An early complication in ACA implementation was the 2012 Supreme Court ruling that the federal government could not require states to expand Medicaid, thus leaving expansion up to the states. In the wake of this decision, about 30 states chose Medicaid expansion.

RAND analysis concluded that Medicaid expansion on the whole boosts state economies and benefits the poorest residents. Increases in insurance coverage were highest in states that chose expansion. Individuals who gained coverage through Medicaid filled nearly 80% more prescriptions and had lower out-of-pocket spending. A similar pattern appeared among individuals who had one of five chronic conditions.

However, there were multiple impediments to coverage. Levels of financial literacy and health insurance literary strongly influenced an individual's choice to gain coverage through Medicaid, purchase it in the Marketplace (with subsidies), or remain uninsured. These two knowledge variables were as important as demographics in explaining insurance choices, suggesting that efforts to decrease the number of uninsured should take these factors into account.

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