Fluent Essays

see attachment Topic: Disparities in healthcare in USA 1- Put all the chapters on one document 2- Write the preliminary pages Preliminary Pages The pages that precede the text (starting with Chapter 1) are usually numbered using lowercase Roman Numerals (i, ii, iii, iv, etc...), but it can be difficult to use two different page numbering styles in one document; as a result, students may use Arabic Numerals (1, 2, 3, etc...) throughout the paper. However, please remember that the title page does NOT have a page number even though it is page #1. You should start numbering your pages on the second page. Each of these pages are described in the Requirements handout found in Shared Documents and include: · title page · copyright page (if you plan to register a copyright) do not need · dedication page (optional) do not need · acknowledgments (optional) do not need · table of contents · list of tables (if appropriate) · list of illustrations (charts, graphs, figures) (if appropriate) · list of symbols (if appropriate) · preface (optional) do not need · abstract Please make sure each is formatted correctly. Some of you might want to include a Preface. It is really the only place in the research project that you can use first person. A Preface is appropriate if you have a particular, personal interest in the topic that you want to share. Some sociologists use “reflexive statements” in their work. These can serve two important functions. First, it shares with the reader that personal connection that led you to do the research. It may be that some of your readers had similar experiences and this will help them identify with your research. The second reason is that the reader should know if you do have strong opinions on the topic: it is partly about honesty and ethics, and partly to help explain if any “passion” is present in your writing. We try to be objective, but we are also human. By disclosing our passion we can defuse any criticism of bias (it won’t excuse us from being biased, but there may be subtleties that creep in). Some students are tempted to write the Abstract first. Resist that temptation! Even though it comes at the beginning of the paper, it is the last section you should write. A good abstract will include the research problem or question, MAYBE a sentence or two about the significance of the problem, the major findings, and a one or two sentence conclusion/recommendations. The Requirements allow you 350 words; you should not need that many. A paragraph is sufficient, but a page is acceptable. 3-4 pages for the preliminary pages See attached sample paper 3- Remove the references at the end of each chapter and put them all at the end of chapter V. Your references should follow APA style. Make sure each reference follows APA style. 4- Number the pages and have a header. Running head: EDUCATIONAL OUTCOMES OF FOSTER YOUTH 2 EDUCATIONAL OUTCOMES OF FOSTER YOUTH Please note this is a sample, NOT an example. This paper is not perfect. (Example: The contents page in the sample paper does not have page numbers after every subheading in each chapter and APA style has changed a bit since the paper was submitted a few years ago. Educational Outcomes of Foster Youth A capstone submitted in partial fulfillment of the requirements for the degree of Bachelor of Arts in Sociology DATE HERE NAME HERE National University COPYRIGHT BY NAME HERE 2015 TABLE OF CONTENTS LIST OF TABLES……………………………………………………………………… 4 ABSTRACT…………………………………………………………………………….. 5 CHAPTER I INTRODUCTION…………………………………………………… Research Questions Statement of the Problem Hypotheses 6 II REVIEW OF RELATED LITERATURE .......................................... Research Questions Hypotheses Who Is Considered At-Risk? The Educational System: Outcomes for Foster Youth Family Systems: Outcomes for Foster Youth Theoretical Framework 13 III RESEARCH METHODOLOGY......................................................... Study 1 Study 2 Study 3 Definition of Terms 23 IV RESULTS………………………………………………..................... Quantitative Data Qualitative Data 29 V DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS.... Parental support Negative Attitudes Additional Factors Need for Future Research Call to Action 39 References ………………………………………………………………………............ 47 List of Tables Figure 1:1 Laws Pertaining to Foster Youth…………………………………………….. 8 Figure 4:1. Proficiency Score on CST English, Grade 11 in 2011………………............. 32 Figure 4:2. Proficiency Score on the CST Math, Grade 11 in 2011……………………... 33 Figure 4:3. Enrollment in Community Colleges Basic Skills Courses…………………... 34 Figure 4:4. Enrollment in California State Universities…………………………………. 35 Abstract The purpose of this study was to determine whether or not foster youth have poorer educational outcomes than their peers who are not in foster care and whether or not these outcomes were related to lack of parental support and negative attitudes. This study explored the educational outcomes of foster youth by comparing data from several sources. Sources included a study by the Stuart Foundation that compares foster youth to another similar cohort of at-risk youth. Other sources included were derived from state databases such as Dataquest, Datamart, and the CSU Analytical Studies, all of which are published through state websites. Additionally, this study used a case study to determine the perspectives of youth regarding their educational experiences. Ultimately the hypotheses were found to be true and it was determined that an additional factor, lack of collaboration and communication, was equally relevant to poor educational outcomes as lack of parental support and negative attitudes. Keywords: foster care, stigma, deviance CHAPTER 1: INTRODUCTION Introduction Foster youth deal with a much higher possibility of negative outcomes in life, which are directly related to less education, a lower quality education, or an incomplete education. This concern is one that often gets lost in the difference between stigma of adults with poor life outcomes and the children with poor educational outcomes. In fact, an overwhelming body of evidence indicates that these two populations are the same people; children with poor educational outcomes often become adults with poor life outcomes such as poverty, joblessness, crime, substance abuse, and unwanted pregnancies. One subgroup in our public schools that face the highest risk of these problems is foster youth. This paper will explore quantitative data that describes the educational outcomes of foster youth as well as analyze qualitative data that describes the sociological factors that contribute to a social stigma surrounding foster youth. What is foster care? The National Adoption Center defines foster care as “a temporary arrangement in which adults provide for the care of a child or children whose birth parent is unable to care for them. Foster care is not where juvenile delinquents go. It is where children go when their parents cannot, for a variety of reasons, care for them.” (National Adoption Center, n.d.) This definition implies that the situations that warrant the need for foster care are not attributed to the child. Ultimately, parents can have any combination of physical, mental, or emotional issues that prevent them from caring for their own children. Some of the possible scenarios for children who enter the foster care system are the following: placement with a foster parent who is temporarily responsible for the child, placement in a kinship care situation with a blood relative who is assuming temporary or permanent responsibilities as guardian, or a facility that offers group and residential care supported by the county or state. (Child Welfare, n.d.) In our current society, education is regarded as an important key to success. (Center for Public Education, 2006) Therefore, as Americans we are constantly concerned with improving our educational opportunities for young people. Students’ success postulates the ultimate success of our country as a whole. It is estimated that as of 2012 there were about 397,000 children in foster care. (U.S. Department of Health and Human Services, 2012, p.ii) Considering this is a large number of students represented in our public school systems, it is important to evaluate how our school systems are serving their needs. This paper will compare the educational outcomes of foster youth to that of their peers who live with parents. Additionally, this paper will examine research studies that identify contributing factors to these outcomes. History & Context of Foster Youth in the United States The ideology of foster youth has had a murky past, yet over time has progressed immensely. Based on The National Foster Parent Association (NFPA) (2015), the idea of a child without parents lead primarily to indentured servitude initially in the United States. This policy was based on the English Poor Law in 1562. This perpetuated exploitation and abuse to poor children without parents for centuries. The first foster home movement described by the NFPA began with a minister named Charles Loring Brace. Brace felt it was important to address the needs of the growing number of immigrant children coming into the New York that were ending up homeless. Though his efforts were filled with good intentions, the efforts placed children with families in the West or South who needed extra workers, resulting in outcomes that were little better than the indentured servitude of the past. In fact, it was not until the early 1900’s that government social services really took on the responsibility of overseeing the care for foster youth. (National Foster Parent Association, 2015) Today our country has a variety of social services and has progressed to make many positive changes towards caring for the needs of foster youth through our laws and policies. There are several laws that affect foster youth and their educational outcomes. Figure 1 below is a chart summarizing the most influential laws that protect the rights of foster youth and in turn affect their educational outcomes. (California Department of Education, 2015)(Education Coordinating Council, n.d.) Figure 1:1 Laws Pertaining to Foster Youth AB408 Protects students right to participate in afterschool and extracurricular activities AB167 Allows foster youth to qualify for graduation based on the California state requirements instead of the district requirements to graduate AB490 Protects students rights to the following: access to mainstream schools, enrollment in school without all necessary documentation, enrollment at their current school for the remainder of the school year even if their placement changes, access to a district liaison, grade protection from absences, opportunity to receive partial credits towards graduation requirements AB12 Allows students who are working or in school to remain in foster care placement until age 21 AB669 Exempts students from in-state residency requirements at community colleges and state colleges AB1393 Allows priority access to on campus, year round housing at all CSUs Although these laws and our social services do great work to protect the interests of foster youth, as a country we must also continue to evaluate our progress in serving their needs to determine if the laws, policies, and efforts we have in place indeed work or need revision. The main reason for this continuous evaluation is that if we do not adequately meet the needs of at-risk youth through their education, they will more than likely become adults that have negative life outcomes. Research Questions The following research questions will be investigated in this paper: 1. What are educational outcomes of students in foster care compared to their peers who are not in the foster care system? 2. What are possible contributing sociological factors? This study will synthesize data on educational outcomes from several sources such as government agencies, non-profit organizations, and academic studies to compare results for both foster youth and the general population. Data such as test scores, graduation rates, acceptance to college, and completion of college will be used to determine educational outcomes. Additionally, this study will analyze several academic studies on emancipated foster youth to see what social factors contribute to their overall success or struggle in education, and as a result life outcomes. Statement of the Problem Education acts as a foundation for many other social systems that exist in America. The outcomes of education can dictate our economy, quality of life, civic engagement, health, and many other aspects of American life. The need to address issues concerning foster youth extends beyond the simple obvious moral of protecting children. In fact, the issues concerning educational outcomes of foster youth have direct effects on other problems in society such as crime, homelessness, teen pregnancy and much more. These concerns are a drain on our economy and our overall well-being as a country. Unfortunately, foster youth are at a much higher risk of these negative life outcomes after emancipation. Shocking statistics concerning foster youth Homelessness. It is estimated that at least ⅓ of foster youth become homeless immediately after emancipation. (Lifting the Veil, 2010) This problem is one that grows for foster youth as they emancipate and they are at risk of this even as adults. In fact, 40\% of people living in homeless shelters are former foster youth (Children Uniting Nations, 2015) and 50\% of foster youth will be homeless during the first two years of emancipation. (Promises 2 Kids, 2013) Abuse. Abuse is a cycle that plagues many foster youth throughout their family experiences. Statistics show that this cycle repeats with many victims of abuse. According to studies on abuse, 30\% of abused children will also abuse their own children. (Promises 2 Kids, 2013) This is a common reason for foster care placement. In fact, 32.9\% of children in foster care were removed from an abusive home. (Children Uniting Nations, 2015) In the United States, a child abuse report is filed every 10 seconds. (Promises 2 Kids, 2013) Obviously this is a horrendous problem that must be addressed. Crime. Crime is obviously a dominant contributing factor to many of the problems foster youth face. 60\% of male emancipated foster youth have been convicted of a crime. (Congressional Coalition on Adoption Institute, n.d.) 50\% of emancipated