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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 extends Medicaid coverage to many low-income individuals in states that have expanded and provides Marketplace subsidies for individuals below 400% of poverty. The ACA’s major coverage provisions went into effect in January 2014 and have led to significant coverage gains. As of the end of 2015, the number of uninsured nonelderly Americans stood at 28.5 million, a decrease of nearly 13 million since 2013. This fact sheet describes how coverage has changed under the ACA, 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

How has the number of uninsured changed under the ACA?
In the past, gaps in the public insurance system and lack of access to affordable private coverage left millions without health insurance. Beginning in 2014, the ACA expanded coverage to millions of previously uninsured people through the expansion of Medicaid and the establishment of Health Insurance Marketplaces. Data show substantial gains in public and private insurance coverage and historic decreases in uninsured rates in the first and second years of ACA coverage. Coverage gains were particularly large among low-income people living in states that expanded Medicaid. Still, millions of people—28.5 million in 2015— remain without coverage.

Why do people remain uninsured?
Even under the ACA, many uninsured people cite the high cost of insurance as the main reason they lack coverage. In 2015, 46% of uninsured adults said that they tried to get coverage but did not because it was too expensive. Many people do not have access to coverage through a job, and some people, particularly poor adults in states that did not expand Medicaid, remain ineligible for financial assistance for coverage. Some people who are eligible for financial assistance under the ACA may not know they can get help, and others may still find the cost of coverage prohibitive. In addition, undocumented immigrants are ineligible for Medicaid or Marketplace coverage.

Who remains uninsured?
Most uninsured people are in low-income families and have at least one worker in the family.  Reflecting the more limited availability of public coverage in some states, adults are 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. One in five uninsured adults in 2015 (20%) 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 2015, over half of uninsured people (53%) said that they or someone in their household had problems paying medical bills in the past 12 months. These bills can quickly translate into medical debt since most of the uninsured have low or moderate incomes and have little, if any, savings.

How has the number of uninsured changed under the ACA?

In the past, gaps in the public insurance system and lack of access to affordable private coverage left millions without health insurance, and the number of uninsured Americans grew over time, particularly during periods of economic downturns. By 2013, more than 41 million people lacked coverage. Under the ACA, as of 2014, Medicaid coverage has been expanded to nearly all adults with incomes at or below 138% of poverty in states that have expanded, and tax credits are available for people who purchase coverage through a Health Insurance Marketplace. Millions of people have enrolled in these new coverage options, and the uninsured rate has dropped to a historic low. Coverage gains were particularly large among low-income people living in states that expanded Medicaid. Still, millions of people—28.5 million in 2015—remain without coverage.

Key Details:

  • The share of the nonelderly population that lacked insurance coverage hovered around 16% between 1995 and 2007, then peaked during the ensuing economic recession (Figure 1). As early provisions of the ACA went into effect in 2010, and as the economy improved, the uninsured rate began to drop. With the implementation of the major ACA coverage provisions in 2014, the uninsured rate dropped dramatically and continued to fall in 2015. In 2015, the nonelderly uninsured rate was 10.5%, the lowest rate in decades.
Figure 1: Uninsured Rate Among the Nonelderly Population, 1995-2015

Figure 1: Uninsured Rate Among the Nonelderly Population, 1995-2015

  • Coverage gains from 2013 to 2015 were particularly large among groups targeted by the ACA, including adults and poor and low-income individuals. The uninsured rate among nonelderly adults dropped from 20.4% in 2013 to 12.8% in 2015, representing a 7.6 percentage point drop, or a 37% decline. In addition, between 2013 and 2015, the uninsured rate declined by more than 10 percentage points for poor and near-poor nonelderly individuals (Figure 2). People of color, who had higher uninsured rates than non-Hispanic Whites prior to 2014, had larger coverage gains than non-Hispanic Whites. Though uninsured rates dropped across all states, they dropped more in states that chose to expand Medicaid (Figure 2). (See Appendix A for state-by-state data on changes in the uninsured rate).
Figure 2: Percentage Point Change in Uninsured Rate among the Nonelderly Population by Selected Characteristics, 2013-2015

Figure 2: Percentage Point Change in Uninsured Rate among the Nonelderly Population by Selected Characteristics, 2013-2015

  • Coverage gains were seen in new ACA coverage options. As of March 2016, over 11 million people were enrolled in state or federal Marketplace plans,1 and as of June 2016, Medicaid enrollment had grown by over 15 million (27%) since the period before open enrollment (which started in October 2013).2

Why do people remain uninsured?

