Introduction

Health insurance enhances access to health care and enables people of all ages to live longer and healthier lives [1,2,3]. The Patient Protection and Affordable Care Act (ACA) was signed into law in 2010. Since then, approximately 20 million Americans have gained health insurance coverage and the national uninsured rate has decreased by 43% (from 16.0% in 2010 to 8.6% in 2016) [4].

Many individuals who remain uninsured rely upon free clinics to fulfill their health care needs [4, 5]. There are approximately 1200 free clinics in operation throughout the United States, which offer medical services to 1.8 million under- or uninsured people [5]. Free clinics commonly rely on volunteer health care professionals and have limited financial resources to help individuals apply for health insurance [5, 6].

With the passage and implementation of the ACA, the number of patients seeking care at free clinics was expected to decrease as more patients gained insurance through both the private insurance market and Medicaid expansion. However, 14.6 million uninsured individuals who were eligible to enroll in Medicaid or private insurance via the ACA online marketplace have not gained insurance [7]. The majority of these individuals are people of color from low-income families [8]. In 2017, three-quarters of uninsured families had a least one full time worker and 45% reported that cost was the major reason for not obtaining insurance [8]. Cost, as well as perceived ineligibility, has been the major concern of uninsured free clinic patients from states that both expanded and opted out of Medicaid expansion through the ACA [9,10,11].

Pennsylvania initially opted out of full Medicaid expansion via implementation of a Section 1115 Medicaid Waiver in August of 2014, but transitioned to full Medicaid expansion in September 2015 with the election of a new governor [12]. The uninsured rate in Pennsylvania was 12.1% in 2010 (1.25 million people) and has since decreased to 6.8% (691,654 people) in 2016 [13].

Little is known about what free clinic attendees in Pennsylvania know about health insurance expansion or what they perceive as barriers in enrolling in health insurance. Regional and state variations in knowledge and barriers may exist, especially for patients in a state that followed an atypical path to Medicaid expansion since the ACA became law. Thus, the objective of this study was to determine the perceptions and experiences of free-clinic patients in southwestern Pennsylvania in seeking and applying for health insurance after the passage of the ACA.

Materials and Methods

We designed and implemented a survey of patients receiving care at three free clinics located within Allegheny County, Pennsylvania from September 2016 to February 2017. This study was reviewed and approved by the University of Pittsburgh Institutional Review Board, which operates out of the Human Research Protection Office (Protocol # PRO16080035, Title: The decline of patient encounters in free clinics after Medicaid expansion and barriers the uninsured face to apply for health insurance in Allegheny County, PA).

Study Population

Allegheny County, Pennsylvania has a diverse population of over 1.2 million individuals and contains the city of Pittsburgh, the second largest city in Pennsylvania [14]. We evaluated the following three free clinics within Allegheny County: (1) the McKeesport 9th Street Free Clinic, (2) the Birmingham Free Clinic, and (3) the Braddock Free Clinic. The McKeesport 9th Street Free Clinic was founded in 2007, operates 1 day a week, and accommodates 1400 patient visits annually. The Birmingham Free Clinic was founded in 1994, is open 6 days a week, and accommodates 2000 patient visits annually. The Braddock Free Clinic was founded in 2011, is open on weekends, and accommodates 500 patient visits annually.

Survey Design

We constructed a 22-item questionnaire, which included 7 questions focused on sociodemographic characteristics and 15 questions regarding the patient’s health status and their perceptions regarding obtaining health insurance. As no well-established survey instrument on this topic exists, our survey was informed by indicators used in prior studies [11, 15] and developed in conjunction with local experts to ensure adequate face and content validity. Specifically, we obtained feedback from administrators, nurses, physicians, and pharmacists from each clinic site to ensure that the survey addressed factors that they felt were important to their patients (see “Appendix 1” for full survey instrument). The survey addressed five domains regarding barriers in obtaining health insurance: lack of knowledge, cost of health insurance, lack of resources, difficulties in providing required enrollment documentation, and lack of trust in the application process.

Survey Implementation

We administered our survey as a one-time, anonymous, written questionnaire to patients 18 years and older at all three clinics. We obtained verbal informed consent during check in at the free clinic sites and provided patients with written information about the survey and purpose of the research. Interested patients completed the survey in the waiting room prior to their visit. Any questions were answered by the clinic administrator or research staff present at the clinic. For Spanish-speaking patients with limited English proficiency, we used a recruitment script and survey translated to Spanish. Spanish interpreters were on site and available as needed. Individuals who were younger than age 18 or who spoke a language other than English or Spanish were excluded from our study population.