foster youth have been involved in substance abuse. (Congressional Coalition on Adoption Institute, n.d.) It is estimated that between 70-80\% of prison inmates were once in the foster care system. (Lifting the Veil, 2010) Not only have foster youth faced issues such a crime, many times these youth are in foster care because crime has happened in their family. Education. Due to the previous statistics shared, it is not surprising that foster youth face difficulty in their education as well. Disabilities are prevalent among this population due to neglect, substance abuse, or even inherited medical issues. In fact, 24\% of foster youth have a physical or learning disability. Due to the academic difficulty they face, their outcomes are very poor. 50\% of foster youth complete a high school diploma and only 3\% of former foster youth complete college. Many believe that some of these outcomes are due to poor educational beginnings and attribute this to the fact that more than half of foster youth attend the lowest performing schools in the country. (Promises 2 Kids, 2013) Personal struggles and negative life outcomes Each of these sets of statistics are linked to a variety of issues. The problems that this population of students face are complex and have multiple outcomes outside education as well. For example, 38\% of foster youth experience five or more placements while in care. This means that supervision is not consistent and behavior expectations change regularly. While this often manifests as criminal activity in males, 60\% of females become pregnant within a few years of emancipation. (Promises 2 Kids, 2013) Additionally, emancipated females are four times more likely to receive public assistance than the general population. (Children Uniting Nations, 2015) Needless to say, this startling list of statistics speaks to the higher risk of foster youth to experience negative situations and necessitates that our society pay careful attention to their educational outcomes. According to the Alliance for Excellent Education, “Compared to a high school dropout, a single high school graduate yields a public benefit of over $200,000 more in lower government spending and higher tax revenues. If the number of dropouts were cut in half, the government would likely see a total of $45 billion in savings and additional revenue.” (2011, p.4) Each of the statistics above support the notion that foster youth are less likely to be engaged in their education and in many cases less likely to complete it. If poor educational outcomes for foster youth continue, their negative life outcomes result in a strain on the entire society through loss of taxes, public assistance, as well as the prevention and punishment of criminal activity. Hypotheses The hypothesis for this study is that students in foster care have significantly poorer educational outcomes due to lack of parental support and negative attitudes about foster youth present in our society. In addition, it is anticipated that deviant behavior, stereotyping, self-awareness and self-image are sociological issues that directly relate to the negative attitudes about foster youth. These negative attitudes contribute to a social stigma that foster youth deal with on a daily basis. CHAPTER 2: REVIEW OF RELATED LITERATURE Although the disadvantages of foster youth are obvious, there is a need for further research to add to our understanding of the needs of this particular group. It is common knowledge in the education and social services fields that this population of students struggles for many reasons. However, there is a complex combination of multiple issues that make any student successful or not. To reiterate, the research questions for this study are: What are educational outcomes of students in foster care compared to their peers who are not in the foster care system? And, What are possible contributing sociological factors? In response to these questions, the hypothesis for this study is that students in foster care have significantly poorer educational outcomes due to lack of parental support and negative attitudes about foster youth present in our society. Therefore, this literature review will investigate the current situations of many foster youth who are at risk of poor educational outcomes by summarizing multiple studies that elaborate on these situations in order to build a context for this study. Who Is Considered At Risk? Foster youth are often labeled as “at-risk.” Although many in the education and sociology fields are not fans of the act of labeling, at this point it is often the most common title given to students who need extra help and serves as a mechanism to provide services. According to Moore (2006), a child can be at-risk, but their family or community can also be at risk. Moore explains, “Families are the most critical setting for the development of children, and family risk factors, such as poverty, single parenthood, and low parental education levels, regularly have been found to undermine children’s development.” (p.1) The label “at-risk” can be applied to many students whose families face one or more of these scenarios, but foster youth are disproportionately more likely than their peers to deal with these life situations. When considering the label of “at-risk” for individual children, Moore explains that there are three major criteria that make a child fit into the category “at-risk.” They are: 1) disability, 2) low-self esteem, and 3) victims of abuse. Most foster youth fit at least one, if not all, of these categories. Not only are all foster youth placed in care due to a negative family situation such as abuse, incarceration, death, etc., but a large number of foster youth are diagnosed with physical or mental disabilities, suffer from low self-esteem due to limited parent contact and negative experiences, and many have been victims of abuse. Needless to say, foster youth usually fit more than one, if not all, of the criteria to be considered at-risk of poor outcomes. The Educational System: Outcomes for Foster Youth Currently our social and educational systems do not adequately serve the needs of foster youth as they emancipate, or age out, of care. Although all children in the system have a social worker and many efforts are made to try and attend to needs while they are minors, there are often negative outcomes experienced in the transition years as they exit care. According to Jones, (n.d.) the majority of foster youth exiting care have aspirations to attend college, but the actual attendance rate is much lower. The majority of former foster youth do not ever attend college, and of the ones who do, most success is found in two year colleges or trade schools. Jones found that the main reason for this is low-income. The demands of higher education often make working and supporting oneself very difficult. Statistics show that in comparison to other independent (not using parents income) college students, whose income was an average of $39,000, foster youth have a median income of only $5,000. (p.18) This disparity is the main reason that completing four year degrees becomes much more difficult. One additional problem with the current system and emancipating foster youth is the lack of additional support needed for people with disabilities. According to Jones (n.d.) one factor not often studied is that foster youth are at much higher risk of mental illness. Geenen, Powers, Hogansen and Pittman (2007) found similar data, indicating that a much higher number of emancipating foster youth suffer from mental illness or mental disabilities. Additionally, almost all foster youth enter the system out of low income situations and remain in that situation after they leave the system. The limited resources for supporting the post-secondary outcomes of these youth is alarming. Geenen, et al. explains that there is adequate research that shows students with disabilities have very poor post-secondary outcomes and adequate research that shows students who emancipate from the foster care system have very poor post-secondary outcomes, but very little research that identifies outcomes for students who fit both categories. (p.20) Disabilities and low income are obviously a major barrier to educational outcomes. Unfortunately, there are many more barriers to positive educational outcomes that research identifies as common issues for foster youth. According to Zetlin, Weinberg and Shea (2006), there are six overarching themes that perpetuate barriers for this population compared to their general population counterparts. These barriers are: 1) placement and stability, 2) treatment/education programs, 3) record transfer/database, 4) accountability/monitoring outcomes/advocacy, 5) interagency collaboration/coordination, and 6) confidentiality. (p.167) These are common issues concerning which the education system and social services often fall short and as a result, limit opportunities for many students in comparison to their general education counterparts. These limitations described by Zetlin et al. (2006) create challenges as students move through their education and have lasting impacts on these students as they leave the system. According to Scannapieco, Connel-Carrick and Painter (2007) youth need a chance to develop life skills and gain opportunities for leadership. These situations can offer the necessary growth for adulthood, as opposed to going immediately from care to independence. Scannapieco et al. contrast these needs to those of non-foster youth who have connections to stable parents and homes in which they can use as an emotional and physical support in times of need. (p433) Lips adds to some of these proposals for solutions to addressing the needs for foster youth. One suggestion is school options. This kind of choice for selecting an educational environment that caters to specific needs may make up for some of the lack of social networks that serve as a safety net, which Lips describes is a luxury of most students who are not in foster care. (p.1-2) Lips describes that many foster youth gain little from their education resulting in low wage jobs or worse outcomes. In fact, “foster children often repeat a grade and are twice as likely to drop out before graduation.” (Lips 2007, p.2) Family Systems: Outcomes for Foster Youth Family provides the basis for growth of all young people. Needless to say, the lack of family support can create a disadvantage for children. Although foster care may provide a safer environment for children, there are often other elements lacking that affect general life outcomes. Knox and Schacht (2008) define family as, “a group of two or more persons related by blood, marriage, or adoption. Broader definitions include individuals who live together, who are emotionally and economically interdependent.” (p.573) A child placed into care is obviously at risk of missing out on some of these elements. Although many foster children do report that they care for their foster parents and vice versa, there can still be a lack of emotional interdependence compared to their real parents. Additionally, once they leave care, the economic interdependence is not required and young people leaving care often do not have the financial support of their foster parents. (Knox & Schacht 2008, p.15) Stone and Zibulsky (2014) describe how academic performance is often a problem for students who have experienced maltreatment of any kind in the past. A large number of foster youth have experienced abuse or neglect prior, and sometimes after, entering the foster care system. This research indicates that there is a huge need for school psychologists to work closely with caregivers and other supports to address academic needs. However, some of the previous barriers discussed by Zetlin et al. make this difficult. For example, if a child is moved regularly and documentation is not adequately recorded or shared with appropriate officials, a child may sit in a classroom in a new district for a long period of time before the school psychologist or counselors even know that he or she has any specific needs. This is an example of how the lack of parent advocacy and involvement results in lesser services throughout a foster child’s education. This issue of mobility is a result of lack of parental support and becomes a major problem for many foster youth. There are many proven adverse effects to regular movements. In fact, Pears, Kim, Buchanan and Fisher (2015) found that this is one of the main reasons for poor academic outcomes for young students in foster care. Additionally, these authors indicate that these records of movement may even be underestimated. Another issue is that behavior problems and low skill level may be less documented and addressed due to this high level of movement between schools. (p.1211) Each of these issues points to a lack of parental support that results in poorer educational outcomes for students. Knox and Schacht (2008) also describe the family course development framework (p.23) for how a family typically develops through stages. The authors explain that when the normal stages are interrupted or experienced out of order, the outcomes can be negative. For example, most people grow up, graduate high school, then leave their family to get married and have their own children. When young people are separated or made independent too young, the outcomes may be negative for all parties. The authors also emphasize the stages as results of choices, but foster youth are in a scenario where they did not choose to leave or become independent of their parents. This lack of control over their own situation can have lasting social and psychological effects. Parents influence an immense amount of outcomes for young people as they transition into adulthood. Among these are self-esteem and behavior problems. According to Wagner, Ludtke, Jonkmann and Trautwein (2012) self-esteem is greatly influenced by parental involvement and is a key to transition into adulthood. Behavior problems are frequent among foster youth and this can become a major factor in growing up in a foster home because parenting is such a crucial part of growing up. A study by Fuentes, Salas, Bernedo and Garcia-Martin (2014) found that “criticism/rejection by foster parents and the use of inadequate parenting styles (authoritarian and permissive) has a negative effect on the behavior of foster children.” (p.709) Another study by