Most of the nonelderly in the United States obtain health insurance through an employer, but not all workers are offered employer-sponsored coverage or, if offered, can afford their share of the premiums. Medicaid covers many low-income individuals, and financial assistance for Marketplace coverage is available for many moderate-income people. However, Medicaid eligibility for adults remains limited in some states, and few people can afford to purchase coverage without financial assistance. Some people who are eligible for coverage under the ACA may not know they can get help, and others may still find the cost of coverage prohibitive.

Key Details:

  • Cost still poses a major barrier to coverage for the uninsured. In 2015, 46% of uninsured adults said that the primary reason they were uninsured was because it was too expensive, making it the most common reason cited for being uninsured (Figure 3).3 Though financial assistance is available to many of the remaining uninsured under the ACA,4 not everyone who is uninsured is eligible for free or subsidized coverage.
  • Some individuals may remain uninsured because they are not aware of coverage options or face barriers to enrollment, even though they may be eligible for financial assistance under the ACA. In 2015, about one in five uninsured nonelderly adults said they remained uninsured because they didn’t know about the requirement to have health insurance (7%) or didn’t think the requirement applied to them (13%) (some in fact may be exempt under specific provisions of the law) (Figure 3). About one in ten said they tried to get coverage but were unable (11%),5 though under the ACA, insurers may no longer deny coverage to applicants based on pre-existing medical conditions or health status, and many enrollment barriers that appeared in the first year of ACA coverage have been addressed.
Figure 3: Primary Reason for Being Uninsured Among Uninsured Nonelderly Adults, 2015

Figure 3: Primary Reason for Being Uninsured Among Uninsured Nonelderly Adults, 2015

  • Not all workers have access to coverage through their job. In 2016, 73% of nonelderly uninsured workers worked at a firm that did not offer health benefits to the worker.6 The main reason uninsured workers give for not taking up an offer of coverage is that the coverage is unaffordable.7 From 2006 to 2016, total premiums for family coverage has increased by 58%, and the worker’s share has increased by 78%, outpacing wage growth.8
  • As of July 2016, 31 states plus DC have expanded Medicaid eligibility for most nonelderly adults under 138% FPL.9 However, in states that have not expanded Medicaid, eligibility for adults remains limited, with median eligibility level for parents just 44% of poverty and adults without dependent children ineligible in most cases.10 Millions of poor uninsured adults fall in a “coverage gap” because they earn too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits.11
  • Undocumented immigrants are ineligible for Medicaid and may not purchase Marketplace coverage.12 While lawfully-present immigrants under 400% FPL are eligible for Marketplace tax credits, only those who have passed a five-year waiting period after receiving qualified immigration status can qualify for Medicaid.

Who remains uninsured?

Most remaining uninsured people are in working families, and most are in families with low incomes.13 Reflecting income and the availability of public coverage, people who live in the South or West are more likely to be uninsured. Most who remain uninsured have been without coverage for long periods of time.

