What the HIX population is saying about out-of-pocket costs could be a start. Thirty-four percent of those respondents covered in 2014 expressed difficulty paying these fees. Money concerns also led 16 percent to skip seeing a doctor when sick or injured, slightly higher than for those with employer plans and double the rate reported by the Medicare enrollees.

At the same time, the exchanges seem to be improving access and making inroads into preventative care. Nearly two-thirds of the HIX respondents say they used their plans to seek services and purchase medication with nearly 75 percent of those saying they may not have been able to afford it without their coverage. Regarding preventative care, 76 percent have a professional they consider to be a primary care provider – twice the rate of the uninsured – and nearly 60 percent report visiting a doctor for a well visit in the past year, similar to people covered by their employers.


"One way to bend the cost and quality curves is to shift the health system to more of a wellness model versus waiting to treat people after something bad happens," said Scott. "It's simple in concept yet difficult in practice. How do you change human behavior? It will be interesting to see if exchange products and coverage can help move this concept forward."

The report presents several implications for insurers and the exchanges. Plans could attract new customers and reduce turnover by focusing on benefit-price tradeoffs and tailoring products to consumers' differing coverage preferences. Exchange customers may be especially receptive to benefit structures that incorporate incentives and tools for pursuing healthier lifestyles and chronic care management.

Exchanges and plans should also consider using both online and personal methods for engaging consumers, as a substantial number still value phone and face-to-face conversations in picking a plan.

"I think for year three of open enrollment we'll see carriers get more personalized and creative in how they appeal to targeted segments of consumers who show signs of becoming discriminating shoppers," said Lambdin. "Insurers in the last two years have been building up their capability to think and act more like a retailer, so we will likely see more tangible examples of execution in the marketplace."

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