The use of explicit health benefits packages increases support for universal health care for people with high objective numeracy

Abstract

Purpose: Universal health care lacks support in the US. Explicit health benefits packages (HBPs) may improve support for UHC by heightening comprehensibility and increasing perceived equality through outlining the cost and scope of care. To test these hypotheses, we compared support for UHC after a HBP intervention, uninformative control, or ‘standard' UHC messaging from the World Health Organization (WHO). Method: Study 1 (N=189) was a 2(pre-post)x3(condition) mixed-subjects design. Participants were randomly assigned to one of three conditions: 1) building an HBP exercise; 2) reviewing a pre-selected HBP; 3) completing an uninformative control exercise. Study 2 (N=412) was a 2(pre-post)x2(condition) mixed-subjects design with random assignment to either building an HBP or reading WHO pamphlets about UHC. HBP building used the “Choosing Healthplans All Together” (CHAT) simulation exercise where participants constructed their own HBP by allocating a limited set of resources to benefit types (e.g. dental) and choosing scope of coverage (basic-to-high). Support for UHC was our primary outcome measure; perceived equality (i.e. is UHC seen as fair?) and comprehensibility (i.e. how easy is it to understand UHC?) were included as mediators. All items were measured both pre and post intervention using 0-100 slider-bar scales. In Study 2, we also included the Rasch Numeracy Scale and the Subjective Numeracy Scale as moderators. Results: In Study 1, both HBP interventions did not increase UHC support versus the control. In Study 2 there was no main effect of experimental condition on support for UHC; ps < .05. However, there was a significant interaction between experimental condition and objective numeracy. Greater objective numeracy predicted increased support for UHC in the ‘active' versus the ‘passive' intervention. Conversely, lower objective numeracy resulted in our ‘passive' intervention increasing support for UHC more than our ‘active' intervention. Support for UHC was mediated by perceived equity, but not comprehensibility. Conclusions: Active (i.e., creating your own plan) and passive (i.e., reviewing a pre-selected plan) HBP interventions did not increase support for UHC. A more externally valid ‘passive' intervention presenting WHO pamphlets about UHC did increase support for UHC. The two interventions appeared to function by highlighting the equity inherent in HBP. However, the ‘active' intervention was only effective for participants with high objective numeracy. Given that 29 percent of American adults (approximately 73 million) have low numeracy, it is important to focus future research on alternative approaches that are less quantitatively taxing.