose to respondents and their format (open-ended or closed-ended). They provide a way of gathering vast amounts of information on diverse subjects. Besides, they can be utilized in various, extensive ways. Moreover, questionnaires serve as a swift approach to collecting data, especially with the help of mobile and online tools. As a result, much information can be acquired in less than a day, depending on the reach of the questionnaires(Boudreau, 2017).

Further, data can be gathered from large audiences. The Internet allows researchers to distribute questionnaires to anyone regardless of their location provided that they are connected to the Web. Respondents can reply to the questions by following the link provided by the researcher. Additionally, data from questionnaires can be compared and contrasted with findings from past and future research. Enhanced comparability reduces interpretation errors. Questionnaires facilitate the visualization and analysis of results. Findings can be assessed by an individual who is inexperienced in scientific research or statistics(Boudreau, 2017).

Research Questions

The research questions outlined below will form the basis of the study. They will guide the data collection process to deepen the researcher’s understanding of the topic. The overarching goal of this study is to better understand healthcare behaviors of ethnic minorities within the middle class who are provided healthcare under the ACA. To complete the objective of this study the following research questions were developed:

RQ1.What is the relationship, if any, between preventive care and the healthcare cost for middle-class Latinos and African-Americans residing in Baltimore City, Maryland and enrolled in the ACA?

RQ2. What is the relationship, if any, between middle-class Latinos and African-Americans enrolled in the ACA regarding the cost of healthcare?

RQ3.What is the relationship, if any, between being insured and skipped care because of high cost of Latinos and African Americans enrolled in the ACA?

Hypotheses

H1₀.There is no relationship between preventive care and the healthcare cost for middle-class Latinos and African-Americans residing in Baltimore City, Maryland and enrolled in the ACA.

H1_a. There is a relationship between preventive care and the healthcare cost for middle-class Latinos and African-Americans residing in Baltimore City, Maryland and enrolled in the ACA.

H2₀.There is no relationship between middle-class Latinos and African-Americans enrolled in the ACA regarding the cost of healthcare.

H2_a. There is a relationship between middle-class Latinos and African-Americans enrolled in the ACA regarding the cost of healthcare.

H3₀: There is no relationship between being insured and skipped care because of high cost of Latinos and African Americans enrolled in the ACA

H3_a: There is a relationship between being insured and skipped care because of high cost of Latinos and African Americans enrolled in the ACA.

Significance of the Study

This research is significant because it will assess the need for availing health services to understudied cohorts, such as persons of ethnic minority in the middle class, especially those that receive benefits under the ACA.  Studying the problem will give stakeholders the footing they require before implementing the future amendments to the ACA or future healthcare systems. Since Americans are already shouldering the majority of healthcare costs, researching this topic may help the national government reallocate social, physical, and economic resources to ensure that the middle-class minorities have access to quality healthcare affordably.

Finding established from the research is essential in filling the existing gaps in the literature. Additionally, the results will contribute to knowledge development in the subject, an aspect that can be used by the policymakers to make informed policy decisions. Access to affordable care is necessary for all Americans, irrespective of their demographic differences. Therefore, the study is essential in promoting the effective implementation of relevant policies to support ACA.

• Affordability: Healthcare services are inexpensive such that people are capable of paying for them (Kolasa & Kowalczyk, 2016).
• Affordable Care Act (ACA): Comprehensive health care reform law ratified in 2010 to guarantee all Americans affordable health insurance (Butler, 2016).
• Approachability: Health care services are within reach of the people who need those (Kolasa & Kowalczyk, 2016).
• Efficiency: The ability to prevent wastage of time, money, effort, and resources during health care delivery (Kolasa & Kowalczyk, 2016).
• Fairness: Just, unbiased, nondiscriminatory, or non-prejudicial treatment or conduct in health care provision (Kolasa & Kowalczyk, 2016).
• Health care: Maintaining or improving health by preventing, diagnosing, and treating diseases, injuries, and other psychological and physical impairments (Mathur, Srivastava, & Mehta, 2015).
• Insurance: Protection from partial or full monetary loss, in this case, relating to medical expenses (Kolasa & Kowalczyk, 2016).
• Medicaid: A health insurance scheme for all Americans, including low-income earners, pregnant women, individuals with disabilities, and the elderly (Waxman &Al, 2017).
• Medicare: A national health insurance initiative endorsed in 1966 and currently administered by Medicaid and Medicare services (Waxman &Al, 2017).
• Medicare for All: A health insurance program run by the American government for all Americans and financed by taxpayers (Butler, 2016).
• Middle-income earners: A group of individuals in the middle of a social hierarchy, with a salary of roughly $26,000 to $78,000.
• Preventive care: It is the care one receives to prevent illnesses or diseases. It also includes counseling to prevent health problems (Butler, 2016).

