Key Facts about the Uninsured Population

The Affordable Care Act (ACA) led to historic gains in health insurance coverage by extending Medicaid coverage to many low-income individuals and providing Marketplace subsidies for individuals below 400% of poverty. Under the law, the number of uninsured nonelderly Americans decreased from 44 million in 2013 (the year before the major coverage provisions went into effect) to less than 28 million as of the end of 2016. Recent efforts to alter the ACA or fundamentally change the structure of Medicaid may pose a challenge to further reducing the number of uninsured and may threaten coverage gains seen in recent years.

How has the number of #uninsured people changed under the #ACA?

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 under the ACA. Coverage gains were particularly large among low-income people living in states that expanded Medicaid. Still, millions of people—27.6 million in 2016— remain uninsured.

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 2016, 45% of uninsured adults said that they remained uninsured because the cost of coverage was too high. 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 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 2016 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 lacking coverage?

The uninsured often face unaffordable medical bills when they do seek care. In 2016, uninsured nonelderly adults were over twice as likely than their insured counterparts to have 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 44 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 their programs, 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 adults living in states that expanded Medicaid. Still, millions of people—27.6 million nonelderly individuals in 2016—remain without coverage.1

Key Details:

Figure 1: Uninsured Rate Among the Nonelderly Population, 1998-2016

Figure 2: Percentage Point Change in Uninsured Rate among the Nonelderly Population by Selected Characteristics, 2013-2016

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: 

Figure 3: Reasons for Being Uninsured Among Uninsured Nonelderly Adults, 2016

Who remains uninsured?

Most remaining uninsured people are in working families, are in families with low incomes, and are nonelderly adults.15 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:  

Figure 4: Characteristics of the Nonelderly Uninsured, 2016

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:

Figure 6: Barriers to Health Care Among Nonelderly Adults by Insurance Status, 2016

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.34

Key Details:

Figure 7: Problems Paying Medical Bills by Insurance Status, 2016

Conclusion

Millions of people have gained coverage under the ACA provisions that went into effect in 2014, and current debate over rolling back ACA coverage threaten these gains in coverage and make it difficult to reach the 27.6 million who remain without coverage. Proposed policies to change the structure of the Medicaid program or cut back subsidies for Marketplace coverage may lead to even more uninsured individuals. On the other hand, if additional states opt to expand Medicaid as allowed under the ACA, there may be additional coverage gains as low-income individuals gain access to affordable coverage. Going without coverage can have serious health consequences for the uninsured because they receive less preventive care, and delayed care often results in serious illness or other health problems. Being uninsured also can have serious financial consequences. The outcome of current debate over health coverage policy in the United States has substantial implications for people’s coverage, access, and overall health and well-being.

