dsmith_increasing health insurance literacy in marketplaces and the communities they serve

Increasing Health Insurance Literacy in Marketplaces and the Communities They Serve

Denise O. Smith


Denise O. Smith

[email protected]

HSM541

Health Services System

Keller Graduate School of Management

Professor Julie Dennis

June 18, 2016


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Table of Contents

Background 3

Define the Problem 4

Literature Review 5

Problem Analysis 11

Possible Solutions 13

Solutions and Implementation 16

Justification 18

References 20


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Background

Health insurance marketplaces established through the implementation of the Affordable

Care Act (ACA), have enrolled more than 12.7 million individual United States citizens since

October 2013 (U.S. Department of Health and Human Services, 2016) through annual and

special open enrollment periods. Across the U.S. hundreds of different insurance plans are

offered through the 16 state-based marketplaces and Healthcare.gov, the federal marketplace,

including Medicaid and CHIP, each with unique eligibility requirements, premiums, deductibles,

copays and coinsurance (National Public Radio, 2013).

“Enrolling in a health insurance plan is not a simple task” wrote Laurie Martin for the

Rand Corporation in the early days of the first open enrollment, “Ignoring this complexity and

failing to support people with low health literacy could create barriers” (Martin, 2013).

Enrollment into health insurance requires one to create accounts on an online website,

knowledge of insurance and other state eligibility rules, ability to calculate a Modified Adjusted

Gross Income (MAGI), analyze and compare insurance plan information, and a grasp of

insurance-specific jargon such as premium, subsidy, cost sharing, coinsurance, in-network and

other terms. Navigators and assisters were funded by states and the federal government to aid in

the completion of complicated enrollment processes (Paez, Development of the Health Insurance

Literacy Measure: Conceptualizing and Measuring Consumer Ability to Choose and Use Private

Health Insurance, 2014).


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Lack of health insurance literacy has emerged as the overarching barrier for new

enrollees, and has continued impact on insurance engagement and access to health care post

enrollment resulting in poor system utilization, lack of engagement in prevention services and

“one in five enrollees experiencing gaps in coverage due to lack of premium payments” (Cohn,

2014).

Using reports and peer reviewed research, this paper explores, what issues surround

health insurance literacy and what upstream population level interventions exist to increase the

health insurance literacy of newly insured communities.

Define the Problem

While the ACA seeks to increase access, reduce cost and improve the quality of health

insurance and healthcare (Berwick, 2008), poor health literacy among U.S. adults remains a

formidable foe. Currently “more than 36% of U.S. adults limited health literacy; 22% have basic

and 14% have below basic health literacy. Only 12% of American adults are considered health

literate” (Glassman, 2013). Thus a review of the current approaches to improving health literacy

is key to solving this problem.

The traditional model in the United States is one of agency and asymmetric knowledge,

skills and resources, favoring health insurance brokers or medical practitioners who recommend

or provide services, resulting in consumers “delegating decision making” (Folland, 2010). Low

health literacy, the inability to “obtain, process and understand basic health information and

make appropriate health decisions” (Office of Disease Prevention and Health Promotion, 2008)

contributes to the prevalence and persistence of asymmetric information. This definition of

health literacy centers on the ability of the consumer to operate within a largely clinical or


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medical setting and does not comprehensively address the interrelatedness of health and health

insurance literacy; the focus of this text and the source of enrollment, access and utilization

barriers. “Although health insurance literacy overlaps with health literacy, it is distinguished by

the need to understand how health insurance benefits are structured, and to understand and

estimate cost sharing responsibilities; health insurance literacy is a factor in whether consumer

delay or avoid seeking care due to cost” (Paez, Development of the Health Insurance Literacy

Measure: Conceptualizing and Measuring Consumer Ability to Choose and Use Private Health

Insurance, 2014). Health literacy was found as a contributing factor to low enrollment for youth,

LEP and people of color who are targeted by the ACA marketplaces (Long, 2014).

Early open enrollment consumer assistance programs coordinated by marketplaces and

staffed by navigators and assisters were seen as an acknowledgement of the complexities

inherent in insurance enrollment and reports indicated that “79% of consumers who enrolled

sought out in-person assistance to help demystify health insurance” (Gupta, 2016), however

funding for these consumer programs in the 16 state-based marketplaces was eliminated after the

first year of open enrollment and funding in the other 34 states remains unstable and

continuously debated in the federal legislature (Kern, 2014).