Summary

There is a tremendous need for affordable healthcare in the United States, especially for middle-class minority citizens. According to Collins et al. (2019), the health system used currently in America is expensive to ordinary citizens who cannot afford the high costs of private insurance. As the cost of care continues to rise, the private insurance actors burden the middle class with higher rates.

Schnake-Mahl, and Sommers (2017) believed that middle class persons, especially those that live in the suburbs, remain largely understudied within literature regarding healthcare coverage, as public perception of habitation within the suburbs implies that families have enough expendable income to afford comprehensive health insurance, however that is often untrue. Likewise, Joseph and Marrow (2017), examined the healthcare behaviors of underrepresented groups, such as immigrants and persons of ethnic minorities and indicated that a need existed to better understand the healthcare behaviors of minority persons that are granted coverage under the ACA.

To better understand healthcare behaviors within the understudied cohort of middle-class minority persons, this study will adopt a descriptive quantitative approach to determine the healthcare behaviors of persons of ethnic minority within the middle class, especially persons that receive healthcare coverage under the ACA. Findings established from the research are essential in filling the existing gaps in the literature. Additionally, the results will contribute to knowledge development in the subject, an aspect that can be used by the policymakers to make informed policy decisions about both the ACA and future healthcare initiatives.

This chapter provided an introduction to this study. The next chapter will provide a comprehensive review of the literature. Throughout this subsequent chapter, a more comprehensive understanding of themes central to this study may be ascertained.

Chapter 2: Literature Review

Chapter 3: Research

The problem being addressed in this study is the lack of basic preventive care among the middle-class minorities. Due to a lack of proper income rates, minorities enrolled in the ACA are unable to participate in preventative healthcare. This is one of the biggest challenges that middle-class minorities face since it leads to the added cost. Since they have to wait for moments they feel unwell, accessing the healthcare provider becomes challenging due to the added cost. The price can go up to 52% which is very high for the middle-class individual to cope up with. Minorities have adapted ways in which they can keep themselves out of any form of illness. They adapt to internet sites among other myths that are linked to healthcare (Boudreau, 2017). Middle-class minorities do this to avoid the added cost for the healthcare they cannot afford due to low incomes.

The purpose of the study is to find out how middle-class Latinos and African Americans enrolled in the ACA fail to participate in preventive care and the cost of healthcare. The study will be conducted through a quantitative study method to get conclusive data. The quantitative descriptive design is also effective since it will allow vivid statics on the targeted participants. The study will embrace the most reliable research design to enable the researchers to expand their design to the larger population. To increase the flexibility of the research, the data collection will be expanded through a survey questionnaire. This will help in the generation of new information that will impact the study while coming up with conclusive findings.

While the adoption of the Affordable Care Act was expected to transform the United States healthcare sector, the statute’s impact is yet to impact middle-class minorities. Middle-class citizens from African American and Latino communities tend to avoid preventive care, with concerns about high healthcare costs being singled out as a significant contributor to this trend (Boudreau, 2017). Additionally, contemporary research has shown that some middle-class earners from the two communities are still uninsured (Krogstad, 2016). The lack of health insurance is a significant problem that continues to affect the American healthcare system, and reforms such as those furnished by the ACA are meant to help in addressing the issue. However, some groups remain uninsured under the ACA. Hence, it is imperative to determine some of the factors that may have contributed to this trend. Besides, such practices expose these groups to an increased risk of paying even more costs when seeking medical care, as well as that of being unable to leverage the full benefits of the American healthcare system.

The amount of scholarship and research that has been dedicated to studying healthcare problems that affect the middle-class segment in the United States is relatively minimal. Most of such projects tend to focus on economically disadvantaged groups, with researchers assuming the middle-class earners have access to incomes that can allow them to afford medical care (Schnake-Mahl and Sommers, 2017). However, it has become evident that this group also faces profound challenges in accessing affordable medical care. Accordingly, there is a need for further research that would provide useful insights concerning some of the primary factors that cause middle-class earners from minority communities to avoid health insurance and preventive care behaviors. An understanding of this knowledge would positively contribute to the creation of a healthcare system that meets the needs of all Americans.

