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Next big obstacle for Obama's Affordable Care Act? It's not just the Supreme Court.

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Moreover, they need to understand concepts such as premiums, co-pays, and benefits, and be able to apply these concepts to their existing or anticipated health situation so that they can select the most appropriate plan. That means they must figure out which services are or are not covered and complete additional paperwork to enroll in a plan they select.

That’s no small order. Our most recent estimates suggest that over half of currently uninsured adults – those who will become newly insured under the ACA – have difficulty finding, understanding, and using even the most basic health information. Fourteen percent of US adults have trouble finding the date of a physician’s visit on an appointment slip. According to the National Assessment of Adult Literacy, only 12 percent can successfully calculate an individual’s contribution toward health insurance costs, even when using a table.

The success of the Affordable Care Act to enroll those newly eligible in an appropriate insurance plan therefore depends on clear communication to individuals who have limited health literacy. It is not realistic to expect that a website and assistance from insurance exchange navigators (counselors) can do this. These insurance counselors will be particularly inefficient if there are no standards to ensure that they understand the language and literacy barriers facing many of those newly eligible for coverage. Even now, state Medicaid programs fail to fully enroll eligible populations. States with the most-successful outreach strategies enroll no more than 88 percent of those eligible for Medicaid, while the least-successful states enroll just 44 percent of those who qualify for services.

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