Simultaneous issues emerge in the context of the continued success of enrollment of the

uninsured through the marketplace; who will provide and coordinate health insurance literacy

interventions

Literature Review

Improving health literacy among newly insured adults is an important part of achieving

the triple aim in the Affordable Care Act (Berwick, 2008). In “Attributes of a Health Literate


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Organization” (Brach, 2012), Brach et al explore the health literacy of organizations as indicative

of their ability to increase health literacy among the population they serve. They hypothesize that

there “is an imbalance between the skills of people and the demands of the healthcare system”

and in response to this deficiency, they propose ten attributes that can be used to evaluate the

capacity of organizations to effectively address this issue, including “leadership that makes

literacy an integral part of its mission, integrates health literacy into planning and quality

improvement, meets the needs of populations with a range of health literacy skills and

communicates clearly what health plans cover and what individuals have to pay for” (Brach,

2012). The authors believe their big tent approach to the adoption of these attributes in all

interconnected sectors, healthcare, public and private payers and among adults of diverse

backgrounds, is the most logical way to respond to the system, communication and access

barriers that low health literacy creates.

In “Health Literacy: A Challenge for Nearly Everyone” (Krause, 2008), the CT Health

Foundation (CHF) agrees that, “even those who are highly educated are challenged to understand

and use health information at some point” (Krause, 2008), yet their solution is focused on

providing health literacy through adult education sites, centers and programs. In their research,

six adult education centers received approximately $72,000 to implement health literacy

education study circles, around themes such as health care access and navigation, disease

prevention and screening and chronic disease management, with results after 15 months showing

“students were more comfortable asking questions of their health providers and more confident

managing their health after being exposed to the curriculum” (Krause, 2008).

Integrating health literacy education into adult education can also be found in the work of

Mooney et al in “Addressing the Health Literacy Needs of Adult Education Students” (Mooney,


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2013). This guide deepens the discussion of health literacy, rejecting the limitations of traditional

definitions about an individual’s “capacity to obtain, process and understand” (Office of Disease

Prevention and Health Promotion, 2008) which “defines health literacy as a risk instead of an

asset, ignores social conditions that can limit access to healthcare and does not reflect the

dynamic social practice of health literacy always situated in specific sociocultural settings”

(Mooney, 2013).

This deep understanding of sociocultural impacts on health literacy is well expressed in

“America’s Health Literacy: Why We Need Accessible Health Information” (Office of Disease

Prevention and Health Promotion, 2008) which, although it adopts the traditional definition of

health literacy as the expression of a person’s ability to function in health systems, explores

significant barriers to this functioning in race, culture and income. Data presented in this report

indicate that while all people experience health literacy barriers, “below basic health literacy

measures disproportionately impact Blacks and Hispanics, adults with less education, the elderly

and those receiving insurance coverage through Medicaid” (Office of Disease Prevention and

Health Promotion, 2008).

This report also addresses health literacy as an organizational priority as does Brach, and

urges organizations to “change the way health information is designed and delivered, establish

policy guidelines about information access and design, address health literacy as part of a

disparities initiative and encourage insurers to model these improvements and innovations” in

their organizations (Office of Disease Prevention and Health Promotion, 2008).

Recommendations of the Office of Disease Prevention are supported by Mooney, Brach

et al: each acknowledges the importance of social orientation of health literacy in their work.

Mooney also echoes the CT Health Foundation’s (CHF) approach of health literacy in adult


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education, citing that their research “dramatically affected the health literacy scores of their

students” (Mooney, 2013). Research found in Mooney, Krause et al points to a effectiveness in

group participatory initiatives, such as the CHF study circles based on the work of Harvard

School of Public Health Rima Rudd (Krause, 2008), as important in the exploration of a best

practice for disseminating information, but each report lacks content to address between health

and health insurance literacy barriers experienced newly enrolled adults.

Rudd’s work on “Health Literacy: The Intersection between Skills of Individuals and

Demands of Health Systems” (Rudd, 2008) begins is a valuable framework that will have future

application in health insurance literacy discussions. She presents a mismatch in the skills of a

significant number of American adults demanded from an increasingly complex health care

system, charges healthcare settings to become more literate friendly and advocates for significant

change in the delivery of health information” (Rudd, 2008). Future researchers will use this

mismatch framework to describe health insurance literacy challenges in marketplace enrollment.

Early innovations included transitioning organizations to become health literate which

researchers believed would impact the products and services they provided. “The Health Literacy

Universal Precautions Toolkit” (North Carolina Network Consortium, 2010) is one of the first

products that provides implementation guidance and tools for health serving organizations. It

eliminates assumptions about consumers’ knowledge and adopts universal protocols, policies to

improve written and oral communication, and consumer skills development (North Carolina

Network Consortium, 2010).

