The Biggest Mistake in the Healthcare Site?

This article originally appeared in the Huffington Post on Nov. 12, 2013.

By Eszter Hargittai

With criticism of The Affordable Care Act's website mounting, some want heads to roll for the "debacle" that is the roll-out, others are calling for the site to shut down, and some claim jokes about healthcare.gov's failings are amusing. But the focus on the flaws of the system since its October 1 launch ignores an equally crucial fact.

That reality is that a huge impediment to Americans' benefiting from this resource is the undeniable, vast difference in people's abilities to use the Internet. The assumption that all Americans - even most Americans--can perform simple online tasks is simply wrong.

Having researched for more than a decade how Americans navigate online content, I have observed firsthand the tremendous confusion and frustration that can result in the use of sites that are not user-friendly and place too high a burden on the user to figure out how to move from point A to point B.

In 2006, I conducted a study on how people approached looking for information about Medicare Part D, the federal program that subsidizes the cost of prescription drugs for Medicare beneficiaries. Watching dozens of people navigate the online landscape and listening to them describe their experiences made it abundantly clear that even with the best of intentions, people were not able to make sense of the available options.

This inability to understand the tools left them frustrated and without answers. Reaching for the telephone was not much help as they were then left with having to navigate complex phone trees.

Seven years later, even if all Americans were wired (and 15 percent of adults do not use the Internet at all according to a recent Pew study), they vary considerably when it comes to their Internet skills. What I mean is, they differ widely in their ability to understand and navigate the Internet effectively and efficiently.

Menu options that appear then disappear depending on where the cursor is on the screen can be confusing and hard to maneuver for those with mobility problems. People look for clues on the screen and don't necessarily think to place the cursor on words or scroll down the screen for crucial information. They get easily derailed when clicking on links by mistake.

When reading an action item such as "create", "apply" or "click", they expect the associated text and images to be clickable. Some double-click on everything - like one does on a computer to open a file - which can result in multiple submissions of information confusing the system. These are just a few of the myriad of online actions that are a source of confusion for many Internet users.

Other studies over the past decade have consistently shown that those from more disadvantaged backgrounds tend to be less skilled than more educated and better off populations. In other words, it is precisely those who most need access to assistance who are the least likely to be able to make sense of and thus take advantage of the online system.

After spending just a few minutes on healthcare.gov, I could already tell what would trip people up. For example, barely into the site, important information requires large monitors or scrolling to see essential information. Words such as "Create an Account" that suggest options when clicking on them are not clickable.

What may be completely intuitive actions for Web designers and engineers are far from the norm for those who only use the Web occasionally and mainly do so to correspond with family members once in a while on Facebook or by email.

Certainly, I am not suggesting we go back to the pencil and paper days of signing up for a plan and dropping the application in the mail. I am not advocating for a step back to registering at an 800 number by phone alone. I am suggesting that such an enormous endeavor for countless Americans should have at least accommodated the millions who are not up to the task of using a website for such an important choice.

Though critics of the site's implementation are legion, undoubtedly a site like healthcare.gov requires tremendous amounts of preparation and work to put together. But that work cannot simply focus on making sure everything is available (a most basic goal yet to be achieved consistently), it must also be easily accessible.

Preparing such a site requires careful usability testing on varied populations that reflect constituents to ensure that people are not left discouraged and exasperated by the experience.

That is, testing cannot simply include asking a few savvy adults what they thought of the site. Rather, it requires sitting down in person with people both young and old, more or less educated, and more or less literate to get a sense for how the many diverse people this site needs to reach are able to make sense of it and navigate it effectively. Lessons learned from such observations then must be incorporated into system design.

In the meantime, if you count yourself among the Internet savvy, next time a friend or family member seems exasperated over the process, don't simply point them to healthcare.gov. Instead, sit down with them to help them through their confusion recognizing that they may lack the necessary skills to navigate the site. Not everything can be solved by just googling it. For now, the human support system can still make a tremendous amount of difference, whether at the library or across the dinner table.

This governmental assumption that all Web users are created equal, may end up being the biggest disappointment and one that may ultimately cause the ideal of affordable health care accessibility to crash.

- Eszter Hargittai is a professor of communication studies at Northwestern University.