Historically, the American healthcare system has often been a target of criticism, since it has not upheld the American belief that “healthcare is a right, not a privilege” [1]. As a result, the Obama administration introduced and enforced the Affordable Care Act (ACA) [2] [3], with the objective of providing access to affordable and high-quality health insurance to every citizen as well as reducing healthcare expenditure by the US government [4].

Currently, each state implements the Act by establishing health insurance exchanges, offering insurance coverage to the uninsured and small businesses [4] [5]. Despite the ACA’s wide implementation, impending challenges exist, such as lack of control on insurance quotes, unexpected expenses (e.g. unnecessary tests), and continuous mark up of premiums [6] [7] [8]. Moreover, citizens also regard the policy as unfair since it provides free healthcare for poor individuals by taxing the upper class [9]. Consumers are not the only stakeholders that the policy impacts, physicians and healthcare providers have experienced financial and bureaucratic pressures due to the implementation of the ACA [10].

In March 2017, in order to repeal and replace the ACA, President Donald Trump introduced his own healthcare reform plan—known as the American Healthcare Act (AHCA), or “Trumpcare”. Surprisingly, major healthcare organizations such as the American Medical Association, American Academy of Family Physicians, and the American Academy of Pediatrics have voiced concerns and lobbied against this GOP bill [11]. Two months later, the House of Representatives passed the bill [12]. This decision generated widespread backlash on social media and protests across the country [13].

There are mixed public opinions toward the AHCA. Few believe it is a better version of the ACA, while others think it helps widen the social gap between the upper and the lower classes [9] [11]. In particular, old, poor, rural, and chronically sick consumers are believed to be hurt the most under the AHCA, while young, rich, and urban consumers stand to benefit the most [14]. Some consumers and healthcare providers with neutral opinions worry about the uncertainties regarding the future of the healthcare industry [15].

The bottom line is that Americans are ambivalent with the implementation of both the AHCA and the ACA [16] [17]. Though many people show concerns, they want to keep the ACA, instead of repealing and replacing it with the AHCA [18] [19] [20]. Given the background, we are especially interested in exploring Hispanic consumers’ perception of the ACA because the Hispanic population of the United States, as of July 1, 2017, was the largest ethnic or racial minority, constituting 18.1 percent of the nation’s total population (58.9 million) [21].

Despite Hispanic Americans being the largest minority ethnic group in the United States, there is a dearth of research that examines their experiences with the ACA and their adaptation process to changes in the American healthcare system. Therefore, the purpose of this paper is to explore consumers’ experiences with the ACA in USA, by reviewing inter-disciplinary literature stemming from services marketing, healthcare marketing, and public policy. Moreover, this research paper also shows how the Hispanic consumers along the border of USA adapt with the healthcare services of the United States and Mexico.

Among the one million residents in Hidalgo County, 33% are under 65 years of age and lack health insurance [22] [23]. Diabetes rate is especially high in this area, where one in four residents suffers from it [24]. Additionally, Hidalgo County is one of the largest urban areas without a public hospital and it is located along the border of the United States and Mexico. Therefore, the current local healthcare providers lack sufficient facilities to meet the local demand [25]. Consequently, the lack of availability of clinical care specialties in the Rio Grande Valley forces patients in the area to travel to different cities of the United States or of neighboring Mexico.

Through narratives attained from in-depth interviews [26], this research allows further deconstruction of micro-stories and uncovers the grand narrative among Hispanic health care consumers in South Texas. In the following parts, the literature review, methodology, findings, theoretical and managerial implications are described in detail.

The study of services marketing began with the realization that consumers view products and services differently. This stream of research resulted in the expanded 7Ps of marketing [27] and the SERVQUAL scale [28], among many other contributions. Transformative service research emerges from the services marketing research steam and focuses on consumers’ well-being through services [29]. Aside from financial outcomes of service [30] [31], research priorities in services marketing now include issues such as consumer union [32], quality of life, social justice [33] [34], and sustainability [35]. Extant literature emphasizes the role of healthcare and health insurance as products and services that enhance quality of life for consumers, in particular low-income consumers [36].

