Graduation Year


Document Type




Degree Name

MS in Public Health (M.S.P.H.)

Degree Granting Department

Public Health

Major Professor

Hamisu Salihu, M.D., Ph.D.

Co-Major Professor

Thomas Truncale, M.D., M.P.H.

Committee Member

Thomas E. Bernard, Ph.D.


Obamacare, healthcare, health insurance, perception


Background: Since 1965, there have not been any major revisions of the healthcare laws in the United States, until the recent implementation of the Affordable Care Act (ACA). However, ACA is not well understood and is often controversial. The purpose of this study is to: (1) evaluate the relationship between the employers’ and the employees’ perceptions regarding the ACA mandates for small businesses, (2) evaluate the relationship between the self-reported and the tested knowledge of individuals regarding the ACA mandates for small businesses, and (3) determine if socio-demographic factors influence individual’s perception of the law. Based on the gathered information, we aim to develop a socio-ecological model of ACA acceptance to address the barriers and facilitators to implementing the new law and recommend changes to address any deficits.

Method: An online questionnaire was distributed anonymously to employees and employers of small businesses. The data gathered included information on the participants' knowledge and perceptions on the law and their socio-demographic information. Kendall correlation test, generalized linear regression models and bootstrapping resampling method were employed to detect differences in the perceptions & knowledge of employees and employers, to evaluate the association between self-reported and tested knowledge, and to generate a SEM model of ACA perception and acceptance.

Results: Based on the analysis, we found that job status significantly affects the individual perception of the law (p = 0.004). The study showed a statistically significant negative association between the self-reported knowledge and the actual-tested knowledge of individuals (r= -0.4174, p-value of 0.01159). We found that interpersonal level had the highest impact on perception (coefficient of 5.67, p-value0.05).

Conclusion: Individual perception is a key factor in adoption of new policies. A socio-ecological model of ACA acceptance can be a powerful tool in addressing the barriers and facilitators to the successful implementation of the new law and to modify the policies to address any deficits in the law.