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Key Facts about the Uninsured Population

Decreasing the number of uninsured is a key goal of the Affordable Care Act (ACA), which provides Medicaid coverage to many low-income individuals in states that expand and Marketplace subsidies for individuals below 400% of the poverty line. Baseline estimates show that over 41 million individuals were uninsured in 2013, prior to the start of the major ACA coverage provisions, and early evidence suggests that the ACA has reduced this number. This brief describes trends in coverage leading up to the ACA, reviews early estimates of the impact of the ACA on the uninsured, examines the characteristics of the uninsured population, and summarizes the access and financial implications of not having coverage.

Summary: Key Facts about the Uninsured Population 

What was happening to the uninsured leading up to the ACA?

Trends in the uninsured have historically tracked economic conditions, with the number of uninsured people increasing during recessionary periods when people lost their jobs. Public programs provided a safety net during the Great Recession and prevented many from going uninsured. On the eve of the ACA, as the economy stabilized, coverage losses slowed. However, over 41 million people were still without coverage in 2013.

What has been happening to the uninsured under the ACA?

As of 2014, the ACA helps expand coverage to millions of currently uninsured people through the expansion of Medicaid eligibility and establishment of Health Insurance Marketplaces. The ACA also includes reforms to help people maintain coverage and make private insurance affordable and accessible. Early evidence on coverage in the first few months of 2014 indicates that the number of uninsured has declined since the availability of these new provisions.

Why are so many Americans uninsured?

The high cost of insurance has been the main reason why people go without coverage. In 2013, 61% of uninsured adults said the main reason they were uninsured was because the cost was too high or because they had lost their job. Many people do not have access to coverage through a job, and gaps in eligibility for public coverage in the past have left many without an affordable option.  Even after ACA coverage expansions, Medicaid eligibility for adults remains limited in states that did not expand their programs.

Who are the uninsured?

Most of the uninsured are in low-income working families. In 2013, nearly 8 in 10 were in a family with a worker, and nearly 6 in 10 have family income below 200% of poverty. Reflecting the more limited availability of public coverage, adults have been more likely to be uninsured than children. People of color are at higher risk of being uninsured than non-Hispanic Whites.

How does the lack of insurance affect access to health care?

People without insurance coverage have worse access to care than people who are insured. Almost a third of uninsured adults in 2013 (30%) went without needed medical care due to cost. Studies repeatedly demonstrate that the uninsured are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases.

What are the financial implications of lack of coverage?

The uninsured often face unaffordable medical bills when they do seek care. In 2013, nearly 40% of uninsured adults said they had outstanding medical bills, and a fifth said they had medical bills that caused serious financial strain.  These bills can quickly translate into medical debt since most of the uninsured have low or moderate incomes and have little, if any, savings.

What was happening to the uninsured leading up to the ACA?

The number of uninsured people steadily increased throughout most of the past decade due to decreasing employer sponsored insurance coverage and rising health care costs. The recent recession led to a steep increase in uninsured rates from 2008 to 2010 as a high jobless rate led millions to lose their employer sponsored coverage.1 Medicaid and CHIP prevented steeper drops in insurance coverage, as many Americans became newly eligible for these programs when their income declined during the recession. From 2011 to 2013, uninsured rates dropped as the economy improved and early provisions expanding coverage under the ACA went into effect.

