to make sound decisions about which plans will best meet their needs. Clearly, attention to health literacy in general and health insurance literacy in particular will be a key consideration in developing an effective health insurance communication strategy for the exchanges.

Funderburk noted that the usual health literacy framework that aims to match an individual’s skills and abilities with the demands and complexity of the material would be useful in this context. He suggested, however, that the utility of the framework would be enhanced if motivational and attitudinal components of the communication were considered. These features will influence the behavioral actions (e.g., consumer engagement in reviewing, comparing, and choosing appropriate coverage) that must occur if the benefits of the program are to be realized. For example, improved access to health insurance and the associated benefits of improved population health and improved quality of life will only occur if consumers use the information to make informed choices that are tailored to their needs and aspirations. Research suggests that motivational and attitudinal issues can be as detrimental to making appropriate health choices as low health literacy (Funderburk, 2011; Kotler and Lee, 2008; Sutton et al., 1995).

Addressing health literacy is essential to the operation of the exchanges, Funderburk said. Attention to health literacy issues is a first step in support of informed consumer decision-making. Using simple, plain language rather than jargon; designing consumer-friendly decision-support tools; presenting comparative information using standardized insurance plan formats; personalizing outreach to diverse, low-literacy consumers; and facilitating communication between consumers and health system navigators can all be marshaled to help consumers understand eligibility rules and the operation of both public and private health coverage. One might think of implementing these diverse communication activities, when combined with a sound understanding of the point of view of the exchange consumers, as part of a broader social marketing campaign. Social marketing involves understanding the mental models that consumers use as they approach their decision-making situations, Funderburk noted. Factors such as health literacy, culture, language, attitudes, perceptions, and life circumstances that might prevent an individual from taking advantage of health benefits for which they are eligible are taken into account, and then strategies to overcome these barriers are developed. Social marketing supports health literacy and health insurance exchange goals. Materials and messages use plain language and are consumer centered. These messages are then tested and refined using real consumers. The process of testing is iterative and ongoing to improve communication and the ability of consumers to make choices. Ongoing testing identifies barriers and improves understanding of market segmen-



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