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Health Aff (Millwood). 2019 Mar;38(3):464-472. doi: 10.1377/hlthaff.2018.05036.

Decision-Making Experiences Of Consumers Choosing Individual-Market Health Insurance Plans.

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Joachim O. Hero ( ) is a research fellow in health policy at the Harvard Pilgrim Health Care Institute and Harvard Medical School, in Boston, Massachusetts.
Anna D. Sinaiko is an assistant professor of health economics and policy in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, in Boston.
Jon Kingsdale is an associate professor of the practice in the Department of Health Law, Policy, and Management, Boston University School of Public Health, in Massachusetts, and an adjunct professor of the practice at Brown University, in Providence, Rhode Island.
Rachel S. Gruver is a doctoral student in epidemiology at the Columbia University Mailman School of Public Health, in New York City. At the time this work was conducted, she was a project manager at the Harvard Pilgrim Health Care Institute.
Alison A. Galbraith is an associate professor of population medicine at the Harvard Pilgrim Health Care Institute and Harvard Medical School.


The health insurance Marketplaces established by the Affordable Care Act include features designed to simplify the process of choosing a health plan in the individual, or nongroup, insurance market. While most individual health insurance enrollees purchase plans through the federal and state-based Marketplaces, millions also purchase plans directly from an insurance carrier (off Marketplace). This study was a descriptive comparison of the decision-making processes and shopping experiences of consumers in two states who purchased a health insurance plan from the same large insurer in 2017, either through the federal Marketplaces or off Marketplace. In a survey, those who selected plans through the Marketplaces reported less difficulty finding the best or most affordable plan than did those enrolling off Marketplace. Respondents in families with chronic health conditions who enrolled through the Marketplaces reported better overall experiences than those who enrolled off Marketplace. Respondents with low health insurance literacy reported poor experiences in enrolling both through the Marketplaces and off Marketplace. Access to consumer assistance in the individual health insurance market should target off-Marketplace populations as well as all populations with low health insurance literacy.


Affordable Care Act; Brokers; Chronic Conditions; Consumer Choice; Decision Support; Direct Enrollment; Health Insurance Literacy; Health insurance marketplace; Individual Market; Insurance Coverage; Marketplace; Navigators; Non-Group Market


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