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Could you pass a 'health literacy' test to get insurance?
Cancer Health Literacy Test, General Health Numeracy Test, Medical Data Interpretation Test - photo by Jennifer Graham
If your insurance coverage depended on it, could you pass a test of basic health knowledge, such as what the numbers in a blood-pressure reading mean, and the difference between being overweight and obese?

Some low-income people in Kentucky may have to, if the state's new requirements for Medicaid survive a lawsuit filed recently.

Kentucky was the first state to obtain the federal government's permission to require many of its Medicaid recipients to work or perform community service in order to receive benefits. People who are unable to work could get around that requirement by taking and passing a course of basic health and financial knowledge, a plan that has been denounced as punitive and cruel by some health-policy analysts.

But proponents of the idea can cite multiple studies that show an association between general knowledge about health and lower health costs, reduced emergency room visits and better patient outcomes.

The studies are part of a widening discussion about "health literacy," defined by the government as the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.

Kentucky has yet to offer any details about what its health literacy test might look like, but more than 100 similar tests have already been developed to gauge basic health knowledge, the sort of things we should have learned in high school, and also to assess knowledge in specific areas of personal health, such as cancer, diabetes and nutrition.

To fare well on these tests, people must exhibit more than knowledge about their bodies and how they best function. They must also master elementary mathematical calculations and be able to reason. For example, one test asks: If taking a pill twice a day helps you get better, will taking it three times a day make you better or worse?

If you are unable to correctly answer that and other health-related questions, researchers have found that you may be more likely to have a disease recur and to overuse emergency rooms.

But should a persons knowledge of health, insurance and finance affect whether they qualify to receive low-cost health insurance from the government? In its five-year Medicaid experiment, Kentucky hopes to demonstrate that the answer is "yes" even as many health-policy analysts say no.

How most Americans fare

The first large-scale analysis of health literacy in the U.S. was in 2003, the last time that Americans general literacy was assessed.

That survey rated respondents as below basic, basic, intermediate and proficient, and researchers concluded that about 53 percent of Americans had intermediate health literacy, while 22 percent had basic and 14 percent as below basic. Twelve percent were proficient.

Among sub-groups, women were more likely to be proficient or intermediate than men. Sixteen percent of men were ranked below basic, compared to 12 percent of women. And people with incomes above the poverty line fared better than people with incomes under the poverty line.

In ensuing years, researchers began to examine if health literacy was associated with better health. One report, published in 2017, found more than 6,000 scientific articles published on the topic between 1991 and 2015. Another published in 2011 analyzed 111 papers about health literacy and found a strong link between health literacy and poor health practices and outcomes.

"Low health literacy was consistently associated with more hospitalizations, greater use of emergency care, lower receipt of mammography screening and influenza vaccine, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret labels and health messages and, among elderly persons, poorer overall health status and higher mortality rates," the authors of the 2011 study wrote.

Such findings are likely the underpinnings of Kentucky's plan to implement a health literacy program for Medicaid recipients as part of its sweeping overhaul of the program. State officials have said their new rules will "empower individuals to improve their health.

Kentucky has said that, beginning in July, Medicaid recipients between the ages of 19 and 64 will have to provide evidence that they have worked at least 80 hours each month at community service or "employment activities." People who would be exempt from the requirement include pregnant women, primary caregivers, full-time students and "medically frail" people who are unable to work because of illness or disability.

Analysts predict that about half of the state's 337,000 Medicaid recipients would be affected by the change. Thirty-eight percent of Kentucky's recipients are not currently employed; more than three-quarters say they don't work because they are ill or disabled, or full-time caregivers, according to the Kaiser Family Foundation. (The numbers are similar in Utah, where 37 percent of 97,000 Medicaid recipients don't work, 39 percent because they are disabled or ill, 46 percent because they are a caregiver.)

Not every Medicaid recipient in Kentucky, however, would be required to take the health literacy course. The state said it will offer the class as a way people can regain coverage if they lose benefits because they did not fulfill the work requirements. State officials did not respond to an interview request, but told The New York Times that the class and pass-fail test might include information on household budgeting, opening a checking account, weight management and how to manage a chronic disease.

A partisan divide

Utah is one of nine other states that also want to add work requirements for people who have health insurance through Medicaid. Utah Gov. Gary Herbert, a Republican, has said such rules help to change the mindset of people who receive government aid, helping them to move from being a passive recipient of assistance to a person actively working to better his or her circumstances.