Key Details:

  • In 2015, nearly three quarters of the uninsured (74%) had at least one full-time worker in their family, and an additional 11% had a part-time worker in their family (Figure 4).
  • Individuals below poverty are at the highest risk of being uninsured (the poverty level for a family of three was $19,078 in 2015). In total, over eight in ten of the uninsured are in low- or moderate-income families, meaning they have incomes below 400% of poverty (Figure 4).
  • While a plurality (45%) of the uninsured are non-Hispanic Whites, people of color are at higher risk of being uninsured than Whites. People of color make up 41% of the nonelderly U.S. population but account for over half of the total nonelderly uninsured population (Figure 4). The disparity in insurance coverage is especially high for Hispanics, who account for 20% of the nonelderly population but nearly a third (32%) of the nonelderly uninsured population. Hispanics and Blacks have significantly higher uninsured rates (17.2% and 12.2%, respectively) than Whites (8.1%).14
Figure 4: Characteristics of the Nonelderly Uninsured, 2015

Figure 4: Characteristics of the Nonelderly Uninsured, 2015

  • Most of the uninsured (79%) are U.S. citizens, and 21% are non-citizens. Uninsured non-citizens include both lawfully present and undocumented immigrants. Undocumented immigrants are ineligible for federally funded health coverage, but legal immigrants can qualify for subsidies in the Marketplaces and those who have been in the country for more than five years are eligible for Medicaid.15
  • Uninsured rates vary by state and by region, with individuals living in the South and West the most likely to be uninsured. The sixteen states with the highest uninsured rates in 2015 were all in the South and West (Figure 5 and Appendix A). This variation reflects different economic conditions, state expansion status, availability of employer-based coverage, and demographics.
Figure 5: Uninsured Rates Among the Nonelderly by State, 2015

Figure 5: Uninsured Rates Among the Nonelderly by State, 2015

  • Over three-quarters (76%) of the remaining uninsured in 2015 have been without coverage for more than a year.16 People who have been without coverage for long periods may be particularly hard to reach in outreach and enrollment efforts.

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

Health insurance makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy they are. Uninsured adults are far more likely than those with insurance to postpone health care or forgo it altogether. The consequences can be severe, particularly when preventable conditions or chronic diseases go undetected.

Key Details:

  • 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.17, 18 One in five (20%) adults without coverage say that they went without care in the past year because of cost compared to 3% of adults with private coverage and 8% of adults with public coverage. Part of the reason for poor access among the uninsured is that most (54%) do not have a regular place to go when they are sick or need medical advice (Figure 6).19
Figure 6: Barriers to Health Care Among Nonelderly Adults by Insurance Status, 2015

Figure 6: Barriers to Health Care Among Nonelderly Adults by Insurance Status, 2015

  • Because of the cost of care, many uninsured people do not obtain the treatments their health care providers recommend for them. In 2015, uninsured adults were three times as likely as adults with private coverage to say that they postponed or did not get a needed prescription drug due to cost (20% vs. 6%).20 And while insured and uninsured people who are injured or newly diagnosed with a chronic condition receive similar plans for follow-up care, people without health coverage are less likely than those with coverage to obtain all the recommended services.21
  • Because people without health coverage are less likely than those with insurance to have regular outpatient care, they are more likely to be hospitalized for avoidable health problems and to experience declines in their overall health. When they are hospitalized, uninsured people receive fewer diagnostic and therapeutic services and also have higher mortality rates than those with insurance.22,23,24,25
  • Research demonstrates that gaining health insurance improves access to health care considerably and diminishes the adverse effects of having been uninsured. A seminal study of a Medicaid expansion in Oregon found that uninsured adults who gained Medicaid coverage were more likely to receive care than their counterparts who did not gain coverage.26 Many studies of the ACA Medicaid expansion point to improvements across a wide range of measures of access to care as well as utilization of some services, including behavioral health care services.27
  • Public hospitals, community clinics and health centers, and local providers that serve disadvantaged communities provide a crucial health care safety net for uninsured people. However, safety net providers have limited resources and service capacity, and not all uninsured people have geographic access to a safety net provider.28,29

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.30

Key Details:

