In this study of low-income, predominantly Hispanic individuals in a U.S.-Mexico border community, little or no knowledge of the ACA was significantly associated with low health literacy levels. This association was significant even after controlling for other factors that could influence ACA knowledge, including sociodemo- graphic factors and health status. This suggests that health insurance literacy exerts an independent effect on knowledge of major healthcare reform policies such as the ACA.

National initiatives, such as Healthy People 2020, the 2011 Department of Health and Human Services Disparities Action Plan, and elements of the ACA, frequently include a goal of addressing widening health disparities in the United States, which are among the largest in the developed world [27,28]. Promoting access to primary care and preventive services for high-risk, vulnerable populations has been posited as one pathway to equitably improve health outcomes, while reducing unnecessary tertiary- and emergency care spending on advanced disease [29]. Moreover, health insurance is a social determinant of health shown to increase financial security, access to preventive and primary care, and treatment for chronic conditions [29,30]. Uninsured popula- tions are more likely to be low-income, non-white, and less likely to report good health [28].

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The ability of health policies to exert intended population health benefits depends on participation and adoption by eligible individuals. This is especially true in vulnerable communities facing high burden of disease and disability, such as Hispanics in border communities, who can benefit from policies that influence access and entry into healthcare. While healthcare reform policies such as the ACA may intend to increase healthcare and insurance access for vulnerable communities, those with low health insurance literacy may not actually know about potentially helpful provisions, coverage options, and health reform efforts, and thus remain uninsured [6]. Despite achieving significant gains in coverage after the passage of the ACA, Hispanics are least likely among all ethnic groups to have insurance [2,4,31]. This is especially unfortunate given that Hispanics represent the fastest- growing U.S. minority, are more likely than any other ethnic group to delay needed care due to cost, and experience significant health disparities in prevalence and severity of diseases such as diabetes, colon cancer and cardiovascular disease – diseases which can be potentially prevented, treated and alleviated through regular primary care