Date of Award


Document Type

Campus Access Dissertation

Degree Name

Doctor of Philosophy (PhD)


Public Policy

First Advisor

Donna Haig Friedman

Second Advisor

Erin O'Brien

Third Advisor

Nancy Turnbull


In April 2006, the Commonwealth of Massachusetts passed one of the most significant pieces of health care reform legislation of any state, Chapter 58 of the Acts of 2006, creating sweeping changes to public health insurance programs and health insurance regulations. This comprehensive health reform has been very successful in creating the lowest uninsurance rate in the nation, below 2 percent by 2010 (Division of Health Care Finance and Policy, 2010b). Even though Massachusetts passed these reforms and offers subsidized public health insurance programs to many earning below 300 percent of the federal poverty level (FPL), some 120,000 Massachusetts residents remain uninsured (Division of Health Care Finance and Policy, 2010b). Individuals earning below 300 percent FPL have uninsured rates significantly higher than the state average (3.4 percent as compared to 1.9 percent statewide). This study sought to determine the perceptions, beliefs, situations, and decision-making strategies that lead low-income adults, earning less than 300 percent FPL, to remain uninsured. This research study utilized the Anderson Behavioral Model of Health Services Use as a conceptual framework to categorize and identify themes, variables, and issues that lead to uninsurance. In addition, adaptations to the model were offered to make it more relevant to understanding why individuals obtain health insurance or remain uninsured. Study findings cluster into five categories for causes of uninsurance: health insurance is a low priority, changes in personal status lead to intermittent health insurance coverage, system engagement barriers prevent enrollment and the maintenance of coverage, lack of awareness of available programs prevents enrollment, and affordability issues hinder enrollment. These findings can be useful in furthering Massachusetts health reform efforts and the federal Affordable Care Act (ACA) implementation.


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