  • Those without insurance for an entire year pay for one-fifth of their care out-of-pocket.31 In addition, hospitals frequently charge uninsured patients much higher rates than those paid by private health insurers and public programs.32,33
  • Medical bills can put great strain on the uninsured and threaten their financial well-being. In 2015, nonelderly uninsured adults were over two and a half times as likely as those with insurance to have problems paying medical bills (53% vs. 20%).34 Uninsured adults are also more likely to face negative consequences due to medical bills, such as using up savings, having difficulty paying for necessities, borrowing money, or having medical bills sent to collection (Figure 7).
Figure 7: Problems Paying Medical Bills by Insurance Status, 2015

Figure 7: Problems Paying Medical Bills by Insurance Status, 2015

  • Uninsured nonelderly adults are also much more likely than their insured counterparts to lack confidence in their ability to afford usual medical costs and major medical expenses or emergencies. Nearly eight of ten uninsured adults (79%) say they are very or somewhat worried about paying medical bills if they get sick or have an accident, compared to 45% of insured adults.35
  • Lacking insurance coverage puts people at risk of medical debt. In 2015, nearly half (45%) of uninsured adults said they owed money on at least one medical bill.36 Medical debts contribute to over half (52%) of debt collections actions that appear on consumer credit reports in the United States37 and contribute to almost half of all bankruptcies in the United States.38 Uninsured people are more at risk of falling into medical bankruptcy than people with insurance.39
  • Though the uninsured are typically billed for medical services they use, when they cannot pay these bills, the costs may become bad debt or uncompensated care for providers. State, federal, and private funds defray some but not all of these costs. With the expansion of coverage under the ACA, providers are seeing reductions in uncompensated care costs, particularly in states that expanded Medicaid.40
  • Research suggests that gaining health coverage improves the affordability of care and financial security among the low-income population. Multiple studies of the ACA have found larger declines in trouble paying medical bills in expansion states relative to non-expansion states. A separate study found that, among those residing in areas with high shares of low-income, uninsured individuals, Medicaid expansion significantly reduced the number of unpaid bills and the amount of debt sent to third-party collection agencies.41

Conclusion

While millions of people have gained coverage under the ACA provisions that went into effect in 2014, over 28 million nonelderly individuals remained uninsured in 2015. Many of these people are ineligible for ACA coverage, either because of their immigration status or because their state did not expand Medicaid. Others may be eligible but either do not know of the new coverage options, have had difficulty navigating the enrollment process, or opted not to take up coverage. Affordability of coverage, even with the availability of financial assistance, remains a barrier to insurance, with remaining uninsured adults naming cost as an ongoing major reason for not being insured.

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 has provided coverage to millions of people in the United States and has the potential to reach many more. Efforts to both extend eligibility in states that have not expanded Medicaid and reach the remaining uninsured who are eligible for coverage may enroll more people in coverage and ensure that fewer individuals and families will face the health and financial consequences of not having health insurance.

Endnotes
  1. State Health Facts. “Total Marketplace Enrollment and Financial Assistance, March 31 2016.” Kaiser Family Foundation, 2016, http://kff.org/health-reform/state-indicator/total-marketplace-enrollment-and-financial-assistance/

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  2. State Health Facts. “Total Monthly Medicaid and CHIP Enrollment.” Kaiser Family Foundation, June 2016, http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/.

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  3. Bianca DiJulio, Jamie Firth, and Mollyann Brodi,  Kaiser Health Tracking Poll: December 2015, (Washington, D.C.: Kaiser Family Foundation, Dec 2015),  http://kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-december-2015/

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  4. Rachel Garfield, Anthony Damico, Cynthia Cox, Gary Claxton, and Larry Levitt, New Estimates of Eligibility for ACA Coverage among the Uninsured (Washington, DC:  Kaiser Family Foundation, Jan 2016), http://kff.org/health-reform/issue-brief/new-estimates-of-eligibility-for-aca-coverage-among-the-uninsured/

