Abstract
The changing landscape of health care as a result of the Patient Protection and Affordable Care Act (ACA) may provide new opportunities for health education specialists (HES). The purpose of this study was to survey HES in the United States on their knowledge and attitudes of the ACA and assess their perceptions of job growth under the law. A random sample of 220 (36% response rate) certified HES completed a 53-item cross sectional survey administered online through Qualtrics. Findings were compared to public opinion on health care reform. HES are highly favorable of the law (70%) compared to the general public (23%). A total of 85% of respondents were able to list a provision of the ACA, and most (81%) thought the ACA would be successful at increasing insured Americans. Over half (64.6%) believe job opportunities will increase. Those who viewed the law favorably were significantly more likely to score better on a knowledge scale related to the ACA. HES understand publicized provisions but are uncertain about common myths and specific provisions related to Title IV, “Prevention of Chronic Disease and Improving Public Health.” Directed and continuing education to HES regarding the ACA is warranted.
The Patient Protection and Affordable Care Act (ACA), passed in 2010, is designed to address what has been coined the “triple aim” (1) improve the quality of health care, (2) improve the health of the population, and (3) reduce the cost of health care. Strategies to achieve the triple aim focus on (1) insurance reform strategies to expand health insurance coverage and (2) health care system reform to improve the quality of health care, build a stronger health care workforce, and give greater attention to prevention and public health. In addition, the Institute for Healthcare Improvement (2015) advocates a systematic approach to addressing the triple aim. This approach includes the identification of target populations, definition of system goals and measures, development of strategies that can move system-level results, and expeditious evaluation and scale-up that are adapted to the local level (Institute for Healthcare Improvement, 2015). Health education specialists (HES) represent an important health profession that can contribute to the achievement of the triple aim because their background and training overlaps with this systematic approach.
HES practice in a variety of settings including, but not limited to, governmental public health, health care, nonprofit organizations, corporations, and academia. According to the U.S. Department of Labor Bureau of Labor Statistics, 47% of health educators work in health care and social assistance settings with an average annual wage of nearly $60,000 (Bureau of Labor Statistics, 2011). While their roles vary based on practice setting, those certified by the National Commission for Health Education Credentialing (NCHEC; 2013) possess prevention oriented skills in seven areas of responsibility including health assessment, program planning, program implementation, evaluation, administration, and communicating health education.
The changing landscape of health care, as a result of quality improvement efforts and changing reimbursement structures associated with the ACA, provides emerging opportunities for HES to serve as care coordinators and patient navigators in health care settings. These structures include the episode-of-care model, bundled payments, and Accountable Care Organizations (ACOs), each of which transitions health care further away from the traditional fee-for-service reimbursement model. In essence, these models designate a portion of provider payment based on the quality of health care, not the amount of health care given. Providers are therefore compensated based on the outcome of their service (health indicators), rather than the number of tests and procedures conducted (Mechanic, 2011). These models incentivize providers to keep patients well and treat underlying causes, rather than symptoms. Wellness and prevention are within the scope of practice of the HES.
To best strategize, adapt to, and participate in emerging health care reform efforts, HES need to understand and be actively involved in redesigning the new environment to promote prevention and health education. An important way for the profession to be involved is through thoughtful engagement with health care systems and policy makers. With “the ACA . . . transform[ing] the nation’s public and private healthcare system into public health delivery vehicles” (Cogan, 2011, p. 361), health education organizations recognize the potential opportunities for HES (Goodman et al., 2013). Yet to date no identified study has broadly explored the knowledge and attitudes of HES with regard to the ACA, though there has been research conducted on the perceptions of other affected professions such as medical students and physicians (Huebner et al., 2006; Huntoon et al., 2011).
The purpose of this study is to survey HES in the United States on their knowledge and attitudes of the ACA and assess their perceptions of job growth under the law. This will add to the body of literature and provide a baseline measurement, which will be useful as national public health and related organizations determine how to best educate members and partner with the health care industry.
