Health Policy$ense

It's All in the Presentation

Defaults and Decision Aids on the Health Insurance Marketplaces

In the beginning (Web Site 1.0), we measured the success of health insurance marketplace sites by whether they worked. Last year (Web Site 2.0), technical glitches were resolved, and we can start to measure success by whether the sites help people make the best decisions in choosing a health plan. A new study by LDI Fellow Charlene Wong and colleagues takes stock of some features of each web site, and should help state and federal policymakers improve their sites even further in Web Site 3.0 (opening Nov. 1, 2015 on a screen near you).

A previous Data Brief looked at the “window shopping” experience of last year’s consumers when they perused HealthCare.gov or a state-based marketplace. The new study adds valuable information on what they saw once they registered on a site as “real” shoppers. The study looked at how plans were ordered in default mode, and how sites helped consumers make better decisions by using quality ratings, yearly out-of-pocket (OOP) cost estimators, provider look up tools, and pop-up definitions for common health insurance terms.  

Three states had OOP cost estimators that helped consumers “do the math” by asking consumers to estimate their predicted use, such as number of physician visits. Six sites had an integrated tool that allowed consumers to search plans on the basis of provider network. Nine sites had pop-up definitions of insurance terms. HealthCare.gov, which is used by the majority of states, had none of these features.

Of the 13 sites studied, 10 sites (including HealthCare.gov) automatically listed plans in ascending premium order. California (below) listed plans by the total consumer cost of the premium plus the estimated out-of-pocket costs before tax credits. Minnesota attempted to “match” plans to consumers using responses about health preferences such as preferred hospitals and plan features. Kentucky simply listed plans in a random order. 

Shoppers on most sites could sort or filter plans by deductibles and premiums, and six sites allowed them to search for plans that include their current health care provider. Colorado’s provider lookup looked like this: 

The authors conclude:

Core technical platforms are in place after a troubled rollout. Now, performance of the health insurance marketplaces will critically depend on the order in which plans are displayed, the plan features listed, and the availability of decision-support tools created for consumers. We identified improved efforts to support decision making in the second open enrollment period, but more can be done. Using the monthly premium, rather than ranking plans by best fit or providing a “smart default,” probably increases the premium's influence on consumer choice, even though the plan with the lowest premium is not necessarily the most cost-efficient…