Therefore, this study seeks to analyze the perceptions of middle-class African Americans and Latinos concerning the affordability of medical care. It is expected that the findings of this research project will offer valuable lessons that could be used to redefine the American healthcare system to consider the needs of minority communities. At the same time, the results of this study will help clinicians and stakeholders to determine interventions that could be used in influencing positive behavioral changes in the selected group. Such developments would have a significant impact on both African American and Latino populations, as well as the rest of American society.

This chapter highlights the research methods that will be used in the study to collect and analyze data from respondents. In doing so, the chapter discusses the rationale for choosing a quantitative approach, including the benefits of such methods. The section also provides information about how other research techniques would not be ideal for the study. Equally important, this chapter provides an overview of the study’s sample, including considerations that the researcher will consider ensuring that the sample’s size and constitution addresses the project’s research questions. The paper also discusses issues concerning generalizability and how the researcher will ensure that the study’s results can be generalized for the target population. A section of this chapter accentuates how the researcher will use quantitative questionnaires as an instrument in collecting the project’s data, along with how the information will be analyzed with the aim of drawing conclusions.

Research Methodology and Design

The study will utilize a descriptive quantitative approach in determining the health behaviors of middle-class citizens from African American and Latino communities. Quantitative research offers significant benefits, including the ability of the researcher to obtain accurate results from a large sample and to generalize the project’s findings (Webster, DeWall, & Smith, 2015). In this regard, the study will focus on two communities that constitute a substantial percentage of the country’s population. quantitative approach will, therefore, be ideal in allowing the researcher to collect and compile valid, reliable, and generalizable findings. Additionally, quantitative data will help to analyze the responses numerically which will help in creating associations. The provision of quantitative data on ACA will also aid in bringing out the differences between the Latinos and African Americans. As a result, the study will calculate the percentage of the insured and uninsured among the Latinos and African-Americans using the quantitative data in order to understand the relationship between the two. This will also bring out the health differences between the two groups.

Moreover, collection of quantitative data provided the capacity to analyze responses numerically. In essence, numeric data helped in supporting or opposing the hypothesis of this research study by determining whether a relationship exists between preventive care and the healthcare cost of middle-class Latinos and African-Americans residing in Baltimore City, Maryland and enrolled in the ACA. In addition, the numeric data will also assist in determining whether a relationship exists between middle-class Latinos and African-Americans enrolled in ACA regarding the cost of healthcare. Collection of quantitative data offered the ability to determine whether a relationship existed between being insured and skipped care because of high cost of Latinos and African-Americans enrolled in the ACA. As a result, the data collected will assist in understanding the healthcare behaviors of ethnic minorities within the middle class who are provided the healthcare under ACA thereby deepening the understanding of the topic.

Besides, this method would enable the researcher to compare the results obtained from each respondent and to identify patterns in the data. Such advantages are crucial for this kind of study, and they demonstrate that a quantitative approach would be better than a qualitative one.

In addition, a descriptive research design is also appropriate for such a project. This method will allow the researcher to collect feedback from respondents in their natural setting (Landrum & Garza, 2015). The target group will be able to respond directly to questions posed to them by the researcher while in their homes or other places and without any interference from the investigator. Other techniques would have required that the researcher influences at least one of the variables. For example, a correlational research design, such as a case-control study would have involved manipulating some of the project’s variables. The same requirement applies to the experimental research design. A review would not be ideal for this study as it would not generate new insights but rather restrict the researcher to knowledge documented by other scholars. All these considerations underscore why the selected method will help the researcher to conduct the study effectively.

Moreover, the researcher will use quantitative questionnaires to collect data from the sample. Quantitative surveys are highly effective, and many respondents would find the tool relatively easy to use (Webster et al., 2015). The survey method can also be used in collecting data from a large sample without incurring high costs. Such a questionnaire can be placed on an online platform where participants can access it quickly irrespective of their location. The format used in most quantitative surveys tends to be easy to understand, and, as such, respondents are bound to find the tool free of unnecessary complexities. The researcher will maximize these benefits to answer the research questions while ensuring the method has been modified to suit the particulars of the project.