According to [37], healthcare services are highly complex and directly affect quality of life. Hence, this subject requires specific research attention [38]. In terms of the four characteristics of service (e.g. intangibility, high levels of credence qualities, inseparability, and heterogeneity), healthcare sector also shares the attribute of services marketing [37]. To be specific, the core benefits of healthcare are largely intangible; for example, medical diagnoses, treatment, and patient education [37]. Additionally, healthcare services are inseparable since they require patients to be physically present in order to consume the service, and they are perishable as they are created through staff resources and expertise [37]. The rapid introduction of technology (e.g. remote robotic control and tele-health) in the healthcare services [39] [40] makes the healthcare services as high credence based services because they are complex to evaluate even after consumption [37]. However, healthcare services are also unique in several aspects. For example, whereas customers may be willing participants in a service transaction, patients are often sick and under stress, and they may not necessarily enjoy a hospital environment where the treatment they receive triggers pain. Additionally, healthcare services require patients to reveal physical or emotional private matters, which oftentimes are considered as sensitive information. Lastly, healthcare providers also undergo heightened stress, as the outcome of their service may be life or death [37].

Though healthcare services are often regarded as a unique type of service, extant research shows the application of the 4Ps as a successful marketing tool in this context [38]. [38] uses a hospital’s pricing strategy of their heart check-ups to illustrate the use of the price element. The example of an international pharmaceutical manufacturer investing promotional dollars to educate neurologists on a new migraine medication illustrates the use of the element of promotion [38]. Finally, [38] argues that hospitals make use of place and location as a competitive advantage over other hospitals that may offer similar services.

Aside from the regular 4P’s, [27] argue that 3 additional P’s should be added when marketing services: people, physical evidence, and processes. These are all part of healthcare services in the form of doctors, nurses, and additional staff (people); medical equipment, recovery rooms, and staff uniforms (physical evidence); procedures used to deliver the service (processes). This last P in healthcare has recently undergone changes with the introduction of health information technology (IT) in order to improve communication processes [41], though it has encountered some resistance [42]. In order to repel this resistance, the government in 2009 introduced the Health Information Technology for Economic and Clinical Health (HITECH) Act [43].

Many Americans are dissatisfied with current healthcare policy in the US [44] [45]. A salient complaint is that private agencies with profit driven goals govern many existing healthcare services, resulting in high cost for the consumer and inefficient or discriminatory policies [46] [47]. Many cannot afford insurance [46] and others lose coverage when laid off or when changing jobs [48]. Popular media reports lack coverage as a contributing factor to the thousands of deaths that happen in America every year [49].

Furthermore, data collected from studies conducted since 2007 suggests that policies that aim to reduce coverage significantly harm the health of individuals with chronic conditions and lower incomes [50]. [50] suggest that the Medicaid expansion driven by the ACA has led to more resources dedicated to healthcare, which enhanced mental health and well-being, however these benefits come at a societal cost.

Policy makers are introduced the ACA with the goal of providing more Americans access to affordable and high-quality health insurance, while reducing healthcare spending in the US. The ACA is a healthcare plan for America, signed by President Obama on March 23, 2010; the Supreme Court upheld it on June 28, 2012 in order to expand the affordability, quality, and availability of private and public health insurance. Aiming to minimize the number of uninsured Americans and make healthcare more accessible and affordable, this act advocates—“Access to healthcare is a human right”. In this regard, the Congressional Budget Office expects that about 94% of Americans will access the healthcare coverage available while staying within the budget of $900 billion and reducing the deficit over the next 10 years [51]. Currently, approximately 20 million Americans remain insured under the ACA [52].