Data Analysis

We used descriptive statistics to characterize the cohort’s sociodemographic characteristics, including number and percent for categorical variables. Microsoft Excel 2016 was used to calculate the overall frequency of each response among the overall cohort, and among those respondents familiar with the ACA, when appropriate.

Results

A total of 203 respondents completed the survey, 110 (54.2%) were men, 99 (48.8%) were African-American, 6 (3%) identified as Hispanic, and 184 (90.6%) were US citizens (Table 1). Overall, 48 respondents (23.6%) reported no income at the time of the survey. For those that did report an income, 92 respondents (45.3%) reported an income below $1293 per month (133% of the federal poverty level for a single household in 2015). Most respondents (n = 133, 65.5%) rented or owned their own house, and 11 (5.4%) identified as homeless.

Table 1 Sample characteristics of participants receiving care at free clinics within Allegheny County, Pennsylvania
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Health and Health Insurance Characteristics

The majority (n = 171, 84.2%) of respondents reported having no health insurance (Table 2). The primary source of health care for most respondents was free clinics (n = 118, 58.1%), followed by the emergency department (n = 36, 17.7%). Respondents rated their health as excellent (n = 5, 2.5%), very good (n = 35, 17.2%), good (n = 95, 46.8%), fair (n = 50, 24.6%), poor (n = 10, 4.9%), and very poor (n = 5, 2.5%).

Table 2 Survey responses from participants regarding health characteristics and insurance
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Perspectives on the Affordable Care Act

Of the overall cohort (n = 203), 36 respondents (17.7%) were unaware of the ACA (Table 2). Among the 164 respondents who did have knowledge of the ACA, 56.1% reported that television was their most common source of information. Only 72 respondents (35.5%) had attempted to sign up for health insurance through the ACA, and among those who tried, 12 respondents (16.7%) were successful. Among respondents in the overall cohort, 83 (40.9%) were not interested in applying for health insurance through the ACA. Regarding Medicaid eligibility, almost half of the survey respondents (n = 99, 48.7%) did not know if they qualified for Medicaid, 136 (67%) were not aware of any local agencies in their communities that could assist in applying for Medicaid, and 154 (75.9%) had not been referred to specific organizations for health insurance navigation. Among those who had been referred, 14 (63.6%) were not satisfied with the service provided by that specific organization.

Barriers Faced in Applying for Health Insurance

Lack of knowledge and understanding of health insurance (n = 127, 62.6%) was the main barrier to obtaining health insurance (Table 3). Among respondents, 60 (29.6%) reported that not knowing whether they qualified for Medicaid was a barrier to enrollment and 44 (21.7%) reported that not understanding the application process was a barrier. The perceived cost of health insurance was a barrier for 85 (41.9%) of the respondents. Lack of resources to complete the application was a barrier for 83 (40.8%) of respondents, many of whom did not have access to a computer (n = 30, 14.8%), the internet (n = 22, 10.8%), transportation (n = 9, 4.4%), or a telephone (n = 7, 3.4%) to sign up for insurance. Having required documentation such as a mailing address, form of identification, or income documentation was a barrier for 43 (21.2%) of participants. Lack of trust regarding the application process was a barrier for 28 (13.8%) of respondents. Only 5 (2.5%) respondents indicated that immigration issues prevented them from applying, but only 6 respondents (3%) identified as Hispanic.

Table 3 Survey responses for participants regarding barriers faced when applying for health insurance
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Discussion

In this study, we identified patients’ key perceptions and beliefs in seeking and applying for health insurance, including several common barriers in obtaining health insurance coverage, such as lack of knowledge of Medicaid eligibility, understanding of how to apply for health insurance, resources or documentation required to complete the application, and cost of health insurance. We found that a significant number of our survey respondents who received health care at free clinics in Allegheny County, Pennsylvania had no health insurance; however, most were Medicaid eligible. While the majority of patients were aware of the ACA, a significant minority remained unaware of the law despite broad public discussion. Among those who were aware, over half of the participants were not interested in applying for health insurance through the ACA.

