Abstract
Navigating health insurance and health care choices requires considerable health insurance literacy. Although recommended preventive services are exempt from out-of-pocket costs under the Affordable Care Act, many people may remain unaware of this provision and its effect on their required payment. Little is known about the association between individuals' health insurance literacy and their use of preventive or nonpreventive health care services. To assess the association between health insurance literacy and self-reported avoidance of health care services owing to cost. In this survey study, a US national, geographically diverse, nonprobability sample of 506 US residents aged 18 years or older with current health insurance coverage was recruited to participate in an online survey between February 22 and 23, 2016. The validated 21-item Health Insurance Literacy Measure (HILM) assessed individuals' self-rated confidence in selecting and using health insurance (score range, 0-84, with higher scores indicating greater levels of health insurance literacy). Dependent variables included delayed or foregone preventive and nonpreventive services in the past 12 months owing to perceived costs, and preventive and nonpreventive use of services. Covariates included age, sex, race/ethnicity, income, educational level, high-deductible health insurance plan, health literacy, numeracy, and chronic health conditions. Analyses included descriptive statistics and bivariate and multivariable logistic regression. A total of 506 of 511 participants who began the survey completed it (participation rate, 99.0%). Of the 506 participants, 339 (67.0%) were younger than 35 years (mean [SD] age, 34 [10.4] years), 228 (45.1%) were women, 406 of 504 who reported race (80.6%) were white, and 245 (48.4%) attended college for 4 or more years. A total of 228 participants (45.1%) had 1 or more chronic health condition, 361 of 500 (72.2%) who responded to the survey item had seen a physician in the outpatient setting in the past 12 months, and 446 of the 501 (89.0%) who responded to the survey item had their health insurance plan for 12 or more months. One hundred fifty respondents (29.6%) reported having delayed or foregone care because of cost. The mean (SD) HILM score was 63.5 (12.3). In multivariable logistic regression, each 12-point increase in HILM score was associated with a lower likelihood of both delayed or foregone preventive care (adjusted odds ratio [aOR], 0.61; 95% CI, 0.48-0.78) and delayed or foregone nonpreventive care (aOR, 0.71; 95% CI, 0.55-0.91). This study's findings suggest that lower health insurance literacy may be associated with greater avoidance of both preventive and nonpreventive services. It appears that to improve appropriate use of recommended health care services, including preventive health services, clinicians, health plans, and policymakers may need to communicate health insurance concepts in accessible ways regardless of individuals' health insurance literacy. Plain language communication may be able to improve patients' understanding of services exempt from out-of-pocket costs.
Highlights
Few Americans have a complete understanding of health insurance terms and details
Each 12-point increase in Health Insurance Literacy Measure (HILM) score was associated with a lower likelihood of both delayed or foregone preventive care and delayed or foregone nonpreventive care
In multivariable logistic regression analyses, each 12-point increase in HILM score was associated with a lower likelihood of delayed or foregone care owing to cost for preventive care
Summary
In 2 recent national studies, only 4% to 14% of individuals were able to respond correctly to a set of questions assessing basic understanding of health insurance.[1,2] This lack of understanding was most pronounced among low socioeconomic status, racial/ethnic minority, older, or previously uninsured populations who often have high health needs necessitating use of health care services.[1,2,3,4,5] Knowledge and application of health insurance concepts (ie, health insurance literacy) have become increasingly important for all Americans as a greater number of health plans have complex costsharing features that can change annually, and many previously uninsured individuals may be newly accessing health care after coverage expansion through the Affordable Care Act (ACA).[6,7] Despite this need, there is an overall dearth of studies examining the association between individuals’ health insurance literacy and their health and health care use.[8] there is a broad amount of literature on the outcome of general health literacy (defined as individuals’ ability to understand health information needed to make health care decisions), studies of health insurance literacy are limited.[9,10] Most prior studies on this topic have focused on consumers’ ability to select a health insurance plan.[11,12,13,14,15,16,17,18] Less is known about how patients navigate and use health insurance after obtaining insurance. Other studies have found that aspects of low health insurance literacy—including lack of knowledge of drug coverage and difficulty estimating copayments—were associated with medication nonadherence[20] and delays or avoidance of outpatient care.[21]
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