Numerous articles have highlighted progress made by the Affordable Care Act (ACA), especially regarding access to health insurance for those who were either previously uninsured or underinsured. But as we enter the third Marketplace open enrollment period, we are faced with evidence that consumers do not understand health insurance, “only about half of those surveyed could correctly figure out what they would need to pay in out-of-pocket cost for a hospital stay when given the deductible and the co-pay,” and the uninsured survey participants had the most difficulty with health insurance literacy.
Insurance Literacy Goes Beyond Enrollment
Beyond the issue of understanding health insurance terms, few have examined the adequacy of knowledge, skills, and attitudes of the newly insured about how to effectively use their health insurance. We believe knowing how to use health insurance effectively is key to getting the right care at the right time in the right place.
The Institute of Medicine Roundtable on Health Literacy commissioned the preparation of a paper that would identify both successful strategies for enrollment as well as explore the issues related to better understanding about how to use health insurance. We conducted interviews with organizations and agencies that achieved success in enrolling individuals and families from hard-to-reach populations such as African Americans, Asian and Pacific Islanders, and Hispanics during the first Marketplace enrollment period. Based on our informant interviews and literature review, we highlight a few important findings below.
Many navigator, assister, and broker organizations described challenges in obtaining the trust of community members to even discuss the role of health insurance. In addition, in many minority communities, there was very little understanding of the implications of having health insurance and how to use insurance for routine health care and prevention. For example, one navigator organization, a large community-based nonprofit, stated that many newly insured community members thought that the insurance only covered emergency room visits and hospitalizations.
Interviews also revealed that many consumers in difficult to reach populations (even those who are insured) lack full understanding about the multiple costs involved in having and using their health insurance beyond premium costs at enrollment. Explaining cost and coverage is challenging, and particularly so for harder to reach populations. Communicating that health insurance is important and required can create frustration and stress among those who believe they cannot afford it. To better capture these issues, we developed a conceptual framework (Figure 1) which describes the need to address three critical areas: Outreach, Sign-up and Retention (often described as “enrollment”), and Use.
The Role Of Navigators, Assisters, Brokers, And Physicians
To successfully engage consumers in getting and using their health insurance, marketplace efforts, including assisters, navigators, and brokers, must provide outreach and education to the populations of interest, help with enrollment and informing populations about use. Individual factors and social and cultural norms influence an individual’s journey through this process. Individual readiness to move from outreach to enrollment to use is critical.
Creating a foundation of trust is critical to success for each of these steps in obtaining and using health insurance. In addition to Marketplace navigators, assisters, and brokers, clinicians, and especially physicians remain trusted sources for many and can play a key role in the process depicted in the figure. Physicians also have a professional obligation to respect patient autonomy, to be honest, and to empower patients to make informed decisions. With this increased national attention on health insurance enrollment and use, and an increasing concern regarding the out-of-pocket costs, the ability of consumers to make informed decisions regarding health insurance will only continue to become more important in obtaining health care services and meeting the objectives of the Triple Aim.
Understanding Insurance Use
Using health insurance is complicated. Each plan has specific rules about where one can obtain services, which providers to see, and what portion of services will be paid for. There are terms that need to be understood — terms such as in-network, primary care physician, deductible, co-pay, co-insurance, etc. While each insurance company sends its enrollees detailed information containing the specifics of their plans, this information is frequently very difficult to comprehend. Navigating the health care delivery system can be just as daunting: where to receive primary care or specialty care, which visits constitute “free preventive” visits, and how best to conduct research to seek out high quality, low-cost care can be quite opaque.
The proposed framework explicitly links outreach with sign-up, retention, and use to better reflect that enrollment is simply not enough. Finally, the framework was developed after conducting interviews of enrollment efforts for hard to reach populations, but the components are inherently generalizable to other populations.
Educating Providers To Help Consumers
The formal and on-going education of navigators, assisters, brokers, and health care providers offers a systematic opportunity to teach the basics about how to best engage with consumers. One such example of a curriculum to teach basic content was developed by Wu and colleagues at Emory University School of Medicine. Materials include slide sets that could be used to specifically teach health providers and students in the health professions to understand how to have conversations with patients. Patients are encouraged to ask four questions:
- What are my options for health insurance?
- How do I get it?
- How do I use it?
- What will it cost?
So far, results of the use of these four questions has been compelling. The Consumer Guide, part of this curriculum, provides easy-to-navigate and updated materials to inform those seeking health insurance and is available through hyperlinks on many consumer-facing sites. The on-going use and feedback from consumers and health care providers suggest our conceptual framework augmented by these four questions could provide an important foundation for achieving the Triple Aim.
The ACA became law in 2010, and as we continue to understand its content, implications, and impact we also know that having health insurance is the law in our country. Indeed just getting health insurance through enhanced outreach and sign-up is not enough, we must simultaneously all learn how to best use it.
Figure 1: A Conceptual Framework For Engaging Consumers In Getting And Using Health Insurance
The views expressed in this paper do not necessarily represent the views of the authors’ organizations. Funding for the project was provided by the Blue Shield of California Foundation.