Appendix A: Uninsured Rate Among the Nonelderly by State, 2013-2016
  2013 Uninsured Rate 2016 Uninsured Rate Change in Uninsured Rate Change in Number of Uninsured
Expansion States 13.6% 8.1% -5.5% -9,110,784
Alaska 15.8% 15.2% -0.5% -4,605
Arizona 21.2% 14.0% -7.1% -383,719
Arkansas 17.8% 9.1% -8.7% -206,013
California 16.4% 8.7% -7.6% -2,526,529
Colorado 13.8% 10.8% -3.1% -139,372
Connecticut 11.8% 7.2% -4.6% -145,215
Delaware 8.3% 10.6% 2.3% 20,756
District of Columbia 8.9% 5.9% -2.9% -15,885
Hawaii 5.7% 6.3% 0.6% 7,414
Illinois 11.9% 8.6% -3.3% -403,107
Indiana 14.6% 7.6% -7.0% -382,508
Iowa 9.5% 6.2% -3.3% -87,375
Kentucky 16.3% 7.2% -9.1% -351,749
Louisiana 16.4% 12.1% -4.3% -158,238
Maryland 13.3% 7.2% -6.0% -309,202
Massachusetts 3.6% 6.4% 2.7% 161,492
Michigan 12.1% 7.4% -4.8% -412,911
Minnesota 7.9% 6.9% -1.0% -52,380
Montana 19.0% 8.5% -10.4% -85,493
Nevada 22.0% 10.2% -11.8% -270,526
New Hampshire 13.2% 7.6% -5.6% -65,367
New Jersey 13.4% 9.0% -4.4% -339,457
New Mexico 19.5% 13.0% -6.5% -112,780
New York 11.1% 6.6% -4.5% -775,319
North Dakota 12.1% 8.9% -3.2% -19,617
Ohio 13.9% 6.5% -7.4% -708,788
Oregon 14.2% 6.2% -8.0% -257,142
Pennsylvania 11.6% 5.7% -5.9% -647,343
Rhode Island 10.7% 5.8% -5.0% -43,871
Vermont 9.1% 6.5% -2.6% -13,549
Washington 13.4% 8.1% -5.4% -299,746
West Virginia 14.2% 8.8% -5.4% -82,642
Non-Expansion States 18.1% 13.3% -4.8% -4,575,853
Alabama 17.8% 10.1% -7.7% -305,483
Florida 22.0% 14.6% -7.5% -1,128,462
Georgia 18.5% 13.7% -4.7% -334,624
Idaho 16.8% 10.2% -6.6% -87,058
Kansas 11.5% 9.8% -1.7% -41,999
Maine 11.3% 8.7% -2.6% -30,792
Mississippi 16.4% 13.9% -2.6% -63,174
Missouri 13.1% 9.8% -3.2% -168,358
Nebraska 10.6% 8.2% -2.4% -38,713
North Carolina 17.3% 12.4% -5.0% -377,650
Oklahoma 18.1% 12.4% -5.7% -163,857
South Carolina 18.9% 10.8% -8.1% -297,343
South Dakota 11.6% 9.4% -2.2% -15,268
Tennessee 15.2% 13.2% -2.0% -90,107
Texas 22.8% 17.1% -5.7% -1,191,130
Utah 13.7% 13.5% -0.2% 16,342
Virginia 13.1% 11.5% -1.7% -125,841
Wisconsin 10.4% 8.3% -2.2% -98,298
Wyoming 17.5% 11.2% -6.3% -34,040
SOURCE: Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement.
Appendix Table B: Characteristics of the Nonelderly Uninsured, 2016
Nonelderly (millions) Percent of Nonelderly Uninsured (millions) Percent of Uninsured Uninsured Rate
Total Nonelderly 271.1 100.0% 27.5 100.0% 10.1%
Age
Children – Total 78.2 28.8% 4.2 15.3% 5.4%
Nonelderly Adults – Total 192.9 71.2% 23.3 84.7% 12.1%
Adults 19 – 25 29.8 11.0% 3.9 14.2% 13.1%
Adults 26 – 34 39.7 14.7% 6.2 22.7% 15.7%
Adults 35 – 44 40.0 14.8% 5.3 19.1% 13.1%
Adults 45 – 54 42.0 15.5% 4.3 15.8% 10.3%
Adults 55 – 64 41.3 15.2% 3.5 12.8% 8.5%
Annual Family Income
<$20,000 35.9 13.3% 6.7 24.3% 18.6%
$20,000 – <$40,000 43.1 15.9% 6.8 24.9% 15.9%
$40,000 + 192.1 70.8% 13.9 50.8% 7.3%
Family Poverty Level
<100% 36.5 13.5% 6.5 23.6% 17.7%
100% – <200% 44.2 16.3% 6.8 24.7% 15.3%
200% – <400% 78.8 29.1% 8.6 31.4% 10.9%
400%+ 111.6 41.2% 5.6 20.4% 5.0%
Household Type
Single Adults Living Alone 45.0 16.6% 6.7 24.5% 15.0%
Single Adults Living Together 35.7 13.2% 4.9 17.7% 13.6%
Married Adults 37.1 13.7% 3.2 11.5% 8.5%
1 Parent with Children 23.4 8.6% 2.2 8.1% 9.5%
2 Parents with Children 83.4 30.7% 5.5 19.9% 6.6%
Multigenerational 14.2 5.2% 1.6 5.9% 11.4%
Other with Children 32.3 11.9% 3.4 12.4% 10.5%
Family Work Status
2+ Full-time 93.4 34.4% 6.8 24.8% 7.3%
1 Full-time 131.1 48.4% 13.7 49.9% 10.4%
Only Part-time 19.4 7.2% 2.9 10.7% 15.1%
Non-Workers 27.2 10.0% 4.0 14.6% 14.7%
Race/Ethnicity
White 157.5 58.1% 12.0 43.9% 7.6%
Black 34.9 12.9% 4.1 14.9% 11.7%
Hispanic 53.6 19.8% 9.1 33.0% 16.9%
 Asian/N. Hawaiian and Pacific Islander 17.1 6.3% 1.4 5.2% 8.3%
American Indian/Alaska Native 2.1 0.8% 0.4 1.5% 18.9%
Two or More Races 5.8 2.1% 0.4 1.6% 7.4%
Citizenship
U.S. Citizen – Native 233.7 86.2% 19.8 72.3% 8.5%
U.S. Citizen – Naturalized 15.7 5.8% 1.6 6.0% 10.4%
Non-U.S. Citizen,
Resident for <5 Years
5.9 2.2% 1.4 5.0% 23.2%
Non-U.S. Citizen,
Resident for 5+ Years
15.8 5.8% 4.6 16.7% 29.0%
Health Status
Excellent/Very Good 186.8 68.9% 16.9 61.5% 9.0%
Good 61.9 22.8% 8.0 29.0% 12.9%
Fair/Poor 22.4 8.3% 2.6 9.5% 11.7%
NOTES: Includes nonelderly individuals ages 0-64. The U.S. Census Bureau’s poverty threshold for a family with two adults and one child was $19,318 in 2016. Parent includes any person with a dependent child. Multigenerational/other families with children include families with at least three generations in a household, plus families in which adults are caring for children other than their own. Part-time workers were defined as working <35 hours per week. Respondents who identify as mixed race who do not also identify as Hispanic fall into the “Two or More Races” category. All individuals who identify as Hispanic ethnicity fall into the Hispanic category regardless of race.