In 2014 health insurance literacy came into focus with the research of Paez who surveyed

adults knowledge of health insurance literacy in four domains: knowledge, information seeking,

document literacy and cognitive skills, and found that while “more than half of the people


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surveyed were moderately or very confident in their ability to select a health insurance plan, their

actual knowledge was less” (Paez, A Little Knowledge is a Risky Thing: Wide Gap in What

People Think They Know About Health Insurance and What They Actually Know, 2014), as was

their grasp of calculating cost sharing, understanding how to use health insurance to access care

and knowing what services their insurance covers (Paez, A Little Knowledge is a Risky Thing:

Wide Gap in What People Think They Know About Health Insurance and What They Actually

Know, 2014). Parragh confirmed the findings of Paez in “Health Literacy and Health Insurance

Literacy: Do Consumers Know What They Are Buying?” (Parragh, 2015), stating that insurance

is “becoming more consumer driven, and often includes higher deductibles, shifts financial risk

to the patient, increases the stakes and requires an even more sophisticated understanding of

health insurance” (Parragh, 2015) which a majority of newly insured Americans do not possess.

She recounts data from 2013 in which “51% of Americans did not understand basic health

insurance terms such as premium, deductible and copay, and 47% of people receiving federal

subsidies to help pay their premium did not know what they were getting” (Parragh, 2015). The

report points to several initiatives, including the National Action Plan to Improve Health Literacy

(NPHL).

The NPHL is considered a landmark resource for medical and public health professionals

to inform initiatives nationwide. Released in 2010 just after the Affordable Care Act was signed

into law, this document includes seven goals, many of which align with previously mentioned

authors including “promote changes in healthcare organizations and systems, support and expand

health literacy in adult education, increase the development, implementation and evaluation of

practices and interventions to improve health literacy” (Office of Disease Prevention and Health

Promotion, 2010). For the authors of this important work, it is the responsibility of organizations,


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policy makers and professionals to clearly communicate and increase the capacity of American

adults to take positive actions in their own health (Office of Disease Prevention and Health

Promotion, 2010).

Since open enrollment began, consumers have looked to the health insurance

marketplaces created by the Affordable Care Act to facilitate enrollment and understanding of

health insurance. While enrollment has largely been a success, consumers’ knowledge of how

health insurance works or how to use it to has not increased. A formal measure of health

insurance literacy was published in 2014 in the Journal of Health Communication: International

Perspectives, developed through an extensive literature review process of prior attempts to

measure this literacy were found to be limited and lacking validity and reliability (Paez,

Development of the Health Insurance Literacy Measure: Conceptualizing and Measuring

Consumer Ability to Choose and Use Private Health Insurance, 2014). Building on the earlier

work of Paez et al, these authors confirmed that the “tasks associated with selecting and using

health insurance are complex and require applying knowledge while performing skills that are

interconnected” and that without these skills, “consumers may hesitate to obtain a service

because of their concerns about out-of-pocket costs” (Paez, Development of the Health Insurance

Literacy Measure: Conceptualizing and Measuring Consumer Ability to Choose and Use Private

Health Insurance, 2014).

Theoretical health insurance literacy frameworks and organization-focused toolkits have

not been widely implemented in response to immediate marketplace and consumer enrollment

needs. Two more pragmatic approaches have emerged from Enroll America and the Centers for

Medicare and Medicaid that have been widely adopted by navigators and assisters an

increasingly by state-based marketplaces.


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“A Framework on Health Insurance Literacy for the Outreach and Enrollment

Community” (Stern, 2015) is the culmination of three years’ experience engaging low income,

culturally and linguistically diverse uninsured Americans to understand the marketplace

insurance plans. Their findings that “substantial gaps in knowledge about health insurance

remain, which may result in buyer’s remorse, improper utilization of health care services, and/or

loss of coverage completely” (Stern, 2015). Their five point framework: “1) understand

persistent consumer knowledge gaps, define what information consumers value, identify the best

time and manner to educate consumers, discover what triggers consumers’ need for new

information and determine what messengers consumers want to hear from” (Stern, 2015) is

person-centered and adaptable for use by clinical providers, enrollment assisters, brokers and

marketplace staff.

“From Coverage to Care” responds to health insurance literacy gaps with “an initiative,

developed by the Centers for Medicare & Medicaid Services (CMS), to help you understand

your health coverage and connect to primary care and the preventive services that are right for

you, so you can live a long and healthy life” (Centers for Medicare and Medicaid, 2016). CMS

has developed an 8-step roadmap used to teach consumers why health insurance is important,

terminology and financial concepts and responsibilities, and improves healthcare navigation

skills.

