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The Uninsured: A Primer - Key Facts about Health Insurance on the Eve of Coverage Expansions

Introduction
  1. G. Kenney, et al. 2013 “State and Local Coverage Changes under Full Implementation of the Affordable Care Act.” Kaiser Family Foundation and The Urban Institute. Available at: http://www.kff.org/report-section/state-and-local-coverage-changes-under-full-implementation-of-the-affordable-care-act-report/

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  2. The ACA expands Medicaid eligibility, beginning in 2014, to people under age 65 who have incomes at or below 138% of the federal poverty level. The Supreme Court ruling on the ACA maintains the Medicaid expansion but limits the Secretary’s authority to enforce it. If a state does not implement the expansion, the Secretary cannot withhold existing federal program funds. For more information: Musumeci M. 2012. “Implementing the ACA’s Medicaid-Related Health Reform Provisions After the Supreme Court’s Decision.” Kaiser Family Foundation Available at: http://www.kff.org/health-reform/issue-brief/implementing-the-acas-medicaid-related-health-reform/

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How Do Most Americans Obtain Health Insurance?
  1. 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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  2. KCMU/Urban Institute analysis of 2013 ASEC Supplement to the CPS.

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  3. Kaiser Family Foundation Analysis of April – July 2010, SIPP 2008 Panel Data.

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

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

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

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

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  8. State Health Access Data Assistance Center (SHADAC). 2011. State Level Trends in Employer Sponsored Health Insurance: A State-by-State Analysis. Available at: http://www.shadac.org/files/shadac/publications/ESI_Trends_Jun2011.pdf

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

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  10. State Health Access Data Assistance Center. 2013. “State-Level Trends in Employer-Sponsored Health Insurance: A State-by-State Analysis.” Available at: http://www.shadac.org/files/shadac/publications/ESI_Report_2013.pdf

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  11. KCMU/Urban Institute analysis of 2013 ASEC Supplement to the CPS.

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  12. Cox C, Levitt L, Damico A, and Claxton G. 2011. “Mapping Premium Variation in the Individual Market.” Kaiser Family Foundation. Available at: http://www.kff.org/health-reform/issue-brief/mapping-premium-variation-in-the-individual-market/

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  13. America’s Health Insurance Plans. 2009 “Individual Health Insurance 2009: A Comprehensive Survey of Premiums, Availability and Benefits.”

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  14. Kenney G, et al. 2013. Medicaid/CHIP Participation Rates among Children: an Update, Available at: http://www.urban.org/uploadedpdf/412901-%20Medicaid-CHIP-Participation-Rates-Among-Children-An-Update.pdf

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  15. Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2010 MSIS.  2009 MSIS data was used for Colorado, Idaho, Missouri, and West Virginia, because 2010 data was unavailable

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  16. Heberlein M, et al. 2013.

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  17. The Patient Protection and Affordable Care Act extends Medicaid eligibility to 133% of poverty, but a special income deduction equal to five percentage points of the poverty level effectively raises the eligibility level to 138% of poverty.

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  18. “Status of State Action on the Medicaid Expansion Decision, as of September 30, 2013,” Kaiser Family Foundation. Retrieved October 17, 2013 from http://www.kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

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  19. States have the option to provide Medicaid coverage to immigrant children and pregnant women who have legally been in the United States for less than five years.

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Who are the Uninsured?
  1. KCMU analysis of 2013 National Health Interview Survey data.

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  2. Levitt L, Claxton G and Damico A. 2011. “Measuring the Affordability of Employer Health Coverage.” Kaiser Commission on Medicaid and the Uninsured. Available at: http://www.kff.org/health-costs/perspective/measuring-the-affordability-of-employer-health-coverage/

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

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  4. KCMU analysis of 2013 National Health Interview Survey data.

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  5. KCMU/Urban Institute analysis of 2013 ASEC Supplement to the CPS.

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

     

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  7. Kaiser Commission on Medicaid and the Uninsured.  2013. “Key Facts on Health Coverage for Low-Income Immigrants Today and Under the Affordable Care Act.” Available at: http://www.kff.org/disparities-policy/fact-sheet/key-facts-on-health-coverage-for-low/

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  8. Heberlein M, et al. 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.” Kaiser Commission on Medicaid and the Uninsured. 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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  9. KCMU/Urban Institute analysis of 2013 ASEC Supplement to the CPS.