SOURCE: Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement.

 

 

Endnotes
  1. Kaiser Family Foundation analysis of the 2016 National Health Interview Survey

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  2. Robin A. Cohen, Michael E. Martinez, and Emily P. Zammitti, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January – March 2017 (Hyattsville, MD: National Center for Health Statistics, August 2017), https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201708.pdf

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  3. State Health Facts. “Total Marketplace Enrollment and Financial Assistance, February 2017.” Kaiser Family Foundation, 2017, http://kff.org/health-reform/state-indicator/total-marketplace-enrollment-and-financial-assistance/

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  4. State Health Facts. “Total Monthly Medicaid and CHIP Enrollment.” Kaiser Family Foundation, June 2017, http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/.

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  5. 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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  6. 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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  7. Karen Pollitz, Jennifer Tolbert, and Ashley Semanskee. 2016 Survey of Health Insurance Marketplace Assister Programs and Brokers (Washington, DC: Kaiser Family Foundation, June 2016), https://www.kff.org/health-reform/report/2016-survey-of-health-insurance-marketplace-assister-programs-and-brokers/

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  8. Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

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  9. Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

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  10. 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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  11. State Health Facts. “Status of State Action on the Medicaid Expansion Decision.” Kaiser Family Foundation, 2017, http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

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  12. Tricia Brooks, Karina Wagnerman, Samantha Artiga, Elizabeth Cornachione, and Petry Ubri, Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2017: Findings from a 50-State Survey (Washington, DC: Kaiser Family Foundation, January 2017), https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2017-findings-from-a-50-state-survey/

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  13. 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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  14. Samantha Artiga and Anthony Damico, Health Coverage and Care for Immigrants (Washington, DC: Kaiser Family Foundation, July 2017), https://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-immigrants/

     

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  15. Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

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  16. $19,318 for a family of three in 2016

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  17. Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

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  18. Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

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  19. Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

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  20. Samantha Artiga and Anthony Damico, Health Coverage and Care for Immigrants (Washington, DC: Kaiser Family Foundation, July 2017), https://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-immigrants/

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  21.  Kaiser Family Foundation analysis of the 2016 National Health Interview Survey

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  22. 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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  23. 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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  24. Kaiser Family Foundation analysis of the 2016 National Health Interview Survey

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  25. 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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  26.   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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  27.   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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  28. 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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  29. 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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  30. 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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  31. 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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  32. Mark Hall, “Rethinking Safety Net Access for the Uninsured,” New England Journal of Medicine 364 (January 2011):7-9.

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  33. 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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  34. 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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  35. 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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  36. 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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  37. 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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  38. Kaiser Family Foundation analysis of the 2016 National Health Interview Survey

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  39. 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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  40. 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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  41. 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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  42. Ibid.

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  43. 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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  44. Ibid.

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