Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Insurance Expansion and Health Literacy

Insurance Expansion and Health Literacy 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.1 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.”2 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.”2 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.3 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.3 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 base4 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.5 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.3 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.6 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, co-payments, 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.6 The historical emphasis on health literacy as central to care quality has overshadowed its conceptualization as a major influence on the success of health policy implementation. Yet the success of such policies depends heavily on outreach to and clear communication with individuals with limited health literacy. For example, state Medicaid programs failed to fully enroll eligible populations—despite a wide range of outreach strategies, levels of enrollment range from 44% to 88% of the eligible population.7 Further complicating existing eligibility and enrollment challenges is Medicaid “churn,” whereby fluctuations in income recategorize millions of individuals and families across the Medicaid-exchange market divide (133% of the federal poverty level),8 requiring them to repeatedly go through the eligibility, decision-making, and enrollment process and placing the burden on individuals and families who experience significant income fluctuations to correctly anticipate where they should be seeking coverage. At the same time, policy makers continue to enact legislation that undermines efforts toward clear communication. There are provisions in the ACA requiring health plans seeking certification in state exchanges to provide information in plain language, meaning “language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-organized, and follows other best practices.”9 Despite these provisions, in February 2011 Wisconsin's new insurance commissioner adopted an “emergency rule,” made permanent in May, to raise the readability scores of insurance policies to a high-school reading level and overturn a mandate to list what is not covered in a single place within the policy. Decisions such as these establish a detrimental precedent. Consumers are often confused or overwhelmed when making health plan choices. Even when consumer assistance is offered, such confusion can lead to delays or failure to enroll in any health plan.6 Delays or nonenrollment, particularly if healthier individuals remain disproportionately uninsured, could have important consequences for the viability and long-term sustainability of the ACA in the form of higher premiums in the exchange markets.6 Although the ACA directly acknowledges the need for greater attention to health literacy in a limited number of provisions related to care quality and dissemination of research, provisions related to insurance reform, outreach, and enrollment do not directly mention health literacy.10 However, without a considerable increase in attention to this issue, such provisions are likely to fail. Although efforts are under way to prepare the United States for the implementation of the ACA, states must consider the importance of user interface and the outreach, communication, and dissemination strategies needed to ensure that those eligible for coverage are appropriately and efficiently enrolled. Back to top Article Information Corresponding Author: Laurie T. Martin, ScD, MPH, RAND Corporation, 1200 S Hayes St, Arlington, VA 22202 (lamartin@rand.org). Published Online: August 9, 2011. doi:10.1001/jama.2011.1212 Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. References 1. Rudd R, Anderson J, Oppenheimer S, Nath C. Health literacy: an update of public health and medical literature. In: Comings J, Garner B, Smith C, eds. Review of Adult Learning and Literacy. Vol 7. Mahwah, NJ: Lawrence Erlbaum Associates; 2007:174-204 2. Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004 3. National Center for Education Statistics. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy. Washington, DC: US Dept of Education; 2006 4. Harvard School of Public Health. Health literacy studies: research findings. Updated July 17, 2010. http://www.hsph.harvard.edu/healthliteracy/research/. Accessed July 21, 2011 5. Institute of Medicine. Leading Health Indicators for Healthy People 2020: Letter Report. Washington, DC: National Academies Press; 2011 6. Dorn S. Implementing National Health Reform: A 5-Part Strategy for Reaching the Eligible Uninsured. Washington, DC: Urban Institute; 2011 7. Sommers BD, Epstein AM. Medicaid expansion—the soft underbelly of health care reform? N Engl J Med. 2010;363(22):2085-208721105788PubMedGoogle ScholarCrossref 8. Sommers BD, Rosenbaum S. Issues in health reform: how changes in eligibility may move millions back and forth between Medicaid and insurance exchanges. Health Aff (Millwood). 2011;30(2):228-23621289343PubMedGoogle ScholarCrossref 9. Pub L No. 111-148 §1311:76, 124 Stat 119 10. Institute of Medicine. Health Literacy Implications for Health Care Reform: A Workshop Summary. Washington, DC: National Academies Press; 2011 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Insurance Expansion and Health Literacy

JAMA , Volume 306 (8) – Aug 24, 2011

Loading next page...
 
