ObamaCare and the limits of technology

It is well known that population health in the United States remains poor in comparison with high-income countries, and that improvements in health outcomes have not kept pace with those in similar nations. The recently implemented Affordable Care Act (ACA), President Obama’s signature legislative success in an administration marred with partisan gridlock, is an attempt to improve healthcare access for people who currently lack access, which is estimated to be at least 48 million Americans.

The ACA- ObamaCare, as it is popularly known- was implemented on 1 October 2013. The legislation contains something called an “individual mandate”, which makes it a legal requirement to have health insurance. The idea is that by having everyone sign up for insurance- the young and healthy as well as the elderly with chronic conditions- health insurance will be made less expensive for everyone. For those for whom the cost is still prohibitive, subsidies are included to bring the cost within reach.

Its successful implementation rests heavily on the performance of a federal website, healthcare.gov, which enables people to sign up for health insurance online. The substantial problems encountered by website users have been widely reported; internal documents show, for example, that on the first day it was available, only 6 people were able to successfully obtain insurance. Since then, improvements have been made, including allowing people to browse estimated prices before signing in and providing personal details.

But the real issue with ObamaCare’s implementation isn’t about the fact that the website doesn’t work. It’s that by making the success of something so important depend on a website, that the whole point of the legislation is jeopardized. And it doesn’t matter if the legislation is perfect, or the provision of new, affordable health insurance policies is dramatically improved.

There is no question that what the website has to do is highly complex. But here is the major problem: people from disadvantaged populations are less likely to have access to computers and to the internet. Even if they do have access, they are more likely to have literacy deficits that make it more difficult for them to effectively navigate and use websites.

The Obama administration included provisions for this in the legislation for providing funding for patient navigators, whose role is to support people to access the insurance- and in turn, the healthcare- they need. But their work has been held up by (largely Republican) opposition, which has come in the form of state-level legislation that inhibits legislators from getting started, either through mandating them to take out expensive malpractice insurance, or to engage in burdensome educational programs prior to starting work.

So there are two major issues: the political and the technological. But both of them miss the real point, which is that millions of people in a prosperous country are still being denied the healthcare they need. Relying on technology to engage people who lack digital access and skills, without providing substantial support to ensure these issues are resolved, will continue to mean that the ACA will not meet its targets.

This is something I have been looking at recently in my own research about internet use for health by people with low health literacy. In the United States it is estimated that a third of the population falls into that category. What we have found, soon to be published, suggests that people with low health literacy are likely to have at least the same difficulty with websites as with printed health information, regardless of how it is designed. So if ObamaCare’s successful implementation relies on people obtaining health insurance through a website, the people who need it most are going to continue to be excluded. Access is everything.

People need more than a website; and fixing every technical glitch in healthcare.gov is not going to fix the problem. So instead of putting all the effort- the political and the technological- to fix the website, the administration needs prioritize getting navigators out there, in order to support those who need it most. Otherwise, no matter how well the website is designed, it’s not going to achieve the aim of getting people the insurance they need.


About Braden O'Neill

Assistant Professor, Department of Family and Community Medicine, University of Toronto
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