Key Details:
Figure 1: Uninsured Rates Among the Nonelderly, 2000-2013

Figure 1: Uninsured Rates Among the Nonelderly, 2000-2013

  • The share of the nonelderly population with employer-sponsored coverage declined steadily between 2000 and 2010, dropping nearly ten percentage points over the decade.2 In 2011, this trend ended as the share with employer-sponsored coverage held nearly constant at around 58% between 2011 and 2013. This break in trend was likely due to uptake of the ACA provision that allowed young adults to continue as dependents on parents’ private plans until age 26. It also reflects improving economic conditions. The unemployment rate peaked at 10.0 percent in October 2009. From 2010 on, the unemployment rate improved steadily, corresponding with a drop in the uninsured rate from 2010 to 2013 (Figure 1).
  • The share of people covered by Medicaid increased significantly during the recent recession due to the weak economy and loss of jobs, which led to declining family incomes and decreasing employer-sponsored coverage among families. Between 2007 and 2013, over 10 million people—primarily children—gained Medicaid coverage. These gains offset some of the loss of employer coverage over the period.
  • In 2013, the uninsured rate among nonelderly individuals was at 16.7%, a level comparable to pre-recession uninsured rates (Figure 1). Still, many uninsured individuals had been uninsured for long periods, often five years or more,3 indicating that their lack of coverage was related to forces outside the recession. With the major ACA coverage provisions going into effect in 2014, many are newly-insured.

What has been happening to the uninsured under the ACA?

Under the ACA, as of 2014, Medicaid coverage is expanded to nearly all adults with incomes at or below 138% of poverty in states that expand, and tax credits are available for people who purchase coverage through a health insurance Marketplace. Early data suggest that the ACA has helped expand coverage to millions of previously uninsured people, but some—particularly poor adults in states that do not expand Medicaid—are still left without affordable coverage.

Key Details:
Figure 2: Percentage Point Decrease in Uninsured by State Medicaid Expansion Status, 2013- Q1 2014

Figure 2: Percentage Point Decrease in Uninsured by State Medicaid Expansion Status, 2013- Q1 2014

  • As of mid-April 2014 (after the first open enrollment period), over 8 million people selected plans through the federal or state Marketplaces.4 The vast majority of Marketplace enrollees (85%) were eligible for premium tax credits. Many Marketplace enrollees are newly-insured. A survey of people with private non-group plans after open enrollment found that nearly six in ten (57 percent) of those with Marketplace coverage were uninsured prior to purchasing their current plan.5 Other data from insurers suggest a large increase in the individual market in the first quarter attributable to the ACA.6
  • Enrollment data also show that as of July 2014, Medicaid enrollment has grown by 8 million since the period before open enrollment (which started in October 2013).7 This growth is an increase of 14% in monthly Medicaid enrollment.8 Enrollment increases were higher (20%) among states that chose to expand Medicaid eligibility. These data suggest that Medicaid enrollment growth is related to ACA expansions.9
  • Early survey data suggest that the uninsured rate is falling. The early release of estimates from the first quarter (January through March) of the 2014 National Health Interview Survey indicates that the uninsured rate dropped for nonelderly individuals in the first quarter of 2014 by a full percentage point relative to the first quarter of the previous year.10 However, the NHIS early results were not likely to have captured most or all of the ACA’s effects, as many people enrolled in coverage after survey data were collected. NHIS early results also show that states that chose to expand Medicaid saw significant declines in uninsured rates among adults from 2013 to the first quarter of 2014 (Figure 2). States that did not choose to expand Medicaid did not see corresponding declines. Several private polls and surveys also indicate that the uninsured rate has been decreasing since the period prior to ACA open enrollment. While these surveys have different methodologies and often have high error margins that make point estimates unreliable, they are all in agreement that the uninsured rate has dropped in 2014.
  • Even with the availability of new coverage options, millions remain uninsured. Previous analyses show that many poor adults in states that do not expand Medicaid will continue to be at risk to be uninsured.11 People of color, people living in the South,12 and individuals living in rural areas are especially at risk to be left out of ACA coverage expansions.13

Why are so many Americans uninsured?

Insurance is expensive, and few people can afford to buy it on their own. Most Americans obtain health insurance coverage through an employer, but not all workers are offered employer-sponsored coverage. Also, not all who are offered coverage by an employer can afford their share of the premiums. Medicaid and the Children’s Health Insurance Program (CHIP) cover many low-income individuals, particularly children. However, Medicaid eligibility for adults remains limited in some states, and few people can afford to purchase coverage on their own without financial assistance.