"And we believe that that's important to not only, as the proverb goes, give them a fish and feed them for a day, but to teach them how to fish so they can feed themselves for a lifetime. We think that's good policy," Herbert told NPR.

Kentuckys proposal is more emblematic of the fundamental differences between Republicans and Democrats than other recent actions on health care by the Trump administration, such as the decision to shrink the enrollment period for Obamacare, said Harold Pollack, the Helen Ross Professor at the University of Chicago School of Social Service Administration, a public-health policy expert.

This is a classic point of dispute between Republicans and Democrats about what the purpose of Medicaid is, to what extent is health care a right, Pollack said. And if we liberals dont like work requirements, what we have to do is go out and win elections and convince people that these policies are a bad idea.

I would rather have Medicaid with a work requirement than no Medicaid at all, but as long as we have Republicans controlling a lot of state government, these governors will have a big role in shaping what Medicaid looks like, he said.

Pollack noted that Kentuckys new requirements affect not just the individuals on Medicaid, but also their health care providers.

One issue is, 'is this person entitled to care?' and the other is, 'is the person who provided that care entitled to be paid?' I happen to believe that health care is a right, but I also believe that people who provide safety-net care must be assured that theyre gong to be paid. Its not just about that individual; its also about the whole ecology of safety-net care, he said.

What happens now

Kentucky's plan to approve some Medicaid recipients on the basis of how much they know about health may be forestalled by a lawsuit filed Jan. 24 against the Department of Health and Human Services, which approved Kentucky's waiver.

Among other things, the complaint alleges that the state's plan threatens "irreparable harm to the health and welfare of the poorest and most vulnerable in our country. It was filed by the National Health Law Program, the Kentucky Equal Justice Center and the Southern Poverty Law Center on behalf of 15 Kentucky residents who could lose their health insurance under the new rules.

Philip Massey, an assistant professor at Drexel Universitys Dornsife School of Public Health in Philadelphia and the lead author of several studies on health literacy, said if Kentucky's changes are upheld, the state must figure out what compromises health literacy. Despite the plethora of research on the subject, there is no single standard on which everyone agrees.

The scholarship and research in health literacy itself is not uniform in terms of there is no one definition (for health literacy). Why is that important? How you define something is what informs its measurement, Massey said.

He also noted that the information a person needs to navigate "an increasingly complex" health-care system has changed significantly since 2003, the first and only time health literacy has been measured on a national scale.

Health literacy as a concept is incomplete without also considering health-insurance literacy (for example, what your coverage allows or doesn't allow). That's knowledge even the most literate of Americans may lack, Massey said.

"The basic knowledge do you know what an endocrinologist is? Do you know what a co-pay is? is fundamental knowledge, but there's also this other part: Do you have the skills and capacities to learn what those things are? Do you have the resources at your disposal be it the internet, be it your partner, spouse, your children to help you understand and navigate those different concepts?"

Tests already in use

Some health literacy tests are already in use as a tool to improve communication between doctors and patients.

The Massey Cancer Center at Virginia Commonwealth University, for example, developed a test designed to help doctors assess their patients' health knowledge in minutes. Called the Cancer Health Literacy Test (or CHLT-30), it has 30 questions about cancer treatment and medication. A subset of six questions was particularly effective in exposing potentially dangerous gaps in knowledge, such as whether taking a pill twice a day, if thats what a doctor prescribes, would be even more helpful if the patient took it three times a day. (The answer is no.)

Levent Dumenci, now a professor at Temple University in Philadelphia, was the lead researcher on a four-year study that examined the usefulness of administering the test to 1,306 patients at Massey Cancer Center and other oncology clinics in Richmond, Virginia.

The Cancer Health Literacy Test showed improved outcomes along a continuum, but the subset of six questions was effective in identifying patients at risk for poor outcomes, which allowed their health-care providers to give them extra help.

But those questions were specifically about a niche of disease cancer not overall health. "I don't know how Kentucky is going to decide what they would ask," Dumenci said.

While acknowledging that better health literacy would help all Americans, Pollack, of the University of Chicago, said he sees no reason to single out Medicaid recipients for improvement in this area. Some studies have shown that people who receive Medicare the governments insurance program for people over the age of 65 have health literacy rates roughly equivalent to people on Medicaid.

The impact of these courses, these interventions, is unclear, and theres a lot of correlation that is not indicating a casual relationship there, Pollack said. Im totally for giving people opportunities to improve their health literacy and their financial literacy, but wow, these things are easy to oversell.