Business of the Patient Protection and Affordable Care Act: examining the effect of health insurance literacy on forgoing or delaying preventive health care services
Creators: name: McKenzie, Camille S.
Publisher: name: No Publisher Supplied
Year: 2023

description: Consumer responsibility and health insurance information is rapidly changing due to perpetual health care policy reforms. Over the years the United States (U.S.) healthcare system has progressively transition to a consumer-driver model where greater burdens are placed on consumers to independently make financial decisions related to health insurance coverage and care utilization. However, consumers lack health insurance literacy (HIL), defined as the knowledge and/or confidence to select and utilize health insurance plans, to make these informed health care decisions. HIL levels are universally low among the U.S. general population. Only 4% of the adult population fully understand basic insurance terms and concepts. Approximately half of adults lack the confidence to understand and use health plans to access health services when in need. The Affordable Care Act enacted in 2010 has successfully expanded coverage for many U.S. residents, however, other factors such as HIL must also be considered to comprehensively understand ACA’s effectiveness on reducing health care disparities. This dissertation study examined the effect of HIL (self-efficacy) on forgoing or delaying medical and dental preventive care services, and whether insurance coverage moderated this relationship while controlling for predisposing-, accessibility-, need-, and contextual factors. The conceptual framework adopted a compilation of HIL and utilization models, including Andersen’s Behavioral Model of Health Service Use and the Conceptual Model of Care Avoidance, to theoretically guide statistical analysis. Several knowledge gaps in the HIL literature were addressed. This was the first nationally representative cross-sectional study to examine HIL’s effect on consumers accessing both medical and dental preventive care services and investigate differences across insurance coverage status. Public-use data from the Health Reform Monitoring 2017 Survey (HRMS) was utilized to estimate utilization patterns (n=6,532). HRMS estimates are credible and track well with other federal survey data. A series of six nested logistic regression models with odds ratio estimates were specified to predict the effect of adequate HIL levels on forgoing or delaying preventive care services while adjusting for a rich set of 21 covariates, including socio-demographic, psychological, health, and environmental factors. Results indicated that respondents with adequate HIL scores reported 17% lower odds (OR=0.83, p&lt;.01) in forgoing or delaying medical preventive care in a fully adjusted model. Comparably, respondents with adequate HIL scores reported 19% lower odds (OR=0.81, p&lt;.001) in forgoing or delaying dental preventive care services while only adjusting for significant predisposing factors. The moderating effect of insurance type was non-significant for both types of preventive care utilization. This dissertation study provides evidence to support HIL’s influential effect on preventive care utilization patterns. Future research is needed to account for state and/or county level differences with a particular focus on individual ACA markets. In addition, health care services should be considered beyond routine annual exams, including preventive reproductive care, specialty visits, prescription adherence, and/or vision health services, where insurance companies tend to provide less coverage with higher out-of-pocket expenses.