Health insurance literacy: How best to measure and does it matter to health care access and affordability?

Background: Health insurance is complex, cost are continuously rising, and people are assuming more of these costs. Health insurance literacy (HIL) is related to healthcare access, yet there is no agreement about how best to measure HIL. Objectives: Contrast two HIL measures. First, evaluating their association with demographic characteristics, insurance type, and health status. Second, comparing how these distinct measures relate to access, forgone care, and financial burden of health care. Methods: Data are from a 2017 telephone survey focused on health insurance coverage and access. Participants were randomly assigned either the 4-item likelihood of proactive use scale or a 4-item measure of confidence in use of insurance. Logistic regressions assess correlates of each HIL measure and their association with a range of access measures. Results: For both measures, 25% of insured adults report high HIL. Few demographic and health status measures are associated with high HIL and they are different for each measure. For both measures, high HIL translates into reports of having a usual source of care and confidence in getting care when needed. The HIL measures behave in opposite ways for forgone care due to costs and problems paying medical bills. Adults scoring high on the likelihood measure are more likely to forgo care and report financial burden. By contrast, adults scoring high on the confidence measure are less likely to forgo care and report burdensome medical bills. Conclusions: The two measures capture different concepts and raise the question of whether reporting a likely behavior or being confident of that behavior are predictive when it is time to use health insurance. Because HIL is measured at the same time as the outcomes, we reason that the likelihood measure is capturing peoples’ past experience using insurance and may result in more proactive use of insurance in the future.