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  10. Kaiser Commission on Medicaid and the Uninsured. 2012. “The Role of Medicaid for Adults with Chronic Illnesses.” Available at: http://www.kff.org/health-reform/fact-sheet/the-role-of-medicaid-for-adults-with/

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  11. Kaiser Family Foundation. 2012 “Summary of Coverage Provisions in the Patient Protection and Affordable Care Act.” Available at: http://www.kff.org/health-costs/issue-brief/summary-of-coverage-provisions-in-the-patient/

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  12. Carrier E, Yee T, and Garfield R. 2011. “The Uninsured and Their Health Care Needs: How Have They Changed Since the Recession.” Kaiser Commission on Medicaid and the Uninsured. Available at: http://www.kff.org/uninsured/issue-brief/the-uninsured-and-their-health-care-needs-how-have-they-changed-since-the-recession/

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  13. Marks C, Schwartz T, and Donaldson L, 2009. “State Variation and Health Reform: A Chartbook”. Kaiser Commission on Medicaid and the Uninsured. Available at: http://www.kff.org/health-reform/report/state-variation-and-health-reform-a-chartbook/

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How and Why Has the Number of Uninsured People Changed?
  1. Collins S, et al. 2012.

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  2. Holahan J and Chen V, 2011. “Changes in Health Insurance Coverage in the Great Recession, 2007-2010.” Kaiser Commission on Medicaid and the Uninsured. Available at: http://www.kff.org/medicaid/issue-brief/changes-in-health-insurance-coverage-in-the/

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  3. Bureau of Labor Statistics.  (Accessed August 6, 2012) Available at: http://data.bls.gov/timeseries/LNS14000000

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  4. Schwartz K and Streeter S, 2011. “Health Coverage for the Unemployed.” Kaiser Commission on Medicaid and the Uninsured. Available at: http://www.kff.org/health-costs/issue-brief/health-coverage-for-the-unemployed/

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  5. Holahan et al., 2013. “Reversing the Trend? Understanding the Recent Increase in Health Insurance Coverage among the Nonelderly Population.” Kaiser Commission on Medicaid and the Uninsured. Available at: http://www.kff.org/uninsured/issue-brief/reversing-the-trend-understanding-the-recent-increase-in-health-insurance-coverage-among-the-nonelderly-population/

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  6. Heberlein M, et al. 2013.

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  7. KCMU analysis of 2013 National Health Interview Survey data.

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  8. KCMU/Urban Institute analysis of 2013 ASEC Supplement to the CPS.

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How Does Lack of Insurance Affect Access to Health Care?
  1. Kenney GM, McMorrow S, Zuckerman S, Goin DE. 2012. “A Decade of Health Care Access Declines for Adults Holds Implications for Changes in The Affordable Care Act.” Health Affairs 31(5): 899-908.

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  2. 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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  3. Rhodes S 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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  4. Tejada S 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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  5. Wilper et al., 2009, “Health Insurance and Mortality in US Adults.” American Journal of Public Health, 99(12) 2289-2295.

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  6. Simard EP, et al. 2012. “Widening Socioeconomic Disparities in Cervical Cancer Mortality Among Women in 26 States, 1993-2007.” Cancer.

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  7. 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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  8. Cohen R, et al. 2013. “Strategies Used by Adults to Reduce their Prescription Drug Costs.” National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/data/databriefs/db119.pdf

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  9. Hadley J, 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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  10.   Abdullah F, et al. 2010. “Analysis of 23 Million US Hospitalizations: Uninsured Children Have Higher All-Cause In-Hospital Mortality.” Journal of Public Health. 32(2):236-44.

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

     

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  12. Greene WR, et al. 2010. “Insurance Status is a Potential Predictor of Outcomes in Both Blunt and Penetrating Trauma.” American Journal of Surgery. 199(4):554-7.

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  13. Lyon SM. 2011. “The Effect of Insurance Status on Mortality and Procedural Use in Critically Ill Patients.” American Journal of Critical Care Medicine. 184(7): 809-15.

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  14. Collins S, et al. 2011.

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  15. Institute of Medicine, 2009.

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  16. Collins S, et al. 2012. “Gaps in Health Insurance: Why So Many Americans Experience Breaks in Coverage and How the Affordable Care Act Will Help.” The Commonwealth Fund. Available at: http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Apr/1594_collins_gaps_in_hlt_ins_tracking_brief_v2.pdf

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  17. Cassedy A, Fairbrother G, and Newacheck PW. 2008. “The Impact of Insurance Instability on Children’s Access, Utilization, and Satisfaction with Health Care. Ambulatory Pediatrics. 8(5):321-8.

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  18. Finkelstein A, 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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  19. Baicker K, et al. 2013. “The Oregon Experiment — Effects of Medicaid on Clinical Outcomes.” N Engl J Med. 368:1713-1722. Available at: http://www.nejm.org/doi/full/10.1056/NEJMsa1212321

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  20. Sommers BD, Baicker K, and Epstein AM. 2012. “Mortality and Access to Care Among Adults After State Medicaid Expansions.” N Engl J Med. 367:1025-1034.

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  21. Hall M. 2011. “Rethinking Safety-Net Access for the Uninsured.” N Engl J Med. 364:7-9.

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  22. Shin P, Rosenbaum S, and Paradise J. 2012. “Community Health Centers: The Challenge of Growing to Meet the Needs for Primary Care in Medically Underserved Communities.” Kaiser Commission on Medicaid and the Uninsured. (#8098-02; March).

