Key Takeaways

• Most employees struggle to understand key health plan concepts, creating a gap between coverage and real-world use.
• Complex plan designs – such as tiered drug lists, deductibles, and narrow networks – often remain difficult to apply in everyday care decisions.
• Limited year-round communication leaves employees without ongoing guidance, reducing plan utilization and increasing costly care choices.
• Mismatches between how employees seek care and how plans classify services create confusion, unpredictable bills, and unnecessary spending.
• Simplified plan design, clearer communication, and usability-focused metrics help employers close the gap and improve benefit experiences.

Chad Wable, a veteran health care executive and consultant, has led complex operational, financial, and strategic initiatives across hospitals, nonprofits, and advisory organizations. As founder and president of AspireResults, he guides health systems through performance improvement, organizational design, and large scale transformation. His leadership experience includes senior oversight of multihospital operations, margin improvement programs, and community outreach strategies that connect care delivery with real population needs.

In his role supporting insurance and employee benefit strategies, Chad Wable has also worked closely with employers navigating rising costs and limited health literacy among employees. His background offers relevant insight into the persistent gaps between plan design and day to day use, a challenge that shapes employee experiences and perception of coverage. Drawing from his combined operational and advisory roles, he provides context for understanding how health plans can fall short in real world settings and what employers can do to address those issues.

Understanding the Gaps Between Health Plans and Real-World Use

Employers often treat health plans as a core part of their workforce strategy, yet those same plans can fall short when employees try to use them. A disconnect opens between what the plan promises and how it works in daily life. That gap shapes care choices, drives spending, and erodes confidence in coverage.

Health literacy sits at the center of the problem. About 12 percent of U.S. adults score at a proficient level on health literacy tests, so most people struggle with terms like deductible, network coverage, or coinsurance. The confusion shows up in real actions. Some skip preventive care without realizing the plan covers it. Others treat the emergency room as the only option. Many pick a plan based on premium price alone because they cannot interpret the benefit summary.

Plan design adds a second challenge. Tiered drug lists, split deductibles, and narrow networks can meet regulatory requirements yet remain hard to apply in real situations. Even diligent employees may not see how a rule maps to a specific appointment, bill, or prescription. These obstacles do not remain isolated. They show up across a workforce when people ignore preventive programs or default to high-cost care because they are unsure where coverage applies.

Employers try to help during open enrollment, but a single briefing rarely suffices. HR teams often deliver a short overview once and do not revisit it when questions arise later in the year. New hires and employees with changing needs may lack an easy way to check whether a specialist sits in network or whether a telehealth visit counts differently from a clinic visit. Without year-round guidance, the plan’s value stays locked behind unclear instructions, creating confusion that resurfaces when care decisions need to be made.

Mismatches between how people seek care and how the plan classifies that care create more friction. Mental health visits may follow different billing rules from primary care. Urgent care may count differently from a routine office visit. Provider directories may list in-network clinics that sit far from where employees live. In practice, these mismatches make it hard to choose the right setting or predict costs.

Those mismatches carry financial consequences. Avoidable emergency visits, delayed follow-up care, and poor medication adherence all raise spending even when coverage exists. Employers often blame plan generosity for rising costs, when the core issue is that members cannot interpret or apply the coverage they already have.

Some organizations have started to close the gap by simplifying choices and explaining benefits more clearly. Plain-language guides, digital decision tools, and smaller plan lineups help employees compare options in a realistic way. Employers who communicate throughout the year with reminders, scenario examples, and navigational support help people use their coverage when it matters.

A longer-term fix shifts how employers develop plans. Instead of focusing only on premiums and cost sharing, benefits teams can ask whether employees can use the plan without confusion or delay. They can measure usability directly: time to find an in-network provider, clarity of prescription pricing, and uptake of preventive services. When designers treat real-world use as a metric, benefits begin to work as intended.

As health benefits mature, usability can also shape how outside partners compete for employer business. Employers can require insurers, pharmacy benefit managers, and navigation vendors to publish transparency metrics that show how quickly people find care, resolve billing questions, or fill prescriptions. A market that rewards usability gives employers clearer leverage, pushes vendors to prove their value, and raises expectations for how benefits support the workforce.

FAQs

Why do employees struggle to use their health plans effectively?

Low health literacy and confusing benefit terminology make it difficult for employees to interpret coverage and navigate care options.

What aspects of plan design contribute to real-world confusion?

Tiered formularies, split deductibles, narrow networks, and differing billing rules often make benefits hard to apply in specific situations.

How does limited communication affect plan utilization?

When employers only explain benefits during open enrollment, employees lack ongoing support and often make costly or avoidable care choices.

What financial impact does this coverage gap create?

Misunderstanding coverage leads to avoidable emergency visits, missed preventive care, and poor adherence – all of which increase spending.

How can employers improve health plan usability?

Simpler plan options, plain-language guides, digital tools, and metrics tied to real-world usability help employees use benefits confidently.

About Chad Wable

Chad Wable is an experienced health care leader who has overseen hospital operations, financial turnarounds, and strategic development across multiple organizations. He founded AspireResults, where he advises health systems on organizational design, margin improvement, and patient centered innovation.

His background includes senior leadership roles guiding large hospital networks, directing community outreach programs, and supporting operational integration through mergers. Wable also contributes to insurance and benefits strategy work, helping employers navigate complex purchasing environments. In addition, he supports several community and industry organizations through board and philanthropic involvement.