Method
The study used a concurrent triangulation mixed-methods design where quantitative and qualitative data were collected simultaneously through the administration of an online survey to HES. This design was used so that findings from both methods might be validated and corroborated. Preferred sample size was based on estimating proportions with 95% confidence and assuming a fixed population of 10,000 NCHEC-registered HES. A target sample size of 370 responses was identified. Anticipating a 60% response rate, a total of 607 U.S.-based NCHEC-certified HES with certified health education specialist (CHES) or master-certified health education specialist (MCHES) certifi-cation were selected from an NCHEC membership database of 9,850 using systematic sampling with a random start point. Individuals in the database who did not have an e-mail address, did not have a complete postal address, or lived outside the United States were excluded prior to sample selection (n = 130). The selected sample (n = 607) was e-mailed an invitation to participate in the study inclusive of the Qualtrics online link to the survey. A reminder e-mail was sent 15 days after the initial survey, followed by a postal letter with a $1 bill to nonrespondents to encourage participation (Dillman, Smyth, & Christian, 2009). After the letter, two additional e-mail reminders were sent 12 days apart to nonparticipants. The incentive and reminder e-mails did help increase the response so that during the 7 weeks the survey was open, 343 individuals (56.7%) began the survey. To be eligible for inclusion in the analysis survey responders must (1) have heard or read about the ACA and (2) be currently employed either full- or part-time in public health or health promotion and education. A total of 98 responders were excluded based on these criteria. An additional 25 responders skipped more than five survey questions and were also excluded from the analysis. The final sample consisted of 220 persons (36.2% of those invited to participate; see Figure 1).
Sample Eligibility Criteria
Instrumentation and Measures
A survey instrument was created consisting of 53 questions; 26 questions were developed by the lead author, 19 questions were derived from the Kaiser Family Foundation (2013; 14 related to knowledge and 5 related to attitude), and 8 demographic questions were derived from Dillman et al. (2009). The Kaiser Family Foundation conducts a monthly public opinion poll on health care reform. Where applicable, questions were identically phrased to existing questions used by the Kaiser Family Foundation for comparison of HES’ responses to those of the general public. Questions were derived from the most recently available surveys for general public responses. Aggregate data for each question was accessed on their findings during September 2013 (Kaiser Family Foundation, 2013).
The instrument was divided into three broad sections measuring knowledge, attitudes and perceived implications, and demographics. Knowledge questions comprised the respondent’s general familiarity with the law, implementation time line, and ability to accurately identify general and Title IV provisions. Attitude questions included respondents’ favorability of the law and perceptions of how successful the ACA will be at increasing the number of insured individuals, improving health care quality, and decreasing cost; the likelihood of job growth for HES within various sectors; and changes to how they perform their job. Demographic variables included sex, age, race, income, education level, and political views. Responses from the Title IV provisions were compared to the subtitles and sections within Title IV to determine accuracy (U.S. Department of Health & Human Services, 2014).
The instrument was pilot tested in January 2013 among HES in Utah, involving 36 responses. Content validity of the instrument was established through two subject matter experts. After the pilot test, questions were aligned to match the Kaiser Family Foundation questions for comparison to the general public.
A scale was created to measures HES’ knowledge about the ACA based on 12 questions regarding current and future provisions of the law (eight items represented accurate provisions and four items represented common myths that are not included in the law). Each question was coded with 1 if correct and 0 if incorrect/don’t know. Scale items were summed to create the overall knowledge score with a theoretical range of 0 to 12, where higher scores represented more correct answers. Responses of “don’t know” were coded with the incorrect answer as it was determined that if the respondent could not confidently identify the correct answer they were more similar to those who answered incorrectly. A univariate analysis was run, and the scale had a normal distribution.
Analysis
Frequencies and proportions were calculated for knowledge, attitude, and demographic questions. Analyses of variance using the knowledge scale as the dependent variable were conducted to examine how knowledge was distributed across levels of attitudes toward the ACA and several demographic factors (independent variables).
