Table 2 Themes, subthemes and example quotes for the qualitative analysis

Perceptions of Challenges with Enrollment

Fears about Making a Suboptimal Insurance Choice

“Um they have trouble making health insurance decisions because sometimes they have a time limit, time limit to get health insurance so it’s like they feel like they’re being rushed and then, once they get in a health plan, it’s like, ‘Can I change up the plans or do I have to stay in it for a certain amount of time or…?’ Cause some of my clients ask me, ‘Well, what if I pick this health plan and in 60 days from now I don’t like it?’” (P3, CAC)

“So, and I have had people come back that, there’s one plan in particular, that they took that plan last year and they went somewhere out-of-network and got all these bills and they got upset about it so they changed this year.” (P6, CAC)

“Because I was so worried about my chronic care I didn’t worry if something might pop up [that’s new]…always afraid of making the wrong choice, I guess. Cause once I make it, it’s done, I imagine…until next year.” (P34, Consumer)

Lack of Knowledge and Financial Literacy among Consumers

“It’s complicated…There are a lot of choices and then there are terms that are unfamiliar or they mean something different in health care than they do in other industries. So, like…the deductible. So a lot of people think, most people are familiar with car insurance. So they think deductible and they think every time you have an accident you have to pay out your deductible and it’s different for health insurance…people get really confused about that term.” (P37, Policy)

“The summary of benefits is not at all clear for most consumers… I don’t think any consumer can figure out on their own, even with the highest level of education…” (P18, CAC)

“Uh, the only thing I see clients struggle with is, they, they tend to think about a lot… how to make those payments.” (P12, CAC)

“Um, people need to have some better information… [about] how to make financial decisions…because this stuff is pretty complicated. So helping them think about, um, so you know what a premium is… [and] how does the premium affect the co-pay and your lifetime use and all those things…and so we need to explain that part a whole bunch better…” (P3, CAC)

“I guess in general, just kind of like…the pros and cons, um, to help people understand that like, no plan’s perfect. And, um, there’s a choice to make and there’s a tradeoff.” (P1, Policy)

What to Include in Decision Support Tools

Importance of Health Insurance Premium

“Um, but in, but in most cases, I’d be looking for, um, what to expect, what am I expected to pay month to month.” (P2, CAC)

“For 80 % of consumers or more I’d the premium they’d say, “the premium rules,” and that rules the day…” (P18, CAC)

“I think like anybody one of the things you have to think about is what’s affordable, what can I afford monthly premium wise, probably even more so than the…deductible.” (P38, Consumer)

“[Client’s priorities should be] … all the pricing of course which would be not only premiums but also deductible and the max out of pocket which not all consumers are immediately aware of.” (P29, CAC)

“You know um a lot of people don’t even know that it’s, their deductibles and so, you know, insurance uh premiums may be low but the deductible might be high.”

(P9, CAC)

Importance of Network Coverage Differs Among Consumers

“Um, or they’re just like, “oh I haven’t been [to the doctor] in a lot of years,” I don’t care if I have to change. Like most people are pretty indifferent about that [network list], unless they, like, actually have…health issues that they’re concerned about.”

(P6, CAC)

“Uh, I would be very upset if I couldn’t keep my doctor. He’s a great guy. Sometimes when we don’t have money he just brings us in and sees us anyway.”

(P32, Consumer)

“Yeah, wherever you want to be able to go, um are there facilities or physicians in your area, which um here in St. Louis it’s not too much of an issue but it can be a challenge again with people with complicated health concerns that those will fit into the network and the plan.” (P19, CAC)

Ways to Modify Strategies

Addressing Challenges through Plain Language Principles

“Ok, I think the language needs to be simplified. It’s very, very complicated to most people…even me… I’m like “What are they talking about here?” (P5, Policy)

“I think this is a really traditional model, that’s what you get when you go to, look in the insurance company and everybody disregards that because it’s just too complex and so breaking them down in a smaller format makes sense.” (P3, Policy)

“…having it broken down into smaller charts would probably make it less intimidating for people to read.” (P6, CAC)

“… And just visually… I think it’s just easier for people, [to] get one subject, um, at a time… I kind of, vote for that.” (P17, Provider)

“Um, I would want to see the basics about each plan…otherwise it would just be way too overwhelming and hard to keep all of the information straight.” (P4, Policy)

“Hmm, (laughs), I think more visual aids would be helpful. Um, so something that’s not just words on the screen…” (P4, Policy)

“I like the picture, I like the white space. Um, very simple, small bit of information on the first page.” (P37, Policy)

Including Comprehensive, Tailored Narratives to Support Insurance Choices

“I think that looking at these, um, the way that these vignettes walk you through somebody’s decision process could be very helpful.” (P33, Consumer)

“Yeah I like, I like this [narrative], this is exactly what I was saying I’d like to see somebody, have an example, somebody that’s got a similar situation and find out what they did. Um, if that’s the one they chose well I can look at that and say “yes, that makes sense, you know, that’s what I probably ought to do as well.”

(P34, Consumer)

“… I think a person like that probably isn’t going to gravitate toward a big block of text and read it. Um…although I think the examples themselves are useful… I just don’t know if I see people actually reading them… especially when they already are taking in so information and they are pressed for time…” (P29, CAC)

“A lot of people have complex enough family situations that there may or may not be just one of the vignettes that matches perfectly with theirs and so then they have to put them all side by side and make those, make those decisions and I think that’s hard.” (P3, Policy)

“…[maybe] include someone who is disabled…include someone who is going to be graduating off their parents insurance at 26 or 27…include someone who, because of their citizenship status does not qualify to get Medicaid then they will be under their parents…maybe possibly even someone who has a kid in college in a different state but their permanent residence is with their parents, what kind of plan would you buy for that?” (P27, CAC)

“[what about] same sex couples....and then the invincible young man kind of thing…and a multi-generational family, you know, where there’s’ like a, mom, or a grandma…we see so many of those types of families…there are those families out there.” (P10, CAC)

“Now so one of my reactions is, my only, so if I had all of these put in front of me, I would actually want somebody to sort of hand me the one (laughs) that fits my situation closest. Um, and so I don’t know if that’s, once again, if you’re sitting with an assister or someone that’s helping you with this, instead of putting all five of these in front of me, if I know I little bit about you as the client, maybe I’m only putting one or two of these in front of you that best [fit] sort of your family situation.”

(P37, Policy)