As the United States celebrates the sixth anniversary of the Affordable Care Act (ACA), there’s no debate that more Texans now have health insurance than before the ACA went into effect. In fact, the uninsured rate has dropped by more than 20 percent in the state.

But do Texans who’ve gained health coverage really understand the basics of health insurance and how to use their plans? Do the uninsured understand their insurance options?

Our survey findings reveal a critical level of health insurance confusion in Texas.

The survey draws from the Texas sample of the Health Reform Monitoring Survey, which surveyed Texans ages eighteen to sixty-four in September 2015, just before the third open enrollment period for the ACA health insurance Marketplace began.  Using the survey data, the Episcopal Health Foundation (EHF) and the Baker Institute at Rice University developed issue briefs focusing on health insurance literacy of Texans.

The first issue brief found about one-quarter of Texans, regardless of insurance status, lack confidence in understanding basic health insurance terminology like “deductible,” “premium,” and “copayment.” Uninsured, low-income, or Hispanic Texans expressed the least confidence in understanding health insurance terminology.

Using the same survey data, a second issue brief discovered that Texans who bought their own health insurance plans were less likely to understand basic health insurance terms than those with public or employer-sponsored plans. For instance, about four in ten Texans with an individual plan expressed lack of confidence in understanding “co-insurance” and “maximum out-of-pocket expenses.”

When it comes to using their health insurance plan, close to half of Texans with an individual plan expressed difficulty in understanding the phrase “cost for choosing out-of-network services” and the phrase “preventive care services.” More than one-third with an individual plan also said they were confused by what counts toward a deductible and what health services were covered under their plan.

Unfortunately, those with an individual plan have the greatest need of understanding health insurance terminology and knowing how to use their plan. These data are important because recent numbers show that more than 1.3 million Texans signed up for an ACA health insurance Marketplace plan during the most-recent enrollment period, which ended January 31, 2016.

Our internal analysis of recently released ACA Marketplace numbers suggests that close to half of the ACA Marketplace enrollees in Texas are new enrollees. The long-term success of the ACA depends on people buying, using, and experiencing satisfaction with their health insurance.

The lack of understanding confirmed in our research demonstrates a critical need to make policy and programmatic changes to clear up the health insurance confusion in Texas.

  • Because Hispanics make up an increasingly large share of the Texas population, it’s critical to develop culturally and linguistically sensitive approaches to use when doing health insurance outreach, enrollment assistance, and navigation services.
  • We need to continue to ramp up and target our education and outreach efforts to the uninsured population to improve their knowledge and confidence about finding and evaluating information about health insurance plans.
  • We have to redouble our efforts—for all insured Texans—to improve understanding of health insurance terms and knowledge about using health plans.

EHF invests in research about the ACA and the uninsured in Texas because we believe it is the kind of information essential to discovering what’s needed for more Texans to gain access to high-quality health services. While we are proud of the progress made in the Lone Star State, organizations that were involved in ACA outreach and enrollment assistance activities need to work even harder to ensure that new consumers not only have more options to access health insurance, but that those consumers really understand what they’re getting.


Over the years, funders of the Urban Institute’s Health Reform Monitoring Survey, mentioned above, have included the Robert Wood Johnson Foundation, the Urban Institute, Ford Foundation, Atlantic Philanthropies, David and Lucile Packard Foundation, and others.