There were two qualitative questions with open text box responses. The questions were, “There are many provisions of the ACA that have already been implemented. As best you can recall, list or briefly describe two of them,” and “There are several major provisions in the ACA that address prevention in Title IV. To the best of your knowledge, list or briefly describe up to three of them.” All responses were reviewed, categorized for accuracy, and then grouped based on the most common responses.
Results
The final sample of 220 was mostly female (88.2%), Caucasian (66.4%), and CHES (85.9%) rather than master-certified health education specialist (14.1%). Most respondents held a master’s degree (63.2%). The age of respondents ranged from 22 to 71 years with a median age of 37.5 years. Respondents worked in a variety of settings such as government (20.0%), hospital/health care (17.2%), nongovernmental organization/nonprofit (18.7%), business/corporation (13.6%), and academia (23.2%). All states were represented, except Montana, New Hampshire, and South Dakota. States with the highest representation were California (10.2%), Texas (8.8%), and Georgia (6.5%). With the exception of a higher proportion of respondents working in academia, these demographic findings are similar to other studies conducted among HES (Doyle et al., 2012; McKenzie & Seabert, 2009). A majority of respondents (55.0%) self-identified as “very liberal” or “somewhat liberal”; 28.4% identified themselves as “moderate”; and only 15.1% identified themselves as “very conservative” or “somewhat conservative.”
HES Knowledge and Attitudes of the ACA
Each respondent was asked to list two general provisions of the ACA. A total of 351 provisions were listed by 188 respondents (85% of the sample). Of the listed provisions, 275 (78.3%) represented accurate provisions currently in place, 46 (13.1%) represented accurate provisions with future implementation dates, and 30 (8.5%) listed provisions were either inaccurate or too vague to be coded. The most common accurate current provisions listed were extension of insurance coverage to children up to age 26 years (n = 73), elimination of the preexisting condition clause (n = 65), creation of insurance exchanges or marketplaces (n = 39), the essential benefits package expanding prevention care (n = 37), and expanded prescription coverage of contraception (n = 19). The two most common future provisions listed were the individual insurance mandate (n = 31) and the employer coverage requirement (n = 10).
Each respondent was asked to list up to three provisions of Title IV of the ACA, and 106 respondents provided at least one response for a total of 260 listed provisions. Of the provisions listed, only 34% (n = 89) were accurate provisions of Title IV, including creating healthier communities (n = 30), disease prevention and public health systems (n = 25), access to clinical prevention services (n = 24), and prevention and public health innovation (n = 10). A majority (57%, n = 149) of the listed provisions were accurate of the ACA but were not part of Title IV, and 8.5% (n = 22) were inaccurate of the ACA or were too vague to be coded.
The sample was highly favorable of the ACA; over 70% viewed the law as either “very favorable” (31.5%) or “somewhat favorable” (38.8%). Respondents also reported being either “very familiar” (11.4%) or “somewhat familiar” (59.6%) with the provisions of the ACA. HES are more favorable (70.3%) of the law than the general public, (23%).
When asked how successful the ACA would be at increasing the number of Americans with health insurance, most responded “very successful” (24.1%) or “somewhat successful” (56.4%). Only 12.7% thought it would be “very unsuccessful” or “somewhat unsuccessful.” HES support expanding Medicaid; 68.0% thought their state should expand. The remainder was divided between having their state keep Medicaid as it is today (16.0%) and not knowing or selecting “other/neither” (16.0%). Nearly three quarters of respondents (71.0%) correctly identified 2014 as the implementation year for central provisions.
Table 1 outlines questions in the survey from the Kaiser Family Foundation that assessed HES’ knowledge of the provisions and myths about the ACA. Among HES, >90% knew the law includes an insurance mandate and eliminates preexisting condition clauses. However, 50% were not aware that payroll taxes would increase for upper-income Americans and only 30% knew the law would increase the health care workforce. A total of 72% don’t know whether the ACA would decrease the amount a medical malpractice lawsuit can award. Over 10% of HES agreed with the myth for three of the four common myths associated with the ACA, with the largest number of HES (15%) believing that undocumented immigrants would receive financial help from the government to buy health insurance.