Lack of knowledge and resources to apply for health insurance were the two key barriers identified among our study participants. Similar to our study, lack of knowledge was a key barrier among uninsured free clinic patients in Utah; a state that, unlike Pennsylvania, did not expanded Medicaid [10]. Consistent with prior studies, our study also found that cost was a prominent barrier among free clinic patients when applying for health insurance [7,8,9,10,11, 16, 17]. A study of free clinic utilizers in Michigan, a state that also expanded Medicaid through a Section 1115 Waiver, found cost to be the single most important barrier to health insurance, followed by lack of employer sponsored health insurance [11]. In contrast, the major barrier for free clinic utilizers in New York, a state that expanded Medicaid at the initiation of the ACA, was undocumented immigration status, though cost of insurance premiums was the second most cited barrier [9]. Over half of our participants reported not being interested in applying for health insurance. Similar trends have been reported in prior studies [9,10,11], where individuals reported preferring to access healthcare at emergency departments and free clinics, and personal beliefs against applying for public insurance. As these studies illustrate, there is great diversity among individuals and across geographic regions in the U.S. for why people do not enroll in health insurance.

Our study and others [10, 11] suggest that the status quo approach for enrolling free-clinic patients in public or private health insurance does not align with the needs of this patient population. Specifically, the free clinics involved in this study had limited success in referring patients to apply for insurance. Of those who were referred for assistance, the majority did not find the organization helpful. Potential barriers to referral include lack of trust in the health insurance navigator or lack of clarity on what a health navigator is or how they can be helpful. The lack of knowledge regarding Medicaid eligibility and the health insurance application process among our participants suggests that a more personalized approach to health insurance referral is necessary [9, 10, 18]. Since the passage of the ACA, many free clinics have made a concerted effort to help patients apply for health insurance and medical assistance, but the nature of that support is key. The free clinics in our study hold partnerships with local healthcare navigation organizations but the referral process appears to be suboptimal. Given the decreased funding for healthcare navigation organizations nationally [19], free clinics can play an even more important role in filling this gap by incorporating education about health insurance as well as further information about application processes [20]. The majority of our respondents also indicated that they lacked resources to apply for health insurance, including inability to access a computer, internet, phone or transportation. [9, 20]. Addressing access to online applications and transportation to referral centers may further assist patients if integrated into the standard referral and assistance process.

Since our study concluded in early 2017, significant changes have been made in the implementation of the ACA, including legislation that removed the individual mandate for health insurance as well as a more recent call for imposing work requirements on Medicaid beneficiaries [21]. These changes are likely to create even more barriers and confusion for free-clinic utilizers. It is yet uncertain how much further the ACA will be modified, or if, with the upcoming election, new single-payer legislation such as “Medicare for All” or a “Public Insurance Option” may be introduced at a national level. Our study highlights that even if a public insurance option exists, where patients can opt in for coverage and cost was no longer a consideration, major barriers to enrollment such as lack of knowledge and understanding of health insurance and lack of resources will remain. Our findings, in conjunction with those studies conducted in Utah, Michigan, and New York, also demonstrate that a local approach that addresses the unique regional barriers to insurance enrollment will be essential to reach a state of universal coverage [9,10,11].

This study has important limitations. Our sample size was not large enough to explore whether documentation status or English fluency was a barrier faced by non-US citizens, or to explore racial differences between responders. The number of Hispanic respondents to our survey was lower than the Hispanic population known to attend these clinics and their viewpoints are likely underrepresented in this study. Patients with limited literacy might also be underrepresented in this study. We surveyed only individuals visiting free clinics in southwestern Pennsylvania; their knowledge and perception about health insurance may be different from those who do not use free clinics for health care needs or who come from different geographic regions. We did not explore reasons why uninsured patients visiting free clinics were not referred to health care navigators. Though three-fourths of our sample reported living at or below 133% of the poverty level, we did not verify which patients were eligible for expanded coverage or subsidies through the ACA expansion and we cannot assume that all individuals who seek care at free clinics are eligible for expanded coverage under the ACA.

We have identified perceptions of and barriers faced by free clinic attendees in southwestern Pennsylvania in obtaining health insurance through mechanisms available via the ACA. Our findings demonstrate that a personalized approach may be needed to better educate patients about their eligibility and options for the health insurance as well as providing important resources such as access to online applications and transportation to referral centers to ease the application process. Nevertheless, free clinics are an important source of health care for uninsured people, and can play a key role in eliminating these barriers to health insurance enrollment.