Understanding Health Insurance Literacy: A Literature Review

Understanding Health Insurance Literacy:A Literature Review

Jinhee Kim, Bonnie Braun and Andrew D. Williams

University of Maryland College Park

The 2010 Affordable Care Act changed health insurance plans for both the insured and uninsured. Currentlyinsured consumers need to understand changes that impact their purchase decisions, and newly eligibleconsumers need to understand how to purchase through the new health insurance marketplace. Healthinsurance literacy is a new concept that addresses the extent to which consumers can make informed purchaseand use decisions. Consumers currently exhibit limited health insurance literacy. Researchers and educatorsneed a comprehensive review of the literature and existing curriculum and materials to conduct research andto create and test educational programs that could increase health insurance literacy. This article provides areview of relevant literature and curricula. It offers implications for additional research, measurement of healthinsurance literacy, and development of educational programs to improve health insurance literacy in theUnited States.

Keywords: financial literacy; health insurance literacy; health insurance education; health insurance decisionmaking

Health insurance is a focus of attention due to the 2010 Affordable Care Act(ACA), which changed health insurance plans and the marketplace impactingmost individuals and families in the United States. Millions of Americans,including many who were previously not eligible for insurance, are expectedto enroll in health insurance plans to improve access to care. Others withinsurance will see a change in benefits (Patient Protection & Affordable CareAct, 2010).

Most Americans purchase health insurance through employers, although thepercentage of employee-sponsored coverage declined from 69% to 60% between1999 and 2010 (Fewer employees getting health insurance at work, 2013). Nearly84% of the 49 million uninsured come from families with at least one worker;62% include at least one full-time worker (American Public Health Association,2012; Kaiser Family Foundation, 2012a). The ACA has created new opportunitiesto provide more affordable options for individuals and families (PatientProtection and Affordable Care Act [ACA], 2010) and is expected to extend

Authors’ Note: Jinhee Kim, PhD, is an Associate Professor and Extension Family Finance Specialist inthe department of Family Science at University of Maryland College Park. Bonnie Braun, PhD, is anProfessor and Extension Family Policy Specialist in the department of Family Science, FacultyScholar, Horowitz Center for Health Literacy at University of Maryland College Park. Andrew D.Williams, MPH, is an Graduate Research Assistant in the department of Family Science at Universityof Maryland College Park. Please address correspondence to Jinhee Kim, Department of FamilyScience, School of Public Health, University of Maryland College Park, College Park, MD 20742;e-mail: [email protected].

Family and Consumer Sciences Research Journal, Vol. 42, No. 1, September 2013 3–13DOI: 10.1111/fcsr.12034© 2013 American Association of Family and Consumer Sciences

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coverage to over 31 million people by 2019 (APHA, 2012; ACA, 2010). Researchsuggests that health insurance is a complex financial product for consumers.

Consumers with documented low-to-moderate levels of financial, health, andhealth insurance literacy will be challenged to make health insurance purchases(Cude, 2005; Huston, 2010; Lusardi, 2008; National Association of InsuranceCommissioners, 2010; Tennyson, 2011). There is an urgent need to helpconsumers understand health insurance and to help optimize decision makingfor their particular situation during open enrollment periods.

The National Institutes of Health, Institute on Medicine, released an ACA-focused report on how to help consumers understand and use health insurance.Navigators and in-person counselors will be funded to reach and enrollconsumers. However, they may not have sufficient expertise or time to puthealth insurance purchases into a broader personal and family perspective andeducate consumers about health insurance (Centers for Medicare & MedicaidServices, 2013; Patel et al., 2013).

Selecting health insurance is a complicated financial decision. Althoughfinancial literacy is believed to be an essential tool to make sound financialdecisions, it might not be a skill for many consumers. Many Americans lackknowledge and skills to make informed financial decisions and to manage theirassets (Fox, Bartholomae, & Lee, 2005; Lusardi, 2008). One such financial andhealth insurance literacy skill is managing risk through health insurance(McCormack, Bann, Uhrig, Berkman, & Rudd, 2009; Tennyson, 2011).