Health Education Specialists’ Knowledge of the Patient Protection and Affordable Care Act Provisions (n = 220)
HES Job Growth and the ACA
Respondents were optimistic that the ACA will increase job opportunities for HES. Well over half (64.6%) thought job opportunities would either “substantially increase” (17.7%) or “slightly increase” (46.8%). Only 16.4% expected no impact and 3.6% predicted job decreases. HES perceptions of the degree to which job opportunities will change within various job sectors as a result of the ACA is shown in Table 2. The sector thought most likely to increase in job opportunities was hospital/health care (53.9%), followed closely by state and local health departments (53.0%). Academia was seen as the sector least likely to have any change in jobs (24.8%).
Health Education Specialists’ Perceptions of Job Change due to the Patient Protection and Affordable Care Act by Job Sector
HES sense the ACA will affect their jobs; 62.7% said it was “very likely” or “somewhat likely” the ACA will affect how they do their job in the future. A majority, (60.9%) said it was “very likely” or “somewhat likely” to change funding sources for their program(s), and 64.6% said the ACA will affect how they work with partners. Far fewer responded the ACA was “somewhat unlikely” or “very unlikely” to affect how they do their job (20.1%), change funding sources (20.5%) or affect how they work with partners (16.8%). The remainder of respondents was “undecided” on the effect of the ACA on these areas.
Difference Between HES Knowledge and Favorability of ACA
Table 3 shows HES’ knowledge and favorability of the ACA. The knowledge scale ranged from 0 to 12 with a sample mean of correct answers of 6.9, median of 7, and mode of 8. Table 3 shows the mean number correct, F value, and p value for each variable. Statistical significance was found on the “view of the ACA” variable, meaning there is a significant difference between those who viewed the law favorably and those who got the most items correct. There is also statistical significance between the knowledge scale and perceived impact of the law on health care cost, the law increasing the number of insured Americans, and the country being better off under the law.
Health Education Specialists’ Mean Knowledge Scale Scores and Favorability of the ACA by Select Demographic Characteristics
NOTE: ACA = Patient Protection and Affordable Care Act.
The F test was used to determine if the mean knowledge scale score differed between demographic groups.
Discussion
The purpose of this study was to determine the knowledge, attitudes, and perceptions of HES related to the ACA. This study is also intended to provide baseline measurement for HES on the ACA.
The majority of respondents self-identified as “very” or “somewhat liberal.” Given this, it is not surprising there was high favorability and support for the ACA. Within that context, it is also consistent that many of the respondents in this study believe the country will be better off under the ACA and that quality and cost of health care will improve. Medical students show similar beliefs in the ACA’s potential to improve access and quality (Huntoon et al., 2011).
When comparing findings from this study to Kaiser Family Foundation general public data on the same topic, HES more often selected the correct answer regarding the provision than the general public, with one notable exception. A higher percentage of the general public correctly identified that the Medicare payroll tax will increase on families making more than $250K per year. In addition, more HES thought the country as a whole would be better off under the ACA as compared with the general public. They were also more likely to say the quality and cost of health care will be better under the ACA.
While HES were more knowledgeable about the ACA than the general public, their average score on the knowledge scale was still low. These findings indicate that more education is warranted to dispel misconceptions of the ACA. As HES are often looked to as a credible source of information about health, having accurate knowledge about the law and awareness of misconceptions is important for disseminating correct information.
Tax increases have been a strong talking point among conservatives. The observed difference here could be closely tied to political views of the sample. Lack of awareness about important provisions could limit the ability of HES to advocate for the profession and their communities. For this reason alone, HES should become more familiar with all aspects of the ACA. While health education professional preparation programs can work to integrate ACA content into their curriculum, practicing HES should look for continuing education opportunities at conferences and through webinars to learn more. Readings such as the SOPHE issue brief Affordable Care Act: Opportunities and Challenges for Health Education Specialists (Goodman et al., 2013) can provide an introduction to the topic.
