populations that have the potential to benefit the most from the implementation of the Patient Protection and Affordable Care Act (ACA), especially if health literacy barriers are attended to (Martin and Parker, 2011).

Compared to individuals with adequate health literacy, individuals with limited health literacy have been shown to have greater difficulty in communicating with clinicians (Schillinger et al., 2004), to be less likely to participate in shared decision making (Sarkar et al., 2011), and to face greater barriers in managing chronic illnesses (Cavanaugh et al., 2008; Williams et al., 1998). Furthermore, limited health literacy appears to be a barrier to access to care, receipt of preventive and self-management support services, and safe medication management (Sarkar et al., 2008, 2011; Sudore et al., 2006). Compared to populations with adequate health literacy, populations with limited health literacy have been shown to have worse self-reported health (Baker et al., 1997), higher rates of many chronic conditions (Sudore et al., 2006), worse quality of life, and intermediate markers of health in some chronic conditions (Schillinger et al., 2002); to experience serious medication errors (Schillinger et al., 2005); and to have increased risk of hospitalization (Baker et al., 2002) and mortality (Sudore et al., 2006). Compared to patients with adequate health literacy, patients with limited health literacy exhibit patterns of utilization of care reflecting a greater degree of unmet needs, such as excess emergency room visits and hospitalizations, even when comorbid conditions and health insurance status are held constant (Hardie et al., 2011). It has been estimated that limited health literacy leads to excess health expenditures of greater than $100 billion annually (Vernon et al., 2007). Improving limited health literacy has been identified as a key strategy to improving the safety, quality, and value of health care (Joint Commission, 2007; National Quality Forum, 2009).

Rationale for This Paper

The vast majority of research on health literacy has focused on characterizing patients’ deficits, on how best to measure a patient’s health literacy, and on clarifying relationships between a patient’s limited health literacy and health outcomes. In addition, most health literacy intervention research has studied how to intervene with patients who have limited health literacy.

There is a growing appreciation, however, that health literacy is a dynamic state that represents the balance (or imbalance) between (a) an individual’s capacities to comprehend and apply health related knowledge to health-related decisions and to acquire health-related skills, and (b) the health literacy–related demands and attributes of the health care system. There is a clear need to develop, in parallel, a set of strategies that



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