Assessment of Children's Public Health Insurance Program Enrollment Applications: A Health Literacy Perspective

Introduction: More than half of uninsured children in the United States qualify for Medicaid or the Children's Health Insurance Program (CHIP). Application readability and other complex features may be barriers to enrollment for some of these families. The purpose of this study was to conduct a literary assessment of state-issued English- and Spanish-language Medicaid/CHIP Internet-based enrollment applications, including an evaluation of reading demands, layout characteristics, and document complexity. Method: In May 2010, we downloaded all currently available English-language (n = 50) and Spanish-language (n = 39) Internet-based, state-issued Medicaid/CHIP enrollment applications. We estimated the reading demands of each CHIP enrollment application " Signature" page using the Lexile Analyzer. We assessed layout characteristics using the User-Friendliness Tool and we evaluated document complexity using the PMOSE/IKIRSCH scale. Results: On average, Medicaid/CHIP enrollment application " Signature" pages were written at a high school reading level (English language = 12th- to 13th-grade reading level; Spanish language = 10th- to 11th-grade reading level). Five Medicaid/CHIP enrollment applications (5.6%) consistently used a 12-point or larger font size throughout. Most Medicaid/CHIP enrollment applications (n = 83; 93.3%) needed " some" or " much" improvement in the amount of white space. Document complexity ranged from level 3 (moderate) to level 5 (very high), with the majority of Medicaid/CHIP enrollment applications ranked at level 4 (high). Discussion: Revisions are required in almost all state Medicaid/CHIP enrollment applications to achieve consistency and to meet standard low-literacy guidelines (e.g., written at a 6th grade or lower reading level and using a font of 12 points or larger). Additionally, to increase access to Medicaid/CHIP for eligible Hispanic children, all states should provide an online Spanish-language version of the Medicaid/CHIP enrollment application.