In the short term, states within the US will take the main responsibility of establishing health insurance exchanges by regulating marketplaces so that the uninsured and businesses have insurance coverage [52]. The ACA requires all large businesses (50 employees or more) to insure employers, and grants tax breaks to small business (less than 50 employees) that do [53]. Eleven states and the District of Columbia currently operate their own exchanges; five states run their own exchanges using a federally supported website, while the rest of the exchanges function as a state/federal partnership at different levels [54]. Although such political developments may indicate that American society embraces the ACA, consumers have also voiced negative opinions against it for not having a well-defined population of beneficiaries and for its diffusing benefits [55] [56] [57]. Some argue that the ACA is unsuccessful in filling the gaps in contemporary insurance consumer needs [58]. Critics argue that the ACA treats different groups of Americans in different ways at different times [59]. Critics suggest that government efforts to explain the law, promoting the enrollment of eligible populations into new benefits, and mobilizing public support will be a lost effort [60]. The long-term challenges faced by ACA have mainly been cost reduction and increase in quality; however, research suggests that both of these goals have been arguable achievements for the ACA [61].

Though public opinion regarding the ACA has been divided since the beginning, a recent Kaiser Family Foundation poll finds that 45% of Americans have a negative view of this bill [9]. Citizens are unhappy with the healthcare plan for various reasons, but the main concerns are the breach of citizens’ freedom to choose whether they want to be covered, and the financial burden it imposes on high income earners in the form of taxes needed to subsidize coverage for low income enrollees [9]. Others are also unhappy with the high premiums and deductibles that should be “affordable” [9]. Not only is the ACA receiving backlash from concerned citizens, politicians such as House Speaker Paul Ryan have also voiced their disapproval of the bill [62].

Business owners are also reportedly unhappy with the ACA. A recent survey conducted by BizBuy sell (a marketplace for small businesses) revealed that 60% of 700 small business owners were in favor of repealing the ACA [63]. The rising premiums and high deductibles have become a financial strain and many owners have opted to pay lower premiums at the cost of higher deductibles, which oftentimes results in unpaid bills for healthcare providers [63].

Various media outlets have debated on the advantages and disadvantages of the ACA endlessly, with the topic gaining even more interest in the light of the AHCA. Some evidence the pros while some argue the cons of the healthcare plan. Thus, there is a need for in-depth study on this topic to explore consumers’ experiences with the ACA and how they adapt with the inadequate the healthcare services in the South-Texas of the United States.

We employed an ethnographic approach to make sense of the text [64]. Ethnographic research method has been widely accepted in the marketing literature [65]. Moreover, there has been several critical studies conducted to understand and improve the ethnographic research methodology; For example, [66] and [67] made great effort to further explore this technique. This research method helps to provide very minute details [68]. Researchers can rely on self-report of the informants and observe informants in the natural environment [69]. Among the various ethnographic research methods (e.g. observation, in-depth interview and narrative textual analysis), we choose to use in-depth interview to explore participants’ experiences and emotions regarding healthcare issues. According to [70], the in-depth interview is appropriate to elicit individual experiences, opinions, and emotions for some healthcare issues, especially personal issues around the social status, privacy and other sensitive questions.

Participants were recruited in the Rio Grande Valley (RGV), located in South Texas, where 93.6% of the population is Hispanic [71], most of whom are first or second generation of immigrants. Therefore, RGV culture is a crossroads between American and Mexican cultures.

We employed purposeful sampling and snowballing technique to recruit participants (for both phase 1, and phase 2), and audio recorded all interviews under participants’ consent. Additionally, we recorded mannerisms and body language in the field notes, and transcribed interviews into electronic files for future analyses. Interviews lasted an average of 45 minutes. This study is conducted in two phases. Several in-depth interviews were conducted during two phases at two different points in time—fall of 2014 (10 participants) and summer of 2017 (11 participants), which makes a total number of 21. Despite the small sample size, in-depth interviews are quite effective in uncovering consumer experiences, as the large amount of information provided allows comprehensive deconstruction of meanings.

Initially, we tried to build rapport with the interview participants and gave a brief description about the goals and purpose of the research to the participants, as [72] suggested. Confirmability of this study is ensured through securing records of audio texts, which enables us to go back to the audio and check the information again. The audio interviews are very common form of data collection in marketing research [73]. Triangulation is achieved when the same texts are checked by different authors and found the same meaning. To ensure integrity and anonymity, we did not use original names. The entire dataset describes participants’ opinions and experiences; however, we describe only the macro-narrative found there. Therefore, the study represents only a small portion of participants’ responses. See Table A1 for participants’ demographics.

