Shopping on the Public and Private Health Insurance Marketplaces: Consumer Decision Aids and Plan Presentation

J Gen Intern Med. 2018 Aug;33(8):1400-1410. doi: 10.1007/s11606-018-4483-x. Epub 2018 May 29.


Background: The design of the Affordable Care Act's (ACA) health insurance marketplaces influences complex health plan choices.

Objective: To compare the choice environments of the public health insurance exchanges in the fourth (OEP4) versus third (OEP3) open enrollment period and to examine online marketplace run by private companies, including a total cost estimate comparison.

Design: In November-December 2016, we examined the public and private online health insurance exchanges. We navigated each site for "real-shopping" (personal information required) and "window-shopping" (no required personal information).

Participants: Public (n = 13; 12 state-based marketplaces and ) and private (n = 23) online health insurance exchanges.

Main measures: Features included consumer decision aids (e.g., total cost estimators, provider lookups) and plan display (e.g., order of plans). We examined private health insurance exchanges for notable features (i.e., those not found on public exchanges) and compared the total cost estimates on public versus private exchanges for a standardized consumer.

Results: Nearly all studied consumer decision aids saw increased deployment in the public marketplaces in OEP4 compared to OEP3. Over half of the public exchanges (n = 7 of 13) had total cost estimators (versus 5 of 14 in OEP3) in window-shopping and integrated provider lookups (window-shopping: 7; real-shopping: 8). The most common default plan orders were by premium or total cost estimate. Notable features on private health insurance exchanges were unique data presentation (e.g., infographics) and further personalized shopping (e.g., recommended plan flags). Health plan total cost estimates varied substantially between the public and private exchanges (average difference $1526).

Conclusions: The ACA's public health insurance exchanges offered more tools in OEP4 to help consumers select a plan. While private health insurance exchanges presented notable features, the total cost estimates for a standardized consumer varied widely on public versus private exchanges.

Keywords: Affordable Care Act; consumerism; decision support; health insurance; health insurance marketplace.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Commerce
  • Decision Support Techniques
  • Health Insurance Exchanges / standards*
  • Humans
  • Insurance, Health / economics*
  • Patient Protection and Affordable Care Act
  • United States