Blog Health Care

Clarifying health insurance options

Written by Mary C. Politi, PhD, professor in the Department of Surgery at the School of Medicine and Brianna Cusanno, Allegheny College and participant in the 2015 Institute for Public Health Summer Research Program

“Whitney has three children. Her youngest son has asthma. He sees a doctor (a specialist) and uses an inhaler (a prescription drug) for his asthma. Right now, Whitney has to take her children to an urgent care center when they get sick and pays a fee on a sliding scale to see a doctor. Her son’s inhaler costs a lot of money, and the urgent care bills add up. Now that she can get health insurance for her and her kids, Whitney thinks she might choose a health insurance plan with low copayment for primary care visits, specialist visits, and prescription drugs.”

The Affordable Care Act (ACA) has opened the door to health insurance to millions of Americans like Whitney, a fictitious person created by researchers at Washington University’s Institute for Public Health based on common insurance needs. Her narrative was used as part of a study to facilitate decision-making about health insurance options in the ACA.

Within the next three years, some 25 million individuals are expected to enroll in health plans using the new insurance exchanges created by the ACA. Many of those who will be enrolling in and using the marketplace will be faced with decisions that require them to weigh trade-offs between cost and coverage for insurance features.

This process can be especially challenging for the many Americans who lack health insurance literacy, defined by Consumers Union as “knowledge, ability, and confidence to find and evaluate information about health plans, select the best plan for their financial and health circumstances, and use the plan once enrolled.”

One recent study found that more than 40% of Americans could not correctly explain the word “deductible.” For those lacking numeracy and literacy skills, and those who have little prior experience with insurance, the enrollment process may be especially daunting.

Many of the millions of users who enrolled in health insurance through the marketplace have reported problems using the website and understanding plan details. If policymakers do not adopt interventions to support individual decision making and comprehension of health insurance information, we can expect that enrollees will continue to face frustration and confusion. Without critical knowledge and skills, Americans may choose plans that do not align with their values or choose to forego enrollment altogether.

Mary Politi, PhD and a team of researchers at Washington University hope to address this need. They are updating and programming a decision support tool for individuals enrolling in health insurance through the marketplaces, drawing on findings from decision-making and communication sciences as well as a series of previous studies led by Dr. Politi. The  tool will contain education and values clarification modules, as well as a tailoring algorithm that will help individuals to identify the plans that coincide most closely with their needs and values.

In an upcoming trial in the fall, uninsured participants will be randomly assigned to learn about health plans through or using the new tool, and will be asked to report what plan they would choose given this information. The researchers will evaluate participants’ knowledge, perceived ability to make a decision, and confidence in choice of insurance to test the tool’s effectiveness.

If the tool is found to be effective at meeting these goals, the team hopes to work with policymakers and stakeholders to make it available for wider use. Through their focus on low-income individuals and those with limited health insurance literacy, the researchers hope the project will have largest impact on members of these high-needs populations. Although much more work is needed to make health insurance terminology accessible to consumers, this project may be an important step to connecting individuals and families with the health plan that best meet their needs.


Updated estimates of the effects of the insurance coverage provisions of the affordable care act from the Congressional Budget Office (2014)

Measuring health insurance literacy: A  call to action Consumers Union, University of Maryland College Park & American Institute for Research

Say what? many patients struggling to learn the foreign language of health insurance, by Gorman, A (2014)

A randomized trial examining three strategies for supporting health insurance decisions among the uninsured, Mary C. Politi, Kimberly A. Kaphingst, Jingxia (Esther) Liu, Hannah Perkins, MPP, Karishma Furtado, et al. (2015)

Knowledge of health insurance terminology and details among the uninsured. by Politi, Kaphingst, Kreuter, Shacham, Lovell, & McBride. (2013), from Medical Care Research and Review