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The Uninsured and the ACA: A Primer - Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act

Executive Summary
  1. Kaiser Family Foundation analysis of 2013 American Community Survey (ACS), 1-Year Estimates.

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  2. Kaiser Family Foundation analysis of the 2017 American Community Survey (ACS), 1-Year Estimates.

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  3. Kaiser Family Foundation analysis of the 2017 National Health Interview Survey.

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  4. Ibid.

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  5. Kaiser Family Foundation State Health Facts, “Distribution of Eligibility for ACA Health Coverage Among those Remaining Uninsured as of 2017,” accessed January 2019, https://www.kff.org/health-reform/state-indicator/distribution-of-eligibility-for-aca-coverage-among-the-remaining-uninsured/.

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Introduction
  1. U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, 2018 Poverty Guidelines. Available at: https://aspe.hhs.gov/poverty-guidelines.

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  2. Samuel L Dickman, David Himmelstein, and Steffie Woolhandler, Inequality and the health-care system in the USA (London, England: The Lancet, April 8, 2017), https://doi.org/10.1016/S0140-6736(17)30398-7.

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How have health insurance coverage options and availability changed under the ACA?
  1. Kaiser Family Foundation analysis of the 2013 Kaiser Survey of Low-Income Americans and the ACA, 2014.

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  2. Jennifer Tolbert, The Coverage Provisions in the Affordable Care Act: An Update (Washington, DC: Kaiser Family Foundation, March 2015), https://www.kff.org/report-section/the-coverage-provisions-in-the-affordable-care-act-an-update-health-insurance-market-reforms/.

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  3. Tricia Brooks, Karina Wagnerman, Samantha Artiga, and Elizabeth Cornachione, Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2018: Findings from a 50-State Survey (Washington, DC: Kaiser Family Foundation, March 2018), https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2018-findings-from-a-50-state-survey/.

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  4. Kaiser Family Foundation State Health Facts, “Status of State Action on the Medicaid Expansion Decision,” accessed January 2019, https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.

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  5. Kaiser Family Foundation State Health Facts, “Medicaid Expansion Enrollment,” accessed January 2019, https://www.kff.org/health-reform/state-indicator/medicaid-expansion-enrollment/.

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  6. Linda J Blumberg, John Holahan, and Erik Wengle, Are Nongroup Marketplace Premiums Really High? Not in Comparison with Employer Insurance, (Washington, DC: Urban Institute, February 2017), https://www.urban.org/research/publication/are-nongroup-marketplace-premiums-really-high-not-comparison-employer-insurance.

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  7. Some states run their own marketplace, and other state marketplaces are run by the federal government. Kaiser Family Foundation State Health Facts, “State Health Insurance Marketplace Types, 2018,” accessed January 2019, https://www.kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/.

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  8. Kaiser Family Foundation, Web Briefing for Journalists: Key Issues Ahead of Marketplace Open Enrollment, October 2018, https://www.kff.org/health-costs/event/web-briefing-for-journalists-key-issues-ahead-of-marketplace-open-enrollment/.

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  9. Ibid.

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  10. Kaiser Family Foundation. 2018 Employer Health Benefits Survey (Washington, DC: Kaiser Family Foundation, October 2018), https://www.kff.org/health-costs/report/2018-employer-health-benefits-survey/.

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  11. U.S. Department of the Treasury, Internal Revenue Service, Form Rev. Proc. 2017-36, (Washington, DC: 2017), https://www.irs.gov/pub/irs-drop/rp-17-36.pdf.

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  12. U.S. Department of the Treasury, Internal Revenue Service, Form Rev. Proc. 2018-34, (Washington, DC: 2018), https://www.irs.gov/pub/irs-drop/rp-18-34.pdf.