The interactions between the researcher and the study’s participants will take place virtually. Each respondent will be provided with a link that allows them to access a copy of the questionnaire online through Survey Monkey. The platform has been used extensively in contemporary research on account of its ability to ensure that the involvement of participants in a study remains anonymous and confidential (Webster et al., 2015). Potential participants will be recruited to the survey via email. Each of these individuals will receive an invitation to take part in the project. Since the research will involve human subjects, efforts to take into account all the considerations associated with such projects need to be implemented (Fisher, Medaglia, & Jeronimus, 2018). Accordingly, the researcher will ensure that all potential respondents have been informed about their rights before they are allowed to take part in the study.

Upon approval from Northcentral IRB, the researcher will ensure that each invitation sent to a potential respondent includes all the necessary information needed to obtain informed consent. In particular, the message will consist of information about how each respondent would be expected to take part in the project, the study’s objectives, as well as the benefits and risks of participating in the project. The researcher will also inform each potential respondent that their involvement in the study will be confidential. The recipient will then be allowed to provide consent electronically before being directed to an online questionnaire through the Survey Monkey platform. Informed consent is necessary to ensure that all participants understand the benefits and risks of taking part in the study, and they are willing to assume the same (Fisher et al., 2018). Once the participant completes the questionnaire, the report will be sent back to the researcher electronically. A respondent’s participation in the study will, therefore, involve providing informed consent, filling the questionnaire, and sending it back to the researcher for analysis.

After administering the structured questionnaires to the samples, the collected data will be analyzed using the Statistical Package for the Social Sciences () version 24.This technique is ideal for quantitative research, and it allows a researcher to manipulate and gain a deeper understanding of data obtained using a survey. The method enables researchers to analyze large sets of data and thereby identify trends and patterns, in addition to being able to develop predictive models (Watson, 2015). SPSS has also proven to be effective in helping researchers in different disciplines to draw informed conclusions from data. Additionally, the use of SPSS version 24 will help in organizing the collected data into percentages for easier presentation. The technique suits the study, and it will undoubtedly allow the researcher to realize all these objectives.

Population and

The study will rely on a sample made up of middle-class individuals from African American and Latino communities. Both groups are among communities that continue to experience health disparities, in addition to participating less in preventive care practices despite being eligible for benefits provided by the Affordable Care Act () (Boudreau, 2017). In line with a report by Statista (2015), up to 48 percent of African Americans in the US were members of the middle-class segment as of 2015. At the same time, at least 48 percent of Hispanics in the US were middle-class citizens. Such statistics indicate that the number of Americans who risk being unable to benefit from ACA and the country’s healthcare system is significantly high. The study will, therefore, focus on these two groups as they represent a substantial percentage of middle-class minorities in the US.

Potential participants will be recruited to the survey via email. Each of these individuals will receive an invitation to take part in the project. Since the research will involve human subjects, efforts to take into account all the considerations associated with such projects need to be implemented (Fisher, Medaglia, & Jeronimus, 2018). Accordingly, the researcher will ensure that all potential respondents have been informed about their rights before they are allowed to take part in the study.

In this regard, the researcher will ensure that each invitation sent to a potential respondent includes all the necessary information needed to obtain informed consent. In particular, the message will consist of information about how each respondent would be expected to take part in the project, the study’s objectives, as well as the benefits and risks of participating in the project. The researcher will also inform each potential respondent that their involvement in the study will be confidential. The recipient will then be allowed to provide consent electronically before being directed to an online questionnaire through the Survey Monkey platform. Informed consent is necessary to ensure that all participants understand the benefits and risks of taking part in the study, and they are willing to assume the same (Fisher et al., 2018). Once the participant completes the questionnaire, the report will be sent back to the researcher electronically. A respondent’s participation in the study will, therefore, involve providing informed consent, filling the questionnaire, and sending it back to the researcher for analysis.

A power analysis will be essential to determine the effect size of this study population. The key purpose of power analysis is to assist the researcher determine the smallest sample size necessary to detect the effect of a given test at the desired level of significance. Although there are many software for conducting power analysis, here, GPower will be used due to its user-friendly nature. Moreover, it supports many designs including correlations, which is necessary for this . The preferred alpha is 0.05 and power of 0.80 with the expected effect is based on the literature.An a priori analysis using G*Power 3.1 analysis, with a = .05, Power (1 – b) = 0.95, effect size f² = 0.15 requires a minimal sample size of 74.  The sample population was all those individuals who have participated in the Alaska Healthcare Transformation Project between October 2017 and November 2019, currently at 175.