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  5. 5 Kaiser Family Foundation, Few Uninsured Know Date of Pending Deadline for Obtaining Marketplace Coverage; Many Say They Will Get Coverage Soon, Though Cost is a Concern (Washington, D.C.: Kaiser Family Foundation, Dec 2015),  http://kff.org/health-costs/press-release/few-uninsured-know-date-of-pending-deadline-for-obtaining-marketplace-coverage-many-say-they-will-get-coverage-soon-though-cost-is-a-concern/

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  6. Kaiser Family Foundation analysis of the 2016 ASEC Supplement to the CPS

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  7. Ashley Kirzinger, Bianca DiJulio, Elise Sugarman, Bryan Wu, and Mollyann Brodie, A Final Look: California's Previously Uninsured after the ACA's Third Open Enrollment Period (Washington, D.C. : Kaiser Family Foundation, April 2016), http://kff.org/report-section/a-final-look-californias-previously-uninsured-after-the-acas-third-open-enrollment-period-section-3-the-remaining-uninsured/

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  8. Kaiser Family Foundation. 2016 Employer Health Benefits Survey (Washington, DC: Kaiser Family Foundation, September 2016), http://kff.org/report-section/ehbs-2016-summary-of-findings/

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  9. State Health Facts. “Status of State Action on the Medicaid Expansion Decision.” Kaiser Family Foundation, 2016, http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

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  10. Of the states not moving forward with the expansion, only Wisconsin provides full Medicaid coverage to adults without dependent children as of 2014. Rachel Garfield and Anthony Damico, The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid—An Update (Washington, DC: Kaiser Family Foundation, Jan 2016), http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/

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  11. Rachel Garfield and Anthony Damico, The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update (Washington, DC: Kaiser Family Foundation, January 2016), http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/

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  12. Kaiser Commission on Medicaid and the Uninsured, Key Facts on Health Coverage for Low-Income Immigrants Today and Under the Affordable Care Act (Washington D.C.: Kaiser Commission on Medicaid and the Uninsured, March 2013), http://kff.org/disparities-policy/fact-sheet/key-facts-on-health-coverage-for-low/

     

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  13. Kaiser Family Foundation analysis of the 2016 ASEC Supplement to the CPS.

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  14. Ibid.

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  15. “Coverage for Lawfully Present Immigrants”, CMS,  https://www.healthcare.gov/immigrants/lawfully-present-immigrants/

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  16.  Kaiser Family Foundation analysis of the 2015 National Health Interview Survey.

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  17. Jack Hadley, “Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition.” JAMA 297, no. 10 (March 2007):1073-84.

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  18. Stacey McMorrow, Genevieve M. Kenney, and Dana Goin,“Determinants of Receipt of Recommended Preventive Services: Implications for the Affordable Care Act,” American Journal of Public Health 104, no. 12 (Dec 2014): 2392-9.

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  19. Kaiser Family Foundation analysis of the 2015 National Health Interview Survey.

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  20. Kaiser Family Foundation analysis of the 2015 National Health Interview Survey.

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  21. Jack Hadley, “Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition,” JAMA 297, no. 10 (March 2007): 1073-84.

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  22.   Fizan Abdullah, et al., “Analysis of 23 Million US Hospitalizations: Uninsured Children Have Higher All-Cause In-Hospital Mortality,” Journal of Public Health 32, no. 2 (June 2010): 236-44.

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  23.   Andrew Wilper, et al., “Health Insurance and Mortality in US Adults,” American Journal of Public Health 99, no. 12 (December 2009): 2289-2295.

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  24. Wendy Greene, et. al., “Insurance Status is a Potent Predictor of Outcomes in Both Blunt and Penetrating Trauma.” American Journal of Surgery 199, no. 4 (April 2010): 554-7.

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  25. Sarah Lyon, “The Effect of Insurance Status on Mortality and Procedural Use in Critically Ill Patients,” American Journal of Critical Care Medicine 184, no. 7 (October 2011): 809-15.