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  13. Under the SHOP, employers with no more than 50 full-time equivalent (FTE) employees can purchase coverage and employers with no more than 25 FTE employees and annual wages below a limit ($53,000 for tax year 2017) may be eligible for tax credits for up to two years to reduce the cost of SHOP coverage. Beginning in January 2016, states had the option to expand the SHOP to include employers with 100 or fewer FTEs. For tax years beginning in 2014 or later, employers could receive a tax credit of up to 50% of the employer’s contribution to the premium, calculated on a sliding scale basis tied to average wages and number of employees. For small businesses with tax-exempt status meeting the requirements above, the tax credit is 35% of the employer contribution. In order to qualify, a business must pay premiums on behalf of employees enrolled in a qualified health plan offered through the SHOP marketplace or qualify for an exemption to this requirement. “Small Business Health Care Tax Credit and the SHOP Marketplace,” Internal Revenue Service, accessed December 2018, https://www.irs.gov/affordable-care-act/employers/small-business-health-care-tax-credit-and-the-shop-marketplace. Centers for Medicare and Medicaid Services, Health Insurance Marketplace, Who Can Use the SHOP Marketplace (Baltimore, MD: CMS, Health Insurance Marketplace, October 2014), https://marketplace.cms.gov/outreach-and-education/who-can-use-shop.pdf.

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  14. Kaiser Family Foundation, 2018 Employer Health Benefits Survey, (Washington, DC: Kaiser Family Foundation, October 2018), https://www.kff.org/report-section/2018-employer-health-benefits-survey-summary-of-findings/.

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  15. Kaiser Family Foundation State Health Facts, “Health Insurance Coverage of Nonelderly 0-64,” accessed January 2019, https://www.kff.org/other/state-indicator/nonelderly-0-64/.

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  16. Kaiser Family Foundation analysis of the 2010 and 2017 National Health Interview Survey.

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  17. “Individual Share Responsibility Provision – Reporting and Calculating the Payment.” ACA Individual Shared Responsibility Provision Calculating the Payment | Internal Revenue Service. February 2018. https://www.irs.gov/affordable-care-act/individuals-and-families/aca-individual-shared-responsibility-provision-calculating-the-payment.

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  18. Lawfully present immigrants who would be eligible for Medicaid but are in a five-year waiting period are eligible for tax credits for marketplace coverage. Samantha Artiga and Anthony Damico, Health Coverage and Care for Immigrants (Washington, DC: Kaiser Family Foundation, July 2017), http://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-immigrants/.

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  19. R. Savransky, The Hill, Trump: There is no such thing as Obamacare anymore, October 2017, http://thehill.com/policy/healthcare/355658-trump-there-is-no-such-thing-as-obamacare-anymore.

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  20. Ashley Kirzinger, Liz Hamel, Biana DiJulio, Cailey Muñana, and Mollyann Brodie. Kaiser Health Tracking Poll – November 2017: The Politics of Health Insurance Coverage, ACA Open Enrollment, (San Francisco, CA: Kaiser Family Foundation, November 2017), https://www.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-november-2017-the-politics-of-health-insurance-coverage-aca-open-enrollment/.

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  21. Karen Pollitz, Jennifer Tolbert, and Maria Diaz. Data Note: Changes in 2017 Federal Navigator Funding, (Washington, D.C.: Kaiser Family Foundation, October 2017), https://www.kff.org/health-reform/issue-brief/data-note-changes-in-2017-federal-navigator-funding/.

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  22. Rabah Kamal, Ashley Semanskee, Michelle Long, Gary Claxton, and Larry Levitt, How the Loss of Cost-Sharing Subsidy Payments is Affecting 2018 Premiums, (San Francisco, CA: Kaiser Family Foundation, October 2017), https://www.kff.org/health-reform/issue-brief/how-the-loss-of-cost-sharing-subsidy-payments-is-affecting-2018-premiums/.

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  23. Rabah Kamal, Cynthia Cox, Care Shoaibi, Brian Kaplun, Ashley Semanskee, and Larry Levitt, An Early Look at 2018 Premium Changes and Insurer Participation on ACA Exchanges (San Francisco, CA: Kaiser Family Foundation, August 2017), https://www.kff.org/health-reform/issue-brief/an-early-look-at-2018-premium-changes-and-insurer-participation-on-aca-exchanges/.

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  24. Rabah Kamal, Cynthia Cox, Rachel Fehr, Marco Ramirez, Katherine Horstman, and Larry Levitt, How Repeat of the Individual Mandate and Expansion of Loosely Regulated Plans are Affecting 2019 Premiums, (San Francisco, CA: Kaiser Family Foundation, October 2018), https://www.kff.org/health-costs/issue-brief/how-repeal-of-the-individual-mandate-and-expansion-of-loosely-regulated-plans-are-affecting-2019-premiums/.