McWey, Cui and Holtrop (2014) found that there is a significant discrepancy between the perspectives of adolescents with behavior problems and their caregivers. There is a lack of agreement over issues such as internalizing behaviors and externalizing behaviors, indicating a lack of communication and understanding over what the real issues are. This means that foster youth may be inherently more difficult to parent because they have different perspectives which they have created out of their variety of experiences in different homes and families. The inconsistency of norms manifests as behavior problems and often affects educational outcomes. Another study by Chapman, Wall and Barth (2004) described the perspectives on parenting and home situations of foster youth while in care and after leaving care. One interesting finding was that although children had a variety of emotional responses concerning visits with their biological family and most reported being content with their placement, still 74\% retain the hope of reunification with biological parents and believed “things would be different this time.” (p.297) Additionally, the same study found that many former foster youth reported that they experienced harsh punishments from caregivers, little connection with caseworkers, and often worried about their educational experience. (p.294) These results and results of previously mentioned studies indicate that often parenting styles may be mismatched with children’s needs and even when children have a positive placement, they still would prefer their own biological parents. Theoretical Framework for Understanding Educational Outcomes of Foster Youth There are two major theoretical concepts that allow an in-depth understanding of the poor educational outcomes of foster youth. As indicated by the studies previously described, foster youth experience many situational problems due to the lack of parental support such as movements in placement and behavior problems. Additional personal problems are also prevalent among foster youth such as physical and mental disabilities and low income level. … CHAPTER III- METHODOLOGY The chapter describes the research methodology used in collecting data for answering the research question. Essentially, the study relies on previously published studies that relate to the hypotheses of the research. In this regard, the study will offer a detailed analysis of the concepts presented in the documents and data from health organizations. Besides, it will outline the setting, subjects, research instruments, procedures, and limitations to each study included in testing the outlined hypotheses.  Setting The first article is, “Three-year impacts of the Affordable Care Act: improved medical care and health among low-income adults” and it is authored by Sommers et al. It was published online in 2017 by Chan School of Public Health. The study was conducted between 2013 and 2016, and it included three states, Kentucky, Arkansas, and Texas. Texas was selected as a control for the remaining two states. The second article, “Health Spending for Low-, Middle-, and high-Income Americans, 1963-2012,” is authored by Dickman et al. and was published in 2016. The study involved details regarding the health expenditures of representatives of the American population over fifty years.  The third article is “The Effect of the Affordable Care Act on racial and ethnic disparities in Health Insurance coverage.” Its authors are Buchmueller et al. The study was published in 2016. It provides the extent of health insurance coverage for groups such as Whites, Blacks, and Hispanic adults under A.C.A. implementation. The fourth study that this research will use is “Change in Utilization and Health among Low-income Adults After Medicaid Expansion or Expanded Private Insurance.” Its authors are Sommers et al., and the study was published in 2016 in JAMA. The study was conducted in three different states, Kentucky, Arkansas, and Texas. Additionally, the research was occurred between 2013 and 2015. Another study whose data is to be used in testing the hypotheses is “The Effects of Household Medical Expenditure on Income inequality in the United States.” Its authors are Christopher et al., and the article was published in 2018. The study was based on the information regarding the United States’ population. The last study related to the hypotheses of the research is “Racial and Ethnic Disparities in Health Care Access and Utilization under the Affordable Care Act.” The authors of the study are Chen et al. and it was published in 2016. The research is based on a previous study that covers information regarding the United States’ population.  Description of the Subjects The participants involved in the study included United States citizens whose ages range between 19 and 64 years. According to Sommers et al. (2017), the population composed of individuals with household earnings below the federal poverty level percentage. The authors recruited the participants within the selected states every year from 2013 up to 2016. The yearly sample-sized that was used during the research period was between 2,209 individuals and 3 011. Thus, 10 885 people participated in the research during the four years. The study included the three states because they all covered various elements of private marketplace insurance expansion and Medicaid expansion under the Affordable Care Act (A.C.A.).  According to Dickman et al. (2016), the research implemented document review as the data collection method, and it involved 22 nationally representative surveys. It involved data from Health Services Utilization and Expenditure survey, National Medical Care Utilization and expenditure surveys, National Medical Expenditure Survey, and Medical Expenditure Panel Surveys. The authors provided that the surveys collected demographic information that includes details regarding income and family size. The research by Buchmueller et al. (2016), on the other hand, used data from a previously conducted survey that contains details of different minority groups living in the United States and are affected by the implementation of the Affordable Care Act. The information included respondents whose ages range from 19 to 64 years. Additionally, the researchers observed the characteristics that led to differences among the White, Black, and Hispanic such as income and education levels. The research by Sommers et al. (2016) included 8676 participants who were citizens of the United States. According to the authors, the minimum age for the participants was 19 years, while the maximum was 64 years, with an income level below the federal poverty level. The researchers surveyed about 1000 different people in each of the three states annually. Christopher et al. (2018) used existing data from the Annual Social and Economic Supplement of 2011 up to 2015 as the source of data for their research. According to the authors, the Current Population Surveys required the respondents to provide information on their income and expenditures for 2010 through 2014 to ensure a broad view of the impacts of household medical expenditures. The subjects to the study conducted by Chen et al. (2016) involved various American groups, including Whites, African Americans, and Latinos. The researchers focused on the groups regarding their health care access and utilization before the implementation of A.C.A. and after its implementation.  Description of Research instruments The researchers used different instruments in their studies. Sommers et al. (2017) implemented a survey that they conducted through random-digit dialing over the telephone. The method automatically generates telephone numbers of individuals to participate in a given study at random. It included both English and Spanish languages for contacting the selected individuals. The method is beneficial since it captures respondents with unlisted numbers which could be missed while using a phone book. Additionally, the method limits challenges associated with the telephone directory as the sampling frame. Dickman et al. (2016) used a document review based on the survey information from different organizations. This gave the researchers a broad view of the American’s health expenditure. Besides, the method is beneficial in collecting detailed information over a large coverage within a short period, making it possible to reduce research biases resulting from the sample included in a study.  The research by Buchmueller et al. (2016) used document analysis as the research instrument for data collection. Based on the data from the survey, the researchers examine the percentage of individuals with health insurance coverage and those without. The analysis provided a broad view of the impact of A.C.A. on the minority groups in the U.S. The research by Sommers et al. (2016) implemented a random-digit telephone survey that involved the use of landlines and cellphones to select and contact the respondents. The researchers used survey questions that were taken from national surveys such as Oregon Health Insurance Experiment and government surveys. Christopher et al. (2018) reviewed existing data as the research instrument for their study. The method is beneficial as it provides adequate background information and broad coverage of data that the researchers might not have collected using the other data collection methods. Additionally, the method allows researchers to study subjects to which they may not have easy physical access. Chen et al. (2016) also used existing data to answer their research question. This broadens their understanding based on the data that they can access.  Description of Variables Regarding the research, the independent variable is the implementation of the Affordable Care Act whiles the dependent variable is health care coverage. Based on the information provided by the authors, the level of health coverage is measured in terms of the number of people with insurance coverage since it directly affects access to health care services. In this regard, the level of health care coverage has been operationalized. Based on the information that Buchmueller et al. (2016) provided in their research, they operationalized access to health insurance coverage for different groups. As such, the study measured the effect that the implementation of A.C.A. resulted in among the minority groups.  Chen et al. (2016) in their research to determine the racial and ethnic disparities in health care access and utilization under A.C.A. defined the measured outcome variables in three main aspects that included the probability of insurance, probability of having medical care delay, and the probability of having foregone medical care. Through the defined aspects, the researchers measured the changes in the dependent variable which is the health care coverage among the racial and ethnic groups.  Definition of Terms The Federal Poverty Level (F.P.L.) indicates the lowest amount of yearly income of a household which provides that they are eligible for receiving certain welfare benefits. Random-digit dialing is a probability sampling technique that uses randomly generated telephone numbers in statistical surveys. Nonresponse bias is an error that occurs when participants of a study are unwilling to respond to a survey due to an aspect that makes them differ from those who respond.  Procedures The research uses document review to collect appropriate data to accept or reject the hypotheses of the study. This allows the study to obtain results quickly and at a low cost. By using six different studies, it is possible to provide accurate information and also eliminates errors that might result due to data collection from primary subjects. The statistical procedure used in testing the hypotheses of the study relates to techniques that the researchers, whose data have been included in the research, used in answering their research questions or testing hypothesis. As such, this study does not depend on a single technique but rather draws conclusions based on different techniques. The following are procedures that the researchers used in their studies.  Sommers et al. (2017) used a survey to collect data from various participants that they selected through the random-digit dialing method. The study then implemented a linear regression model on the data they collected during the four years and from different states. The data was then taken through an instrumental variable analysis that included a two-stage least squares regression. In the first step, the researchers predicted the probability of an individual having health insurance, and the second stage involved the provision of an estimate of the impact of A.C.A.  Based on data presented from different surveys used in the study, Dickman et al. (2016) examined the trends related to per capita health spending. The analysis method that the authors used explored trends related to income according to data of individuals on payment, service type, and self-reported health status. The researchers then divided the population represented in the survey into equal quintiles and used the federal poverty level to categorize income from different families as a percentage of poverty. Additionally, Dickman et al. (2016) categorized health services into groups including inpatient care, outpatient care, dental care, and prescription medicines to accurately calculate the total health expenditure.  