title: A Randomized Trial Examining Three Strategies for Supporting Health Insurance Decisions among the Uninsured.
abstract: The Affordable Care Act allows uninsured individuals to select health insurance from numerous private plans, a challenging decision-making process. This study examined the effectiveness of strategies to support health insurance decisions among the uninsured.
  
  
  
  Participants (N = 343) from urban, suburban, and rural areas were randomized to 1 of 3 conditions: 1) a plain language table; 2) a visual condition where participants chose what information to view and in what order; and 3) a narrative condition. We administered measures assessing knowledge (true/false responses about key features of health insurance), confidence in choices (uncertainty subscale of the Decisional Conflict Scale), satisfaction (items from the Health Information National Trends Survey), preferences for insurance features (measured on a Likert scale from not at all important to very important), and plan choice.
  
  
  
  Although we did not find significant differences in knowledge, confidence in choice, or satisfaction across condition, participants across conditions made value-consistent choices, selecting plans that aligned with their preferences for key insurance features. In addition, those with adequate health literacy skills as measured by the Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) had higher knowledge overall ([Formula: see text] = 6.1 v. 4.8, P < 0.001) and preferred the plain language table to the visual (P = 0.04) and visual to narrative (P = 0.0002) conditions, while those with inadequate health literacy skills showed no preference for study condition. A similar pattern was seen for those with higher subjective numeracy skills and higher versus lower education with regard to health insurance knowledge. Individuals with higher income felt less confident in their choices ([Formula: see text] = 28.7 v. 10.0, where higher numbers indicate less confidence/more uncertainty; P = 0.004).
  
  
  
  Those developing materials about the health insurance marketplace to support health insurance decisions might consider starting with plain language tables, presenting health insurance terminology in context, and organizing information according to ways the uninsured might use and value insurance features. Individuals with limited health literacy and numeracy skills and those with lower education face unique challenges selecting health insurance and weighing tradeoffs between cost and coverage.
authors.affiliation: Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO (MCP, KAK, JEL, HP, KF)
authors.forename: Mary C
authors.initials: MC
authors.lastname: Politi
authors.affiliation: Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO (MCP, KAK, JEL, HP, KF)
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Kaphingst
authors.affiliation: Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO (MCP, KAK, JEL, HP, KF)
authors.forename: Jingxia Esther
authors.initials: JE
authors.lastname: Liu
authors.affiliation: Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO (MCP, KAK, JEL, HP, KF)
authors.forename: Hannah
authors.initials: H
authors.lastname: Perkins
authors.affiliation: Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO (MCP, KAK, JEL, HP, KF)|Washington University in St. Louis, George Warren Brown School of Social Work, St. Louis, MO (KF, MWK, TM)
authors.forename: Karishma
authors.initials: K
authors.lastname: Furtado
authors.affiliation: Washington University in St. Louis, George Warren Brown School of Social Work, St. Louis, MO (KF, MWK, TM)
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Kreuter
authors.affiliation: Department of Behavioral Science and Health Education, St. Louis University College for Public Health and Social Justice, St. Louis, MO (ES)
authors.forename: Enbal
authors.initials: E
authors.lastname: Shacham
authors.affiliation: Washington University in St. Louis, George Warren Brown School of Social Work, St. Louis, MO (KF, MWK, TM)
authors.forename: Timothy
authors.initials: T
authors.lastname: McBride
mesh_terms: D000293:Adolescent; D000328:Adult; D003657:Decision Making; D005260:Female; D006801:Humans; D007348:Insurance, Health; D008297:Male; D008875:Middle Aged; D058991:Patient Protection and Affordable Care Act; D014481:United States; D055815:Young Adult
keywords: Affordable Care Act; health communication; health insurance; health insurance literacy