Low health insurance literacy is one potential pathway influencing disparity in ACA-related coverage. Low health insurance literacy predicted little or no knowledge of the ACA reform; low awareness could in turn prevent eligible individuals from accessing ACA enrollment opportunities. Of note, a serious lack of ACA knowledge among participants in our Hispanic sample was found even after the conclusion of two enrollment periods in the health insurance marketplace.
Our study findings are mirrored in other vulnerable communities around the world. Mounting evidence is pointing to inade- quate understanding of health insurance concepts as a barrier to the success and sustainability of various health insurance schemes in low- and middle-income countries . In the Lucknow region in India, low health insurance literacy has an indirect potential impact, distinct from affordability, on the purchase of private health insurance through its contribution to negative perceptions about health insurance . Across West Africa, education, a likely contributor to a better understanding of the benefits of health insurance, is an independent predictor of enrolling and remaining in plans [34,35]. In Ghana, negative beliefs and attitudes towards health insurance decrease the odds of remaining insured for the richest quintile . Such evidence underscores the need for promoting health insurance literacy to ensure that government efforts to expand access, whether through free or subsidized coverage, achieve their goal of equity in the provision of health care.
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