Buchmueller et al. (2016) used the data from the American Community Survey to examine the differences in healthcare coverage in terms of health insurance cover of the individuals. The researcher implemented three approaches in evaluating disparities. The approaches included comparing unadjusted differences in means, calculating means after controlling health needs and preferences of the individuals, and lastly, getting differences in mean for various variables that significantly affect the health status of individuals like socioeconomic status. Regarding the study conducted by Sommers et al. (2016), the researchers used multivariable linear regression which is a statistical technique for predicting an outcome based on the response of a given variable. The study used the technique to analyze the outcomes before the expansion of Medicare under A.C.A. and after its expansion. The researchers then compared the outcome from Arkansas and Kentucky with the control state, Texas, to assess the impact of health insurance coverage expansion. Based on the data from Annual Social and Economic Supplement, Christopher et al. (2016) used the Gini index, a technique for measuring income distribution across a population, to evaluate income inequality. First, the researchers calculated the Gini index based on the total income of a family and then subtracted medical outlays. Additionally, the researchers further explored the data by calculating the net income changes that are attributable to the outlays to explore the difference existing for groups. Chen et al. (2016) used survey weights to adjust sample characteristics thus preventing the occurrence of nonresponse bias. The authors implemented linear probability models for the estimation of trends in health care access and utilization for the groups after the introduction of A.C.A. The models took into account factors such as predisposing factors, enabling factors like family income, and the need factors for the population. Additionally, the researchers examined the different exposures of Obamacare for specific ethnic and racial groups to determine the relation between A.C.A. indicator and racial or minority groups. Limitations The research on the impacts of the Affordable Care Act: improved medical care and health among low-income adults may be limited by the sample since it uses a sample from only three states and therefore might not apply to the general American population. This may affect the research due to the sampling method. Additionally, using the random-dialing digit may make it difficult to recruit targeted respondents thus affecting the outcome of the research. Some of the limiting factors to the research on Health Spending For Low-Middle- And High-Income Americans regard the method of data collection as it might not cover all the necessary information that addresses the aspects of the study.  The study conducted by Buchmueller et al. (2016) might be limited by the accuracy of the information presented in the existing data sources. As such, this might also limit this research since the information is due to dependence on the already presented data where there is no control over data included in the research. The various potential limitations to the study conducted by Sommers et al. (2016) include nonresponse bias which might result from the data collection method, random-digit dialing survey. This results in low response rates, below the federal government surveys. However, using weighting for the population features has the potential of mitigating nonresponse bias. Another potential limitation to the study regards the states involved in the research. This may not adequately reflect the situation of the general population in American. As such, this will limit the application of the research’s findings. Various limitations that might affect the outcomes of research conducted by Christopher et al. (2018) on the medical expenditures on Income inequality include the method of data collection the researchers implemented. In this regard, they have no control of the data that should be included and the ones to be excluded in the research and as a result, it might significantly affect the results of the study. Another limitation to the study relates to the scope provided by the data that was implemented in the study. According to the authors, the data provides a scope that is beyond their study. Some of the factors that might limit the use of Chen et al.s (2016) findings include being too much dependent on the existing data which affects the outcome of the research. However, this might result in the wrong prediction. The study investigated a portion of the aspects that regards the changes in health care quality and outcomes under the implementation of A.CA. Besides, the data might not provide specific information on the various racial and ethnic subgroups that significantly impact the outcome of the research. References Buchmueller, T. C., Levinson, Z. M., Levy, H. G., & Wolfe, B. L. (2016). Effect of the Affordable Care Act on racial and ethnic disparities in health insurance coverage. American journal of public health, 106(8), 1416-1421. Chen, J., Vargas-Bustamante, A., Mortensen, K., & Ortega, A. N. (2016). Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Medical care, 54(2), 140. Christopher, A. S., Himmelstein, D. U., Woolhandler, S., & McCormick, D. (2018). The effects of household medical expenditures on income inequality in the United States. American Journal of Public Health, 108(3), 351-354. Dickman, S. L., Woolhandler, S., Bor, J., McCormick, D., Bor, D. H., & Himmelstein, D. U. (2016). Health spending for low-, middle-, and high-income Americans, 1963–2012. Health Affairs, 35(7), 1189-1196. Sommers, B. D., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2016). Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance. JAMA internal medicine, 176(10), 1501-1509. Sommers, B. D., Maylone, B., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2017). Three-year impacts of the Affordable Care Act: improved medical care and health among low-income adults. Health Affairs, 36(6), 1119-1128. CHAPTER II-LITERATURE REVIEW            Generally, the U.S health care system is unique considering all the advanced industrialized countries because it does not have a uniform health care coverage for all its population (Williams, 2017). However, it recently enacted legislation that mandates health care coverage for almost everyone regardless of gender or ethnicity. Joseph and Marrow (2017) suggests that high cost is the primary reason that leads to challenges that Americans face in accessing health care. In 2013, about 31 percent of the uninsured adults reported facing challenges like delayed medical care while accessing health care services (Williams, 2017). The paper provides a literature review by examining the disparities in health care in the U.S. Literature Review Disparities in healthcare in the U.S Health care disparity is socially constructed, and it results in tangible effects on the health status of individuals. Health care disparity is differences in the healthcare coverage, access to, and quality care that various groups receive. Wheeler and Bryant (2017) mentioned that racial and ethnic disparities are arguably the most form of inequalities in the U.S health care system. However, they become the most silent factors while examining health inequity. The report released by the Institute of Medicine (IOM) reveals that racial and ethnic minorities, especially blacks, are more likely to receive a low valued medical care which leads to increasingly poor health outcomes among the population (Dickman et al., 2017). Over the years, efforts have been made to eliminate various disparities in health care to achieve health equity Root causes of Disparities in Health Care. According to Kelley et al. (2015), health disparities often result from system conflict, inadequate resources, and the distribution of the resources. The American government is responsible for ensuring control of the distribution of health services and resources to various individuals in need. For instance, the government should ensure that people living in extreme poverty are provided with medical care at a low cost (Travers et al., 2017). However, the government may not offer the required resources to every person in need due to the increased population. As such, some patients may not be in a position to receive the care that they require. Notably, these individuals tend to be from poverty-stricken regions because they cannot afford the required cost.  Poverty. Grubbs (2019) defines poverty as a state in which individuals lack the socially acceptable material possession such as income and productive resources that promote sustainable livelihood. Based on a 2018 report, more than 41 million Americans live in poverty (Grubbs, 2019). Regarding the information, the individuals experience detrimental health impacts due to their socioeconomic status and environmental conditions (Sanyal et al., 2010). As a result, the persons experience various health conditions and health risk behaviors. About 30 communities in the U.S are dominantly minority communities with lower socioeconomic status, barriers to healthcare access, and increased risk of health conditions compared to the remaining population.  Environmental Risks. Health care disparities result when specific communities get exposed to a combination of poor environmental quality and social inequities. This makes people living in these areas to be at high risk of diseases. (Artiga et al., 2020) asserts that some communities reside in areas with adequate health care facilities. Whereas, some communities have reduced health care facilities, which reduces their ability to access health care services that match their needs.  Unequal Access to Health Care. Notably, the increasing economic inequality in the U.S is accompanied by increased level of disparities in health outcomes. Byrd and Clayton (2013) assert that the wealthy Americans life expectancy exceeds that of the poor individuals by about 15 years. This indicates that the wealthy get access to high-quality care while those with low-income access inadequate health care services. Grogan (2017) attributes unequal access to health care services because America relies on Private health insurance. In this regard, individuals with corporate-sponsored plans have better access to healthcare services than the remaining population. This results in disparity in health care. Irregular Source of Care.  Individuals from ethnic or racial minority groups are, in most cases, less likely to get access to health care services from the same doctor regularly than the whites. Additionally, Lee et al. (2010) add that individuals rely more on clinics and emergency rooms. As such, they do not access regular health care services, thus more difficulty in obtaining prescriptions according to their needs. Another factor that leads to the irregular source of care is structural barriers like lack of transport to the available healthcare providers and lengthy waiting times (Clouston and Link, 2021). The factors reduce the likelihood of the individuals to access health care services based on their health conditions successfully.  Health Care Disparities Drivers Multiple potential aspects could promote health care disparities; however, there is no single factor that can be pointed out as the cause. The following are some of the driving factors associated with disparities in the U.S’s health care. Socioeconomic inequality According to Joseph and Marrow (2017), racial groups are more likely to be employed in lower-paying jobs with less or no access to comprehensive insurance packages. Additionally, they experience high rates of unemployment which as a result hinder them from accessing high-quality health care. High numbers of minorities have less access to health insurance. Williams (2017) mentioned that people from lower socioeconomic families have limited access to education, resulting from the fact that more than 24\% of the minority groups live below the national poverty line, thus poor health outcomes. Notably, financial status directly impacts health. This is one of the major problems leading to disparities in health care coverage in the U.S.  Bias from Care Providers Grubbs (2019) explains that the difference in health care coverage between the minority and non-minority results from the persistence in racial bias and discrimination against the minorities within the health care system. There is implicit bias in how non-Hispanic white care providers offer treatment services to minority racial groups (Griffith et al., 2017). This as a result significantly influence and determine the extent of health care access among the minorities.  Forms of Disparities in the U.S Healthcare There are several forms of disparities that exist in the U.S health care system. Various social determinants such as age and sexual identity greatly impact the health outcome of individuals in a specific risk population (Artiga et al., 2020).  Race and Ethnicity Kelley et al. (2015) refer to racial and ethnic inequality as advantages and disadvantages that the different groups experience and how the socially constructed groups impact individuals. Despite the improvements in healthcare, education, and social mobility, Clouston and Link (2021) provides that health care disparities originating from race and ethnicity have remained a great problem in the United States. Racial and ethnic discrimination in health care contributes to increased morbidity and mortality levels among minorities. Some of the sources of the racial and ethnic disparities in health care include factors such as differences in location, inadequate health coverage, difficulties in communication between the providers and patients, and reduced access to providers (Kavanagh et al., 2021). Gender While women tend to have a longer life expectancy in most countries than men, the difference is not significant in America (Gonzalez et al., 2010). The average life expectancy of males in the U.S is 75, while that of females is 80. The difference results from cultural, biological, and environmental factors that combine to create gender behaviors differences (Byrd and Clayton, 2013). Women tend to rate their health worse and visit health care facilities more often than men of the same group. The disparities are not always based on biology but rather developed through the various experiences over the life course.  Geographic Area While several views provide that genetic code significantly determines the health status of a group of people, Travers et al. (2017) provide that zip code is a better health outcome predictor. In minority communities, the quality of health care is lower. Communities in urban or suburban areas have increased income levels, increasing the quality of health care services they receive. According to Blewett et al. (2018), communities in rural setup experience a high level of healthcare access challenges. Also, the areas have fewer job opportunities which significantly affect their income level. Williams (2017) found that people living in rural areas had poor health conditions due to reduced healthcare facilities and the number of providers. The study also provides that areas populated by minority groups have a high risk of certain conditions that adversely affect their health status.  