Optimizing Your Shopping Cart: Decision tools, presentation & total cost estimators on health care marketplaces
OBJECTIVE: Choosing health insurance is a complex and often confusing task. Consumers who make a poor health plan choice miss out on the opportunity to save money in the best case or fall into financial crisis in the worst case. The design of the ACA’s health insurance marketplaces and the data they present to consumers influence complex health plan choices. We compared the choice environments of the public state-based marketplaces (SBMs) and HealthCare.gov (HC) in the fourth open enrollment period (OEP4) to the third (OEP3), plus exchange websites run by private companies. We also compared total cost estimates (TCEs) for various plans from the public exchanges to estimates on private exchanges for a uniform consumer. TCEs sum the monthly premium with expected cost-sharing (deductible, copays) based on a consumer’s expected health care use.
DESIGN: In November/December 2016, we examined public and private online health insurance exchanges for decision support tools and how plans were displayed. We examined private exchanges for notable features, which were not found on public exchanges. We navigated each site as an exchange shopper for “real shopping”, which required an account and personal information, and “window-shopping”, which did not require an account. We shopped as a standardized consumer with type II diabetes and asthma on two medications who selected a silver plan with premium tax credit and cost-sharing reduction discounts. TCEs for the same plan were compared.
POPULATION: 13 public exchanges (12 SBMs & HC) and 24 private online health insurance exchanges. Total cost estimators were included in 7 public and 2 private exchanges. FINDINGS Nearly all decision support tools saw increased deployment in the public marketplaces compared to OEP3. Total cost estimators were found on over half (n=7) of the public exchanges in window-shopping. Only California and HC had total cost estimators in OEP4 real-shopping. The TCEs for our standardized consumer varied substantially between the public and private exchanges, with public exchange TCEs averaging $867 less than the private exchange estimates for the same plan. For a plan in Pennsylvania sold on HC, the estimate was $1,905 compared to ~$3,900 on private exchanges. Questions included rating medical/prescription use, health status, health conditions, and expected procedures. For the first time, pop-up definitions were universally available on public exchanges. Fewer public exchanges (n=4) listed plans in order of premium compared to OEP3 (n=11) in window-shopping. Private exchanges offered notable features for their total cost estimators (e.g., estimates for specific conditions, such as concussion). Other private exchanges incorporated personalized plan display features, such as recommending a specific plan (Stride Health, Honey Insured) or a personalized plan score (Get Insured). Health Sherpa provided a map of in-network providers enhancing network transparency.
CONCLUSIONS: The public health insurance exchanges created under the ACA continue to evolve and offer more choice tools. Variation in choice architecture and total cost estimators warrants further study.