Problem Analysis

Health insurance marketplaces, community-based navigators and assisters, medical

providers and payers have a stake in successful implementation of the Affordable Care Act.

Research above summarizes the following problems in marketplace approaches to health

insurance literacy programs and services 1) Ineffective assumptions about newly enrolled adults


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and those who remain uninsured, 2) Lack of an evidence-based framework for program

development, 3) The need for organizations and their staff to become health literate.

Newly Insured Have Additional Sociocultural Barriers

Reports on ACA enrollment indicate that newly insured Americans are diverse in

language, ethnicity, income and literacy levels. Five in ten newly insured adults “were mostly

people of color and those who have a family income below 200% of the federal poverty level”

and people who have lived for longer periods “without having insurance” (Kaiser Family

Foundation, 2015). Research presented above shows that either many adults assume a better

understanding if health insurance concepts than they actually have or that they are avoiding

engagement in services to hide their lack of knowledge (Paez, Development of the Health

Insurance Literacy Measure: Conceptualizing and Measuring Consumer Ability to Choose and

Use Private Health Insurance, 2014). Poor health insurance literacy may be even more

pronounced among the elderly, low income and minority populations. Lack of a universally

accepted definition of health insurance literacy and framework for educating adults allows these

knowledge gaps to persist.

Lack of an Evidence-based Framework

Current health literacy focuses on a definition of the consumers’ ability to function in a

clinical or medical environment, an insufficient perspective that lacks integration of health

insurance concepts and consumer barriers. Traditional clinical framing care of health insurance

literacy perpetuates consumer knowledge gaps, providing few opportunities to increase their

knowledge. New frameworks based on research-based initiatives are effective tools to help

marketplaces evaluate current literacy engagement, products and services and address gaps.


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Promote a Health Literate Organization

After three years of ACA enrollment in the United States, health insurance marketplaces

have not become initiated organizational transformation to become more health literate,

effectively addressed the complexity of health insurance products, or provided navigators and

assisters with simplified tools to educate consumers on insurance financial concepts, terminology

or how to navigate the integrated environments of health and health insurance literacy. Recent

reports indicate that without significant changes, newly enrollment adults may experience gaps

in coverage, misuse of their insurance and lack of access to needed health services.

Possible Solutions

Health insurance marketplaces do not presently implement a comprehensive approach to

helping consumers to understand their insurance plans and use their plans to access healthcare

and improve their lives. However research included above identifies best practices rom several

different perspectives.

Adopt the Health Literacy Conceptual Model

This conceptual model establishes a clear definition and scope of work for health

insurance marketplaces and organizations to assess and understand the range of skills,

terminology and concepts required of consumers to enroll and use their health insurance.


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Based on an extensive literature review of previous health insurance literacy research, this model

was created with consumer and stakeholder input, and validated through data collection and

analysis.

Health Literacy Universal Precautions Toolkit

Health insurance marketplaces would benefit their consumers by adopting an

organizational-wide training in and implementation of the Universal Precautions Toolkit. This

toolkit empowers management to engage in continuous quality improvement across departments

by ensuring that all employees become health literate, integrate health literacy universal

precautions in their products and services and treat all consumers as if they require health

insurance literacy assistance. Organization-wide adoption of these strategies will create a more

equitable environment for elderly, low education and minority populations disproportionately

impacted by low health insurance literacy.


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Implement From Coverage to Care

Coverage to Care was developed by the Centers for Medicare and Medicaid Office of

Minority Health. From Coverage to Care is an initiative to help people with new health care

coverage understand their benefits and connect to primary care and the preventive services that

are right for them, so they can live a long and healthy life (Centers for Medicare and Medicaid,

2016).

The tool presented above, created as a summary expression and orientation of the

Coverage to Care Initiative is the “Road Map to Better Care and A Healthier You (Centers for

Medicare and Medicaid, 2016). The roadmap includes 8 steps which communicates what it


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means to have health insurance, when and where to seek health services, why prevention and

partnering with a provider is important for having the best health” (Centers for Medicare and

Medicaid, 2016). Information, terminology and skills are presented to help people “find and

schedule an appointment with a primary care provider, prepare for a primary care visit, and

determine if they have the right provider for their family” (Centers for Medicare and Medicaid,

2016).

Solution and Implementation

To achieve increased health insurance literacy among marketplace staff, enrollment

assisters and consumers, state-based marketplaces should implement From Coverage to Care.