Efforts towards Addressing Healthcare Disparities in the U.S In the past years, numerous interventions have been developed to address disparities in healthcare services and the quality of health care. However, most of the interventions have not been successful regardless of the improvements that have resulted from them (Wheeler and Bryant, 2017). The interventions reflect important gaps that have been in existence and continue to exist in the U.S health care system. For instance, the Centers for Population Health and Health Disparities established in 2003 to primarily eliminate disparities in access, and the quality of health care services developed various interventions focused on cardiovascular disease and cancer (Gonzalez et al., 2010). Based on the results that the group achieved, it is evident that reducing health care disparities does not only deal with one aspect like access or quality, but rather includes numerous aspects that should be taken into account to effectively eliminate such disparities (Lee et al., 2010). Decades of surveillance and research in the U.S estimated the cost of health inequalities and premature death between 2003 and 2006 to be about $2 trillion (Kavanagh et al., 2021). In response to the claim on health inequity, there have been various national initiatives, including Healthy People 2020 and National Partnership for Action to End Health Disparities, which have taken various strategies of providing health care services to individuals, especially among the minorities and people with low socioeconomic status (Clouston and Link, 2021). Based on the findings provided by Healthy People 2020, a solution that can be effective in addressing the persistent disparities in health care among the minorities should target an improvement in the various social determinants of health such as health care access, quality, and utilization (Kavanagh et al., 2021).  Another effort towards addressing healthcare disparities has been put by Public Health Accreditation Board which ensures that public health agencies meet national standards based on the essential health services (Travers et al., 2017). The provision of accreditation standards ensures improvement in community-driven health plans and emergency operations plans, which help address health equity and cultural competency among vulnerable populations (Artiga et al., 2020). According to Griffith et al. (2017), the accreditation process and national standards enacted in various healthcare facilities have in the past drove the focus towards vital actions which not only encourage preparedness and response of various communities to the health impacts but also improve efforts focused on addressing threats that minorities and other vulnerable communities’ experience. Notably, non-profit organizations have also participated in ensuring local strategies to improve health equity. For instance, NACCHO, an organization representing local public health department in the United States, has been working to protect and promote the health and well-being of all people (Kavanagh et al., 2021). The organization coordinates different services and programs that ensure that individuals are healthy and safe from health emergencies. ASTHO is another non-profit organization that directs its efforts towards ensuring healthy equity while also improving social determinants of health (Blewett et al., 2018). Since health inequalities result due to gender, sexual orientation, race, and geographical location, the vision of the organization, as Grubbs (2019) mentioned, is to support the state of health agencies to ensure health equity advancement and health care access to health care everyone.  A.C.A on Healthcare Disparities in the U.S Notably, disparities in health insurance coverage that regards ethnicity and race are some of the long-standing features in the health care system of the United States. Joseph et al. (2017) assert that reducing the level of exposure to broad medical coverage can lead to better financial outcomes, reducing disparities in health insurance coverage and economic inequality. In this regard, Dickman et al. (2017) provides that among the legislations that have shown a great improvement in addressing health care disparities is A.C.A. However, the legislation has not fully addressed the difference in health care.  According to Grogan (2017), millions of Americans who are disabled rely on the A.C.A for health insurance coverage. As such, increased healthcare coverage provided under the legislation has helped several disabled individuals access care based on income level. Clouston and Link (2021) provides that not all disabled people qualified for the traditional Medicaid disability before A.C.A. However, Medicaid expansion with A.C.A allows the individuals to join the workforce without putting their benefits in any danger and also allows low-income workers to access employer-sponsored insurance. Besides, Travers et al. (2017) indicate that the implementation of the legislation significantly reduced unmet needs that the population report due to the cost of health care.  No doubt, since the passage of the law, most seniors have benefited from it and the non-cost preventive services. Kelley et al. (2015) provides that A.C.A has significantly lowered out-of-pocket costs through “donut hole” for prescription drugs. Before implementing the legislation, the individuals who reached certain levels of prescription drug cost faced the donut hole, under which they had to incur the full cost of the prescription drugs. Before A.C.A covered the hole, most five million senior individuals on Medicare experienced it (Dickman et al., 2018).  Major primary care organizations and legislation have led to the endorsement of PCMH as a model with the potential to ensure reforms in the health care system and eliminate health care disparity. Griffith et al. (2017) provide that the model has primarily improved access to health care services while reducing the cost. However, Shakir et al. (2018) mentioned that the model should include equity dimensions that address different social determinants of a specific population. Many stakeholders regarding the PCMH initiatives provide and believe that a primary care system promoting preventive care and also offers services based on a community has an increased chance of reducing health disparities (Joseph and Marrow, 2017).  According to the study conducted by Griffith et al. (2017), the implementation of A.C.A made healthcare costs to become more affordable to several Americans despite their color, sex, or ethnicity. Under the legislation, most states have expanded Medicaid to millions of eligible low-and middle-income Americans. The various changes regarding enrollment and eligibility have ensured easier enrolment of children, with coverage requiring little to no cost-sharing. As mentioned in one study, better affordability improves access (Wheele and Bryant, 2017). Under A.C.A, there has been a significant reduction in the probability of individuals not receiving medical care due to the cost. As such, this dramatically increased the number of individuals who report their satisfaction with the care they receive.  Health Care Coverage among Minorities   Before A.C.A., there was a growing pattern of limited health care access among racial groups in America. Gonzalez et al. (2010) provide more insights into the various challenges that few Americans, the minorities, including the lowest rates of access and use of major depression therapies among Mexican and African American individuals. Based on the study, the authors provide that few Americans were able to access standard care. As such, ethnicity and race significantly impacted the nature of care individuals received before 2010. In addition to the information, Lee et al. (2010) further provide that underrepresented communities reported unique additional barriers to accessing health care in America. Based on their research to obtain in-depth information on health care access among Asian Americans, Lee et al. (2010) assert that the barriers occur due to limited opportunities and resources to the communities.  Sanyal et al. (2010) provided in their study that there existed a gap in the risk types that individuals belonging to different communities experience. After performing a database search, the authors claimed that treatment options in clinical setups favor some communities over others. Thus, there is a need to provide healthcare awareness and education to the communities at risk. Travers et al. (2017), based on their study to examine the various changes in racial disparities in forgone care before and after the Great Recession between 2006 and 2013, found that African-Americans were disproportionately after the Recession as they experienced financial constraints, compared to the whites, in obtaining medical care. This information adds to what Sanyal et al. (2010) demonstrate in their study on the risk gaps of various communities regarding access to health care services.  Before implementing A.C.A., the U.S. had a heavily privatized health care system that resulted in more than 42 million Americans with limited access to affordable health care. According to Joseph and Marrow (2017), the majority of this population was made of immigrants and minorities. The authors assert that most migrants are poor and are mainly people of color, and as such, they experience reduced treatment options. Dickman et al. (2017) provided through their research that economic inequality in America was responsible for increased disparities in health outcomes of individuals in various communities. Additionally, like others who have addressed the topic, poor Americans have worse healthcare access than wealthy individuals. The implementation and spread of A.C.A. have significantly eliminated health care coverage disparities among minorities. Blewett et al. (2018) assess health insurance disparities since the implementation of A.C.A. found that insurance rates reduced from 16.7\% to 5.5\% among racial groups. Based on the implementation, the authors conclude their research by mentioning that the extensive outreach and enrollment campaign among various communities in America played a significant role in eliminating coverage disparities among Blacks, the most overrepresented among the uninsured communities. In another study that analyzes the national health plan, Kavanagh et al. (2021) provide that A.C.A. has a guideline that countries use to ensure physical accessibility of health care facilities and policies for increasing affordable access to medicines.  Even though A.C.A.s future is not clear, the program remains one of the policies that will reduce various challenges that the U.S. health system faces. A study conducted by Shakir et al. (2018) to determine the different effects of P4P (Pay-for-performance) indicates that financial risks contribute to disparities among races and classes and across hospitals. The authors found that safety hospitals under the program experience increased penalties. However, it improves health outcomes among minority individuals. A.C.A.s introduction led to coverage gains among groups facing challenges like disparities (Artiga et al., 2020). However, the plan puts some groups at higher risk of increased health conditions and poor health outcomes than others.  The health system of Americans still has a long way to go in achieving health equity. Grogan (2017) provided that A.C.A. has been one of the significant steps the U.S. has taken in creating new programs and different regulations that have shown potential in improving health care equity. Based on one research that examined the extent to which A.C.A. reduced disparities in healthcare across socioeconomic groups, Griffith et al. (2017) assert that lower socioeconomic individuals in America made a substantial gain in the first two years of the acts implementation. Besides, the authors claim that the policy significantly improved health insurance coverage and access to care for the poor. As a result, this led to a reduced socioeconomic gap, which most minority communities do experience. Health care disparities can be taken to mean avoidable health differences that adversely affects various socially disadvantaged groups (Clouston and Link, 2021). Based on the conflict theory that provides structural conditions regarding competition between communities, the study focuses on the various social needs leading to the creation of groups based on classes, thus inequality. As such, different changes are the primary causes that create varying outcomes. Health disparities among underrepresented communities result from unique conditions that affect the population more than the remaining individuals, thus leading to significant differences. The various factors that the minorities experience impact the multiple outcomes that can either be similar for such communities or different.  Health Care Coverage of Middle Class  The middle class in America refers to individuals with income ranging from $ 44 000 to 88 000 for a family consisting of four people (Shakir et al., 2018). Considering that most individuals within the group have jobs, they depend on their employers insurance coverage to access high-quality care. Clouston and Link (2021) provide that lack of employer-based coverage and limited access to public coverage leaves close to 15 percent of Americans uninsured. Besides, the most uninsured middle-class individuals come from full-time workers. Even though the members of the population are employed, the insurance coverage is unaffordable, thus the increased insurance level. Kelley et al. (2015) provide that the availability of employer-sponsored coverage has been declining over the years. The firms that offered health coverage between 2000 and 2008 reduced from 69 percent to 63 percent. Notably, the nature of a job makes a difference in whether one is offered health insurance coverage or not (Dickman et al., 2017). For instance, most firms with a high percentage of low-wage workers in America are less likely to offer health benefits than high-wage firms. As Travers et al. (2017) mentioned, insurance becomes increasingly unaffordable for many when it is offered. This makes workers spend a large portion of their income annually to cater for their health care needs.  