1158 — Texas Veterans and the Affordable Care Act: Using Community-Based Participation Research to Inform Survey Development
Bollinger MJ, South Texas Veterans Health Care System, Audie L. Murphy VAMC, San Antonio TX; Finley EP, South Texas Veterans Health Care System, Audie L. Murphy VAMC, San Antonio TX; Pugh MJ, South Texas Veterans Health Care System, Audie L. Murphy VAMC, San Antonio TX; Willrodt P, South Texas Veterans Health Care System, Audie L. Murphy VAMC, San Antonio TX; Cortez L, South Texas Veterans Health Care System, Audie L. Murphy VAMC, San Antonio TX;
Texas is one of 21 states electing not to expand Medicaid to cover all adults (not just those with a disability) under the Affordable Care Act (ACA). We are undertaking community-based participatory research (CBPR) to assess implications of the ACA among veterans in a non-Medicaid expansion state. Initial work has included developing a survey tool and validating it in close consultation with community-based partners.
We conducted qualitative interviews with Veteran Service Officers (VSO's) in Texas counties using purposeful sampling in rural and urban counties with large veteran populations. To maximize stakeholder participation, we also interviewed key informants at VA healthcare systems, representatives of the American Legion, ACA navigators, and a convenience sample of veteran-focused organizations. Semi-structured interviews focused on experiences with the ACA (i.e., assisting veterans with ACA or VA enrollment and barriers/facilitators to ACA or VA coverage). A grounded theory approach was used to analyze interviews (n = 33) to identify emergent themes.
Themes emerging from stakeholder interviews included: frequent lack of knowledge of ACA; negative attitudes toward "Obamacare" alongside positive attitudes toward ACA; significant "red tape" involved in enrolling veterans in VA care; problems with transportation and scheduling, particularly for veterans with acute illness; and difficulty in qualifying for ACA subsidies because veteran pensions are excluded income under ACA rules. Qualitative interviews provided valuable information for prioritizing survey topics and refining the assessment plan.
Veteran health, perceptions, and service use emerged as both multifaceted and complex but key themes related to both ACA enrollment and VA care were identified facilitating validation of our survey. Specifically, we developed our survey using a modified version of the Fortney et al state of the art (SOTA) access model. However, analyses revealed that a consumer decision journey model more adequately captured key themes from our interviews requiring a restructuring of the survey to accommodate questions that reflected our changed model.
Using a CBPR approach to develop a survey demonstrates how enhanced understanding of Veterans issues can inform the refinement of survey development ensuring capture of relevant and accurate information.