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  26. Amy Finkelstein, et. al, “The Oregon Health Insurance Experiment: Evidence from the First Year” (National Bureau of Economic Research, July 2011), http://www.nber.org/papers/w17190

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  27. Larisa Antonisse, Rachel Garfield, Robin Rudowitz, and Samantha Artiga, The Effects of Medicaid Expansion on the ACA: Findings From a Literature Review (Washington, D.C.: Kaiser Family Foundation, Jun 2016),  http://kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-findings-from-a-literature-review/

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  28. Mark Hall, “Rethinking Safety Net Access for the Uninsured,” New England Journal of Medicine 364 (January 2011):7-9.

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  29. John Holahan and Brenda Spillman, Health Care Access for Uninsured Adults: A Strong Safety Net is not the Same as Insurance (Washington, DC: The Urban Institute, January 2002), http://www.urban.org/research/publication/health-care-access-uninsured-adults

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  30. Sherry Glied and Richard Kronick, The Value of Health Insurance: Few of the Uninsured Have Adequate Resources to Pay Potential Hospital Bills (Washington, DC: Office of Assistant Secretary for Planning and Evaluation, HHS, May 2011), http://aspe.hhs.gov/health/reports/2011/ValueofInsurance/rb.pdf

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  31. The Kaiser Commission on Medicaid and the Uninsured, Uncompensated Care for the Uninsured in 2013: A Detailed Examination, (Washington, D.C.: Kaiser Commission on Medicaid and the Uninsured, May 2014), https://kaiserfamilyfoundation.files.wordpress.com/2014/05/8596-uncompensated-care-for-the-uninsured-in-2013.pdf

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  32. Glenn Melnick, “Fair Pricing Law Prompts Most California Hospitals to Adopt Policies to Protect Uninsured Patients from High Charges,” Health Affairs 32, no. 6 (Jun 2013); 1101-8.

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  33. Stacie Dusetzina, Ethan Basch, and Nancy Keating, “For Uninsured Cancer Patients, Outpatient Charges Can Be Costly, Putting Treatments out of Reach,” Health Affairs 34, no. 4 (April 2015): 584-591, http://content.healthaffairs.org/content/34/4/584.abstract

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  34. Liz Hamel, Mira Norton, Karen Pollitz, Larry Levitt, Gary Claxton, and Mollyann Brodie, The Burden of Medical Debt: Results from the Kaiser Family Foundation/New York Times Medical Bills Survey, (Washington, D.C.: Kaiser Family Foundation, Jan 2016),  http://kff.org/health-costs/report/the-burden-of-medical-debt-results-from-the-kaiser-family-foundationnew-york-times-medical-bills-survey/

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  35. Kaiser Family Foundation analysis of the 2015 National Health Interview Survey.

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  36.  Kaiser Family Foundation/New York Times Medical Bills Survey, Jan 2016, https://kaiserfamilyfoundation.files.wordpress.com/2016/01/8806-t-the-burden-of-medical-debt-results-from-the-kaiser-family-foundation-new-york-times-medical-bills-survey-topline.pdf

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  37. Consumer Financial Protection Bureau, “Consumer Credit Reports: A Study of Medical and Non-Medical Collections.” (Consumer Financial Protection Bureau: December 2014), http://files.consumerfinance.gov/f/201412_cfpb_reports_consumer-credit-medical-and-non-medical-collections.pdf

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  38. David U. Himmelstein, Deborah Thorne, Elizabeth Warren, Steffie Woolhandler, “Medical Bankruptcy in the United States, 2007: Results of a National Study.” The American Journal of Medicine, 122, no. 8 (2009): 741-6, http://www.pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf

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  39. Ibid.

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  40. Larisa Antonisse, Rachel Garfield, Robin Rudowitz, and Samantha Artiga, The Effects of Medicaid Expansion on the ACA: Findings From a Literature Review (Washington, D.C.: Kaiser Family Foundation, Jun 2016),  http://kff.org/report-section/the-effects-of-medicaid-expansion-under-the-aca-findings-from-a-literature-review-issue-brief/

     

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  41. Ibid.

     

     

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