Next big obstacle for Obama's Affordable Care Act? It's not just the Supreme Court.

Over the next three years, as the Patient Protection and Affordable Care Act (ACA) goes into effect, America’s state and local officials will be responsible for reaching out to more than 30 million individuals and enrolling them in publicly funded or subsidized health plans offered through state insurance exchanges. The majority of those individuals have low health literacy and will have difficulty finding, understanding, and using insurance information critical to getting them properly enrolled.

Failure to meet the enrollment goals of new health care law, however, will not only undermine the success of the new health law, but more importantly, will do little to expand health insurance coverage. Unless steps are taken to clarify the language and procedures surrounding the enrollment process, individuals are not likely to enroll, resulting in a significant waste of time, energy, and taxpayer dollars.

Properly enrolling in a health insurance plan, particularly a government funded or subsidized plan (such as Medicare or Medicaid), is a complex task. Individuals must navigate the system to find accurate and usable information. They need to understand eligibility guidelines, complete forms, and provide mandatory citizenship and financial documentation necessary for enrollment and for periodic reestablishment of eligibility.

Moreover, they need to understand concepts such as premiums, co-pays, and benefits, and be able to apply these concepts to their existing or anticipated health situation so that they can select the most appropriate plan. That means they must figure out which services are or are not covered and complete additional paperwork to enroll in a plan they select.

That’s no small order. Our most recent estimates suggest that over half of currently uninsured adults – those who will become newly insured under the ACA – have difficulty finding, understanding, and using even the most basic health information. Fourteen percent of US adults have trouble finding the date of a physician’s visit on an appointment slip. According to the National Assessment of Adult Literacy, only 12 percent can successfully calculate an individual’s contribution toward health insurance costs, even when using a table.

The success of the Affordable Care Act to enroll those newly eligible in an appropriate insurance plan therefore depends on clear communication to individuals who have limited health literacy. It is not realistic to expect that a website and assistance from insurance exchange navigators (counselors) can do this. These insurance counselors will be particularly inefficient if there are no standards to ensure that they understand the language and literacy barriers facing many of those newly eligible for coverage. Even now, state Medicaid programs fail to fully enroll eligible populations. States with the most-successful outreach strategies enroll no more than 88 percent of those eligible for Medicaid, while the least-successful states enroll just 44 percent of those who qualify for services.

Provisions in the Affordable Care Act require health plans seeking certification in state exchanges to provide information in plain language. This means, according to the ACA, using “language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-organized, and follows other best practices.” Yet policymakers continue to take action that undermines clear communication.

In May 2011, for example, Wisconsin’s insurance commissioner made permanent an “emergency rule” to raise the readability scores of insurance policies to a high school reading level. He also overturned a mandate to list what services and procedures are not covered by the insurance in a single place within the policy.

Decisions like that set a detrimental precedent. To be sure, there are up-front costs to create insurance information and enrollment processes using language that is accessible, usable, and actionable to people of all literacy levels. But there are even greater costs to ignoring or downplaying the need to make enrollment materials, and the enrollment process, understandable to everyone.

A system that is difficult to understand and navigate can lead to further delays or failure to enroll in any health plan at all, particularly among healthier individuals who feel less pressure to have insurance coverage. If healthier individuals remain disproportionately unenrolled, the pool of individuals participating in the exchange market will, on average, be sicker. This results in higher health-care costs and ultimately higher premiums in the exchange market.

Efforts are underway to prepare the nation for the implementation of the Affordable Care Act, but it is a field of dreams to assume that just because we build an exchange and mandate participation “they will come.”

We must proactively engage and support individuals through the enrollment process. Trusted community-based organizations and health providers can help consumers navigate the enrollment process and fill out applications, as was shown to be effective in Massachusetts. And performance standards for exchange counselors can include an understanding of and sensitivity to challenges related to low health literacy.

Without considerable attention to this issue, the impact of the new health law may fall well short of expectations.

Laurie T. Martin is a health policy researcher at the nonprofit RAND Corporation and Ruth M. Parker is a professor at the Emory University schools of medicine and public health. This piece is based on an article published by the authors in August in the "Journal of the American Medical Association."