The project’s sample will be drawn from communities in Baltimore, Maryland. The city hosts a significant number of African Americans and Latinos. It is expected that the sample will be obtained using purposive sampling from an initial group of at least 100 individuals, including males and females. Each of the participants will be drawn from a middle-class family, earning between $30,000 and $90,000 annually.

Materials or Instrumentation

The study will involve the use of quantitative questionnaires (Appendix A) as the primary instrument of collecting data. The questionnaire will yield data that is quantitative in nature. It is also highly structured and uses closed ended questions where the respondent will tick either yes or no answer. Additionally, the questionnaire is not designed to offer descriptive answers but rather requires numerical ones for ease of data analysis. Questionnaires have been recommended as efficient tools for collecting research data from as early as the 20^th century (Khaldi, 2017). The instrument is highly effective in the sense that it minimizes the involvement of the researcher in a project while facilitating the collection of data from a large sample. Traditionally, researchers had to present hard copies of questionnaires to respondents. This approach had a significant shortcoming since it would limit the geographic area of a study while also causing the project to incur substantial costs. Advancements in technology have, however, allowed researchers to avoid such inconveniences by using online platforms to share questionnaires with respondents. This study will adopt a similar technique by enabling participants to complete the survey virtually.

In this case, the tool will contain a list of questions that are to be presented to each participant. The questions are aimed at understanding the perceptions and experiences of middle-class citizens from minority communities regarding health behaviors and the cost of healthcare. Human subjects tend to provide useful insights concerning their experiences compared to information that is obtained from other sources (Carlisle, Kimmelman, & MacKinnon, 2015). Some of the questions included in the instrument touch on the respondent’s demographics, including age, gender, and whether the individual has health insurance. Even though the study will be limited to individuals from African American and Latino communities, the feedback obtained through the questionnaire must reflect the specific demographics of each participant. Besides, the decision to ask each respondent if they have health insurance is meant to allow the researcher to determine the percentage of middle-class earners from the two groups who lack such coverage. The questions are, therefore, suited to enable the study to realize its objectives.

Equally important, the participants will be asked to offer their opinions concerning the affordability of healthcare in the United States. In particular, the questionnaire will ask participants if they think the American government has pursued adequate efforts to ensure that all Americans are able to access quality medical care. Additionally, each respondent will be asked what they believe the government should do to make healthcare more accessible and affordable for middle-class earners. The questionnaire will also ask each respondent to state if they think that insurance companies engage in unfair practices to control their expenditures. Other questions to be included in the instrument include those concerned with Medicare and health insurance as part of employee benefits. All these questions are intended to allow respondents to provide adequate feedback about their opinions and experiences.

Both closed-ended and open-ended questions will be included in the questionnaire. However, most of these questions will be closed-ended, and will require the respondent to provide a “Yes” or “No” response. On the other hand, a few of the items will require the participant to furnish a short explanation to augment their answer. Responses to this question will not be limited to “Yes” or “No” options. Besides, the researcher will use the existing questionnaires since it is much easier and less time consuming. Confirmatory factor analysis (CFA) will be used to measure the psychometric properties of the instrument. CFA is an optimal tool for determining the construct validity of a scale and it is applauded for providing stronger evidence than other scale validation tools, particularly for dichotomous scales (Makransky, Lilleholt, &Aaby, 2017).

Operational Definition of Variables

Independent Variable

             The independent variable is healthcare insurance coverage under the ACA. This involves subsidized insurance coverage through federal funded Medicaid, whose intention is to offer health insurance for the poorest and medically vulnerable citizens (Rosenbaum, Rothenberg, Gundalus, & Schmucker, 2017).  Individuals qualifying for Medicare must meet certain requirements. Notably, they must be below 65 years and have low-incomes, up to 138 percent of the federal poverty level. Insurance coverage in this study will be defined by whether an individual is covered by Medicaid, with a yes or no answer. Insurance will be coded as a binary variable equal to 1 if the respondents answer “yes” and 0 if the answer is “no” or the box is left unchecked. Therefore, the level of measure for this variable is numerical.

