Supporting Decisions About Health Insurance to Improve Care for the Uninsured

Not Applicable

Completed

Conditions: Health Services Accessibility
Informed Decision Making
Health Insurance
Health Literacy

Brief Summary: The overall purpose of the study is to better understand how the investigators previously developed decision support (DS) tool can help people make decisions about health insurance plans available through the federal exchanges created by the Affordable Care Act (ACA). The investigators will evaluate the DS tool compared to the federal government website. The investigators will also evaluate the feasibility of disseminating this tool. There are two primary aims to be completed in this project: (1) examine the reach and effectiveness of the health insurance DS tool; and (2) collect stakeholders' feedback to improve the likelihood of implementation of the DS tool.

Detailed Description: First, for Aim 1 part 1, the investigators will recruit 40 key stakeholders (uninsured participants, health providers, community advisors, and health policy experts) to refine the DS tool through a series of individual semi-structured interviews. Next, the investigators will use their feedback to program the DS strategies into an online DS tool. After its initial production, the tool will be pilot tested with 30 individuals to assess readability, message clarity, format, and function of the tool as well as to test the randomized trial study procedures. Then, for Aim 1 part 2, the investigators will test the DS tool in a randomized trial with 362 participants eligible for the Affordable Care Act (ACA) exchanges. Half will use the DS tool and the other half will use the federal government site to learn about the exchanges. The investigators will use computerized random assignment to assign participants to study condition, after which they will all complete the same short survey. For Aim 2, the investigators will collect 40 stakeholders' feedback on likelihood of adoption and implementation of the DS tool to plan for dissemination and implementation. Stakeholders will be asked both open-ended and closed-ended questions in order to gather feedback about delivering the DS tool. These stakeholders will be different from those who were interviewed in Aim 1 as to ensure broader applicability of the DS tool.

Recruitment & Eligibility

Inclusion Criteria

Exclusion Criteria

Currently has health insurance that was not provided by being enrolled in one of the ACA exchange plans in the past year
Currently has health insurance that is provided through public insurance or private employer-based insurance
Does not speak English

Arm && Interventions

Group	Intervention	Description
Decision Aid (DA)	Decision Aid (DA)	The decision aid (DA) will be provided to participants randomized to the experimental/intervention group.

Primary Outcome Measures

Name	Time	Method
Knowledge Score (% Correct)	Completed immediately after reviewing Decision Aid tool, taking about 5 minutes to complete.	8 questions developed in researchers' past work. Assessed health insurance knowledge.
Decision Self-efficacy	Completed immediately after reviewing Decision Aid tool, taking about 5 minutes to complete.	The decision self-efficacy (DSE) scale measured participants' perceived ability to understand insurance info and resist unwanted decision pressure. The 6 items on the DSE scale were each rated on a 3-point scale (0=Not confident; 2=A little confident; 4=Very confident). The sum of the DSE items was divided by 6 and multiplied by 25 to obtain a score on a 0-100 scale. Higher values indicate more confidence in one's decision-making ability.
Confidence in Choice	Completed immediately after reviewing Decision Aid tool, taking about 5 minutes to complete.	The 4-item SURE (Sure of myself; Understand information; Risk-benefit ratio; Encouragement) decisional conflict scale assessed confidence in plan choice. Each item could be answered dichotomously (1=yes; 0=no). Responses were summed and a group average was obtained. Higher SURE values indicate more confidence in choice. The scale ranged from 0-4.

Secondary Outcome Measures

Name	Time	Method
Improvements in HILM 1 (Health Insurance Literacy Measure)	Pre-intervention and post-intervention	Assessed confidence estimating costs of care.Improvement in HILM was defined as moving from "not confident" pre-intervention to "a little confident" or "very confident" post-intervention, or from "a little confident" pre-intervention to "very confident" post-intervention.
Improvements in HILM 2 (Health Insurance Literacy Measure)	Pre-intervention and post-intervention	Assessed confidence understanding terms.Improvement in HILM was defined as moving from "not confident" pre-intervention to "a little confident" or "very confident" post-intervention, or from "a little confident" pre-intervention to "very confident" post-intervention.
Intended Choice Metal Level	Completed immediately after reviewing Decision Aid tool, taking about 5 minutes to complete.	Participants indicated the plan they would choose that day. We categorized plans by governmental classifications of metal level (catastrophic, bronze, silver, gold).

Locations (1): The Washington University in St. Louis School of Medicine
🇺🇸
Saint Louis, Missouri, United States