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  23. Summer L. 2011. “The Impact of the Affordable Care Act on the Safety Net.” AcademyHealth.  Available at: http://www.academyhealth.org/files/FileDownloads/AHPolicybrief_Safetynet.pdf

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  24. Cunningham P and Hadley J. 2008. “Effects of Changes in Incomes and Practice Circumstances on Physicians’ Decisions to Treat Charity and Medicaid Patients.” The Milbank Quarterly 86(1): 91-123.

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  25. Shin P et al. March 2013.  Community Health Centers in an Era of Health Reform: An Overview and Key Challenges to Health Center Growth . Kaiser Commission on Medicaid and the Uninsured. Available at:  http://www.kff.org/health-reform/issue-brief/community-health-centers-in-an-era-of-health-reform-overview/

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  26. Shin P et al. March 2013.

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What Are the Financial Implications of Lack of Coverage?
  1.   Collins et al. 2011

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

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  3. Carrier E, Yee T, and Garfield R. 2011.

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

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  5. Hadley J, Holahan J, Coughlin T, and Miller D. 2008. “Covering the Uninsured in 2008: Current Costs, Sources of Payment, and Incremental Costs.” Health Affairs 27(5):w399-415.

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  6. Caswell K, O’Hara B. 2010. “Medical Out-of-Pocket Expenses, Poverty, and the Uninsured.” U.S. Census Bureau. Available at: http://www.census.gov/hhes/povmeas/methodology/supplemental/research/Caswell-OHara-SGE2011.pdf

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  7. Hadley J, et al. 2008.

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  8. Hadley J, et al. 2008.

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  9. “Federal Medicaid Disproportionate Share Hospital (DSH) Allotments,” Kaiser Family Foundation. http://www.kff.org/medicaid/state-indicator/federal-dsh-allotments/

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  10. Congressional Budget Office. July 2012. “Estimates for Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decisions.” Available at:

    http://www.cbo.gov/sites/default/files/cbofiles/attachments/43472-07-24-2012-CoverageEstimates.pdf

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  11. Kaiser Family Foundation’s Health Tracking Poll: June 2010. Available at: http://www.kff.org/kaiserpolls/8082.cfm

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  12. Glied S and Kronick R, 2011. “The Value of Health Insurance: Few of the Uninsured Have Adequate Resources to Pay Potential Hospital Bills.” Office of Assistance Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Available at: http://aspe.hhs.gov/health/reports/2011/ValueofInsurance/rb.pdf

     

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

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  14. Cohen RA, et al. 2012. “Financial Burden of Medical Care: Early Release of Estimates from the National Health Interview Survey, January-June 2011.” Centers for Disease Control and Prevention.  Available at: http://www.cdc.gov/nchs/data/nhis/earlyrelease/financial_burden_of_medical_care_032012.pdf

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  15. Himmelstein D, 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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How Will the Affordable Care Act Affect the Uninsured Population?
  1. Smith V, et al. 2013. “Medicaid in a Historic Time of Transformation: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014.” Kaiser Commission on Medicaid and the Uninsured. Available at: http://www.kff.org/medicaid/report/medicaid-in-a-historic-time-of-transformation-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2013-and-2014/

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  2. “Status of State Action on the Medicaid Expansion Decision, as of September 30, 2013,” Kaiser Family Foundation. Available at: http://www.kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

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  3. “Medicaid Eligibility for Adults as of January 1, 2014.” 2013. Kaiser Family Foundation. Available at: http://www.kff.org/medicaid/fact-sheet/medicaid-eligibility-for-adults-as-of-january-1-2014/

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  4. “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid.” 2013. Kaiser Commission on Medicaid and the Uninsured. Available at: http://www.kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/

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  5. “State Decisions For Creating Health Insurance Exchanges, as of May 28, 2013,” Kaiser Family Foundation. Available at http://www.kff.org/health-reform/state-indicator/health-insurance-exchanges/

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  6. Kaiser Family Foundation Analysis based on 2014 Medicaid eligibility levels.

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  7. “State-by-State Estimates of the Number of People Eligible for Premium Tax Credits Under the Affordable Care Act.” 2013. Kaiser Family Foundation. Available at: http://kff.org/report-section/state-by-state-estimates-of-the-number-of-people-eligible-for-premium-tax-credits-under-the-affordable-care-act-methods/

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  8. Kenney G et al., 2013.

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  9. Holahan, et al., “The Cost of Not Expanding Medicaid,” Kaiser Commission on Medicaid and the Uninsured, July 2013. Available at: http://www.kff.org/medicaid/report/the-cost-of-not-expanding-medicaid/

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  10. Congressional Budget Office. July 2012.

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  11. Hoffman C, Damico A, and Garfield R. 2011. “Research Brief: Insurance Coverage and Access to Care in Primary Shortage Areas.” Kaiser Commission on Medicaid and the Uninsured, February 2011.

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