Journal of General Internal Medicine

, Volume 33, Issue 8, pp 1400–1410 | Cite as

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

  • Charlene A. Wong
  • Sajal Kulhari
  • Ellen J. McGeoch
  • Arthur T. Jones
  • Janet Weiner
  • Daniel Polsky
  • Tom Baker
Health Policy



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


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.


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).


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.


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).


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.


health insurance marketplace Affordable Care Act consumerism health insurance decision support 




Funding Information

Funding for this project was provided by the Robert Wood Johnson Foundation.

Compliance with Ethical Standards

Conflict of Interest

Tom Baker is a co-founder of Picwell, Inc., a health information/technology company that leverages big data and predictive analytics to help consumers optimize health plan choice. All other authors declare no conflicts of interest.

Prior Presentations

Presented as a poster at the AcademyHealth Research Meeting, June 2017 in New Orleans, Louisiana.


  1. 1.
    Center for Medicare and Medicaid Services. Health insurance marketplaces 2017 open enrollment period final enrollment report: November 1, 2016-January 31, 2017 2017. Available from: Accessed 18 March 2018.
  2. 2.
    Politi MC, Kaphingst KA, Kreuter M, Shacham E, Lovell MC, McBride T. Knowledge of health insurance terminology and details among the uninsured. Med Care Res Rev. 2013;71(1):85-98.
  3. 3.
    Wong CA, Asch DA, Vinoya CM, Ford CA, Baker T, Town R, et al. Seeing health insurance and through the eyes of young adults. J Adolesc Health. 2015;57(2):137-43.
  4. 4.
    Bhargava S, Loewenstein G. Choosing a health insurance plan: complexity and consequences. JAMA. 2015;314(23):2505–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Iyengar SS, Lepper MR. When choice is demotivating: can one desire too much of a good thing? J Pers Soc Psychol 2000;79(6):995–1006.CrossRefPubMedGoogle Scholar
  6. 6.
    Ubel PA, Comerford DA, Johnson E. 3.0—behavioral economics and insurance exchanges. N Engl J Med. 2015;372(8):695–8.
  7. 7.
    Dafny LS, Hendel I, Marone V, Ody C. Narrow networks on the health insurance marketplaces: prevalence, pricing, and the cost of network breadth. Health Aff. 2017;36(9):1606–14.CrossRefGoogle Scholar
  8. 8.
    Johnson EJ, Hassin R, Baker T, Bajger AT, Treuer G. Can consumers make affordable care affordable? The value of choice architecture. PLoS One. 2013;8(12):e81521.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Wong CA, Polsky DE, Jones AT, Weiner J, Town RJ, Baker T. For third enrollment period, marketplaces expand decision support tools to assist consumers. Health Aff. 2016;35(4):680–7.CrossRefGoogle Scholar
  10. 10.
    Wong C, Nirenburg G, Polsky D, Town R, Baker T. Insurance plan presentation and decision support on and state-based web sites created for the Affordable Care Act. Ann Intern Med. 2015;163(4):327–8.
  11. 11.
    Giovannelli J, Curran E. Efforts to support consumer enrollment decisions using total cost estimators: lessons from the Affordable Care Act's marketplaces. Issue Brief. 2017;3:1–12.PubMedGoogle Scholar
  12. 12.
    Hempstead K. Consumer decision support on the individual market will be more important than ever. Health Affairs Blog. 2017. Available from: Accessed 18 March 2018.
  13. 13.
    Antos J, Capretta J. The President’s executive order: less than meets the eye? Health Affairs Blog. 2017. Available from: Accessed 18 March 2018.
  14. 14.
    Kaiser Family Foundation. State health insurance marketplace types. 2017. Available from: Accessed 18 March 2018.
  15. 15.
    Center for Medicare and Medicaid Services. Web-broker public list 2016. Available from: Accessed 23 Feb 2017.
  16. 16.
    Taylor EA, Carman KG, Lopez A, Muchow AN, Roshan P, Eibner C. Consumer Decision Making in the Health Care Marketplace. Santa Monica: RAND Corporation; 2016.CrossRefGoogle Scholar
  17. 17.
    Johnson E, Shu SB, Dellaert BG, Fox C, Goldstein DG, Haubl G, et al. Beyond nudges: tools of a choice architecture. Mark Lett. 2012;23:487–504.CrossRefGoogle Scholar
  18. 18.
    Smith A, Anderson M. Online shopping and E-commerce. 2016. Available from: Accessed 18 March 2018.
  19. 19.
    Sinaiko AD, Ross-Degnan D, Soumerai SB, Lieu T, Galbraith A. The experience of Massachusetts shows that consumers will need help in navigating insurance exchanges. Health Aff 2013;32(1):78–86.CrossRefGoogle Scholar
  20. 20.
    Rao A, White J, Hewitt P. 2017 Health insurance exchanges: the good, the bad and the ugly. Clear Choice. 2017. Available from: Accessed 18 March 2018.
  21. 21.
    Zhu JM, Zhang Y, Polsky D. Networks in ACA marketplaces are narrower for mental health care than for primary care. Health Aff. 2017;36(9):1624–31.CrossRefGoogle Scholar
  22. 22.
    Wong CA, Kan K, Cidav Z, Nathenson R, Polsky D. Pediatric and adult physician networks in Affordable Care Act marketplace plans. Pediatrics. 2017;139(4).
  23. 23.
    Yala SM, Duru OK, Ettner SL, Turk N, Mangione CM, Brown AF. Patterns of prescription drug expenditures and medication adherence among medicare part D beneficiaries with and without the low-income supplement. BMC Health Serv Res. 2014;14:665.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Jackson EA, Axelsen KJ. Medicare Part D formulary coverage since program inception: are beneficiaries choosing wisely? Am J Manag Care. 2008;14(11 Suppl):SP29–35.PubMedGoogle Scholar
  25. 25.
    Greene J, Hibbard JH, Sacks RM. Summarized costs, placement of quality stars, and other online displays can help consumers select high-value health plans. Health Aff. 2016;35(4):671–9.CrossRefGoogle Scholar
  26. 26.
    Pacific Business Group on Health. Supporting consumers' decisions in the exchange. Available from: Accessed 18 March 2018.
  27. 27.
    Benedict GC, Baker T. Regulating robo advice across the financial services. Iowa Law Review. 2018;103(forthcoming).Google Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Charlene A. Wong
    • 1
    • 2
    • 3
  • Sajal Kulhari
    • 4
  • Ellen J. McGeoch
    • 4
  • Arthur T. Jones
    • 4
  • Janet Weiner
    • 4
  • Daniel Polsky
    • 4
  • Tom Baker
    • 4
    • 5
  1. 1.Department of Pediatrics, Margolis Center for Health Policy, Duke Clinical Research InstituteDuke UniversityDurhamUSA
  2. 2.Margolis Center for Health PolicyDuke UniversityDurhamUSA
  3. 3.Duke Clinical Research InstituteDuke UniversityDurhamUSA
  4. 4.Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaUSA
  5. 5.University of Pennsylvania Law SchoolPhiladelphiaUSA

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