Shopping on the Public and Private Health Insurance Marketplaces:
Consumer Decision Aids and Plan Presentation
Charlene A. Wong, MD MSHP
, Sajal Kulhari
, Ellen J. McGeoch, MS
Janet Weiner, PhD MPH
, Daniel Polsky, PhD
Department of Pediatrics, Margolis Center for Health Policy, Duke Clinical Research Institute, Duke University, Durham, NC, USA;
for Health Policy, Duke University, Durham, NC, USA;
Duke Clinical Research Institute, Duke University, Durham, NC, USA;
Leonard Davis Institute of
Health Economics, University of Pennsylvania, Philadelphia, PA, USA;
University of Pennsylvania Law School, Philadelphia, PA, USA.
BACKGROUND: The design of the Affordable Care Act’s
(ACA) health insurance marketplaces influences complex
health plan choices.
OBJECTIVE: To compare the choice environments of the
public health insurance exchanges in the fourth (OEP4)
versus third (OEP3) open enrollment period and to exam-
ine online marketplace run by private companies, includ-
ing a total cost estimate comparison.
DESIGN: In November–December 2016, we examined the
public and private online health insurance exchanges. We
navigated each site for Breal-shopping^ (personal informa-
tion required) and Bwindow-shopping^ (no required per-
PARTICIPANTS: Public (n = 13; 12 state-based market-
places and HealthCare.gov) and private (n = 23) online
health insurance exchanges.
MAIN MEASURES: Features included consumer decision
aids (e.g., total cost estimators, provider lookups) and
plan display (e.g., order of plans). We examined private
health insurance exchanges for notable features (i.e.,
those not found on public exchanges) and compared the
total cost estimates on public versus private exchanges for
a standardized consumer.
RESULTS: Nearly all studied consumer decision aids saw
increased deployment in the public marketplaces in OEP4
compared to OEP3. Over half of the public exchanges (n =
7 of 13) had total cost estimators (versus 5 of 14 in OEP3)
in window-shopping and integrated provider lookups
(window-shopping: 7; real-shopping: 8). The most com-
mon default plan orders were by premium or total cost
estimate. Notable features on private health insurance
exchanges were unique data presentation (e.g., info-
graphics) and further personalized shopping (e.g., recom-
mended plan flags). Health plan total cost estimates var-
ied substantially between the public and private
exchanges (average difference $1526).
CONCLUSIONS: The ACA’s public health insurance
exchanges offered more tools in OEP4 to help consumers
select a plan. While private health insurance exchanges
presented notable features, the total cost estimates for a
standardized consumer varied widely on public versus
KEY WORDS: health insurance marketplace; Affordable Care Act;
consumerism; health insurance; decision support.
J Gen Intern Med
© Society of General Internal Medicine 2018
ore than 12 million Americans selected a health insur-
ance plan on the Affordable Care Act’s (ACA) public
marketplaces in fourth open enrollment period (OEP4; Novem-
ber 2016–January 2017).
However, consumers have a hard
time choosing health insurance plans because of the number
and complexity of plan options, limited health insurance liter-
acy, and lack of information.
Sometimes consumers forgo
insurance enrollment all together if too overwhelmed.
Consumers’ insurance choices strongly influence how they
access (or are unable to access) high-quality health care, par-
ticularly in the primary and inpatient care settings. To under-
stand the true cost of a health insurance plan, consumers must
calculate often complicated cost sharing values (e.g., deducti-
bles and coinsurance) to estimate out-of-pocket spending. As a
result, cost-conscious but overwhelmed consumers may overly
focus on monthly premiums with suboptimal plan choices.
Similarly, as insurers use narrow provider networks to control
costs, consumers need to know if their preferred providers are
covered in their selected plan.
Choice errors carry substantial
financial consequences, as cost sharing rises and out-of-
network costs are often not subject to out-of-pocket maximums
(meaning that consumers bear even more financial risk).
The design of the online health insurance marketplaces
influences complex health plan choices.
Our prior work
has demonstrated that the public ACA marketplaces have
offered various tools in prior open enrollment periods (OEPs)
to help consumers make informed health plan choices.
Total cost estimators, for example, are tools that can help
consumers estimate their yearly total out-of-pocket spending
on healthcare—by predicting the amount of cost sharing
(based on expected healthcare utilization), adding it to the
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11606-018-4483-x) contains supplementary
material, which is available to authorized users.
Received September 14, 2017
Revised January 29, 2018
Accepted May 4, 2018