While A.C.A. has been described as resulting in devastating cuts to lower-income families and vulnerable American communities, it has improved middle-class individuals health coverage. However, Grubbs (2019) indicates that the legislation provides less attention to the middle class. Thus, they may not benefit from it as such. Importantly, most of the population groups get their coverage through the A.C.A. marketplace. This is one of the benefits that the legislation provides to middle-class individuals since, before its introduction, the individuals could easily lose their security of employer-based coverage (Joseph and Marrow, 2017). The legislation has made it possible to easily secure health insurance coverage.  Williams (2017) mentions that the middle-class is one of the vulnerable groups to high insurance costs A.C.A., which is based on the changes that former President Trump and his government pushed for. Based on the recommended changes, pulling the premium tax credits will create a large and stable market for individuals insurance. Defunding the cost-sharing reduction payments and the 2019 repeal would have adversely affected health care access among middle-class families as this would have increased the cost of health care access. Making the population realize the full benefits of the legislation requires the government to recognize that the individuals experience unaffordable insurance costs with less or no financial assistance (Kavanagh et al., 2021).  Theories The study will apply two social theories to support the results of the study. First, the conflict theory. In regards to the theory, issues associated with health care systems are rooted in capitalist society. As such, health care services have become a commodity that individuals must buy because they need them. In this view, people with money and power in different American communities decide how the healthcare system should run (Penner et al., 2013). Therefore, the dominant groups ensure adequate healthcare coverage while simultaneously ensuring that the underrepresented groups experience reduced access to the services. This, as a result, leads to disparities regarding various social services, including healthcare. The second theory that the research will be based on is interaction theory. The theory tries to provide specific insights regarding the relationship of various individuals to certain illnesses. It attributes health and illness to social constructions (Penner et al., 2013). A group of people who frequently experience a specific health condition, based on the theory, are associated with the conditions. The theory supports the fact that most American minorities are associated with various kinds of illness. They appear to be more vulnerable and in need of health care services. As a result, their needs exceed what is available, thus disparities in healthcare.  Terms and Concepts Health care disparity refers to the differences that exist in the access and availability of health care services. Also, it indicates variation in disease occurrence within population groups with different characteristics. Healthcare inequality describes unjust and avoidable differences existing in the nature of health care across a given population and between specific groups. Addressing healthcare disparities as “socially constructed” means that the disparities result from human interaction, and they exist because individuals agree that they exist. A capitalist society describes a society with different classes, hierarchies of power, and privileges.  Chapter three will describe how the data were collected that answer the research question and its component parts and studies that will be used to test the hypotheses in chapter four. References Artiga, S., Orgera, K., & Pham, O. (2020). Disparities in health and health care: Five key questions and answers. Kaiser Family Foundation. Blewett, L. A., Planalp, C., & Alarcon, G. (2018). Affordable Care Act impact in Kentucky: increasing access, reducing disparities. American journal of public health, 108(7), 924-929. Byrd, W. M., & Clayton, L. A. (2013). Racial and ethnic disparities in healthcare: A background and history. Unequal treatment: Confronting racial and ethnic disparities in health care, 455-527. Clouston, S. A., & Link, B. G. (2021). A Retrospective on Fundamental Cause Theory: State of the Literature and Goals for the Future. Annual Review of Sociology, 47. Dickman, S. L., Himmelstein, D. U., & Woolhandler, S. (2017). Inequality and the health-care system in the USA. The Lancet, 389(10077), 1431-1441. Gonzalez, H. M., Vega, W. A., Williams, D. R., Tarraf, W., West, B. T., & Neighbors, H. W. (2010). Depression care in the United States: too little for too few. Archives of general psychiatry, 67(1), 37-46. Griffith, K., Evans, L., & Bor, J. (2017). The Affordable Care Act reduced socioeconomic disparities in health care access. Health Affairs, 36(8), 1503-1510. Grogan, C. M. (2017). How the ACA addressed health equity and what repeal would mean. Journal of health politics, policy and law, 42(5), 985-993. Grubbs, V. (2019). Another Example of Race Disparities in the US Healthcare System. Joseph, T. D., & Marrow, H. B. (2017). Health care, immigrants, and minorities: lessons from the affordable care act in the US. Kavanagh, M. M., Norato, L. F., Friedman, E. A., & Armbrister, A. N. (2021). Planning for health equity in the Americas: an analysis of national health plans. Revista Panamericana de Salud Publica, 45, e29. Kelley, E., Moy, E., Stryer, D., Burstin, H., & Clancy, C. (2015). The national healthcare quality and disparities reports: an overview. Medical care, I3-I8. Lee, S., Martinez, G., Ma, G. X., Hsu, C. E., Robinson, E. S., Bawa, J., & … CHAPTER V-DISCUSSION, CONCLUSION AND RECOMMENDATIONS Discussion  Various countries continue to debate on better ways of expanding insurance coverage among minority and low-income Americans. The data provides vital evidence on the benefits that Americans have realized since the Affordable Care Act (A.C.A.) was introduced. The data analysis indicates that the insurance coverage in various states has been increasing over time, with a small impact realized during the first two years of its implementation. The study realized a pattern that indicates that the increase in health insurance coverage under Obamacare significantly reduced the cost-related barriers to care, outpatient visits, and an increase in the number of yearly checkups.   The study realized a slower spending growth among the poor and middle-income individuals before A.C.A. and during the first year of its implementation. This pattern is associated with the increased disparity in health care spending within different income groups during the period. However, the data do not provide adequate insights into whether the current acceleration in health expenditure has the potential of reversing the trend. The sharp increase in health expenditures among the high-income Americans and slow growth for the rest of the American population widen the income-based medical care receipt gap. Besides, there are increased chances that the gap might signify increased disparities in health care.  Notably, the low-income individuals had the lowest healthcare expenditure before A.C.A., besides their increased need for healthcare services. However, the expenditure for the healthy was twice that of the poor. Several factors might have contributed to this occurrence. One of the factors the study realized from the data is that most wealthy individuals enrolled for Medicaid when the program was first implemented. Another factor that might have contributed to the pattern is a reduced number of health care facilities and professionals in areas occupied by low-income groups, thus the increased spending to access the services (Manchikanti et al., 2017).  Since the implementation of A.C.A., various countries have reported significant improvement in the quality of care and health (Stefanacci, 2017). The improvement is associated with the Medicaid expansion under Obamacare, which is consistent with findings from some of the earlier evidence on the impact of the legislation on the health care system in the United States. The collected data indicate the increased quality of care even in areas of care shortages. As a result, this suggests that expansion in insurance services has demonstrated a positive impact in the areas regardless of the capacity of the clinicians.  The analysis of the data provides key contributions to the growing research on the Affordable Care Act. An increase in insurance coverage under the legislation resulted in increased access to primary care and medications and affordability of care services. Most of the changes were realized during the first three years of A.C.A. implementation. In this regard, the Americans who gained insurance coverage during the period realized larger policy-relevant changes, including reduced out-of-pocket medical expenditure, increased likelihood of accessing the source of care, and increased chances of experiencing excellent health. Prior research indicates that poor health rating increases the mortality risk among low-income groups than the remaining population (Alcalá et al., 2017). Based on the finding of this study, the effect can be eliminated through the policy interest of A.C.A. on health status. Most uninsured American families spend on premiums, deductibles copayments that are not subjected to their income. Due to this, the medical care expenses increase their poverty and income inequality level, which are some of the primary social determinants of health. In most cases, the techniques that the individuals use in care payment, especially when the insurance programs fail to scale premiums, can widen health disparities among a group regardless of their family status.  The pattern realized from examining the data related to the Gini index is attributable to the medical outlays. The values before the introduction of the A.C.A. suggest a modest improvement in the health care financing system. Based on this, it is possible to deduct that the individuals from low-income families increased their care utilization while ensuring that their medical outlays remain constant. The study findings indicate that most private insurance coverage offered under the legislation exchanges tend to lead to high deductibles. As a result, this can drive several families into extreme poverty despite the cost-sharing subsidies.  The data analysis indicates that various ethnic and racial minority groups experiencing disparities in health care access and coverage before the introduction of A.C.A. have realized improved measures under the legislation. In this regard, the African American minority group has realized the highest benefit as several individuals have had access to insurance coverage. For instance, African Americans are more likely to gain insurance coverage through Medicaid and Marketplace under A.C.A. than whites or other minority groups (Rosenkrantz et al., 2017). The findings also indicate a slower rate regarding the decline of the insurance rates among the Latino. This could be attributed to the individuals being more likely to live in American states that do not participate in the Medicaid expansion.  The study provides a snapshot of various ways in which the provisions of A.C.A. have significantly increased the insurance coverage among the minorities in American. The data demonstrate that the reform has increased Americas overall insurance coverage rate and eliminated insurance coverage disparities associated with ethnicity and race. The introduction of the legislation increased the number of insured Americans even though about 30 million individuals remain uninsured. Among the uninsured population, the number of racial and ethnic minorities remains the highest in the population size. This is because most minority groups experience low income. Considering that health expenditures account for a similar income share for the poor and rich, the difference in health care access exists.  The above results reflect the theoretical frameworks that support the study. Health and health care quality tend to differ greatly from one group to another. For instance, the results indicate increased access to health care services among black Americans than Latinos or whites after A.C.A. As a result, health care inequalities occur along with social class, race, and ethnicity (Alcalá et al., 2017). Notably, individuals from disadvantaged social backgrounds are most likely to experience limited access to health care services which negatively impacts their health status. Besides, the increased cost of healthcare services is likely to affect a portion of the population, with the highest impact felt among the minorities and low-income individuals.  The findings allow the demonstration of health care disparity as a social construction due to its existence as a result of human interactions. In this regard, the disparity is shaped by both historical and cultural contexts (Courtemanche et al., 2018). Based on this, society has a significant influence on the definition of the health status of individuals. For instance, the study results indicate that the low-class is associated with the minority groups. As such, society has a label for the position that such individuals hold. Thus they are often associated with increased levels of poverty and poor health conditions. Additionally, society and its members associate low-class families with reduced access to health care services, which explains health care disparities. Therefore, the results reflect the theoretical framework, conflict theory, and interactionism theory related to the causes of health care disparities in American society.  Limitations The study has several limitations. First, the study used peer review as the data collection method, which might have affected the data used in answering the research question. It is possible that the data collected from various research studies have changed due to time, and many people have benefited from A.C.A. Therefore, our results might not reflect the current impact of Obamacare regarding the number of uninsured Americans. However, the information provides a broad overview of the state of health care among Americans. Additionally, the study provides a great understanding of different American groups and their access levels to health care services regardless of when the actual data collection occurred. This provides great ground for developing effective policies for reducing health care disparities among the American population.  