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(The RAND Blog)

November 7, 2013

Quick Takes: Health Literacy and ACA Enrollment

The Affordable Care Act (ACA) expands coverage to millions of Americans. But the newly eligible may face challenges enrolling if they lack understanding of how the health care system itself works. Laurie Martin explains the role of health literacy in determining how successful the ACA will be in providing coverage for America's uninsured.

What is health literacy?

Health literacy refers to one's ability to find, understand, and use the basic health services and information necessary to make informed choices about health care.

Enrolling in a health insurance plan is not a simple task, whether it's through your employer or through the website of the government's new health care exchanges. But there are two sides to health literacy: the skills and knowledge of individuals, and the literacy of the information and materials those individuals are expected to use. When these two sides are not in balance (e.g., when materials are too difficult to understand), problems arise.

Why is health literacy important?

First, research indicates that individuals with limited health literacy have higher rates of many different poor health outcomes including mortality. They also are more likely to struggle with health management tasks (e.g., medication adherence, monitoring weight or blood pressure, etc.) and experience difficulties navigating the health system. Low health literacy can also undermine efforts to improve health care quality, reduce costs, and eliminate health disparities.

How could health literacy affect the Affordable Care Act (ACA)?

Enrolling in a health insurance plan is not a simple task. This is especially true if the plan is funded or subsidized by the government, with eligibility requirements that must be verified, as is the case with various provisions of the ACA.

Individuals must locate accurate and practical information, understand their own eligibility (and that of their family), complete the necessary paperwork, provide documentation for enrollment (e.g., citizenship and financial documents), and have a grasp on concepts such as benefits, co-payments, and premiums.

Ignoring this complexity and failing to support people with low health literacy could create barriers to entry for those who might otherwise be newly insured under the ACA. If healthier people remain disproportionately uninsured, this could threaten the ACA's long-term viability, since the law's provisions depend on healthier, low-cost individuals (e.g., “young invincibles”) enrolling in the state insurance exchanges.

What can the government and other stakeholders do to help ACA implementation with regard to health literacy?

To its credit, the ACA explicitly acknowledges the importance of health literacy. The measure requires insurance plans seeking a place in the state health exchanges to use “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.” The law also carves out a role for “navigators,” insurance counselors who can help individuals find a plan through the exchanges.

Despite these guidelines, it is unclear which states have adopted these principles in their outreach efforts. The implications of failing to communicate information in a way that can be readily understood are unknown. That is, success is not guaranteed. It's worth noting that before the ACA, state Medicaid programs failed to enroll all eligible individuals. (Even those with the most successful outreach campaigns capped out at 88 percent enrollment; the least successful states enrolled only 44 percent of eligible individuals.)

Stakeholders should engage and support individuals with low health literacy proactively — and throughout the entire process. In addition, performance standards for state exchange counselors, community-based organizations, and health providers can play a role in helping consumers navigate the complex enrollment process.

However, attention to health literacy should not stop at enrollment. It is also critical to facilitate engagement with the health system as the millions of newly insured Americans pursue routine and preventive care.

Pete Wilmoth