Implications for reform: survey of California adults suggests low health literacy predicts likelihood of being uninsured.

Despite high rates of low health literacy among uninsured American adults, empirical research until now has not quantified whether low health literacy is associated with lack of health insurance above and beyond other related factors, such as employment, the availability of employment-based insurance, race or ethnicity, and poverty. This study analyzed a large, representative sample of adults in California and found that even when these related factors were considered, people with low health literacy were more likely to be uninsured than those with adequate health literacy. This finding represents the first empirical evidence that low health literacy predicts the lack of health insurance in adults. The study also found that among people who were uninsured, those with low health literacy were sicker and less likely to have ever had health insurance. They were also more likely to be eligible for the expanded Medicaid program under the Affordable Care Act, compared to uninsured respondents with adequate health literacy. These findings suggest that it will be critical to keep health literacy in mind in implementing the law--for example, in the design of eligibility documents and required forms, insurance exchange interfaces, and educational and outreach campaigns related to the Medicaid expansion and the insurance exchanges.