Young adults just entering the market for health insurance on HealthCare.gov and state-operated insurance exchanges are not receiving the kind of education they need to make informed choices, according to research conducted by clinicians at the University of Pennsylvania.

The research, which followed 33 well-educated young adults in the Philadelphia area, was published in the Journal of Adolescent Health. The study represents the full data set of research the team began publicizing late in 2014 in an effort to improve the decision tools available on the federal insurance exchange site.

The cohort studied can offer much insight for the designers of the exchanges as well as insurers who need to reach the young adult demographic, according to lead author Charlene Wong, M.D., a Robert Wood Johnson Foundation Clinical Scholar at Penn.

Also See: Where the States Lie with Health Insurance Exchanges

The technology of the insurance exchanges was not a source of confusion, Wong said.

"They had no trouble navigating the website itself," she said. "It was the process of navigating the decision making process. They were choosing among 30 different plans, which they found to be a really daunting and sometimes overwhelming task, because it wasn't like choosing between 30 different pairs of shoes, but rather choosing among products they weren't familiar with."

For examples of this unfamiliarity, a bare majority, 52 percent, knew what the term deductible meant, while a whopping 78 percent incorrectly defined coinsurance.

"We were not surprised that young people had difficulty making a health insurance choice, because we find that even populations that have a lot of experience choosing a health insurance plan find it a very complex and challenging decision to make," Wong said. "We were surprised by the degree of difficulty and unfamiliarity young adults had with very basic health insurance terms, like deductible and co-insurance, because understanding those terms is really fundamental if you have any hope of making an informed choice about which plan may be best for you and your family."

Among the recommendations the study subjects made, according to a RWJF blog post Wong wrote shortly after completing the study were:

*Other online programs, like Turbo Tax, are good models where easy-to-understand definitions and examples appear when you hover your cursor over an important term.

*Participants in the study suggested using check boxes for important insurance features they wanted, like dental coverage or mental health benefits, or sliding bar ranges for prices they’re willing to pay.

*Another recommendation was to change the name for the category of health insurance called “Catastrophic.” In Philadelphia, this category included three high-deductible health insurance plans available to adults under age 30 and typically cost less than other plan tiers, like silver or gold plans. But rather than understanding these plans as offering lower up-front monthly cost options, young adults were scared away by the mere mention of the word “catastrophic.”

Wong said the federal exchange did indeed include some tools during the Affordable Care Act's first open enrollment period in 2014.

"It's hard to know of, course, if it was due to our recommendations or not, but we did notice that by the end of the first open enrollment period that the pop-up explanations young adults had been asking for appeared in HealthCare.gov," she said. "Interestingly enough, they were gone for the second open enrollment period, but we have also notified our contacts at the Office of Health Reform they were gone, so we are hopeful they will reappear during the next open enrollment period or even before."

Wong said one particularly useful tool might be something like a total cost estimator, which is something she said the Centers for Medicare and Medicaid Services is working on now.

"There are some  marketplaces, very few, that have already implemented this sort of technology," she said. "There are so many different cost variables, and calculating premiums,. deductibles, co-insurance, and other out-of-pocket costs is very complicated. These kinds of tools can really help consumers identify and understand what they may be responsible for paying when they are looking at 30-plus different plan options."

Since many of the consumers in the demographic covered by the study are employed in situations where there is no human resources department to assist in navigating the insurance marketplace, as well as taking the next step of finding a healthcare provider, the tools to do so would have to come from public agencies, insurers themselves, and advocacy groups, Wong said.

"Some of our study subjects were saying, 'I got my insurance but don't know how to find a doctor – do I go by Yelp reviews, should I use Google?' They weren't sure how to take that next step," Wong said. "We do know now that HealthCare.gov and the marketplaces have developed materials around this, because they also identified that this was an area where access to care was hitting barriers."

Wong also said leveraging online platforms such as social media sites could help reach the young adult population, and also cited organizations such as the policy research and advocacy group Young Invincibles, which specializes in issues affecting the millennial generation, as potential sources of more information.

"I don't think it's their fault they don't know about this," she said. "It's just the first time they're really engaging with this and encountering these sorts of decisions and terms and issues."

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