Among the challenges encountered in passing and implementing President Barack Obama’s signature health care reform law has been the public’s perception of what it means. A new study released today finds that many Americans — particularly those the new law was intended to help most — may not have basic knowledge about the law or health insurance in general.
The study, published Monday in the Proceedings of the National Academy of Sciences, used a nationally representative survey of 6,000 respondents and found that half of them were unaware of the exchanges set up for people to find and purchase health plans and that more than 40 percent could not accurately describe a deductible. People who were earning just above the federal poverty level performed worse on questions about the health care law and health insurance in general than people in the top income category did.
“I think the take-home message is we find there are very low levels of preparedness” for the Affordable Care Act, said Silvia Barcellos, the author of the study and an economist at the University of Southern California Dornsife Center for Economic and Social Research. She said an area of particular concern is that the levels of knowledge were often lowest among people who are uninsured or low income and therefore are the target population for the new exchanges.
“If these exchanges are to work, we need some policy responses to help these people make good choices on the exchanges,” she said. While the study was done shortly before the exchanges opened and the respondents are being surveyed again to see how their knowledge changes over time, Barcellos said she is not optimistic that the numbers from the study will have improved by now.
“There was already substantial press coverage about health care reform and the exchanges that were about to open, and here we found very low levels of information among the population,” she said.
Leighton Ku, director of the Center for Health Policy Research at the Milken Institute School of Public Health at George Washington University and an executive board member of the Health Benefit Exchange Authority, which was involved in setting up the exchanges for Washington, D.C., called the findings important “but not entirely unexpected.”
“There could be some serious problems in trying to implement the Affordable Care Act because there are many provisions people don’t understand as well as many basic concepts they have difficulty understanding,” he said.
Ku pointed to a similar study being performed by the Urban Institute. In a paper published in December, it similarly found that most Americans — especially those who were uninsured but even those who were — were not confident that they understood basic terms of health insurance.
Too soon to judge?
While the early numbers don’t provide much reason for optimism, it’s far from clear what will happen as people sign up and the 2014 enrollment period ends on March 31.
“I’m not surprised or even that alarmed at how low the knowledge is,” said Ellen Meara, an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice. She said that the numbers in the study provide an important baseline for seeing how successful the exchanges and the navigators who help people sign up for plans are at helping people make decisions but that it’s too soon to decide whether efforts put into publicizing the health care law were unsuccessful.
“I don’t think I would go quite as far as the authors in the conclusions, in wanting to shape new policies,” Meara said.
“These are things we don’t do that often. Most people who are not ill are not interacting with the health care system very often, so there are fewer opportunities for learning,” she said, adding that the unpleasant thought of being sick is something many avoid. “As humans, we’re bad at thinking about uncertainty and low-probability events.”
In addition to knowledge gaps between those at higher and lower income levels, there was also a gap between men, who tended to be more knowledgeable about the Affordable Care Act, and women, who tended to be more knowledgeable about health insurance in general. While the exact reasons for the gap are unclear, the researchers speculated that women may learn more about the health care system from interacting with it more at a younger age, while men may know more about the health law because they tend to have better financial literacy.
Opinion vs. knowledge
But perhaps more surprising was a gap the researchers did not find. While political controversy surrounding the law has resulted in different messages in different states, that controversy seems to be affecting people’s attitudes but not their knowledge.
Barcellos noted that while states have varied widely in how receptive they have been to the law, there was not a significant gap between red and blue states in how much people knew about the health care law. But while people in blue states did not have greater knowledge about changes in the health care law, they were more optimistic about benefits they might derive from the ACA.
It remains to be seen how the Affordable Care Act will roll out as many people choose health insurance plans for the first time. The authors recommend finding a default plan to sign up for, but even that will pose a challenge as the government may be reluctant to be seen as endorsing any particular health plan over another.
The hope, Ku said, is that as people a century ago had to adjust to the new presence of automobiles on thoroughfares, they will learn to adjust to changes in how they pay for health care.
“They may be confused initially,” she said, “but over time, for good or bad, you learn how to deal with it.”