Key Details:
Figure 3: Reasons for Being Uninsured among Uninsured Nonelderly Adults, 2013

Figure 3: Reasons for Being Uninsured among Uninsured Nonelderly Adults, 2013

  • Uninsured individuals report that cost poses a major barrier to purchasing coverage. In 2013, 61% of adults said that the main reason they are uninsured is either because the cost is too high or because they lost their job, compared to 1.7% who said they are uninsured because they do not need coverage (Figure 3). Under the ACA, financial assistance is available to help many uninsured people afford coverage.
  • Not all workers have access to coverage through their job. Most uninsured workers are self-employed or work for small firms where health benefits are less likely to be offered.14 Low-wage workers who are offered coverage often cannot afford their share of the premiums, especially for family coverage.15,16
  • Workers usually enroll in employer-sponsored health insurance if they are eligible.17 However, it has become increasingly difficult for many workers to afford coverage. In 2014, the average annual total cost of employer-sponsored family coverage was $16,834, and the worker’s share averaging $4,823 per year.18 Between 2004 and 2014, total premiums have increased by 69%, and the worker’s share has increased over 81%.19 Starting in 2015, under the ACA, employers with 50 or more workers will be penalized if they do not offer affordable coverage. As of 2014, the ACA provides Marketplace tax credits or Medicaid coverage for many employees without access to affordable employer-sponsored insurance.20
  • In 2013, over 51 million nonelderly individuals were covered by Medicaid and CHIP.21 Historically, Medicaid was only available to low-income children, parents, pregnant women, people with disabilities, and the elderly. While states have increasingly expanded eligibility for children over time, eligibility for parents remained much more limited before ACA coverage expansions.22
  • As of September 2014, 28 states are moving forward or will be moving forward with expanded Medicaid eligibility for most nonelderly individuals under 138% FPL.23 This expansion will fill in historical gaps in eligibility for public coverage. However, in states that do not expand their Medicaid programs, eligibility for adults remains limited: the median eligibility level for parents is just 47% of poverty, and adults without dependent children are ineligible in nearly all states not expanding.

Who are the Uninsured?

The majority of the uninsured are in low-income working families. Reflecting the more limited availability of public coverage, adults are more likely to be uninsured than children. People of color are at higher risk of being uninsured than non-Hispanic Whites.

Key Details:
Figure 4:  Characteristics of the Nonelderly Uninsured, 2013

Figure 4: Characteristics of the Nonelderly Uninsured, 2013

  • Based on the most recent data that is available (which reflects coverage prior to the major ACA provisions), over six in ten of the uninsured have at least one full-time worker in their family, and 16% have a part-time worker in the family (Figure 4).
  • Individuals below poverty are at the highest risk of being uninsured, and this group accounted for 27% of all the uninsured in 2013 (the poverty level for a family of three was $19,530 in 2013). In total, almost nine in ten of the uninsured are in low- or moderate-income families, meaning they are below 400% of poverty (Figure 3).
  • While a plurality (46%) of the uninsured are White, non-Hispanic, people of color are at higher risk of being uninsured than White non-Hispanics. People of color make up 40% of the population but account for over half of the total uninsured population. The disparity in insurance coverage is especially high for Hispanics, who account for 19% of the total population but more than 30% of the uninsured population. Hispanics and non-Hispanic Blacks have significantly higher uninsured rates (25.6% and 17.3%, respectively) than Whites (11.7%).24
  • About eight in ten of the uninsured are U.S. citizens and 19.7% are non-citizens. Uninsured non-citizens include both lawfully present and undocumented immigrants. Undocumented immigrants and legal immigrants residing in the U.S. for less than five years are ineligible for federally funded health coverage.
  • Uninsured rates vary widely by state and by region, with individuals living in the South and West the most likely to be uninsured (Figure 5). This variation reflects different economic conditions, availability of employer-based coverage, demographics, and eligibility for public coverage.

How does the lack of insurance affect access to health care?

