Insurance Expansion and Health Literacy

Abstract

OVER THE NEXT 3 YEARS, STATE AND LOCAL OFFIcials will be responsible for reaching out to and enrolling more than 30 million individuals in publicly funded or subsidized health plans offered through state insurance exchanges. Because low health literacy tends to be more prevalent in certain minority groups and among those with low income and education, the majority of the newly eligible individuals are likely to have low health literacy. Failure to meet enrollment goals will not only undermine the credibility and success of the Patient Protection and Affordable Care Act (ACA) but, more importantly, will do little to expand health insurance coverage and improve access to care among those at greatest need. Health literacy is “the degree to which individuals have the capacity to obtain, process, communicate, and understand basic health information and services needed to make appropriate health decisions.” A 2004 Institute of Medicine report estimated that 90 million Americans lack the skills needed to understand and act on health information and concluded that “ . . . efforts to improve quality, reduce costs, and reduce disparities cannot succeed without simultaneous improvements in health literacy.” Recent estimates suggest that more than half (53%) of currently uninsured adults—those who will become newly insured under the ACA—have “below basic” or “basic” literacy skills. Such individuals have difficulty with tasks such as finding the date of a physician’s visit on an appointment slip or explaining why someone should have a medical test using information from a clearly written pamphlet. Individuals with low health literacy are less likely to actively participate in health care decision making and more likely to struggle with health management tasks and to face significant challenges navigating the health system. Recent studies also document higher rates of mortality among patients with limited health literacy. This growing evidence base prompted the Institute of Medicine to select “improving the health literacy of the population” as one of 24 Healthy People 2020 objectives submitted to the Department of Health and Human Services to help guide the US health agenda. The ongoing evolution of the health care system is leading US households toward greater responsibility for their own well-being. With this responsibility, however, comes an increasing need to be able to find, trust, use, and act on relevant information to make informed choices. Yet there continues to be a substantial mismatch between the high literacy burden of health information materials designed to support such choices and the health and financial literacy skills of individuals who use them. For example, approximately 9 of 10 US adults (88%) cannot calculate an employee’s share of health insurance costs using a table based on income and family size. In the current economic and policy environment, low health and financial literacy remains a barrier to reducing gaps in health care, raising concerns about the health and well-being of those who are unprepared for the increasing responsibility of choice. Enrollment in a health insurance plan, particularly a government-funded or subsidized plan in which eligibility must be verified, is a complex task. Individuals must navigate the system to find accurate and usable information; understand eligibility guidelines, complete forms, and provide mandatory citizenship and financial documentation necessary for enrollment (and for periodic reestablishment of eligibility); understand concepts such as premiums, copayments, and benefits and be able to apply these concepts to their existing or anticipated health situation to select the most appropriate plan; understand which services are and are not covered; and complete additional paperwork to enroll in their selected plan. The steps must occur prior to an actual visit with their physician, during which patients may spend limited time obtaining the information that is essential for maintaining optimal health and managing acute and chronic health conditions. In addition to developing a consumer-friendly enrollment system, evidence from Massachusetts’ 2006 reforms suggest that financially supporting community-based organizations and health care practitioners to help consumers navigate the process and fill out applications is effective: of all successful subsidy applications, 60% were completed with personal assistance to the consumers by such organizations.