Dependent Variable

The dependent variable is healthcare behaviors. We will examine the three dependent variables that denote healthcare behaviors. We will examine three measures of health behaviors namely: (1) an indicator for whether the respondent has visited a primary doctor in the past one year; (2) an indicator for whether the respondent has participated in preventive care in the last one years; and (3) an indicator for the participant’s healthcare spending in the last one year. The researcher will create a binary index for these numerical variables, with a value equal to 1 if the individual has visited a primary care doctor, engaged in preventive care, or spent on healthcare in the last one year, and 0 if they have not engaged in any of the three activities in the last year.

Moderating

Demographic variables such as age, ethnicity or race, gender, employment status, and household characteristics will be analyzed for moderating influences on health behaviors. A nominal approach will be used to represent these characteristics.

Study Procedures

A quantitative descriptive design will be used to investigate the perceptions of middle-class Latino and African-Americans enrolled in the ACA regarding their participation in preventive care and the cost of healthcare. Quantitative descriptive designs collect information about variables of interest without interfering with their environment (Drummond & Murphy-Reyes, 2018). It creates snapshots of the variables with the goal to develop theories, identify shortcomings of current practice, rationalize present practice, judge, or investigate what activities practitioners in similar practices are engaged (Drummond & Murphy-Reyes, 2018). By investigating the perceptions of the target population regarding ACA using this researchapproach, this research will reveal the current usefulness of ACA in the population and provide potential recommendations for improvement.

Since data gathering is a crucial element of research, selecting the manner of obtaining data and from whom to acquire this information is important. The target population of this study will be middle class African-American and Latino minorities enrolled in ACA. The sample population will be found using purposive sampling; a nonprobability sampling approach that involves deliberate selection of study participants due to certain characteristics that they possess (Etikan, Musa, Alkassim, 2016). This definition implies that the researcher determines what needs to be known and identifies a set of people who are in a position and willing to provide the required information by virtue of expertise or experience In this study, adult (19-65 years) middle-class Latino and African-American minorities living in various parts of the city of Baltimore, Maryland will be the sample population. Adults older than 65 will be excluded from the study since they do not benefit from ACA. The rationale for choosing Baltimore is due to the prevalence of Latino and African-American populations. will be based on informed consent, which will involve individuals willing to provide information about their experience with ACA. The data will be collected through recruitment email and surveys after receiving IRB approval. An appropriate sample size will be determined using linear multiple regression option (Fixed Model, R^2 deviation from zero), a statistical test method known as the G*Power3.1.9.4.

Data Collection and Analysis

Gathering data is an important aspect of research since the data collected contributes to a better understanding of the phenomena under investigation and theoretical frameworks. In this research, the data collection instrument will be questionnaire surveys. The surveys will be distributed and completed on online avenues such as Survey Monkey. Online questionnaire surveys are inexpensive to administer, involve instantaneous recording of the information, and are easy to modify when necessary (Bhattacherje, 2017). They also assure participants of anonymity and confidentiality.

Data will be analyzed through the Statistical Package for the Social Sciences (SPSS), a comprehensive statistical analysis software that offers advanced statistical tools. Quantitative descriptive analysis tools will be used to analyze the data. Firstly, all data will be classified into several demographic categories including insured status, gender, ethnicity/race, age, employment status, and household characteristics. Descriptive statistics will be applied to provide descriptions of the sample population. This information will be presented in terms of means, modes, range, and standard deviations. Moreover, several inferential statistics will be applied to the data to determine the relationship between ACA and health behaviors, including doctor visits, engagement in preventive care, and costs of healthcare.

Pearson’s correlational coefficient (r) will be measured to determine the strength and direction of the relationship between each of the three variables. Inferential statistics such as Pearson’s correlational coefficient, t-test, and ANOVA will be carried out to test the hypotheses. To determine the moderating effects of moderating characteristics on health behaviors, any differences in doctor visits, engagement in preventive care, and costs of healthcare scores based on gender, ethnicity/race, age, employment status, and household characteristics will be examined using t-tests and analysis of variance to determine the relationship between variables. T-tests and analysis of variance are suitable for testing more than one sample (Sarstedt & Mooi, 2019). All hypotheses will be tested at a minimum of .05 level of significance.

Assumptions

The study makes two main assumptions. The first is that individuals involved in the study have utilized ACA. It is possible that some respondents have not used ACA despite being enrolled due to factors such as good health. Therefore, there responses may not be an accurate representation of the impact of ACA on the health behaviors of users.