Figure 5: Uninsured Rates Among the Nonelderly by State, 2013

Figure 5: Uninsured Rates Among the Nonelderly by State, 2013

Almost a third of uninsured adults (30%) in 2013 went without needed care each year due to cost (Figure 5). Studies repeatedly demonstrate that the uninsured are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases.25, 26, 27, 28 Research also has suggested that insurance can decrease likelihood of depression and stress.29

Key Details:
  • Health providers can choose to not provide care to the uninsured. Only emergency departments are required by federal law to screen and stabilize all individuals. However, the uninsured are not necessarily more likely to use the emergency room than those with insurance.30 If the uninsured are unable to pay for care in full, they are often turned away when they seek follow-up care for urgent medical conditions.31
  • The uninsured receive less preventive care and recommended screenings than the insured. In 2013, only 1 in 3 uninsured adults (33%) reported a preventive visit with a physician in the last year, compared to 74% of adults with employer coverage and 67% of adults with Medicaid.32 Uninsured older adults (ages 50-64) were far less likely than their insured counterparts to report having been screened for cancer in the past five years.33
Figure 6:  Barriers to Health Care Among Nonelderly Adults by Insurance Status, 2013

Figure 6: Barriers to Health Care Among Nonelderly Adults by Insurance Status, 2013

  • Receiving needed care is especially important for the uninsured since they are generally not as healthy as those with private coverage. The uninsured are at higher risk for preventable hospitalizations and for missed diagnoses of serious health conditions.34 After a chronic condition is diagnosed, they are less likely to receive follow-up care and as a result are more likely to have their health decline.35 Lack of follow-up attributed to being uninsured can delay the detection of certain cancers, which can result in adverse outcomes.36 It follows that the uninsured also have significantly higher mortality rates than those with insurance.37,38
  • The uninsured report higher rates of postponing care and forgoing needed care or prescriptions due to cost compared to those enrolled in Medicaid and other public programs (Figure 6). A seminal study of health insurance in Oregon found that the uninsured were less likely to receive care from a hospital or doctor than newly insured Medicaid enrollees.39 A follow-up study found that newly insured Medicaid enrollees were much less likely to delay care because of costs than the uninsured.40

What are the financial implications of lack of coverage?

The uninsured often face unaffordable medical bills when they do seek care. These bills can quickly translate into medical debt since most of the uninsured have low or moderate incomes and have little, if any, savings.

Key Details:
Figure 7: Financial Consequences of Medical Bills by Insurance Coverage, 2013

Figure 7: Financial Consequences of Medical Bills by Insurance Coverage, 2013

  • Those without insurance for an entire year pay for one-fifth of their care out-of-pocket.41 They are typically billed for any care they receive, often paying higher charges than the insured.42
  • Medical bills can put great strain on the uninsured and threaten their physical and financial well-being. The uninsured are significantly more likely than individuals covered by employer coverage, non-group insurance or Medicaid to have trouble paying medical bills (Figure 7). Almost 40% of uninsured adults have outstanding medical bills.
  • A study based on the Oregon Health Insurance Experiment found that the uninsured were more likely to experience financial strain from medical bills and out-of-pocket expenses than those with Medicaid coverage. The uninsured were also more likely than the insured to have to postpone care because of costs.43
  • The uninsured live with the knowledge that they may not be able to afford to pay for their family’s medical care, which can cause anxiety and potentially lead them to delay or forgo care. Almost three-quarters (70%) of the uninsured are not confident that they can pay for the health care services they think they need, compared to 13% of those with employer coverage and 37% with Medicaid.44
  • The average uninsured household has no net assets.45 Without sufficient income or assets to pay their medical bills, uninsured individuals often see their debts accumulate while their credit ratings are compromised. Medical debts contribute to almost half of all bankruptcies in the United States.46

Conclusion

Over 41 million nonelderly individuals were uninsured in 2013.  This figure represents the baseline against which most changes in the ACA will be measured. While we do not yet know the full effect of the major coverage provisions of the ACA, early evidence indicates that it is working to expand insurance to those who need it.

Going without coverage can have serious health consequences for the uninsured because they receive less preventive care, and delayed care often results in more serious illness requiring advanced treatment. Being uninsured also can have serious financial consequences. The ACA holds promise for many people who will gain access to health insurance coverage, but monitoring how coverage changes and who is left out of coverage expansions is also important.

