Wong published a letter in the Annals of Internal Medicine based on observations of 33 “highly educated young adults” who used HealthCare.gov between January and March 2014.
She offered six suggestions in the letter for improving the website: better explanations of health-insurance terminology, perhaps through a pop-up glossary; more emphasis on coverage for preventive primary care, which confused users; clarification that dental coverage options were available, although they are described as “not covered” on the website; better filter provision, allowing users to exclude plans whose premiums were too high, as an example; better explanation of subsidy options; and a new name for the “catastrophic” category on the site, which “caused confusion” among users.
Wong has distributed her recommendations to government contacts and hopes to discuss them with HHS officials soon.
Mary Politi, an assistant professor at the Washington University Institute for Public Health in St. Louis, has also been investigating potential HealthCare.gov design improvements. Drawing from the results of a pending-review study that randomized 343 uninsured or recently uninsured users among three design strategies, Politi made three simple recommendations for the site: use plain language; provide familiar examples to put information in context; and organize information well.
Alphabetical ordering of plans is not user-friendly, she wrote in an email, while “organizing it in order of commonly important features of health insurance plans is more accessible.”
Leavitt Partners Senior Director of Exchange Technology Dan Schuyler agreed that the website could improve its information presentation. He said illustrating how prior utilization would impact out-of-pocket spending would be a key piece of information to include. Another improvement would be to facilitate comparisons between plans, allowing users to “drill down into the benefits of the plan,” such as mental health and specialty care, he said.
A December 2013 survey conducted by the Commonwealth Fund asked HealthCare.gov users how much trouble they encountered using the website. Many respondents found it very difficult: 32% found it “very difficult or impossible” to compare the covered benefits of different insurance plans; 27% said it was “very difficult or impossible” to compare potential out-of-pocket costs from deductibles and copayments. Those percentages showed only slight changes from earlier October 2013 survey questions addressing the site's usability.
Some degree of confusion may persist, even among those who have already purchased plans. A poll conducted for the Commonwealth Fund between April and June found that 39% of adults who gained coverage didn't know which doctors were included.
The lack of usability is compounded by a lack of knowledge among many Americans about healthcare insurance. An October 2013 study conducted by Politi found that many consumers were unfamiliar with insurance terminology, such as the meaning of a deductible or prior authorization, as examples. “I've never heard that word,” one respondent said in an interview, about the term co-insurance.
The government has been trying to improve the design of HealthCare.gov. June reports surfaced in Wired and the Wall Street Journal about proposed changes to the website's design. One change: the use of an email address to simplify the log-in and registration process, which prompted opposing reactions. Silicon Valley engineers working on the website declared it “common sense,” while an insurance executive expressed panic.
But outside observers are a bit more sanguine. Wong says that she was “happy they are trying to do more rapid-cycle innovations and improvements to the websites,” though she acknowledged the process “would challenge any web designer—it's more complicated than trying to buy a book.”
So far, Schuyler grades the current HealthCare.gov site at “about a C+” —below the state-based marketplaces and private exchanges—but he anticipates the user experience will be better the next time around.
And there may be important consequences to improving the user experience and presenting information well. A May 2008 brief from the Commonwealth Fund focusing on Medicare Part D enrollment noted that plan design was complicated and poorly, sometimes deceptively, presented. “Some of the estimated 4.6 million beneficiaries who still have no source of drug coverage might have enrolled, had the process of choosing been less confusing,” the brief stated.
But perhaps that won't be the case for exchange-based plans. The Commonwealth Fund's recent poll showed that 73% of those who selected a private plan were “somewhat” or “very” satisfied with the plan they chose. So perhaps they found the annoyance of laboring through the site's complexities worth the effort.