Secondly, an assumption regarding the income group of the respondents is made, by classifying them into a broad category without taking into consideration their actual income and other variations. The middle-class is a heterogeneous population in terms of income, with some individual in the upper end of the middle-class category having significantly more income than those in the other extreme. Aaron and Burtless (2016) note that ACA supports income-related subsidies which lower the premiums of certain families. Besides, other factors such as age, gender, and dependents influences the range of premiums paid. It is likely that the perceived impact and satisfaction of ACA may be influenced by premiums paid.

and Delimitations

There are four primary limitations to the study. Firstly, the generalizability of the study will be limited to the context of the respondents. This implies that the results are not generalizable to African-American and Latino populations in other parts of the country since the sample is affected by the context in Baltimore and Maryland. ACA guidelines often vary by state, which leads to different effects. Furthermore, ACA is subject to frequent policy changes regarding factors that may affect its impact on a relatively large population. The researcher will impose several delimitations. Firstly, to enhance generalizability, replication of respondents, which involves adding to the sample size, will be utilized. Replication of participants in quantitative research boosts the statistical power of the sample (Polit & Beck, 2016). It enhances generalization by allowing researchers to find similar outcomes in diverse conditions. The influence of policy changes will be mitigated by studying the sample during a specific period and under the prevailing circumstances.

A second potential limitation is the assumption that the respondents will provide honest responses since the study’s variables are measured by the subject’s perception and not actual behavior. This aspect is referred to as response bias, in which individuals answer survey questionnaires inaccurately or untruthfully. This may affect the outcomes of the study significantly. Furthermore, the survey does not take into consideration the likelihood of varied participant responses based on mediating factors such as level of education and English proficiency. Response biases will be mitigated by assuring the participants of anonymity and confidentiality. The researchers will not ask for any identifying information to further enhance privacy. To reduce varied responses, participant responses will be classified into broad categorizations, which will also make analysis easier. Respondents will also be required to have a working knowledge of English to fill the questionnaires.

Finally, the reliability and validity of the instrument to be used in the research is a major concern, especially the ability to measure what it purports to measure. There are also concerns of temporal validity since ACA is likely to change over time and it may change respondent perceptions over time.

Ethical

Several ethical considerations will be implemented during this research that will occur prior to, during, and after conducting the study. Upon approval from the IRB, the researcher will commence the research process. IRB committees ensure that the research does not harm or exploit the respondents (Creswell & Creswell, 2018). Local approvals will also be sought, such as gatekeeper and other key personnel that may be required for the study. As the study begins, the researchers will contact the participants, inform them about the general purpose of the study and obtain consent. Informed consent ensures that participants agree voluntarily to provisions of the study before providing data (Creswell & Creswell, 2018). Voluntary participation is essential during research and appropriate instructions for withdrawing will be provided should the participants decide not to participate in the study in the course of data collection. The only expected risk of respondent’s participation in the study was minimal loss of time in reading the introduction email and completing the online surveys. Since the risk is minimal, the only measure to mitigate the risk will be to make the introduction emails as brief as possible and straight to the point. The investigators will also respect the cultures and norms of the participants more so in matters pertaining to their health which could compromise on the quality of data. However, this will be mitigated through data protection and ensuring confidentiality.

During the data collection phase in this study, the main ethical issues are creating and maintaining the trust of the participants. . When respondents perceive that their identity remains confidential, they are likely to provide accurate data (Creswell & Creswell, 2018). The issue of privacy will also be extended to the last phase after conducting the study. The participants will be assured that no identifying information will be revealed when reporting, sharing, and storing data. In addition to avoiding any information that might identify the client, participants will also be protected from any unauthorized access of the provided information. Coding will be done where their names will be replaced by specific codes throughout the entire study period. The questionnaires containing the responses will be kept under lock and key to avoid any unauthorized access. Additionally, data will be password protected as a precaution after it has been fed into the computer. Theresearcher will also pledge to provide an accurate account of the information after analysis, regardless of whether it meets their needs. Fraudulent practice in research such as falsifying, suppressing, or inventing data to meet the researcher’s or audiences’ needs is unethical.