Endnotes
  1. Bureau of Labor Statistics. Labor Force Statistics from the Current Population Survey. Available at: http://data.bls.gov/timeseries/LNS14000000

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  2. Kaiser Commission on Medicaid and the Uninsured analysis of the 2000-2012 National Health Interview Surveys

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  3. R. Garfield, R. Licata, and K. Young, 2014. “The Uninsured at the Starting Line: Findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA.” Kaiser Family Foundation..

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  4. Health Insurance Marketplace: Summary Enrollment Report, October 1, 2013 - April 19, 2014, Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services (HHS); May 1, 2014. Available at: http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf

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  5. L. Hamel et al., 2014. “Survey of Non-Group Health Insurance Enrollees.” Kaiser Family Foundation. Available at: http://kff.org/report-section/about-the-groups/

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  6. C. Cox et al., 2014. “Individual Market Enrollment Ticks up in Early 2014.” Kaiser Family Foundation. Available at: http://kff.org/health-reform/issue-brief/individual-market-enrollment-ticks-up-in-early-2014/

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  7. Centers for Medicare and Medicaid Services. 2014. “Medicaid & CHIP: July 2014 Monthly Applications, Eligibility Determinations and Enrollment Report September 22, 2014.” Available at: http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/FINAL-July-Medicaid-Applications-Eligibility-Enrollment-Report-2.pdf

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  8. State Health Facts. “Total Medicaid and CHIP Enrollment, February – July, 2014.” Kaiser Family Foundation, 2014. Available at: http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/

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  9. Wachino et al., 2014. “How is the ACA Impacting Medicaid Enrollment?” Kaiser Family Foundation. Available at: http://kff.org/medicaid/issue-brief/how-is-the-aca-impacting-medicaid-enrollment/

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  10. National Center for Health Statistics. 2014.

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  11. Kaiser Family Foundation, 2013. “The Impact of the Coverage Gap in States not Expanding Medicaid by Race and Ethnicity.” Available at: http://kff.org/disparities-policy/issue-brief/the-impact-of-the-coverage-gap-in-states-not-expanding-medicaid-by-race-and-ethnicity/

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  12. J. Stephens, S. Artiga and J. Paradise, 2014. “Health Coverage and Care in the South in 2014 and Beyond.” Kaiser Family Foundation. Available at: http://kff.org/disparities-policy/issue-brief/health-coverage-and-care-in-the-south-in-2014-and-beyond/

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  13. V. Newkirk and A. Damico, 2014. “The Affordable Care Act and Insurance Coverage in Rural Areas.” Kaiser Family Foundation. Available at: http://kff.org/uninsured/issue-brief/the-affordable-care-act-and-insurance-coverage-in-rural-areas/

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  14. Kaiser Family Foundation analysis of the 2014 ASEC Supplement to the CPS.

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  15. Kaiser Family Foundation and Health Research & Educational Trust. 2013.  2013 Kaiser/HRET Employer Health Benefits Survey. Available at: http://www.kff.org/private-insurance/report/2013-employer-health-benefits/

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  16. State Health Access Data Assistance Center (SHADAC). 2013. “State-Level Trends in Employer-Sponsored Health Insurance.” Available at: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf405434

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  17. P. Cunningham, S. Artiga and K. Schwartz, 2008 “The Fraying Link Between Work and Health Insurance: Trends in Employer-Sponsored Insurance for Employees, 2000-2007.” (#7840 November).

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  18. Kaiser Family Foundation and Health Research & Educational Trust. 2014.  2014 Kaiser/HRET Employer Health Benefits Survey. Available at: http://files.kff.org/attachment/2014-employer-health-benefits-survey-full-report

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  19. Kaiser Family Foundation and Health Research and Educational Trust, 2013.

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  20. Kaiser Family Foundation. 2014. “Employer Responsibility Under the Affordable Care Act.” Available at: http://kff.org/infographic/employer-responsibility-under-the-affordable-care-act/

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  21. Kaiser Family Foundation analysis of the 2014 ASEC Supplement to the CPS.