We analyzed data by integrating interview transcripts and field notes, and employed a process of phenomenological reduction, and narrative analysis based on interview transcripts. The goal of this method is to have an in-depth understanding of the way people create meanings in their lives and the way they make stories to interpret the world [74].

Narrative analysis uses a holistic approach to discourse that preserves context and particularity [64]. Sequence and consequence make texts into narratives; one researcher selects, organizes, connects, and evaluates events as meaningful for particular audiences.

Firstly, we read the transcript in order to obtain an initial understanding of each participant’s experience with healthcare and the ACA. Secondly, we conducted the narrative analysis, and examined the transcripts in terms of what each participant’s experience and consideration with ACA. Through the interview, we found that participants have concerns about healthcare and the ACA.

Based on [75], the analysis includes “what” participants know of the ACA and “how” participants experienced the ACA based on the transcripts. The “what” indicates the features of the ACA and is acquired directly from the interview. The “how” question aims to capture how they perceive the features of the ACA, and it includes the efforts, emotions, and feelings they experience which some of us coded. During this process, we grouped all transcripts based on the content and meaning similarities, then created categories regarding different themes based mostly on the psychology or feelings expressed by participants. There are two different levels of categories: the upper level or more general categories are derived from the research aims, while the lower level or specific categories are usually derived from multiple readings of the raw data [76].

We based participants’ behavior traits on the provided statements, we then extracted each trait by making use of logical interpretations, which will serve as support for recommendations provided later in the manuscript.

Our findings from both phases are consistent with those of [77]. Participants revealed uncertainty arising from situational factors, such as exposure to information piracy or the lack of reliable information. Other participants implicitly suggested that they were actually unaware of the risks and consequences of not having a health insurance plan. Echoing [77] findings, participants declared high dependence on word-of-mouth from trusted sources in their networks, such as family and friends, to make decisions in the healthcare domain. Financial constraints emerged as the main deterrent to obtain health insurance under both the ACA and the AHCA, as participants acknowledge their willingness to pay the penalizing fee for their lack of enrollment instead. Another emergent deterrent was the complicating enrollment procedure. Some participants disclosed their preference for obtaining healthcare in Mexico to avoid such complications and financial burdens.

On the other hand, some participants showed a high level on engagement during the information seeking stage and enrollment process. However, their lack of reliable sources of information paired with a language barrier discouraged them to enroll in the end.

In phase 2, the idea of the AHCA was included in the interviews, together with the ACA. Text generated from phase 2 data collection revealed that negative experiences with the ACA (frustrating application process, and confusion during information seeking stage) negatively affected participants’ attitudes towards the AHCA and their intentions to enroll in the new health insurance policy. Besides, having a positive experience with the ACA may lead consumers to develop negative attitudes towards the AHCA.

Encouragingly, our findings in phase 2 suggest that though Hispanic consumers may perceive several barriers to enroll in health insurance, trusted individuals in their social networks, such as family members, greatly ameliorate this process as they encourage and guide consumers. Moreover, the penalty for not having health insurance pressures consumers to acquire the ACA. Thus, it helps increase the number of people who have some type of health insurance across the US.

Additionally, in phase 2, the attitudes toward the ACA are significantly different between those who possess higher education, are under a family health plan, and have health issues versus those who possess lower education, have no insurance or have individual health plan, and are healthy. Specifically, the early group show strong preferences toward the ACA since it helps them obtain health services and medication they need. They would have to pay much more under other policies. They were also capable of reading the materials related to the ACA and identified the benefits that this healthcare policy could provide. Moreover, the family plan seems much more affordable than the individual plan under the ACA. In other words, the ACA seems to provide more support for families than single consumers.

In contrast, the latter group expressed negative attitudes towards the ACA because they are healthy. Thus, the cost of acquiring health insurance is not justified since they see no need for it. Moreover, they tend to obtain information about the ACA mainly from the media and their close-knit networks which may result in acquiring unreliable information. Thus, they might not understand the costs and benefits that the ACA might present to them.