Second, the study results may be prone to bias which might have occurred from the previous studies that have been used in the research. There are high chances that during the review of the article, the individuals reviewing them may misinterpret the data collected, and as a result, this distorts the findings. The occurrence of biases due to the methodology might have reduced the validity and reliability of the research findings. However, researchers can implement various strategies such as ensuring sufficient depth and relevance of data and ensuring different perspectives in future research to improve the validity and reliability of their findings.  Conclusions A.C.A has significantly impacted the health care system of the United States since its implementation. The implementation of the legislation led to the expansion of health insurance coverage which provides increased opportunity to the Americans to enroll in the programs, thus saving thousands of lives. Its implementation reduced the number of uninsured individuals to historically low levels regardless of ethnic or racial groups of the individuals. Due to the complexity of the United States health system, it is difficult to measure the effects that the legislation has had on the cost and quality of the services offered within the system. However, based on other factors such as health status and health spending of various American families, it is safe to conclude that A.C.A has improved the quality and reduced the cost of health care services. More Americans have been covered through the expansion of Medicaid under A.C.A. Historically, Medicaid has been used to insuring low-income adults, children, and disabled people. However, the introduction of Obamacare has expanded the insurance cover of adults living below 138 percent of the federal poverty level. Additionally, its expansion has improved the number of newly eligible low and middle-income families to insurance coverage. The various changes that have resulted from the legislation make it easier for children to get enrolled and stay covered at a lower cost. Besides, A.C.A has opened new opportunities for the development and promotions of systems that allow Medicaid beneficiaries to enroll online for the services, thus increasing the coverage.  The disparity in health care is one of the major social issues that have been prevalent in the history of the American healthcare system. Among the ethnic and racial groups which have continued to show an increased number of uninsurance rates are Hispanic, Blacks and Latinos. The introduction of Obamacare has increased the ability of individuals to access quality health care services through the expansion of insurance coverage. Therefore, the Medicaid expansion under A.C.A has played a significant role in reducing disparities among the ethnic and racial minority groups in the United States.  Various efforts have been put in place in the United States to reduce disparities in health care. However, A.C.A is the only effective effort that has shown the potential for reducing the disparity. Based on the research findings, dealing with differences in health care access requires strategies that consider the socioeconomic status of individuals. The research deepens the understanding of individuals on the impact of the Affordable Care Act on Americans lives. Also, it demonstrates effective strategies that various groups can implement in their programs to eliminate disparities in healthcare in the United States.  Recommendations Considering that the introduction of A.C.A has not fully eliminated health care disparities, it is important for the government to initiate additional programs that raise public and provider awareness and expand health insurance coverage among the American population, especially among the minority groups. Additionally, there is a great need for the government and other private organizations to ensure an improved capacity of health care facilities and the number of providers in the underrepresented communities. It is vital to integrate information from different research to increase the knowledge base on the cause of healthcare disparities and interventions to reduce them.  There is a great need for different changes in the current health policies in America. It is essential for policymakers to assess the current health policies and determine ways to reduce the yearly increase in health care expenditure for the general population and increase access of the individuals to care despite the number of uninsured. The policies should also ensure improved quality and eliminate inequalities in healthcare. Achieving this will require the policymakers to stage a constructive policy debate that focuses on the coverage and spending of Americans on health care services.  Future research should explore healthcare utilization under A.C.A for specific racial and ethnic groups to provide detailed information on the impacts of the legislation on the health care system. Different states experience variations in health care reforms and strategies that include Medicaid expansion and health insurance coverage. Therefore, future research needs to evaluate the variation across different states to measure the impacts of the policies and identify the changes. Besides, the studies should incorporate other methodologies to explore the impacts further.  References Alcalá, H. E., Chen, J., Langellier, B. A., Roby, D. H., & Ortega, A. N. (2017). Impact of the Affordable Care Act on Health Care Access and Utilization among Latinos. The Journal of the American Board of Family Medicine, 30(1), 52-62. Courtemanche, C., Marton, J., Ukert, B., Yelowitz, A., & Zapata, D. (2018). Effects of the Affordable Care Act on Health Care Access and Self-Assessed Health after 3 Years. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 55, 0046958018796361. Manchikanti, L., Benyamin, R. M., & Hirsch, J. A. (2017). Evolution of US Health Care Reform. Pain physician, 20(3), 107-110. Rosenkrantz, A. B., Nicola, G. N., & Hirsch, J. A. (2017). Anticipated impact of the 2016 Federal Election on Federal Health Care Legislation. Journal of the American College of Radiology, 14(4), 490-493. Stefanacci, R. G. (2017). The Impact of Federal Health Care Reform on LTC. Annals of Long-Term Care. CHAPTER I- INTRODUCTION Introduction This paper will examine the difference in health care coverage in underrepresented American households before and after the introduction of healthcare under the Affordable Care Act. Chapter two will be a literature review; chapter three will describe in detail studies that will later be used to test the hypotheses in chapter four. Then chapter five will describe the results, the conclusion and the recommendation. Affordable Care Act (A.C.A.) is one of the federal health reforms signed on March 31, 2010, under the administration of former President Barack Obama. A.C.A. was primarily enacted to expand Americans access to insurance, put more effort into disease prevention and wellness, improve quality and system performance and reduce health care costs (Blewett et al., 2018). As described in the A.C.A. itself, it aims to extend insured Americans health coverage to around 32 million, including those with private and public insurance. Some of the guidelines related to expanding insurance access coverage include ensuring that employers offer insurance coverage to their workers, providing a tax credit to cover specified costs of health insurance of small business employees, and ensuring that individuals have insurance. Before introducing A.C.A., most Americans were not under any insurance health policy, especially the low-income individuals, since they could not afford the cost of insurance. Various insurance companies used individuals underwriting to protect a healthy risk pool by ensuring that Americans pay premiums that significantly reflected their medical plans (Grogan, 2017). In 2009, a year before the A.C.A. passage, only about 15\% of the American population had health insurance. The introduction of the Act in the subsequent year significantly reduced the rate of uninsured individuals as it lowered to about 9\%, indicating that almost 20 million Americans got insurance coverage in the first year of A.C.A. introduction. More than 31 million people are currently enrolled for health coverage through A.C.A., implying that the Act has significantly reduced the rate of insurance in every state. As of February 2021, about 11 million people enrolled in the A.C.A. Marketplace plans, while about 15 million enrolled in Medicaid through the Acts expansion of eligibility to adults by December 2020 (Kavanagh et al., 2021). Therefore, A.C.A. has benefited individuals from low-class and middle class and ethnic and minority households. Problem Statement The introduction of A.C.A. has significantly affected disparities in health insurance coverage among different racial and ethnic groups. Based on the U.S. Census Bureaus nationally representative American Community Survey, the increase in the rate of nonelderly adults enrolling for insurance coverage, which increased from 12.3\% in 2013 to about 40\% in 2017, led to a significant reduction in racial gaps. Notably, the insurance rates of underrepresented American households declined from 11\% to about 6\% (Christopher et al., 2018). Before introducing the Act, people of color, the underrepresented, were at higher risk of being uninsured than whites. This, as a result, reflected the limited access of the minority towards the health coverage options. Before A.C.A., the eligibility for various groups of color was limited to those with very low income. However, it helped in filling some of the gaps. The introduction of A.C.A. significantly improved health insurance coverage which led to increased Medicaid to nearly all adults with incomes below the poverty level. For instance, the groups of color experienced an increased percentage in the coverage compared to whites between 2010 and 2016 (Sommers et al., 2017). As such, the trend continues to significantly impact the health status of the underrepresented individuals making A.C.A. one of the primary aspects that reduce health care access disparities among Americans. Pointing out the difference in health care access coverage between before and after the introduction of A.C.A. will provide more insights into the importance of the Act on the well-being of the minorities. Policymakers can use the information to adjust policy, thus improving the coverage in underrepresented groups of Americans. The research analyzes the differences between the underrepresented American households before and after the introduction of A.C.A. We will identify the differences by performing a literature review to measure the impact of the Act. Research Questions The research question asked in this study is: Has the introduction of healthcare under the Affordable Care Act (Obamacare) increased the percentages of minority and lower-and middle-class households with health insurance significantly? Peer-reviewed data and studies from health organizations will be used to answer the research question and produce high quality research, other relevant information necessary that will help in addressing the topic. Research Hypotheses The first hypothesis tested in this study is that the introduction of healthcare under the Affordable Care Act increased the percentage of low-income American households with health insurance by 70\%. The second hypothesis tested in this study is that the introduction of A.C.A. increased the rate of middle-class American households with health insurance by 20\%. The third hypothesis tested in this study is that the introduction of A.C.A. has increased the percentage of ethnic and racial minority households in the United States with health insurance by 20\%. The next chapter will offer a literary review, a summary of research on the thesis of this study and provide the readers with sufficient background and understanding of the research topic. Reference Blewett, L. A., Planalp, C., & Alarcon, G. (2018). Affordable Care Act impact in Kentucky: increasing access, reducing disparities. American journal of public health, 108(7), 924-929. Grogan, C. M. (2017). How the ACA addressed health equity and what repeal would mean. Journal of health politics, policy and law, 42(5), 985-993. Kavanagh, M. M., Norato, L. F., Friedman, E. A., & Armbrister, A. N. (2021). Planning for health equity in the Americas: an analysis of national health plans. Revista Panamericana de Salud Publica, 45, e29. Christopher, A. S., Himmelstein, D. U., Woolhandler, S., & McCormick, D. (2018). The effects of household medical expenditures on income inequality in the United States. American Journal of Public Health, 108(3), 351-354. Sommers, B. D., Maylone, B., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2017). Three-year impacts of the Affordable Care Act: improved medical care and health among low-income adults. Health Affairs, 36(6), 1119-1128. CHAPTER IV- DATA AND ANALYSIS Introduction Based on the collected data from the previous chapter, the information supports the first hypothesis that: The introduction of healthcare under the Affordable Care Act (Obamacare) increased the percentage of low-income American households with health insurance by 70\%. The data also support the second hypothesis that: The introduction of healthcare under the Affordable Care Act (Obamacare) increased the percentage of ethnic and racial minority households in the United States with health increased by 20\%. Finally, the data support the last hypothesis of the study that: The introduction of healthcare under the Affordable Care Act (Obamacare) increased the percentage of ethnic and racial minority households in the United States with health insurance by 20\%. The paper examines the difference in health care coverage in the underrepresented American households before and after the implementation of the Affordable Care by analyzing the data from six different sources. The policy was enacted to primarily expand American’s access to insurance and improve the quality of health care services that American citizens get access to. As such, the reform has resulted in a significant impact regarding the health status of different groups living in America, especially among the minorities. Besides, the introduction of the reform has, over the years, been associated with a reduction in disparities in the U.S health care system. Notably, before A.C.A, various groups