Health insurance marketplace administrators, trainers and outreach coordinators can will impact

ACA health reform discussions, design and implementation of health insurance literacy

consumer engagement and education by incorporating the Paez health insurance literacy

framework (Paez, Development of the Health Insurance Literacy Measure: Conceptualizing and

Measuring Consumer Ability to Choose and Use Private Health Insurance, 2014) with From

Coverage to Care (C2C) initiative tools (Centers for Medicare and Medicaid, 2016).

Marketplaces should recruit and coordinate cross sector implementation teams including

private insurance payers, state-based Medicaid administrators, community-based navigators,

assisters and medical associations, doctors and other clinical providers in education and training

in the framework and C2C. Through this educational process, marketplaces will improve

stakeholders’ knowledge of consumer needs based on research – not assumptions – and explore

the intersection of health and health insurance literacy gaps expressed in the framework and

identified among American adults. During open enrollment, marketplaces can establish technical


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assistance programs for engaged stakeholders to help them develop policies and procedures that

are aligned with the framework and programs that incorporate the tools and skills building

concepts of C2C.

Learning objectives of training will include (1) increased knowledge of framework

concepts; (2) Understanding of C2C tools, why they are important for consumers to understand

and how to help consumers use them; (3) Understand of consumer health insurance literacy

knowledge gaps; (4) Skills on using the framework to develop person-centered policies across

the organizations and (5) Learn innovations to increase consumer health and health insurance

literacy, enrollment and health system navigation. Marketplace administrators and staff can

establish technical assistance services to support implementation of the framework and C2C.

One to one organizational consultation, webinars and regional meetings with stakeholders should

be a part of the implementation and technical assistance process to resolve immediate and

ongoing needs of medical providers, navigators and assisters, build organizational capacity and

“push” the best practice framework.

Issues that will persist during early implementation will include the need for funding and

organizational capacity building of stakeholders to achieve implementation of C2C and the

framework. Clinical providers may experience time barriers to use C2C with clients, navigators

and assisters may need ongoing training, funding support and deeper engagement of their

management and supervisors to incorporate the framework knowledge and use of C2C into their

normal enrollment activities. New trainings may have to be developed to address low literacy

and diverse language needs of consumers.

Effective implementation of these resources should be developed through person-

centered evaluations, surveys and focus groups that can be used to promote continuous quality


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improvement and organizational transformation in knowledge and skill to address health and

health insurance literacy gaps. C2C currently has not evaluation tools developed for its initiative,

however the framework developed by Paez et al was developed during research with consumers,

medical providers and enrollment assisters and can support evaluation tool development.

Long term process analysis should be established through the measurement of the

following lag and lead indicators:

Number of organizations/administrative leaders engaged in framework training and

implementation

Number of navigators, assisters and medical providers engaged in C2C training

Stakeholder increased knowledge, understanding and implementation capacity

Number of consumers touched by programs developed using C2C tools

Consumer feedback on sociocultural relevance, content and effectiveness to improve

their health and health insurance literacy and healthcare navigation skills

Justification

Health insurance marketplaces are the primary resource for American adults to access public

and private health insurance and enrollment assistance. While millions of adults have enrolled in

the last three years, research indicates that many newly enrolled and the remaining uninsured do

not have sufficient health and health insurance knowledge that they think they do, resulting in

poor utilization of insurance and healthcare services, unforeseen and costly financial

responsibilities and gaps in coverage. Marketplaces must take the lead in transforming their own


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organizational approaches and those of their stakeholders in understanding the real needs of

consumers and best practice frameworks and tools that address these complexities.

Increased health literacy among U.S. adult populations can be achieved through a person-

centered, population-level, health literacy education and skills building intervention. While

historical approaches to literacy are focused on a traditional clinical model and lack integration

of health and health insurance literacy, the framework develop by Paez et al is an evidence-based

approach that clearly identifies consumer knowledge gaps in insurance financial literacy,

navigation of health services and terminology used to maintain insurance and use it

appropriately.

Further, the framework helps to transition organizations to becoming health literate.

Organization-wide engagement in the framework as a quality improvement approach is a best

practice that engages managers, develops the enrollment assistance workforce and employees,

and “applies research-based tools which can result in better quality products and processes”

(Evans, 2012) in the marketplaces and among their stakeholder organizations. Successful ACA

implementation, enrollment of the uninsured and improved health insurance literacy among

American adults requires system-wide collaborative ownership (Centers for Medicare and

Medicaid, 2016). “The primary responsibility for improving health literacy lies with public

health professionals and the healthcare and public health systems. We must work together to

ensure that health information and services can be understood and used by all Americans. We

must engage in skill building with healthcare consumers and health professionals.” (Office of

Disease Prevention and Health Promotion, 2005)


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