PHILADELPHIA -- Balloons, party hats and buckets of candy aren't the normal decor for the University of Pennsylvania's Wharton School's Health Care Management 101 class. But Tuesday, October 1, was, in the history of U.S. health care, quite an extraordinary day that witnessed the launch of the Affordable Care Act's health insurance exchanges. Hanging a "Grand Opening" sign on the front of his class room, Wharton Professor Dan Polsky used the visual levity to engage his students in a serious exploration of the new exchanges' structures. The assignment for the 85 Penn juniors and seniors was to log into any of the states' exchange websites and analyze their internal content, decision architecture and ease of use.
By age and life experience, the students were a close approximation of the "young healthies" whose patronage of the exchanges is considered crucial to the fiscal stability of those expanded health insurance markets. One of the first things some of the Googling students noted was confusion over the fact that although announced and promoted for more than two years as "exchanges," the ACA insurance portals are now also being called "marketplaces." Students were also irked that most sites require the time-consuming entry of personal information before offering insurance products for viewing. There was a strong desire for the exchanges to adopt the strategy of the Massachusetts "Connector" allowing users to effortlessly enter the exchange anonymously and "window shop" all of its offerings before signing up.
"These exchange structures initially remind me of the financial aid online process," said senior Sherry Yang (above). "It looks complicated. I think my folks would be a bit confused trying to use this. Many people who try to do this are going to get frustrated and are going to need someone to take them through it, or they're not going to be able to finish." The perceived complexity and/or inflexible functions was a common complaint. Some students who sought to find functions that would allow various insurance packages to be easily compared gave up in the face of long lists of products with no obvious way to compare them.
Mounika Kanneganti (above) was able to access the Texas health insurance exchange but didn't find it a satisfying experience. "It gave me maybe 50 different choices I would have to look through, including options for max duration, deductible, co-insurance and office visits," she said. "Some of the terminology was an issue. Like, 'deductible' and 'co-insurance,' I'm only familiar with them because we discussed them in this Health Care Management 101 class last week. But I think the Affordable Care Act's primary target group of uninsured people tend to be less educated about these issues than Wharton Health Management students. At this point, I'm not even sure how to assess my own risk and that will also be a big problem for people trying to figure how much of a deductible they should go with. I think many people will find this all very off-putting."
One of the most frustrating aspects of the exercise turned out to be the fact that when searched for health insurance-related terms, Google returned top hits of sites like eHealthInsurance.com and HealthInsurance.org that looked to students like ACA health insurance exchanges but actually are commercial insurance company sites. HealthInsurance.org has a "State Guides" matrix at the top of its page that enhanced their assumption that it is a government site, students said. "I was Googling to get to New Jersey's exchange and the first thing to pop up was HealthInsurance.org," said Samantha Satchell, a student from New Jersey. "I clicked on its 'NJ' button but was taken to a site that was not actually the New Jersey government health insurance exchange. But I didn't know that at first -- it was really confusing."
The fact that many of the state exchanges and even the federal government's central HealthCare.gov site were only sporadically accessible on their first day of operation was not a surprise to students. "It's like any new web thing, the first few days, the whole world wants to get in all at once and everything crashes. A week later, it's all normal. No big deal," said one. Juniors Brent Jules (above, left) and Semi Ibikunle (above, right) agreed but were still flummoxed. "It's understandable but I still think the states' IT operations could have been much better prepared -- they had to know there would be a deluge of people on the first day," said Jules. "All we've been hearing is how important it is to get people enthused about buying insurance this way and then, on the day that gives people the first taste of it, nothing works. It is discouraging not to be able to get into the New York site but a report earlier today said a million people an hour were trying to get in." Ibikunle concurred. "From a marketing point of view, you have to wonder why the states weren't more worried about frustrating people rather than piggybacking on all the first day excitement to make it a cool experience. This has definitely not been a cool experience."
As class ended, Professor Polsky said, overall, it appeared "a lot of the students got frustrated quickly." He noted the exercise was "a bit of a construct because these are Penn students who all have insurance. If they didn't have it and needed it, their motivation would have been different. "Nevertheless," he said, "I can see how what we saw here today can extend to people who need insurance but are still out there on the fence about it. They might be just as turned off as some of these students."
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Hoag Levins is a journalist and Managing Editor of Digital Publications at the Leonard Davis Institute of Health Economics.