Consumers think choosing a health insurance plan is important but they mightmake less than optimal health insurance choices for reasons such as low healthinsurance literacy, lack of information or misinformation, information overload,and time constraints (Farley Short et al., 2002; Frank & Lamiraud, 2009; Hanoch& Rice, 2011; Lako, Rosenau, & Daw, 2011; Sinaiko & Hirth, 2011). Lack ofinformation or understanding how to use information could lead to a mismatchof insurance to needs. Consumers may be carrying too much or too little healthinsurance for their individual and family health and financial situations.

The ACA provides researchers and educators an opportunity for healthinsurance research and education. Consumer behavior can be influenced byeducation (McGregor, 2009). Effective education programs could improveconsumers’ health insurance literacy and decision making. While there is littleresearch on health insurance literacy education programs, the effectiveness offinancial education programs in improving financial literacy has beendocumented as a successful way to invest in human capital (Lusardi, Michaud,& Mitchell, 2011).

Lusardi and Mitchell (2009) have suggested that effective financial literacyeducation uses simplification, personal approach, and target programs.Following an extensive review of financial education program evaluation, Foxet al. (2005) suggested that an overarching framework for evaluation of financialeducation programs should provide a guide for collecting information aboutprogram development, delivery, effectiveness, and accountability. Therefore, thisarticle provides a review of relevant literature and curricula. It concludes withimplications for additional research, measurement of health insurance literacy,and the development of educational programs to improve health insuranceliteracy in the United States.

4 FAMILY AND CONSUMER SCIENCES RESEARCH JOURNAL

METHODOLOGY

The review of literature was conducted in four parts: (1) financial literacy, (2)health literacy and health insurance literacy, (3) consumer decision making andchoice, and (4) existing curriculum. The authors identified keywords and specificcontent areas to guide the search. Keywords included health education,education, adult education, financial literacy, adult literacy, health care, andhealth insurance from these content areas: (i) personal finance, (ii) consumerbehavior, (iii) health insurance, (iv) health services, and (v) family and consumersciences. Current health insurance literacy curriculum and education materialswere researched through Internet search engines and clearinghouses such as theNational Endowment for Financial Education, eXtension.org, and Jump$tart.Internet search included: Ebsco Host databases, PsychINFO, JSTOR databases,and Google Scholar.

REVIEW OF LITERATURE

Financial Literacy

Financial literacy is essential to sound consumer financial decisions inincreasingly complex financial markets. Financial literacy is defined as “… theability to use knowledge and skills to manage financial resources effectively fora lifetime of financial well-being” (U.S. Department of Treasury, 2008).

Financial literacy affects financial decision making regarding insurance,retirement plans, and more (Lusardi, 2008). A high level of financial literacy isnot prevalent in the United Sates. Some groups, such as racial minorities,women, and those with less education may be more vulnerable than others(Lusardi, 2008). Increasing adult consumer financial literacy is a policy objectiveto improve the goal of consumer well-being through better decision making infinancial management for all consumers including vulnerable groups (Huston,2010).

A metastudy of financial literacy found that most studies focused oninvesting and savings, while only 16 out of 52 surveys (30.8%) included anyquestions about insurance (Huston, 2010; Tennyson, 2011). Using an insuranceliteracy scale, Tennyson (2011) found that U.S. consumers had low levels ofinsurance literacy associated with low consumer confidence in insurancedecision making. Those with low insurance literacy and low confidence weremore likely to seek informal sources of insurance information like friends andfamily (Tennyson, 2011). In health insurance decision making, consumers facesimilar issues as when making other types of decisions as both financial servicesand the health insurance marketplace have become increasingly complex andspecialized. These decisions require consumers to have higher levels ofsophistication and involvement (McCormack et al., 2009).

Health Literacy

The Institutes of Medicine (2004) defined health literacy as “… the degree towhich individuals have the capacity to obtain, process, and understand basichealth information and services necessary to make appropriate health decisions”

Kim et al. / HEALTH INSURANCE LITERACY: A TIMELY LITERATURE REVIEW 5

(p. 31). A study of American adults determined that only 12% were fully healthliterate; the majority were at or below basic health literacy (Kutner, Greenberg,Jin, & Paulsen, 2006). Levels of health literacy are predictive of personal health(American Medical Association, 1999). Health literacy affects the ability ofindividuals to provide self- and family care especially preventative care. Whenpeople do not understand how to access information or services, they are morelikely to get costly medical care in advanced stages of poor health (Vernon,Trujillo, Rosenbaum, & DeBuono, 2007).

