First, similar to other cross-sectional designs, we merely establish an association, and not causality, between ACA knowledge and HIL. We also cannot establish the directionality of the relationship, as it is likely that knowledge of the ACA will also influence HIL. Second, cultural dynamics may have influenced comprehension and relevance of HILM measures. In Mexico, health insurance is universal and nationally owned, and bears little resemblance to the U.S. market- driven insurance system. However, the relationship between ACA knowledge and HIL maintained significance when considering only U.S.-born individuals, mitigating this possibility. Third, the assessment of HILM’s psychometric properties was conducted in a majority White, non-Hispanic population group and to our knowledge has not been tested in Spanish-speaking groups. Our reliability analyses, however, reflects high internal consistency of the scales. We also ran the analyses separately for the Spanish- and English-speaking subgroups (not reported) and had similar findings regarding the significance of the association between the two HILM scales and ACA knowledge. Fourth, our ACA knowledge assessment is measured by one subjective knowledge question at a time when there are multiple components and provisions to the ACA. This is especially problematic given that comparisons between subjective and objective measures of ACA knowledge revealed that people were not as knowledgeable as they thought they were [8]. This, however, may be mitigated by the fact that self-assessments of knowledge in our sample were generally low and, therefore, unlikely to be overestimated. Finally, given the large number of uninsured participants and, conse- quently, the small number of those who have used insurance, it was difficult to assess the associations between ACA knowledge and scales 3 (confidence using health insurance) and 4 (using health insurance/being proactive) of the HILM.
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