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  25. Karen Pollitz and Gary Claxton, Proposals for Insurance Options That Don’t Comply with ACA Rules: Trade-offs in Cost and Regulation, (Washington, DC: Kaiser Family Foundation, April 2018), https://www.kff.org/health-reform/issue-brief/proposals-for-insurance-options-that-dont-comply-with-aca-rules-trade-offs-in-cost-and-regulation/.

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  26. Karen Pollitz, Michelle Long, Ashley Semanskee, and Rabah Kamal, Understanding Short-Term Limited Duration Health Insurance (Washington, DC: Kaiser Family Foundation, April 2018), https://www.kff.org/health-reform/issue-brief/understanding-short-term-limited-duration-health-insurance/.

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  27. MaryBeth Musumeci, Robin Rudowitz, Elizabeth Hinton, Larisa Antonisse, and Cornelia Hall, Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers, (Washington, DC: Kaiser Family Foundation, September 2018), https://www.kff.org/report-section/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers-issue-brief/.

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  28. Kaiser Family Foundation, Proposed Changes to “Public Charge” Policies for Immigrants: Implications for Health Coverage, (Washington, DC: Kaiser Family Foundation, September 2018), https://www.kff.org/disparities-policy/fact-sheet/proposed-changes-to-public-charge-policies-for-immigrants-implications-for-health-coverage/.

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  29. Kaiser Family Foundation State Health Facts, “Marketplace Enrollment, 2014-2019,” Trend Graph: United States 2014-2019, accessed January 2019, https://www.kff.org/health-reform/state-indicator/marketplace-enrollment.

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  30. Robin Rudowitz, MaryBeth Musumeci, and Cornelia Hall, Year End Review: December State Data for Medicaid Work Requirements in Arkansas (Washington, DC: Kaiser Family Foundation, January 2019), https://www.kff.org/medicaid/issue-brief/state-data-for-medicaid-work-requirements-in-arkansas/.

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  31. MaryBeth Musumeci, Robin Rudowitz, and Barbara Lyons, Medicaid Work Requirements in Arkansas: Experience and Perspectives of Enrollees (Washington, DC: Kaiser Family Foundation, December 2018), https://www.kff.org/medicaid/issue-brief/medicaid-work-requirements-in-arkansas-experience-and-perspectives-of-enrollees/.

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  32. Kaiser Family Foundation, In Focus: Immigrant Families, including Immigrants Lawfully in the U.S. and Those Who Are Undocumented, Report Rising Fear and Anxiety Affecting Their Daily Lives and Health (Washington, DC, December 13, 2017), https://www.kff.org/disparities-policy/press-release/in-focus-immigrant-families-including-immigrants-lawfully-in-the-u-s-and-those-who-are-undocumented-report-rising-fear-and-anxiety-affecting-their-daily-lives-and-health/.

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How many people are uninsured?
  1. Kaiser Family Foundation analysis of 2013 American Community Survey (ACS), 1-Year Estimates.

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  2. Kaiser Family Foundation analysis of the 2017 American Community Survey (ACS), 1-Year Estimates.

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  3. Ibid.

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  4. Kaiser Family Foundation analysis of the 2017 American Community Survey (ACS), 1-Year Estimates.

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  5. Kaiser Family Foundation State Health Facts, “Distribution of Eligibility for ACA Health Coverage Among those Remaining Uninsured as of 2017,” accessed January 2019, https://www.kff.org/health-reform/state-indicator/distribution-of-eligibility-for-aca-coverage-among-the-remaining-uninsured/.

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  6. Kaiser Family Foundation analysis based on 2017 Medicaid eligibility levels and March 2017 Current Population Survey, Annual Social and Economic Supplement.

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  7. Tricia Brooks, Karina Wagnerman, Samantha Artiga, and Elizabeth Cornachione, Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2018: Findings from a 50-State Survey (Washington, DC: Kaiser Family Foundation, March 2018), https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2018-findings-from-a-50-state-survey/.

