Young adults find health insurance enrollment on HealthCare.gov challenging

Findings illustrate need for tools to assist young adults with navigating and selecting plans

When trying to enroll in a health insurance plan through HealthCare.gov during the first open enrollment period of the Affordable Care Act's (ACA) health insurance marketplaces, young adults were confused by unfamiliar health insurance terms, concerned about the affordability of plan options, and unsure how to seek good primary care. Those findings were among the results of a study led by researchers at the Perelman School of Medicine at the University of Pennsylvania that followed a group of well-educated young adults as they shopped for health insurance on HealthCare.gov. The new study is published online in the Journal of Adolescent Health.

"Selecting a health insurance plan, which is a complex task even for experienced insurance consumers, was particularly challenging for young adults," said the study's lead author Charlene A. Wong, MD, a Robert Wood Johnson Foundation Clinical Scholar and Fellow in Penn's Leonard Davis Institute of Health Economics. "Their benefit and plan preferences, such as primary care coverage and affordable out-of-pocket expenses, as well as the areas where they had difficulty, give us a better understanding of how we can make the enrollment process more accessible to young adults and how we can better meet their insurance needs."

Her team observed 33 highly educated young adults in Philadelphia in real time during the first three months of 2014 as they completed the enrollment process online, and then interviewed them for feedback about their experiences. The young adults ranged in age from 19 to 30, and almost all had a bachelor's or graduate level degree.

According to these young adults, the biggest advantages to getting health insurance coverage were access to primary or preventive care and peace of mind. However, they were worried about the financial burden of paying for insurance. The majority of young adults in the study considered premiums over $100 per month unaffordable, yet the least expensive plan without tax credits in Philadelphia was $187 monthly.

Another clear challenge during the enrollment process was that the young adults were confused by standard health insurance terminology, such as "deductible" (48 percent defined incorrectly) and "co-insurance" (78 percent defined incorrectly). They reported that their unfamiliarity with, or misunderstanding of, these terms made it difficult for them to make informed plan choices.

In the first portion of the study, the young adults were observed as they shopped for insurance on the HealthCare.gov website and were asked to talk through their reactions to the shopping experience. The researchers then interviewed each participant to ask about issues that may not have been mentioned spontaneously during the observation period, such as advantages and disadvantages of having health insurance and their understanding of health insurance terminology. Later, follow-up interviews were conducted to determine participants' enrollment decisions and plans for using their insurance.

"Based on the results of this study and its implications for a broader population of young adults, it's clear that tools are needed to help people better understand their options and select an optimal plan," said senior author Raina M. Merchant, MD, MSHP, co-director of the Robert Wood Johnson Clinical Scholars Program at Penn, director of the Penn Social Media and Health Innovation Lab, and an assistant professor of Emergency Medicine, who also noted that the uninsured rate for 19 to 34 year-olds decreased from 28 percent to 18 percent after the first ACA enrollment period.

The authors are now working on documenting what types of decision aids are available on HealthCare.gov and the state-based marketplace websites that help simplify or support consumers in making informed health insurance choices. Some of these tools, such as pop-up explanations for basic health insurance terms or a tool that helps people estimate their total out-of-pocket cost for a given plan, were ideas suggested by the young adults in this study and would likely be useful to consumers of all ages and backgrounds.