The Experience of Young Adults on HealthCare.gov: Suggestions for Improvement

Background: Young adults comprise a large percentage of uninsured persons (1). Efforts to insure more young adults were widespread during the Patient Protection and Affordable Care Act's first open enrollment period for the health insurance marketplace. Objective: To elicit reactions and feedback from young adults on ways to improve the HealthCare.gov insurance selection process. Methods: We observed 33 highly educated young adults, aged 19 to 30 years, navigating the HealthCare.gov Web site in Philadelphia, Pennsylvania, between January and March 2014. As they made decisions about health insurance, they explained their thinking in real time. We interviewed participants about their impressions and suggestions for improvement. Findings: Participants were challenged by poor understanding of health insurance terms that were inadequately explained. Although participants expressed their preferred benefits (for example, preventive care and dental coverage), they had difficulty matching plans with their preferences, partially because they perceived that the amount of information was overwhelming. Young adults qualifying for affordability provisions were confused by discount applications that made more-comprehensive plans (such as silver) cheaper than less-comprehensive alternatives (such as catastrophic). Discussion: Using a systematic approach, we identified 6 actionable improvements for HealthCare.gov that could be implemented before the next open enrollment period, beginning 15 November 2014 (Table). Table. Recommendations From Young Adults for Approaches to Improve the Health Insurance Selection Process on HealthCare.gov 1. Provide more accessible explanations of health insurance terminology. Young adults preferred instantly accessible glossary definitions paired with concrete examples for complex cost concepts (for example, the deductible). 2. Emphasize mandatory inclusion of preventive primary care services in all marketplace plans at no additional cost. Young adults identified preventive services (for example, well-woman visits and contraception) as top coverage priorities but were unaware of their universal inclusion and instead assumed that available plans would charge for these services. Emphasizing free preventive coverage within each plan's details may motivate more young adults to purchase marketplace plans. 3. Clarify or expand options for adult dental coverage earlier in the enrollment process. Participants were unaware of the dental insurance marketplace that becomes available after selecting a health insurance plan, because adult dental coverage within the health insurance marketplace was described only as not covered. Mentioning the dental insurance marketplace or expanding adult dental benefits in more health insurance plans, if feasible, may encourage broader enrollment. 4. Present health insurance choices tailored to consumer preferences. Filters for cost and coverage details were poorly accessible on the primary HealthCare.gov page that presents plan options. Young adults wanted prominently positioned and improved sorting tools to enable them to narrow plan options. They also favored decision-support tools; suggested organizing principles included ordering plans by estimated total monthly or annual cost (premiums plus expected cost-sharing), best fit for people like me, or a smart default (3, 4). 5. Provide a better explanation and presentation of the affordability provisions for qualifying health insurance consumers. Participants who qualified for premium tax credits and cost-sharing reduction plans were confused that these plans only applied to certain metallic categories (5). Without discounts, premiums increased while deductibles and out-of-pocket maximums decreased predictably from catastrophic to platinum plans (Appendix Figure 1). With discounts, those intuitive progressions were lost and silver plans tended to be the least expensive (Appendix Figure 2). The counterintuitive premium structure and insufficient explanation of how discounts are applied caused participants to doubt their own understanding, even when they correctly leaned toward the highest-value plan. Appendix Figure 1. HealthCare.gov presentation of plan categories without qualification for tax subsidy and cost-sharing reduction plans. Appendix Figure 2. HealthCare.gov presentation of plan categories with qualification for tax subsidy and cost-sharing reduction plans. 6. Rename the catastrophic insurance category. A high-deductible insurance category available to all young adults is named catastrophic, a term that caused confusion or was interpreted negatively. Other names, such as value or minimal, could be tested to determine which is most acceptable and effective at conveying the actual meaning. Young adults in this study revealed how small changes to HealthCare.gov could improve their understanding of a typically difficult process and the usability of the marketplace Web site.