/lp/american-medical-association/insurance-expansion-and-health-literacy-o5Y6RWzhww
Publisher
American Medical Association
Copyright
Copyright © 2011 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2011.1212
Publisher site
See Article on Publisher Site

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.1 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.”2 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.”2 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.3 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.3 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 base4 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.5 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.3 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.6 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, co-payments, 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.6 The historical emphasis on health literacy as central to care quality has overshadowed its conceptualization as a major influence on the success of health policy implementation. Yet the success of such policies depends heavily on outreach to and clear communication with individuals with limited health literacy. For example, state Medicaid programs failed to fully enroll eligible populations—despite a wide range of outreach strategies, levels of enrollment range from 44% to 88% of the eligible population.7 Further complicating existing eligibility and enrollment challenges is Medicaid “churn,” whereby fluctuations in income recategorize millions of individuals and families across the Medicaid-exchange market divide (133% of the federal poverty level),8 requiring them to repeatedly go through the eligibility, decision-making, and enrollment process and placing the burden on individuals and families who experience significant income fluctuations to correctly anticipate where they should be seeking coverage. At the same time, policy makers continue to enact legislation that undermines efforts toward clear communication. There are provisions in the ACA requiring health plans seeking certification in state exchanges to provide information in plain language, meaning “language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-organized, and follows other best practices.”9 Despite these provisions, in February 2011 Wisconsin's new insurance commissioner adopted an “emergency rule,” made permanent in May, to raise the readability scores of insurance policies to a high-school reading level and overturn a mandate to list what is not covered in a single place within the policy. Decisions such as these establish a detrimental precedent. Consumers are often confused or overwhelmed when making health plan choices. Even when consumer assistance is offered, such confusion can lead to delays or failure to enroll in any health plan.6 Delays or nonenrollment, particularly if healthier individuals remain disproportionately uninsured, could have important consequences for the viability and long-term sustainability of the ACA in the form of higher premiums in the exchange markets.6 Although the ACA directly acknowledges the need for greater attention to health literacy in a limited number of provisions related to care quality and dissemination of research, provisions related to insurance reform, outreach, and enrollment do not directly mention health literacy.10 However, without a considerable increase in attention to this issue, such provisions are likely to fail. Although efforts are under way to prepare the United States for the implementation of the ACA, states must consider the importance of user interface and the outreach, communication, and dissemination strategies needed to ensure that those eligible for coverage are appropriately and efficiently enrolled. Back to top Article Information Corresponding Author: Laurie T. Martin, ScD, MPH, RAND Corporation, 1200 S Hayes St, Arlington, VA 22202 (lamartin@rand.org). Published Online: August 9, 2011. doi:10.1001/jama.2011.1212 Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. References 1. Rudd R, Anderson J, Oppenheimer S, Nath C. Health literacy: an update of public health and medical literature. In: Comings J, Garner B, Smith C, eds. Review of Adult Learning and Literacy. Vol 7. Mahwah, NJ: Lawrence Erlbaum Associates; 2007:174-204 2. Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004 3. National Center for Education Statistics. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy. Washington, DC: US Dept of Education; 2006 4. Harvard School of Public Health. Health literacy studies: research findings. Updated July 17, 2010. http://www.hsph.harvard.edu/healthliteracy/research/. Accessed July 21, 2011 5. Institute of Medicine. Leading Health Indicators for Healthy People 2020: Letter Report. Washington, DC: National Academies Press; 2011 6. Dorn S. Implementing National Health Reform: A 5-Part Strategy for Reaching the Eligible Uninsured. Washington, DC: Urban Institute; 2011 7. Sommers BD, Epstein AM. Medicaid expansion—the soft underbelly of health care reform? N Engl J Med. 2010;363(22):2085-208721105788PubMedGoogle ScholarCrossref 8. Sommers BD, Rosenbaum S. Issues in health reform: how changes in eligibility may move millions back and forth between Medicaid and insurance exchanges. Health Aff (Millwood). 2011;30(2):228-23621289343PubMedGoogle ScholarCrossref 9. Pub L No. 111-148 §1311:76, 124 Stat 119 10. Institute of Medicine. Health Literacy Implications for Health Care Reform: A Workshop Summary. Washington, DC: National Academies Press; 2011

Journal

JAMAAmerican Medical Association

Published: Aug 24, 2011

Keywords: insurance,health literacy

References