Methods: We examined 51 uninsured adults’ health insurance knowledge and preferences through semi-structured interviews.
Results: Participants were between the ages of 18 and 65 without current health insurance. 71% of participants had an income of less than $15,000 per year. 69% identified as African-American, 28% identified as non-Hispanic White, and 4% identified as Hispanic. 47% had inadequate (<7th grade reading level) or marginal (7th – 8th grade reading level) health literacy as measured by the REALM-SF. Several themes emerged from this data. Many uninsured individuals had little or no past experience with important details about health insurance. They often confused the meaning of similar terms (such as coinsurance vs. copayment, urgent vs. emergency care). Individuals drew from the context of passages we presented to better understand the terms. They also used familiar non-health contexts to assist in understanding the terms (e.g. car insurance was used to understand deductibles). After we explained the terms to participants, most (96%) reported that a health insurance premium would be very important to their choice of plans, followed by specific covered benefits (92%) and being responsible for fixed or known costs vs. a percentage of health care costs (82%). The amount of paperwork and having a choice of doctors or hospitals were less important factors when thinking about choosing a health insurance plan.
Conclusions: Our study was one of the first to examine uninsured individuals’ health insurance knowledge and preferences. Uninsured individuals have different information needs and preferences than those studied in previous research. Clear information that explains differences across the exchange plans will be important when the ACA is implemented. Narratives and contexts familiar to individuals may help improve understanding. Tailoring information by emphasizing details that are important to individuals may also facilitate decision. We developed and are currently testing decision support strategies to facilitate decision-making about the ACA exchange plans (25 enrolled; 280 planned by this fall).