Accessing primary care following the Affordable Care Act: a qualitative study of low-income women’s experiences in urban California

TL;DR

This study explores how low-income women in urban California experienced accessing primary care after Medicaid expansion under the Affordable Care Act.

Contribution

The study provides a nuanced understanding of primary care access barriers for low-income women post-ACA Medicaid expansion using a qualitative approach.

Findings

Low-income women's access to primary care is shaped by individual, health system, and structural factors.

Levesque’s framework could be improved by including macro-level structural determinants of healthcare access.

Findings highlight the need for multi-level policies to address ongoing access barriers for vulnerable populations.

Abstract

The 2010 Affordable Care Act (ACA) led to Medicaid expansion, which expanded eligibility to low-income individuals below 138% of the federal poverty level in 41 states and Washington, DC. In California, over one-third of state residents are covered by Medicaid (Medi-Cal) insurance. Despite the 2014 Medicaid expansion in California, many individuals remain uninsured. Low-income women, in particular, face significant primary care access challenges due to socioeconomic status, education, and minority/disability status. This qualitative study aimed to explore the experiences of low-income women seeking and accessing primary care services following the ACA’s Medicaid expansion in California in an urban setting.

In-depth, semi-structured interviews were conducted with 18 women in Northern California (2021–2022). Data analysis employed Braun and Clarke’s reflexive thematic analysis using a deductive approach. Levesque’s conceptual framework of access to healthcare guided the coding and interpretation.

The experiences of low-income women with primary care access post Medicaid expansion in an urban California setting were shaped by the complex interplay of individual demand-side factors and health system supply-side factors, and structural determinants. Levesque’s framework highlights how individual factors (self-efficacy, health literacy, social support, and affordable insurance) interact with health system factors (geographic accessibility, availability and accommodation of services, and provider-patient relationships) to shape low-income women’s experiences. However, Levesque’s framework could be strengthened by incorporating macro-level structural factors (socioeconomic, political factors, and health policies) as these profoundly influence healthcare access.

These findings provide a strong foundation for policymakers and practitioners to develop multi-level policies and interventions to address the ongoing barriers that urban low-income women encounter when accessing primary care following the ACA’s Medicaid expansion. These findings are also relevant for other U.S. states and international settings that face similar challenges stemming from healthcare inequalities, including a lack of universal healthcare.

The online version contains supplementary material available at 10.1186/s12913-025-13853-9.

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