Health literacy and finances are related—poor health affects finances and lackof financial resources can contribute to poor health. Braun, Kim, and Anderson(2009) explored the relationship between the two and concluded that both areessential to personal health and finance decisions.

Health Insurance Literacy

McCormack et al. (2009) developed and tested a health insurance literacy scalefor Medicare programs and found low-to-moderate levels of health insuranceliteracy among older adults. In 2011, 12 experts in financial literacy, healthliteracy, and/or health insurance plans were invited to a roundtable to definehealth insurance literacy and to recommend how to measure it. The roundtablewas hosted by Consumers Union, the University of Maryland College Park, andthe American Institutes of Research (AIR). Health insurance literacy was definedas “… knowledge, ability, and confidence to find and evaluate informationabout health plans, select the best plan for his or her family for their own ortheir family’s financial and health circumstances, and use the plan onceenrolled” (Quincy, 2012a). In 2013, the AIR released a standardized measure ofhealth insurance literacy with three purposes: “(i) assess a person’s ability tomake informed decisions when selecting and using health insurance, (ii) isdesigned for use of the population’s level of education, and (iii) is a tool with aseries of multiple-choice questions that are easily understood.” The topic areasincluded insurance terms, information seeking, document literacy, and cognitiveskills such as numeracy and ability to assess health insurance value (AIR, 2013).The tool is intended for use by educators, policy makers, and researchers tobetter understand the health insurance literacy of U.S. consumers. Using thisvalidated tool, educators could design education and outreach to match thecomplexity and type of information provided to the ability of target groups(AIR, 2013).

Consumer Decision Making in Health Insurance

While it is assumed that consumers make informed choices based on the costand quality of competing health plans, research has documented that manyconsumers are overwhelmed by health insurance plan options and thatconsumers are not confident in their ability to choose (Quincy, 2011a). To makehealth insurance decisions, consumers need: clarity of financial aspects ofavailable plans; reliable and easy-to-understand information; an effective way tonavigate through the myriad options available to them in the health insurancemarketplace; and sources they can trust (Farley Short et al., 2002; Hanoch &Rice, 2011; Hibbard, Slovic, Peters, & Finucane, 2002; Quincy, 2011a,b,c;Wroblewski, 2007).


Primary insurance variables in previous studies of health plan choicesincluded price, quality, choice of provider, benefits/coverage breadth, and planconvenience; price was found to be the most significant factor. Other factorssuch as quality were not widely studied (Scanlon, Chernew, & Lave, 1997).Consumers seem to be interested primarily in financial cost but they might notfully understand the financial implications of health insurance plans (FarleyShort et al., 2002; Quincy, 2011b, 2012b; Royalty & Hagens, 2005; Smith &Rogers, 1986; Wroblewski, 2007). In addition to premiums, consumers areinterested in the cost of prescriptions, copays for primary and specialist care, in-and out-of-network fees, and estimation of out-of-pocket expenses (Barringer &Milkovich, 1996; Royalty & Hagens, 2005; Sinaiko & Hirth, 2011; Walsh,Fitzgerald, Gurley-Calvez, & Pellillo, 2011; Wroblewski, 2007). Walsh et al.(2011) reported that consumers chose a more appropriate plan for their needswhen they were able to obtain specific plan details.

Type and quality of sources of information are likely to contribute todecision making. Farley Short et al. (2002) found that most consumers prefertwo or three sources of information from the following ranked highest tolowest: (i) health plan sponsors (employers); (ii) health insurance companies;(iii) family or friends; and (iv) medical doctors. Research has shown thatconsumers are wary about the information they receive from employers andhealth insurance companies. Consumers are concerned that information sourceswill attempt to coerce them into “bottom-line friendly” policies rather than topolicies which are best for their situation (Hibbard et al., 2002). In contrast,information provided by physicians was often looked upon favorably (Walshet al., 2011).