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  22. Kaiser Family Foundation. 2013. “Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012–2013.” Available at: http://www.kff.org/medicaid/report/getting-into-gear-for-2014-findings-from-a-50-state-survey-of-eligibility-enrollment-renewal-and-cost-sharing-policies-in-medicaid-and-chip-2012-2013/

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  23. State Health Facts. “Status of State Action on the Medicaid Expansion Decision.” Kaiser Family Foundation, 2013. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

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  24. Kaiser Family Foundation analysis of the 2014 ASEC Supplement to the CPS.

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  25. Wilper et al., 2009, “Health Insurance and Mortality in US Adults.” American Journal of Public Health, 99(12) 2289-2295.

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  26. Collins et al., 2011, “Help on the Horizon: How the Recession Has Left Millions of Workers Without Health Insurance, and How Health Reform Will Bring Relief.” The Commonwealth Fund. Available at: http://www.commonwealthfund.org/Surveys/2011/Mar/2010-Biennial-Health-Insurance-Survey.aspx

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  27. J. Hadley, 2007, “Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition.” JAMA 297(10):1073-84.

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  28. S. Rhodes et al., 2012. “Cancer Screening—United States, 2010.” Centers for Disease Control. Available at: http://www.cdc.gov/mmwr/pdf/wk/mm6103.pdf

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  29. K. Baicker et al., 2013. “The Oregon Experiment — Effects of Medicaid on Clinical Outcomes.” N Engl J Med 368 (18): 1713-1722.

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  30. Newton et al. 2008. “Uninsured Adults Presenting to US Emergency Departments: Assumptions vs. Data”, JAMA 300(16):1914-24.

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  31. B. Asplin, et al, 2005, “Insurance Status and Access to Urgent Ambulatory Care Follow-up Appointments.,” JAMA  294(10):1248-54.

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  32. R. Garfield, R. Licata, and K. Young, 2014. “The Uninsured at the Starting Line: Findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA.” Kaiser Family Foundation.

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  33. Collins et al., 2011.

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  34. Institute of Medicine, 2002. Health Insurance is a Family Matter. Washington, DC.

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  35. J. Hadley, 2007.

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  36. S. Tejada et al., 2013. “Patient Barriers to Follow-Up Care for Breast and Cervical Cancer Abnormalities.” Journal of Women's Health 22(6):507-517.

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  37. Wilper et al., 2009.

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  38. Institute of Medicine, 2009. America’s Uninsured Crisis: Consequences for Health and Health Care. Washington, DC: National Academies Press. p. 60-63.

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  39. Finkelstein et al., 2011, “The Oregon Health Insurance Experiment: Evidence From the First Year”, National Bureau of Economic Research. Available at http://www.nber.org/papers/w17190

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  40. K. Baicker et al., 2013.

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  41. T. Coughlin, J. Holahan, K. Caswell and M. McGrath, 2014. “Uncompensated Care for the Uninsured in 2013: A Detailed Examination.” Kaiser Family Foundation. Available at: http://kff.org/uninsured/report/uncompensated-care-for-the-uninsured-in-2013-a-detailed-examination/

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  42. G. Anderson, 2007, “From ‘Soak The Rich’ To ‘Soak The Poor’: Recent Trends In Hospital Pricing.” Health Affairs 26(4): 780-789.

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  43. K. Baicker et al., 2013.

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  44. R. Garfield, R. Licata, and K. Young, 2014. “The Uninsured at the Starting Line: Findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA.” Kaiser Family Foundation. Available at: http://kff.org/report-section/the-uninsured-at-the-starting-line-findings-from-the-2013-kaiser-survey-of-low-income-americans-and-the-aca-iv-health-coverage-and-financial-security/

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  45. P. Jacobs and G. Claxton, "Comparing the Assets of Uninsured Households to Cost Sharing Under High Deductible Health Plans," Health Affairs 27(3):w214 (published online 15 April 2008).

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  46. D. Himmelstein et al., 2009. “Medical bankruptcy in the United States, 2007: results of a national study.” Am J Med. 122(8): 741-6. Available at: http://www.pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf

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