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  8. Kaiser Family Foundation analysis of the 2017 American Community Survey (ACS), 1-Year Estimates.

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Who remains uninsured after the ACA and why do they lack coverage?
  1. Kaiser Family Foundation analysis of the 2017 National Health Interview Survey.

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

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  3. “Poverty Thresholds,” U.S. Census Bureau, accessed October 2018, http://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html.

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  4. Kaiser Family Foundation analysis of the 2017 American Community Survey (ACS), 1-Year Estimates.

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  5. See Supplemental Tables, Table 8.

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  6. Kaiser Family Foundation analysis of the March 2018 Current Population Survey, Annual Social and Economic Supplement.

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  7. Kaiser Family Foundation analysis of the 2017 American Community Survey (ACS), 1-Year Estimates.

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  8. Ibid.

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  9. Tricia Brooks, Karina Wagnerman, Samantha Artiga, and Elizabeth Cornachione, Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2018: Findings from a 50-State Survey (Washington, DC: Kaiser Family Foundation, March 2018), https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2018-findings-from-a-50-state-survey/.

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  10. Kaiser Family Foundation analysis of the 2017 American Community Survey (ACS), 1-Year Estimates.

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  11. Other public programs include some state-funded programs for immigrants otherwise ineligible for Medicaid. Kaiser Family Foundation analysis based on 2018 Medicaid eligibility levels and 2017 American Community Survey, 1-Year Estimates.

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  12. Julie L. Hudson and Asako S. Moriya, “Medicaid Expansion for Adults Had Measureable ‘Welcome Mat’ Effects on Their Children,” Health Affairs 36, no.9 (September 2017): 1643-51.

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  13. Elisabeth W. Burak, Health Coverage for Parents and Caregivers Helps Children (Washington, DC: Georgetown University Center for Children and Families, March 2017), https://ccf.georgetown.edu/wp-content/uploads/2017/03/Covering-Parents-v2.pdf.

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  14. Kaiser Family Foundation analysis of the 2017 American Community Survey (ACS), 1-Year Estimates.

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  15. Ibid.

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  16. Kaiser Family Foundation analysis of the 2017 National Health Interview Survey.

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  17. Rachel Garfield, Anthony Damico, Kendal Orgera, Gary Claxton, and Larry Levitt, Estimates of Eligibility for ACA Coverage among the Uninsured in 2016 (Washington, DC: Kaiser Family Foundation, June 2018), https://www.kff.org/uninsured/issue-brief/estimates-of-eligibility-for-aca-coverage-among-the-uninsured-in-2016/.

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  18. Ashley Kirzinger, Liz Hamel, Cailey Muñana, and Mollyann Brodie. Kaiser Health Tracking Poll – March 2018: Non-Group Enrollees, (San Francisco, CA: Kaiser Family Foundation, April 2018), https://www.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-march-2018-non-group-enrollees/.

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

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  20. Karen Pollitz, Jennifer Tolbert, and Maria Diaz. Data Note: Further Reductions in Navigator Funding for Federal Marketplace States, (Washington, D.C.: Kaiser Family Foundation, September 2018), https://www.kff.org/health-reform/issue-brief/data-note-further-reductions-in-navigator-funding-for-federal-marketplace-states/.

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

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  22. Ibid.

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  23. Ibid.

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How does lack of insurance affect access to care?
  1. Kaiser Family Foundation analysis of the 2017 National Health Interview Survey.

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  2. Ibid.

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  3. Ibid.

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  4. Ibid.

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  5. Ibid.

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  6. 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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  7. Broadwater-Hollifield et al. “Predictors of Patient Adherence to Follow-Up Recommendations after an ED Visit,” The American Journal of Emergency Medicine 33, no.10 (October 2015): 1368-73.

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  8. Silvia Tejada et al., “Patient Barriers to Follow-Up Care for Breast and Cervical Cancer Abnormalities.” Journal of Women's Health 22, no. 6 (June 2013): 507-517.

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  9. Steffie Woolhandler, et al., “The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?” Annals of Internal Medicine 167 (June 2017): 424-431.

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  10. Andrea S. Christopher, et al., “Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured,” American Journal of Public Health 106, no. 1 (January 2016): 63-69.