How the information is presented is also important. Hibbard et al. (2002)found that consumers perform well when presented information in a singleformat but their performance deteriorates when formats are combined orbecome too complex. Quincy (2011b,c, 2012b) suggested that difficulty inunderstanding terms, inability to properly calculate true costs, and financialuncertainty add to the difficulty in choosing a health insurance plan. Researchalso showed that consumers lose interest, ignore available information, andultimately choose inappropriate plans when faced with multiple choices (Frank& Lamiraud, 2009; Hanoch & Rice, 2011; Lako et al., 2011; Sinaiko & Hirth,2011).

Research conducted by Consumers Union provided consumerrecommendations to improve health insurance information. Among these areimproving glossary and definition terms, plan-specific examples to allowconsumers to understand their health plan, and examples of consumer’s out-of-pocket spending (Quincy, 2011b).

Research has called for helping consumers make better health insurancedecisions (Frank & Lamiraud, 2009; Hanoch & Rice, 2011; Hibbard et al., 2002;Wroblewski, 2007). Hibbard et al. (2002) found that consumers perform wellwhen given a tool that presents information in a simple format that allows themto compare plan aspects without viewing unneeded or cluttered information.Plan summaries highlighting specifics were found to improve consumerperformance (Wroblewski, 2007). Consumers do not perform well when giventoo many choices in the health insurance marketplace (Frank & Lamiraud, 2009;Hanoch & Rice, 2011; Quincy, 2012c). In addition to tools to apply theirknowledge and skills effectively, consumers need education to enhance health


insurance literacy. Educational interventions could reduce cognitive demands bymaking information helpful, providing decision-making tools, making tools aspersonalized as possible, and offering consumers trusted resources (Quincy,2012c).

Curricula and Material Review

The purpose of the curricula and material review was to identify existing healthinsurance curricula and determine the extent to which the curricula addressedneeds identified in the review of literature. This included a review of materialsfrom the Cooperative Extension Service, nonprofits and foundations, andgovernment information sources.

The review began with curricula and educational materials produced by theCooperative Extension Service. Curricula for adults and families were located infive states (University of Missouri Extension, 2012; University of WisconsinCooperative Extension, 2013; Texas A & M University Extension, 2012; NorthCarolina State University Cooperative Extension, 2009). The University ofMissouri’s “Making Money Count” curriculum (2012) includes health insurancelesson plans and tools to assist consumers in identifying and purchasing healthinsurance plans that work best for themselves and their families. Most of thesepersonal finance curricula included information on the importance of healthinsurance as a risk management tool.

The University of Wisconsin materials (2013) focused on health insurancethrough a public policy lens. The University of Wisconsin has produced a“Health Reform” Web site allowing Wisconsin residents to stay current on theirstate’s progress through the health reform process and ACA impact onWisconsin. North Carolina State University Cooperative Extension (2009)produced a downloadable document explaining what types of coverage areavailable to residents.

Together, these extension materials cover basic details of health insurancesuch as plan types, terms and definitions, and explanation of basic benefits.Most address the family aspect of purchasing health insurance in contrast tofocusing on consumers’ reading materials or attending an educational session.None of the materials explained total expenses associated with purchasinghealth insurance. Most materials did not include information about the levels offinancial, health, and health insurance literacy required to use the materials, andthey did not indicate any testing with consumers.

Nonprofit organizations and foundations have produced educationalprograms [LIFE Foundation, 2012; Griffith Foundation, 2006; NationalAssociation of Insurance Commissioners (NAIC) 2012; American Academy ofPediatrics and Children’s Hospital Association (AAP & CHA) 2012]. GriffithFoundation (2006) and LIFE Foundation (2012) specifically targeted youth. Thegoal of engaging youth is to prepare them for the health insurance marketplacewhen they are adults. The AAP and CHA (2012) partnered with the Universityof Wisconsin to produce information describing current Medicaid benefits forfamilies in need of healthcare coverage for their children. NAIC’s“InsureUOnline” offers consumers general insurance information and providescontact information for state and jurisdiction insurance commissioner offices(NAIC, 2012).


In response to ACA, government agencies, nonprofits, consumer groups, anduniversities have created a large number of informational materials. ConsumerReports (2012, 2013) produced consumer informational materials on changes thatwill affect consumers when the ACA is fully implemented and on key questionsto ask about health insurance. The “Update on Health Reform” Web site allowsconsumers to receive the latest health reform information (Consumer Reports,2013).

