New Penn Study Outlines How to Improve Healthcare.gov

New Penn Study Outlines How to Improve Healthcare.gov

A new three month observational study by a University of Pennsylvania research team led by LDI Fellow Charlene Charlene Wong has identified the most serious problems on Healthcare.gov that confuse or thwart the young adults who are the insurance website's most important targets.

The problems and the recommended solutions are outlined in an article just published in the July 8 issue of the Annals of Internal Medicine.

Project team members included two physician researchers specializing in adolescent medicine, a law professor specializing
Charlene Wong
Charlene Wong, MD, the primary investigator on the new study, is a Robert Wood Johnson Foundation Clinical Scholar and a Fellow at Penn's Leonard Davis Institute of Health Economics (LDI).

in insurance, two top Wharton School health economists, and the head of Penn's social media lab specializing in the study of digital communications behaviors.

From January to March of this year, the investigators observed and recorded the interactions of 33 young Philadelphia professionals as they used the federal insurance exchange or "marketplace" site.

'Young healthies'
By age and life experience, these professionals were a close approximation of the "young healthies" whose patronage is considered crucial to the long-term fiscal stability of the insurance exchange system.

"These were highly educated young adults who were either uninsured or looking to switch insurance being observed as they went through the real experience of selecting health insurance," said Wong, a pediatrician and Robert Wood Johnson Clinical Scholar who is the project's primary investigator and author.

She pointed out that while some surveys have documented consumers' general unfamiliarity with insurance terminology or their general frustrations with Healthcare.gov, this project is believed to be the first to comprehensively analyze consumers going through the real-time process of using the site.

Minute-by-minute web moves
Her team recorded the computer screen and the subjects' minute-by-minute web moves and audio recorded their explanations and perceptions of what they were doing as they were doing it. This was followed up by immediate interviews and additional phone interviews.

"It took several times for most of them to complete the process," said Wong. "They looked through the site multiple times and talked to their parents or their navigators as they figured out what plan they wanted."

"One observation," she said, "is that if even these extremely well-educated young adults are having the difficulties we detail, then surely others who are less educated, less computer literate and less supported are going to have greater difficulties."

"What we're trying to do here is give data-informed direction to those people who are currently redesigning Healthcare.gov," Wong said.

Most common problems
After analyzing the data, the research team identified the most common problems encountered by the subjects and worked out recommendations for potential solutions. Common problems were:

  • Despite their high level of education, the young professionals stumbled on health insurance terms whose meaning they didn't know and couldn't find explained elsewhere on the site.
  • They were frustrated by their inability to match specific plans against their own personal preferences and, in part, blamed this on the "overwhelming" amount of information they had to root through.
  • Filters for sorting through the information were poorly positioned and functionally inadequate.
  • Subjects who qualified for subsidies such as premium tax credits and cost-sharing reductions were confused by an application process that made more comprehensive coverage appear cheaper than less comprehensive coverage.
  • Subjects were also confused and put off by the name of the high-deductible, minimal-cost category called "catastrophic" insurance.

Recommendations for change
The authors recommended the following changes to Healthcare.gov:

  • Provide an instantly accessible glossary of insurance terminology.
  • Provide a similar glossary of examples and succinct explanations of complex cost concepts, like deductibles.
  • Announce up front the existence of the dental insurance marketplace that becomes visible only after a user finally selects a health plan.
  • Include decision support tools that enable users to narrow options according to monthly or annual costs.
  • Rename the "catastrophic" category something more like the "value" or "minimal" category.

"One thing we found," said Wong, "was that these young adults may be the hardest to recruit to sign up for health insurance, but once they actually get on the site, they become unique assets in thinking about how to make it better. They are the generation that grew up with the internet. They may not know what insurance terms mean but they have a lot of expertise and insights about maximizing the usability of the digital platforms that have always been such an integral part of their lives."