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  11. Institute of Medicine, America’s Uninsured Crisis: Consequences for Health and Health Care (Washington, DC: Institute of Medicine, February 2009), http://iom.nationalacademies.org/~/media/Files/Report%20Files/2009/Americas-Uninsured-Crisis-Consequences-for-Health-and-Health-Care/Americas%20Uninsured%20Crisis%202009%20Report%20Brief.pdf.

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  12. 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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  13. Steffie Woolhandler, et al., “The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?” Annals of Internal Medicine 167 (June 2017): 424-431.

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  14. Destini A Smith, et al., “The effect of health insurance coverage and the doctor-patient relationship on health care utilization in high poverty neighborhoods.” Preventive Medicine Reports 7 (2017): 158-161.

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  15. Andrea S. Christopher, et al., “Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured,” American Journal of Public Health 106, no. 1 (January 2016): 63-69.

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  16. Kaiser Family Foundation analysis of the 2017 National Health Interview Survey.

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  17. Institute of Medicine, America’s Uninsured Crisis: Consequences for Health and Health Care (Washington, DC: Institute of Medicine, February 2009), http://iom.nationalacademies.org/~/media/Files/Report%20Files/2009/Americas-Uninsured-Crisis-Consequences-for-Health-and-Health-Care/Americas%20Uninsured%20Crisis%202009%20Report%20Brief.pdf.

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  18. Amanda Haboush-Deloye, Spencer Hensley, Masaru Teramoto, Tara Phebus, Denise Tanata-Ashby, “The Impacts of Health Insurance Coverage on Access to Healthcare in Children Entering Kindergarten,” Maternal and Child Health Journal 18, no.7 (Sep 2014): 1753-64.

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  19. MaryBeth Musumeci, Medicaid Restructuring and Children with Special Health Care Needs (Washington, DC: Kaiser Family Foundation, July 2017), https://www.kff.org/report-section/medicaid-restructuring-and-children-with-special-health-care-needs-issue-brief/.

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  20. Sara Collins et al., Gaps in Health Insurance: Why So Many Americans Experience Breaks in Coverage and How the Affordable Care Act Will Help (The Commonwealth Fund, April 2012), 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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  21. Amy Cassedy, Gerry Fairbrother, and Paul Newacheck, “The Impact of Insurance Instability on Children’s Access, Utilization, and Satisfaction with Health Care,” Ambulatory Pediatrics 8, no. 5 (October 2008): 321-8.

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  22. Thomas Buchmueller, Sean Orzol, and Lara Shore-Sheppard, “Stability of Children’s Insurance Coverage and Implications for Access to Care: Evidence from the Survey of Income and Program Participation”, International Journal of Health Care Finance and Economics 14, no.2 (Jun 2014).

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  23. Salam Abdus, “Part-Year Coverage and Access to Care for Nonelderly Adults,” Medical Care 52, no. 8 (August 2014): 709-14.

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  24. 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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  25. Katherine Baicker et al., “The Oregon Experiment — Effects of Medicaid on Clinical Outcomes,” New England Journal of Medicine 368 (May 2013): 1713-1722.

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  26. Larisa Antonisse, Rachel Garfield, Robin Rudowitz, and Samantha Artiga, The Effects of Medicaid Expansion on the ACA: Updated Findings From a Literature Review (Washington, D.C.: Kaiser Family Foundation, March 2018), https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/.

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  27. James B Kirby and Jessica P. Vistnes,“Access to Care Improved for People Who Gained Medicaid or Marketplace Coverage in 2014” Health Affairs,35, no.10 (Oct 2016): 1830-1834.

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  28. Sara Rosenbaum, Jennifer Tolbert, Jessica Sharac, Peter Shin, Rachel Gunsalus, and Julia Zur, Community Health Centers: Growing Important in a Changing Health Care System, (Washington, DC: Kaiser Family Foundation, March 2018), https://www.kff.org/medicaid/issue-brief/community-health-centers-growing-importance-in-a-changing-health-care-system/.