Summary

This chapter will begin by providing operational definitions of the study’s variables, including the independent, dependent, and moderating variables. The study procedures will be highlighted briefly such as the research design, target population, sampling approach, sample population, and instrumentation. A description of statistical methods to determine the sample will be provided. Furthermore, an overview of data collection procedures, such as the dissemination of the survey questionnaires will be discussed. Data analysis procedures will be explained in detail. The raw data will be subjected to descriptive statistics to provide descriptions of the study population. Inferential statistics such as Pearson’s correlational coefficient, t-test, and ill be carried out to test the hypotheses.  The main focus of the data analysis is to determine the impact of ACA on the health behaviors of Latino and African-American populations.

This chapter will pave way for the next section, which will comprise of the results of the study. In the following chapter, the results of data analysis will be presented in various forms depending on the type of analysis conducted. The results of data analysis will also provide the outcomes of hypotheses testing, which will determine the direction and strength of the link between variables and, therefore, reject or uphold the hypotheses. The chapter will serve as the basis for the discussion and conclusion sections of the project since they encompass an interpretation of the findings of the study and possible recommendations for policy, practice, ad further . In the next chapter, more details about the data collections, results, research questions/hypothesis, and evaluation of the finding findings will be elaborated.

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Appendix A: Survey Questionnaire

1. Name:

1. Gender:

1. Age:

1. Do you have an insurance coverage?

Yes                                          No

1. Do you think the American government has done enough to provide adequate care for everyone?

Yes                                      No

1. What should the government do to provide access to healthcare for Americans?

1. Do you think insurance companies utilize unfair practices to control spending?

1. Do you believe Medicare for all will solve the healthcare problems in the U.S currently?

1. Should the government order employers to offer healthcare to their employees?

1. Do you think Medicare for All has disadvantaged the middle class in America? If yes, why? If no, why?

1. Do you think the government is doing enough to solve the situation with quality healthcare and the middle class?

1. What should the government do to help the middle class in America afford quality healthcare?

If you know how to perform the power analysis, add to this section. If not, please visit the ASC for assistance on determining the power analysis.

Note: For quantitative studies, a power analysis must be reported to include the parameters (e.g., effect size, alpha, beta, number of groups) that were included, and evidence must be presented that the minimum required sample size will be (proposal) or was (manuscript) reached.

Please add the following below in this section. Take out the information from the Research Meth/Design section and add it in this section.

☐ Describe how the participants will be (proposal) or were (manuscript) recruited (e.g., email lists from professional organizations, flyers) and/or the data will be (proposal) or were (manuscript) obtained (e.g., archived data, public records) with sufficient detail that the study could be replicated.

See below.

Potential participants will be recruited to the survey via email. Each of these individuals will receive an invitation to take part in the project. Since the research will involve human subjects, efforts to take into account all the considerations associated with such projects need to be implemented (Fisher, Medaglia, & Jeronimus, 2018). Accordingly, the researcher will ensure that all potential respondents have been informed about their rights before they are allowed to take part in the study.

In this regard, the researcher will ensure that each invitation sent to a potential respondent includes all the necessary information needed to obtain informed consent. In particular, the message will consist of information about how each respondent would be expected to take part in the project, the study’s objectives, as well as the benefits and risks of participating in the project. The researcher will also inform each potential respondent that their involvement in the study will be confidential. The recipient will then be allowed to provide consent electronically before being directed to an online questionnaire through the Survey Monkey platform. Informed consent is necessary to ensure that all participants understand the benefits and risks of taking part in the study, and they are willing to assume the same (Fisher et al., 2018). Once the participant completes the questionnaire, the report will be sent back to the researcher electronically. A respondent’s participation in the study will, therefore, involve providing informed consent, filling the questionnaire, and sending it back to the researcher for analysis.

Please check on validation and reliability. Is the instrument validated through confirmatory factor analysis? For you would need to base the operational definitions on published research and valid and reliable instruments.

A regression analysis occurred to test for statistical significance between groups on the level of XYZ.  SPSS Statistics computed descriptive statistics, cross tabulation to identify the relationship between variables, and perform appropriate recording actions for the survey data. The descriptive statistics reported were between groups and include the mean, standard deviation, 95% confidence interval and significance level. An ordinal regression analysis was applied to test the null hypothesis that there is no relationship between level of XYZ and XYZ.

Add Your DV and IV

The dependent variable of level of XYZ is an ordinalvariable and was measured by a self-evaluation on a five-point Likert scale of level of XYZ. The independent variable XYZ is anordinal variable: extremely important, very important, somewhat important, not so important, or not at all important.

Good. Now, discuss the measures that were taken to mitigate these limitations.