Politi Mary C, Kaphingst Kimberly A, Liu Jingxia Esther, Perkins Hannah, Furtado Karishma, Kreuter Matthew W, Shacham Enbal, McBride Timothy
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)
Med Decis Making. 2016 Oct;36(7):911-22. doi: 10.1177/0272989X15578635. Epub 2015 Apr 3.
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.
《平价医疗法案》允许未参保个人从众多私人保险计划中选择医疗保险，这是一个具有挑战性的决策过程。本研究考察了支持未参保者做出医疗保险决策的策略的有效性。
来自城市、郊区和农村地区的参与者（N = 343）被随机分配到三种情况中的一种：1）一份通俗易懂的表格；2）一种可视化情况，即参与者可以选择查看哪些信息以及按什么顺序查看；3）一种叙述性情况。我们进行了多项测量，评估知识（关于医疗保险关键特征的正误回答）、选择的信心（决策冲突量表的不确定性子量表）、满意度（来自《健康信息国家趋势调查》的项目）、对保险特征的偏好（用从一点都不重要到非常重要的李克特量表测量）以及计划选择。
尽管我们未发现不同情况在知识、选择信心或满意度方面存在显著差异，但不同情况的参与者都做出了符合价值观的选择，即选择与他们对关键保险特征的偏好相符的计划。此外，根据医学成人识字快速评估简表（REALM - SF）测量，具备足够健康素养技能的人总体知识水平更高（[公式：见正文] = 6.1对4.8，P < 0.001），并且比起可视化情况更喜欢通俗易懂的表格（P = 0.04），比起叙述性情况更喜欢可视化情况（P = 0.0002），而健康素养技能不足的人对研究情况没有偏好。在医疗保险知识方面，主观数字运算技能较高以及教育程度较高与较低的人也呈现出类似模式。收入较高的人对自己的选择信心较低（[公式：见正文] = 28.7对10.0，数字越高表示信心越低/不确定性越高；P = 0.004）。
那些编写有关医疗保险市场的材料以支持医疗保险决策的人，可能会考虑从通俗易懂的表格入手，在具体情境中呈现医疗保险术语，并根据未参保者可能使用保险特征的方式以及对其重视程度来组织信息。健康素养和数字运算技能有限以及教育程度较低的人在选择医疗保险以及权衡成本和保障范围之间的利弊时面临独特挑战。
