An Introduction To Health Literacy And Enrollment

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By Nicole Donnelly, Penny Lane, Joan Winchester, Christina Powell | MAXIMUS Center for Health Literacy | December 2011

Nearly 50 million Americans lack health insurance.1 Many of the uninsured will have new coverage options available starting in 2014, either through health insurance exchanges with the help of tax credits or through expanded Medicaid coverage. Much focus has been placed on how people will apply for the health coverage options that become available, addressing such questions as: How will online applications work? Will people be able to apply for coverage using their smart phones or tablets? What are the best ways to simplify the renewal process so that people keep coverage once they’re enrolled?

However, surveys suggest that most people aren’t even aware that this new coverage will be available.2 So, before we focus on how to apply and renew, it’s important to realize that people can’t enroll in health insurance plans in the first place unless they know what coverage is available, how to apply, and how to enroll. Because many of those looking for information have low health literacy, the information itself can be a significant barrier to enrollment if it is poorly organized, text heavy, written with difficult vocabulary, or translated poorly. To be effective, the information must be written, formatted, and translated clearly. Our challenge will be to make sure that as many people as possible understand their options and are armed with the information they need to choose what’s best for them.

This series, written by experts from the MAXIMUS Center for Health Literacy, will share best practices for writing and designing materials—websites, applications, instructions, and even marketing materials—that are clear, easy to read and understand, and that make it easier for people to enroll.

Health Literacy Matters

Health literacy is the ability to find, understand, and use complex information to make choices about health care. Health literacy has an impact on routine tasks, such as whether a person can read and understand the instructions on a medicine bottle, and on more complicated tasks, such as whether someone can easily compare multiple health insurance plans.

Poor health literacy can result from a lack of exposure to the experiences and education that help most of us learn about health. It can also result from other limitations, such as those caused by aging, disabilities, language, or learning capacity.

People of all ages, races, incomes, and education levels struggle with limited health literacy, but the groups who struggle the most are older adults, recent immigrants, and people with low incomes—some of the same people who are most likely to be uninsured and eligible for expanded health coverage in 2014. The National Assessment of Adult Literacy found health literacy to be lowest among adults who are uninsured or who are enrolled in Medicare or Medicaid, as shown below.

Adult Health Literacy, by Type of Insurance, 2003

For the Uninsured, Health Literacy Matters More

More than half of the nearly 50 million uninsured Americans have either basic or below-basic health literacy. That means they can understand health information written at or below a fifth-grade level. They face formidable barriers to getting the health care and services they want, need, or are required to have. Without information and resources tailored for them, they may not be able to complete an application for health coverage or make appropriate choices about their care.

Many uninsured adults are responsible not just for themselves, but also for family members. They need to know whether they, their children, or their parents qualify for public programs or other insurance. They want to know how changing circumstances, such as employment or family composition, affect the kind of coverage they are eligible to receive and what financial assistance is available for the cost of coverage. They have to compare risks and benefits and make personal evaluations of tradeoffs and preferences.

Poor health literacy is a huge barrier standing between uninsured Americans and enrollment in health coverage. Most health-related materials are written at a tenth-grade reading level or higher, despite the fact that nearly half of the American public finds it difficult to understand and use information written above an eighth-grade level. Compare these examples:

Example: State Health Coverage Enrollment Notice

College reading level:

If we determine that having to pay a premium results in extreme hardship for a member, we may, at our sole discretion, waive payment of the premium or reduce the amount of the premiums assessed for a particular family.

5th-grade reading level:

We may lower or cancel your payment if it is too hard for you to pay.

Example: State Health Coverage Program Renewal Form

High school reading level:

Do not use this renewal form to add a new child to [the program]. This form can only be used to renew coverage for children already enrolled in [program] who are under the age of 19 and to evaluate existing [program] members for Medicaid eligibility. If your child(ren) is found eligible for Medicaid, you may be contacted for more information and will need to complete a new application.

7th-grade reading level:

Do not use this form to add a new child to [the program]. Use this form only to renew [program] for children under age 19. If your children qualify for Medicaid, we may need more information. You will need to fill out a new application.

Misunderstandings and Missed Actions

It is possible to communicate complicated concepts, such as how to pay health insurance premiums or how to renew coverage, using simple language. Clear and easy-to-understand materials are easier for everyone to use, regardless of literacy level.

For people with limited literacy or technology skills, medical jargon and other technical language can make print and web communication difficult, if not impossible, to understand. Jargon and technical language also make it harder for consumers to enroll in and retain health coverage. Many people also face linguistic and cultural barriers that compound these problems. These barriers force otherwise self-sufficient people into an unwanted dependence on family and friends—sometimes even children—to navigate the system. Some avoid the system altogether, which can lead to more emergency room visits and poor health outcomes.

Together, these factors are a recipe for missed deadlines and appointments, misunderstood instructions, poor understanding and management of chronic diseases such as high blood pressure or diabetes, and unintentional noncompliance. Often, the results are frustration and inconvenience, but some misunderstandings can be life-threatening.

Everyone Has a Role in Health Literacy

Everyone who has a stake in health coverage enrollment also has an important role to play in improving health literacy. Whether you are creating an exchange or Medicaid website, working on your state’s streamlined application, writing consumer outreach or assistance materials, choosing materials to make available to your patients, or designing enrollment and renewal materials for your future customers, you can make it easier or more difficult for people to understand critical health information. If the information is easy to understand, and if the technology is intuitive and easy to use, the new systems, websites, and materials will be cost-effective and successful—and you will contribute to your readers’ health literacy. People will understand your materials, making it easier for them to enroll in coverage. If materials are not written clearly, with consumers’ health literacy in mind, people may fail to enroll—even if the technology underlying the materials functions perfectly.

This series on health literacy will offer guidelines for improving communication, including how to:

  • Write in plain language, so that consumers with limited literacy skills can read and understand your materials.
  • Design materials and websites that are accessible, user-friendly, and easy to navigate.
  • Use translations that are adapted for readers with limited literacy skills.
  • Organize content in a way that helps your audience find the information they need.
  • Explain legal or technical terms and difficult concepts in clear and concise language.

Stay tuned for the next publication in this series, Communicating with Plain Language, an introduction to plain language techniques, with tips and tools that you can put into practice right away to improve your communication.


This piece was written for the Enroll America Best Practices Institute by the MAXIMUS Center for Health Literacy.

Assistance was provided by Jennifer Sullivan, Director of the Best Practices Institute, and Rachel Klein, Executive Director, Enroll America.

Enroll America thanks Families USA for their editorial and design support in the production of this piece.


1. Carmen DeNavas-Walt, Bernadette D. Proctor, and Jessica C. Smith, U.S. Census Bureau, Current Population Reports, P60-239, Income, Poverty, and Health Insurance Coverage in the United States: 2010 (Washington: U.S. Government Printing Office, 2011).

2. Kaiser Health Tracking Poll – September 2011 (Washington: Kaiser Family Foundation, September 2011), available online at

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