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  29. Allen Dobson, Joan DaVanzo, Randy Haught, and Phap-Hoa Luu, Comparing the Affordable Care Act’s Financial Impact on Safety-Net Hospitals in States That Expanded Medicaid and Those That Did Not, (New York, NY: The Commonweath Fund, November 2017), https://www.commonwealthfund.org/publications/issue-briefs/2017/nov/comparing-affordable-care-acts-financial-impact-safety-net.

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  30. Peter Shin et al., Health Center Patient Trends, Enrollment Activities, and Service Capacity: Recent Experience in Medicaid Expansion and Non-Expansion States, (Washington, DC: Kaiser Commission for Medicaid and the Uninsured, Dec 2015), https://www.kff.org/medicaid/issue-brief/health-center-patient-trends-enrollment-activities-and-service-capacity-recent-experience-in-medicaid-expansion-and-non-expansion-states.

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  31. Julia Paradise, Sara Rosenbaum, Anne Markus, Jessica Sharac, Chi Tran, David Reynolds, and Peter Shin, Community Health Centers: Recent Growth and the Role of the ACA (Washington, DC: Kaiser Family Foundation, January 2017), https://www.kff.org/medicaid/issue-brief/community-health-centers-recent-growth-and-the-role-of-the-aca/.

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  32. Ibid.

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What are the financial implications of lacking insurance?
  1. Kaiser Family Foundation analysis of the 2017 National Health Interview Survey.

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  2. Gerard Anderson , “From ‘Soak The Rich’ To ‘Soak The Poor’: Recent Trends In Hospital Pricing” Health Affairs 26, no. 4 (May 2007): 780-789.

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  3. 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.

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  4. Kaiser Family Foundation analysis of the 2015 Kaiser Family Foundation/New York Times Medical Bills Survey.

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  5. Brent Asplin et al., “Insurance Status and Access to Urgent Ambulatory Care Follow-up Appointments,” JAMA 294, no. 10 (September 2005): 1248-54.

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  6. Brendan Saloner, et al., “Most Uninsured Adults Could Schedule Primary Care Appointments Before The ACA, But Average Price Was $160,” Health Affairs 34, no. 5 (May 2015), https://doi.org/10.1377/hlthaff.2014.1258.

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  7. Kaiser Family Foundation analysis of the 2015 Kaiser Family Foundation/New York Times Medical Bills Survey.

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  8. MEPS Summary Tables. Use, expenditures, and population. Available at: https://meps.ahrq.gov/mepstrends/hc_use/.

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  9. Roemer, M. I. Out-of-Pocket Health Care Expenses by Insurance Coverage, 2000-2014. Statistical Brief #500. February 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/st500/stat500.pdf

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  10. Ibid.

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  11. Medicaid and CHIP Payment and Access Commission (MACPAC), Report to Congress on Medicaid and CHIP, Chapter 3: Annual Analysis of Disproportionate Share Hospital Allotments to States, (MACPAC, March 2018), https://www.macpac.gov/wp-content/uploads/2018/03/Annual-Analysis-of-Disproportionate-Share-Hospital-Allotments-to-States.pdf.

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  12. Ibid.

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  13. 42 U.S.C. § 1396r-4 (f)(7)(A).

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  14. Kaiser Family Foundation analysis of the 2017 National Health Interview Survey.

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  15. 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, DC: Kaiser Family Foundation, January 2016), http://www.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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  16. Matthew Rae, Gary Claxton, and Larry Levitt, Do Health Plan Enrollees have Enough Money to Pay Cost Sharing? (Washington, DC: Kaiser Family Foundation, November 2017), https://www.kff.org/health-costs/issue-brief/do-health-plan-enrollees-have-enough-money-to-pay-cost-sharing/.

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  17. Kaiser Family Foundation analysis of the 2017 National Health Interview Survey.

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  18. Consumer Financial Protection Bureau, “Consumer Experiences with Debt Collection: Findings from the CFPB’s Survey of Consumer Views on Debt.” (Consumer Financial Protection Bureau: January 2017),

    https://www.consumerfinance.gov/data-research/research-reports/consumer-experiences-debt-collection-findings-cfpbs-survey-consumer-views-debt/.

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  19. Ibid.

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  20. 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, January 2016), https://www.kff.org/report-section/the-burden-of-medical-debt-section-1-who-has-medical-bill-problems-and-what-are-the-contributing-factors/.

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