More concerning than the knowledge scale provisions was the lack of knowledge about Title IV. This title, “Prevention of Chronic Disease and Improving Public Health,” will have the greatest impact on public health in a variety of settings. The title created the Prevention, Health Promotion, and Public Health Council and the Public Health Fund. It also includes, but is not limited to, community transformation grants, school-based health centers, nutrition labeling at chain restaurants, employer-based wellness programs, funding for childhood obesity demonstration projects, and health disparities data collection and analysis. The health education and broader public health profession possess expertise in these areas to make a positive impact. If HES are unaware that the law has specifically outlined related areas for improvement, then they will be unable contribute to building the infrastructure to support these changes. Additionally, without a strong advocacy effort for funding these initiatives, legislators will continue to view them as an easy target for budget cuts (Stine & Chokshi, 2012).
Most HES were optimistic about job growth opportunity under the ACA. While few in the sample knew the law would increase the health care workforce, they did predict hospital/health care as the most likely sector for job growth. With a greater emphasis on prevention and wellness, the skills of HES may become increasingly valuable within health care.
Although HES listed businesses and corporations as low–job growth sectors and high on “no change,” there is growing opportunity in this area. In Title IV and other places, there is an increased emphasis on wellness programs. The number of employers implementing such workplace programs is on the rise (National Institute for Health Care Management Foundation, 2011). Research shows a return on investment of $3 for every $1 spent on worksite wellness programs (Aldana, 2001). This makes worksite wellness programs an attractive option for employers to help keep their workers healthy, increase productivity, decrease absenteeism, and potentially manage rising health care costs. Some public health departments are moving into this area as they see growth potential and the chance to have a healthy influence on their communities through worksites (State of Rhode Island Department of Health, 2014).
Limitations
The results of this study should be interpreted within the context of the following limitations. First, the survey was administered during October/November of 2013. During that time, the healthcare.gov marketplace was launched and experiencing considerable difficulty. As a result, there was significant media coverage on the marketplaces and ACA in general, increasing the possibility of historical bias. Second, there is a potential selection bias as political views and favorability of the ACA was heavily skewed toward liberal acceptance of the law. This could result from HES being a more liberal group of professionals, or from greater participation among those more likely to favor the law. A randomly selected sample from across the United States was employed to neutralize this threat. Third, with an analytical sample of 220 it is difficult to generalize the findings to all HES. However, as the first study of its kind, this provides a starting point for research into the subject. Further research should expand the sample size to provide additional evidence for the profession as a whole and to determine what HES specifically value about the ACA. Fourth, no attempt was made in the present study to determine what type of insurance reform efforts were occurring by state. Depending on state policy decisions regarding insurance under the ACA, some states launched educational campaigns to increase knowledge about health insurance marketplaces and enrollment. Future research could explore this as a variable and explore the findings by state.
Conclusion
This study provides a baseline assessment of what HES know about the ACA and its perceived impact on the profession. As the health care landscape transitions to one more focused on prevention, HES have the opportunity to provide insight in shaping care. However, their input will be more impactful if they show a clear understanding of what is currently in the law and its goals. If the profession wants to be included in the strategic direction of health care reform, significant advocacy efforts will be required. Advocacy efforts have been successful in the past to improve public health programs and could be beneficial during this transition (Bliss, 2013).
Based on survey results, more education about the ACA needs to occur among HES. While they are fairly knowledgeable on the widely publicized provisions, they are uncertain about common misconceptions. Additionally, they know relatively little about Title IV, the act that will most directly influence their work. Those who were more educated on the law were more optimistic about its potential to improve health in the U.S. A greater emphasis on directed education to HES on how the law could affect their work is recommended.
In summary, health care reform through the ACA is an opportunity for HES to become more valuable in a variety of settings to use their knowledge, expertise, and training in prevention and wellness. Sufficient knowledge of the law and its implications is needed to advocate for strategic changes in health care and public health systems. Increased visibility will likely lead to job opportunities in many sectors. To reach the goal of quality, affordable care for all, an enhanced partnership between health education and health care professionals will be essential.