Health-focused foundations and organizations have provided ACAinformation (American Public Health Association [APHA], 2012; Kaiser FamilyFoundation [KFF], 2012b). The APHA and KFF take a similar approach indescribing how the ACA will impact health insurance for Americans and whatthat means for individuals and families. Both have up-to-date informationavailable to consumers through their Web sites (APHA, 2012; KFF, 2012b).

APHA provides an overview of the basics of the ACA: a list of frequentlyasked questions and timely downloadable handouts and presentations (APHA,2012). KFF provides basic information on the ACA and consumer tools tounderstand finances (KFF, 2012b). A “subsidy calculator” enables consumers todetermine eligibility for financial assistance based on income, family size, andtobacco usage (KFF, 2012b). Snapshots of state programs are also available fromKFF. Consumers can visit KFF’s Web site and learn which states are creatingtheir own exchanges, which states are opting for the federal government’sexchange, and which are partnering (KFF, 2012b).

State governments are regulating their responses to the ACA and areresponsible for communicating those responses to their population. As a result,several states have produced Web sites for their residents to learn about thechange in ACA (Maryland Health Benefit Exchange, 2012; Washington StateOffice of the Insurance Commissioner, 2013; Washington Health BenefitExchange, 2013). The main purpose of these Web sites is to connect consumersto the new health insurance marketplace.

Maryland’s approach provides consumers with a timeline detailing open andclosing dates for open enrollment, as well as effective dates of coverage for newhealth insurance plans (MHBE, 2012). Washington State’s “Health Plan Finder”is organized to allow both consumers and small businesses to compare healthplans, find financial assistance, and enroll online (WHBE, 2013). WashingtonState’s Office of the Insurance Commissioner’s Web site and handouts describehealth insurance changes the state is making and how they will impactindividuals, families, businesses, and seniors (WSOIC, 2013). These Web sitesinclude tools to allow consumers to compare plans and find additionalinformation, like financial assistance eligibility, to make the best decision forthemselves and their families.

The federal government is using a Web site, Healthcare.gov, as their primaryconsumer resource for ACA information (Department of Health & HumanServices, 2013). Healthcare.gov provides consumers with direct access to theACA text, key features of the law, and a detailed timeline of implementation.The Web site also provides a basic understanding of how the health insuranceexchanges operate. The main difference between Healthcare.gov and state Websites is that the former provides consumers with an understanding of the ACAand some information about health insurance, while the latter focuses onconnecting consumers to healthcare exchanges to purchase insurance (DHHS,2013; MHBE, 2012; WSOIC, 2013).


The review found more informational materials and decision-making toolsthan health insurance educational curriculum. Little evidence was found ofcurriculum or materials development and testing based on research to enhancehealth insurance literacy.

IMPLICATIONS

Implementation of the ACA presents a teachable moment for consumereducators as all Americans will be affected by changes in health insurance.Currently insured consumers need to understand changes that impact theirpurchase decisions, and newly eligible consumers need to understand how topurchase through the new health insurance marketplace. Consumers needsources of current information they can trust.

Health insurance literacy—knowledge, ability, and confidence to effectivelychoose and use health insurance—is a relatively new concept. Even withoutstandardized measures of health insurance literacy, the authors found evidencethat many consumers do not know how to get and process information to makeoptimal health insurance choices for their situation.

A standardized measure of health insurance literacy in development willcover insurance terms, information seeking, document literacy, and cognitiveskills such as numeracy and ability to assess health insurance variables (AIR,2013). The measure will help researchers collect baseline and impact data overtime. Educators can use the measure to develop and tailor curricula andmaterials based on levels of health insurance literacy. The authors recommendthat educators develop research-based educational curriculum by incorporatingthe already-identified core topics in health insurance for consumers withdiffering levels of literacy.

Policy makers can use the results to determine whether changes are neededin the implementation of the ACA and to financial literacy education. Resultsfrom a curriculum that is research based and that has been evaluated willprovide evidence of the extent to which consumers are meeting the challengeof making sound health insurance purchase decisions. Sound decisions are akey step toward improving the health and well-being of consumers andfamilies.

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Documents

Understanding Health Insurance Literacy: A Literature Review