Based on our findings, we concur with recommendations made by [77]. Additionally, strengthening reliable communications by including health insurance education in school is a proactive strategic implementation. Though education does not tackle all of the barriers present in health insurance enrollment, it does mitigate the uncertainty that consumers may face due to lack of information about the topic.

Overall, the findings at current stages seem to indicate some potential gaps: 1) a need for specific marketing concepts in healthcare insurance context, and 2) how the ACA reflects the transformative services marketing direction initiated by [29]. This work also provides preliminary data regarding consumers’ cognitive (awareness, discouragement, neglect), andaffective (fear, insecurity) reactions to the ACA and the AHCA, as well as theircoping strategies when unable to enroll in health insurance (i.e. seeking access to alternative healthcare services). Finally, findings are limited to specific consumer experiences as evidenced by results of Phases 1 and 2, thus, may not have captured an exhaustive array of experiences (if any) of how other customers experience the ACA.

Their high dependence on trusted relationships caused two major issues for Hispanic consumers in their quest to obtain health insurance, specifically: 1) lack of awareness of the policies available, and 2) lack of reliable sources of information. As evidenced in our interviews, some consumers were interested in enrolling or even learning about health insurance policies simply because trusted family and friends did not have health insurance or were not interested in enrolling either. Even in cases when consumers were proactively seeking out information, they abandoned their efforts if they encountered difficulties with the application process and no one was around to guide them through it. When consumers actually had someone willing to instruct them, they were successful in their enrollment as exemplified by Ana’s interview where the neighbor helped her and her mom. On a more positive note, addressing this dependence properly could provide a means for a more effective communication between policy makers and consumers.

Moreover, marketers should spend more efforts to alleviate the language barrier experienced by Hispanic consumers. Making sure that Spanish speakers are available when policy makers target the Hispanic community will ensure that communication will flow smoothly between consumers and service provides increasing the probability of enrollment. Moreover, this could increase awareness among Hispanics regarding the risks of not having health insurance and the benefits of the same.

Another issue that came to the fore from our interviews relates to the proactivity with which Hispanic consumers searched for information regarding health insurance. The data revealed a tendency from Hispanic consumers to rely on others to provide them with such information, meaning that public healthcare workers were only able to help those who actively reached out for their assistance. A potential solution would be to educate consumers about healthcare and health insurance in high school, this would ensure that consumers would at least have the basic information to be able to reach out and continue on the information seeking stage on their own should they need to. These same consumers could then act as trusted informants for family and friends by providing information through word-of-mouth, thus increasing awareness of health insurance among their social networks.

Based on our findings, policy makers should also simplify enrollment process, as this was a major deterrent for consumers who were willing to obtain health insurance. Several respondents, such as Marcos, expressed feeling frustrated with the enrollment process which led them to quit their quest for health insurance altogether. Simplifying enrollment process would encourage more consumers to apply without having to seek external support.

Finally, it became evident that the cost of health insurance was in itself an influential barrier of enrollment to respondents. Though our participants reported a low annual income, they were willing to incur the costs of crossing the border to obtain medical care since enrolling in health insurance in the US is a more expensive option for them. Policy makers should consider areas around the border where consumers prefer to travel to Mexico than enroll in health insurance when calculating premium prices, this would make health insurance in the US a more attractive option compared to crossing the border.

First, readers should interpret current findings with caution due to small sample size. This factor limits us in depicting the bigger picture of the subject matter. Future research should attempt to design a survey-based study with an acceptable sample size to test and achieve generalizability of experiences. Second, these findings are context dependent to Hispanic consumers in the RGV and thus cannot echo experiences by other minority groups. Having said this, our findings are transferrable to other similar contexts (i.e. low-income areas with a large portion of Hispanic population). Future research could focus on examining experiences of different ethnicities of consumers to achieve an exhaustive understanding of consumer experiences with the ACA and the AHCA.

The authors declare no conflicts of interest regarding the publication of this paper.

Hossain, T., Hoang, M. and Nguyen, S. (2019) A Qualitative Study of Consumers’ Perceptions of the Affordable Care Act. Theoretical Economics Letters, 9, 1569-1593. https://doi.org/10.4236/tel.2019.95101