Leaving aside the perceptions of Obamacare that prove so vexing to conservatives, there’s a huge problem with the current conception of the Affordable Care Act: It requires Americans to determine something complex on their own.
This is not a criticism of the Health Insurance Marketplace websites like healthcare.gov, which look like they’re using a language remarkably like everyday English and navigation that’s reasonably intuitive. No, this is a criticism of average people, both educated and uneducated, who must engage a process that involves reading, comprehension, and decision-making—and applied to a process developed by bureaucrats and described as "an ugly patch on an ugly system." It’s no wonder the roll-out involved hiring “navigators” who can offer in-person help for people drowning in data.
But no navigators for me. As for so many others, my first stop in looking into anything isn’t the phone, but the keyboard. And as a new paper looking at Internet browsing for quality and cost information on medical needs points out, just because it’s available doesn’t mean individuals are finding, or perhaps even capable of finding, what they need. This is known as the “field of dreams fallacy,” which Louisiana State political scientist (and Pelican State polling guru) Kirby Goidel defines as “the assumption that audiences will use the information and technology as intended.”
Pew researcher Susannah Fox reported in July that 72 percent of Internet users have looked up health info in the past year, and in an earlier report Fox reported that one in three U.S. adults had tried to diagnose themselves online.
On health questions, my own experience has yielded two inconsistent messages from medical professionals. On one hand, various doctors I’ve seen have pooh-poohed home diagnoses about medical conditions, suggesting that individuals either couldn’t tell reliable sources from bad, or were liable to develop a severe case of cyber-hypochondria. [Update: I see it's called cyberchondria and it's under academic study.] Then the same doctors would print out material for me to take home that was essentially identical to what my own research had found. That reaction has led me to sometimes deny my own Web searching, only to have the doctor seem a little put out that I didn’t at least Google my problem before taking up their time.
At least I’m in good company: Pew researcher Susannah Fox reported in July that 72 percent of Internet users have looked up health info in the past year, and in an earlier report Fox reported that one in three U.S. adults (59 percent of the Web users) had tried to diagnose themselves online. About half—and 60 percent among the middle income—decided they’d better see a doctor with their printouts in hand. (The poor were the least likely to see a doctor after their online diagnosis.)
What about the equally baffling hunt for information on the quality of medical services and the cost?
Reporting in The Social Science Journal, Goidel and three colleagues polled Louisianans to see how well they were able to deduce such quality and care information while surfing the Internet. While these issues are broadly proxies for what someone would be investigating in a health insurance exchange, I should stress that this work was not looking at Obamacare and never mentioned it by name. Nonetheless, here’s a key takeaway from the research: “Being uninsured is associated with greater difficulty in learning about both quality and costs.”
Medical billing is renowned for being opaque, whether by circumstance or design, although there are continuing efforts to make it more transparent. Goidel’s team, not surprisingly, found that, overall, respondents found it easier to find data on quality of care than its costs. Plus, since consumers don't aggressively track down quality data and can’t find costs data, they rely on their bad old habits—like equating cost with quality—even when they pay the bill out of their own pockets.
The digital divide—the disconnect between people wanting to be online but not having the wherewithal to do so—is also a concern. “Specifically, less educated, older, and lower income individuals are all more likely to say it is difficult to learn about health care quality,” the authors write. “These findings are not particularly surprising and reflect existing research on online health information seeking with respect to medical conditions and illness.” These people are the least likely to be online, the least savvy about the Internet—and well represented among the one in seven Americans without health insurance.
So applying the Field of Dreams metaphor again, if you build it, the well-heeled and the well-educated will come. But the others—the ones you built the stadium for in the first place—well, we’ll see. The Health and Human Services Department and various state exchanges, despite the glitches that come with the birthing of a grand new scheme, has actually enacted many of the recommendations the authors put forward, such as links on how to interpret what you're reading and lots of comparisons. (I will quibble with the California website, which offers me a PDF of the explanatory booklet instead of an interactive experience when I get down to the actual quality and costs questions.)
But Goidel’s work also offers some hope. Take the idea of “tyranny of choice,” in which having too much information—whether it’s about what causes boils or which plan offers the best OBY/GYN options—stymies making a decision. And yet, the authors report, “self-reported choice in providers results in individuals reporting greater ease in learning about health care quality and cost. Perceived choice in providers, it seems, provides greater incentive and opportunity to learn about health care costs and quality.”
Keep in mind that there are tons of caveats about applying this to Obamacare. Their phone survey was completed in 2009, well before the advent of the October 1 debut of exchanges. Still, the human terrain likely hasn’t changed as much as the bureaucratic one. Secondly, the health exchange websites have been set up to focus on these issues—no futzing required. And a lot of what’s taken place so far online has been, as Bloomberg described it, "window shopping," which is in line with Goidel’s observation about perceived choice directing self-education.
And Louisianans—poorer, less educated, and more likely to be a minority than the “average” American—may not be Everyman. By the same token, they may be better stand-ins for the uninsured now seeking coverage than Everyman, especially given concerns about the digital divide. “Making the information available is step one,” Goidel’s paper concludes. “Providing it in a usable format is step two.”
Obamacare has achieved step one. As we countdown toward coverage starting on January 1 and open enrollment ending next March, we’ll see how well step two has been met. Can it serve its primary audience without making them feel stupid?