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Improving health insurance literacy aids Missourians' ACA enrollment

August 22, 2018

Community outreach and educational support for navigating health insurance options available in the Affordable Care Act (ACA) marketplace are crucial for helping people choose the best plan based on their individual needs, according to researchers, health policy experts and community partners across Missouri - one of 19 states that hasn't expanded Medicaid eligibility.

Such efforts at the state level likely contributed to a higher enrollment in ACA plans among Missourians in 2018 than in 2017, noted the team, consisting of researchers at Washington University School of Medicine in St. Louis, health policy experts at the Missouri Foundation for Health, and health communication and community partners at Health Literacy Media and the Cover Missouri Coalition. Specifically, 245,580 Missourians enrolled in 2018, about 1,000 more than in 2017. The boost in enrollment came despite a federal decision to shorten the enrollment period for ACA plans and dwindling federal support for initiatives to explain the confusing world of health insurance.

Lessons learned in Missouri from five years of efforts to facilitate enrollment in health insurance and the ACA health plans are described Aug. 22 in NEJM Catalyst.

"Health insurance education and decision support is critical to enrollment," said the study's first author, Mary Politi, PhD, an associate professor of surgery and a health psychologist in the university's Division of Public Health Sciences. "The lessons learned from our collective efforts offer key strategies for health insurance enrollment in Missouri and on a national level for 2019 and beyond. This is particularly important because far fewer resources are being allocated to education and outreach."

Politi collaborated with colleagues at Washington University's Brown School of Social Work, the Cover Missouri Coalition, Missouri Foundation for Health and Health Literacy Media to work with Missouri residents, organizations and policy officials starting in 2013. Their aim is to support health insurance enrollment through in-person and phone-based assistance, online education, personalized cost calculators and language aimed at combating stigma associated with Obamacare, a moniker for the ACA.

Missouri can serve as a model for the United States because it includes urban, suburban and rural communities, and represents the full spectrum of opinions regarding ACA, Politi said.

"The higher enrollment rate in 2018 in Missouri was multifaceted," Politi said. "Some people might have lost employer-based health insurance, some might have realized the benefits of health insurance protection, and some might have gone on and off Medicaid due to variable incomes. But health insurance education likely played a role in the enrollment uptick among Missourians."

Fewer than 25 percent of people who are uninsured feel confident that they understand basic health insurance terms, such as deductibles and out-of-pocket maximums. To help consumers make decisions about ACA marketplace plans, Washington University researchers developed a free, online decision support tool called Show Me Health Plans, which is written at a sixth-grade reading level and incorporates personalized cost estimates for users based on their age, sex and health conditions.

In studies evaluating Show Me Health Plans, the researchers noted that those who used the tool reported significantly higher health insurance knowledge and more confidence in selecting a plan that matched their health needs and preferences, compared with those who turned to, a website developed by the Department of Health and Human Services.

Additionally, efforts from the Missouri Foundation for Health, Health Literacy Media, and the Cover Missouri Coalition also cited several health-literacy initiatives that they said are critical to educating consumers about their insurance choices. These included cost calculators to help consumers learn about the value of insurance for the upfront costs by comparing estimated costs of care to costs of insurance. In-person or phone-based support also helped to reduce consumer anxiety and aid residents who were unfamiliar or skeptical of working with online tools.

Politi and colleagues also said that empowering language may help people overcome the resistance and perceived stigma of enrolling in ACA marketplace insurance plans.

"Empowering language is important," she said. "One enrollment facilitator suggested statements such as: 'You are not alone in needing this help.' Statements like these could help people feel more comfortable enrolling in services when they find themselves unable to access health insurance through other avenues." This support aligns closely with Missouri Foundation for Health's new initiative called The Net Benefit, which raises awareness about health-care access.

"As states nationwide prepare for changes due to health insurance reform, with limited federal resources and the potential for cuts to subsidies and cost-sharing, these broad strategies may become imperative in helping people to attain health insurance and ultimately improve their ability to seek needed health care," Politi said.

Washington University in St. Louis

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