of color had limited access to health insurance coverage which adversely affected their health care conditions. Similarly, individuals from low-income families also experienced this effect. In this regard, the paper aims at answering a question that: Has the introduction of healthcare under the Affordable Care Act (Obamacare) increased the percentages of minority and lower-and middle-class households with health insurance significantly? The paper implements the statistical procedure used in the articles identified and whose data have been included in the research. In this regard, the paper depends on more than one method for analyzing data that will be used in answering the research questions. Additionally, the chapter explores data presented in all the articles and analyzed them to determine whether they support, partially support, or reject the hypotheses. Hypothesis #1 The first hypothesis that the paper is focused on is: The introduction of healthcare under the Affordable Care Act (Obamacare) increased the percentage of low-income American households with health insurance by 70\%. One of the research articles that the paper uses in testing the hypothesis outlined above is the study by Sommers et al. (2017). Based on the methods used by the researchers, the study found that 72 percent of the respondents living in Kentucky were affected with chronic conditions, 69 percent in Arkansas, and 55 percent in Texas. According to the results, the disease prevalence between 2013 and 2016 decreased within the expansion states with a P-value of 0.06. Sommers et al. (2017) provided that the mean number of various conditions including depression, hypertension, and diabetes ranged from 2.0 to 2.3. According to the results of the study, the three states involved in the research began the assessment when the uninsurance rate was about 40 percent among the low-income individuals. At the end of the research period, in 2014, the uninsurance rate was at 7.4 percent in Kentucky, 11.7 percent in Arkansas, and 28.2 percent in Texas. The study realized an increase in insurance coverage, access, affordability, and prevention with a p-value of 0.05 while that of quality was at p<0.010. Figure 1: Percentage of the uninsured Low-income adults between 2013 and 2016 The second article used in testing the hypothesis is by Sommers et al. (2016) and it addresses changes in utilization and health among low-income adults after the expansion of Medicaid. The study found that the expansion regarding health uninsurance rate reduced by 22.7 percent as of 2015 with a p-value less than 0.001. The expansion rate of insurance cover was associated with an increased rate of 12.1 percent and a p-value of less than 0.001. The results indicate that there was a reduced level of out-of-pocket spending for the respondents during the research period. The quality of care rating indicated significant improvement with a -7.1 percentage point indicating “fair/poor” care quality and a p-value of 0.03. Considering the states, Sommers et al. (2016) found that Arkansas realized an increased level of private insurance coverage while Kentucky showed an increased Medicaid of 1.3 percent. The uninsurance rate reduced from 41.1 to 14.2 percent in Arkansas, from 40.2 to 8.6 percent in Kentucky, and from 38.5 to 31.8 percent in Texas. During the research period, private coverage gains showed greater values in Kentucky and Arkansas. However, the two states showed the lowest Medicaid gains. Besides, the minority experienced a significant increase in insurance coverage which showed a p-value of 0.004. Both the two studies that address the first hypothesis realized an increase in the rate of insurance coverage expansion while the rate of uninsurance greatly reduced. The studies indicate high number of insurance rates for most respondents in the three cities between the starting and ending period of the research. The increase in health insurance coverage led to a reduced level of income spending on health care services and out-of-pocket spending among low-income individuals. In this regard, the two studies support the first hypothesis. They both realized an increase in the insurance coverage among the low-income individuals after the implementation of A.C.A thus supporting the hypothesis that: The introduction of healthcare under the Affordable Care Act (Obamacare) increased the percentage of low-income American households with health insurance by 70\%. Hypothesis 2 The second hypothesis is: The introduction of healthcare under the Affordable Care Acct (Obamacare) increased the percentage of middle-class American households with health insurance by 20\%. The first study that relates to the above hypothesis is by Dickman et al. (2016) and it addresses low-, middle- and high-class individuals’ spending on health. The results of the study indicate that the per capita health expenditure grew between 1963 and 2012. The researchers found that the health expenditure for the high-class income groups outpaced those of the middle-class individuals. Notably, individuals from low-class indicated the worst health status before the implementation of A.C.A. The study found an increase in prescription drug spending for the income groups after 2004. However, the high-income group showed an increased inpatient and outpatient expenditures while the middle-class indicated a flat growth and a declining growth for the low-class. Based on the research study, the researchers found that the participants from the high-class made 40 percent more outpatient visits per capita than the remaining groups with a higher spending per visit approximately $303 compared to $241 for the remaining groups by2012 (Dickman et al., 2016). The results indicate that private insurance expenditures for the three income groups became different after 2004. In this regard, the expenditures rose rapidly for the wealthiest groups while it fell for the low-income group. Concerning the per capita Medicare expenditure growth, the low-class individuals realized a slower growth than the middle- and high-class groups. Private insurance expenditures per enrollee for individuals younger than 65 years fluctuated for the low-class group indicated a modest growth for the middle-class and sharply increased for the wealthiest individuals. According to Dickman et al. (2016), the Medicaid spending for every nonelderly recipient significantly declined during the research period. However, the study did not realize any trend associated with the proportion of the total spending for the low-income group. Besides, the faster growth of expenditures realized among the poor before 2004 was driven by the costliest. However, the expenditures for both low-cost and high-cost after year surged. Figure 2: Diagram showing spending per capita The second study related to the hypothesis is “The Effects of Household Medical Expenditure on Income inequality in the United States.”  From the study, Christopher et al. (2018) indicated that the Gini index was 46.77 at the start of the research in 2010. However, subtracting medical outlays led to an increase in the index to 48.22. The researchers realized a Gini index of 47.84 in 2014 which increased to 49.21 after subtracting medical outlays. When premium contributions of employers were treated as additions to employee income, the research realized outlays redistribution of about 1.7 percent for all income groups, the poor, middle class, and wealthier individuals. The results indicate that the medical outlays in 2013 led to a decrease in income for the low-income individuals by 49.2 percent, 10.7 percent for the middle-income population, and 2.5 percent for the wealthiest group. This indicates unequal pattern that slightly improved in 2014 based on the research findings. Additionally, the medical outlays reduced for the median income individuals by 47.6 percent and 2.7 percent for the same group in the top decile. According to Christopher et al. (2018), about nine million American citizens whose incomes before subtracting their medical outlays for their family income were above the poverty level were pushed into the 150 percent federal poverty level in 2014. The two studies provide data on medical expenditures and income inequality regarding a section of the American population. Based on the data, there was a significant decrease after the implementation of Medicaid under Obamacare for all the income groups involved in the two studies. As such, the introduction of A.C.A among the Americans realized positive results, especially for the low- and middle-class individuals. Therefore, the data from the studies support the hypothesis that: The introduction of healthcare under the Affordable Care Act (Obamacare) increased the percentage of middle-class American households with insurance by 20\%. Hypothesis 3 The third hypothesis that the paper focuses on is: The introduction of healthcare under the Affordable Care Act (Obamacare) increased the percentage of ethnic and racial minority households in the United States with health insurance by 205. The first study that is related to the hypothesis is “The Effect of the Affordable Care Act on Racial and Ethnic Disparities in Health Insurance Coverage.”   The results of the study indicate that the percentage of adults in various groups, White, Black, and Hispanic of the uninsured individuals increased between 2008 and 2010. However, the values significantly declined between 2010 and 2013. Buchmueller et al. (2016) found an average coverage gap between Blacks and whites to be 11 percentage points while the average gap between Hispanics and whites was about 27 percentage points. The study found that the percentage of the uninsured reduced by 7.1 percent among Hispanic, 5.1 percent among Blacks, and 3 percent among whites in 2014. The results indicate a decline in public insurance coverage for all the three groups between 2008 and 2013 before realizing an increase between 2013 and 2014. During the period in which public insurance increased, the percentage point and gain were greater for the two minority groups than the Whites. In this regard, Buchmueller et al. (2016) indicated that private coverage for Hispanics increased by 4.3 percentage points, 3 percentage points for the Blacks, and 1.5 percentage points for the Whites. The public coverage between 2013 and 2014 increased by 2.8 percentage points for Hispanics, 1.9 percentage points for the Blacks and the whites realized an increase of 1.5 percentage points. Before A.C.A insurance expansions, about 60 percent of the Hispanic noncitizens were uninsured while only 28 percent of the Hispanic citizens were uninsured. Between 2013 and 2014, the percentage point change was 7.0 for Hispanic noncitizens and 6.7 for Hispanic citizens. In regards to the adults from families whose income was below 138 \%, the results indicate more decline for Hispanics (9.3 percentage points) than for the non-Hispanics (6.1 percentage points). The percentage of Blacks without health insurance reduced by 5.6 percentage points in 2013 considering the expansion states while the group realized a decrease of 4 percentage points in the non-expansion states. Figure 3: Uninsured percentage of the Nonelderly between 2008 and 2014 The second study that is related to the hypothesis is “Racial and Ethnic Disparities in Health Care Access and utilization under the Affordable Care Act.”  According to Chen et al. (2016), the study found that the implementation of A.C.A significantly reduced the rate of uninsured for all ethnicities and races. Based on the research study, the uninsured rate decreased by 7 percent for the African Americans and Latinos, 3 percent for the Whites, and 5 percent for the remaining racial and ethnic groups in 2014 compared to 2011. Additionally, the results show that 5 percent of the Latinos were likely to visit physicians, 3 percent for African Americans, and 2 percent for whites in 2014 compared to 2011. The implementation of Obamacare led to a significant reduction of the likelihood of an individual getting uninsured with a coefficient value of -0.03 and p-value <0.01. The delay in any necessary care was reduced with a coefficient value of -0.03 and a p-value <0.001. The reduction in the uninsured rates was more pronounced in 2014. Besides, the possibility of being uninsured in 2014 was 3 percentage points for the whites and 4 percentage points for the African Americans and Latinos. However, the likelihood of delayed or forgone care decreased by 2 percentage points for the Latinos. On the other hand, Chen et al. (2016) indicated that there was no significant difference for the African Americas compared to the Whites in regards to forgone care or physician visits in 2014. The data from the two studies indicate an increase in health care access among the ethnic and racial groups after the implementation of the A.C.A relativee to the periods before the reform. Based on the data, the rate of uninsured also reduced significantly over the years after A.C.A implementation. As such, the data support the hypothesis that: The introduction of healthcare under the Affordable Care Act (Obamacare) increased the percentage of ethnic and racial minority households in the United States with health insurance by 20\%. References Buchmueller, T. C., Levinson, Z. M., Levy, H. G., & Wolfe, B. L. (2016). Effect of the Affordable Care Act on racial and ethnic disparities in health insurance coverage. American journal of public health, 106(8), 1416-1421. Chen, J., Vargas-Bustamante, A., Mortensen, K., & Ortega, A. N. (2016). Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Medical care, 54(2), 140. Christopher, A. S., Himmelstein, D. U., Woolhandler, S., & McCormick, D. (2018). The effects of household medical expenditures on income inequality in the United States. American Journal of Public Health, 108(3), 351-354. Dickman, S. L., Woolhandler, S., Bor, J., McCormick, D., Bor, D. H., & Himmelstein, D. U. (2016). Health spending for low-, middle-, and high-income Americans, 1963–2012. Health Affairs, 35(7), 1189-1196. Sommers, B. D., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2016). Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance. JAMA internal medicine, 176(10), 1501-1509. Sommers, B. D., Maylone, B., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2017). Three-year impacts of the Affordable Care Act: improved medical care and health among low-income adults. Health Affairs, 36(6), 1119-1128.