{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T17:45:11Z","timestamp":1787161511140,"version":"build-2736575974"},"reference-count":27,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T00:00:00Z","timestamp":1787097600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>As healthcare costs and patient cost-sharing continue to rise in the United States, little is known about patients\u2019 understanding of healthcare pricing, insurance-related expenses, and cost-planning strategies.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To assess healthcare cost literacy (HCL) among U.S. adults and identify domains in which patients report the greatest and least confidence in understanding healthcare costs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A total of 2,308 American adults were surveyed. A cross-sectional design was utilized, incorporating a 12-item survey that examined key dimensions of healthcare cost literacy (HCL), such as healthcare cost knowledge, health insurance cost knowledge, and proactive cost planning behaviors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Participants reported knowing most about pharmacy-level price differences for prescription drugs (77%) and how to contest a hospital bill (56%); they reported knowing least about hospital chargemasters (33%). When asked to describe various healthcare terms, participants found it easiest to describe \u201cdeductible\u201d (mean 2.85 [SD 0.83]) and hardest to describe \u201chealth insurance formulary\u201d (mean 2.10 [SD 0.96]). Regarding preemptive cost planning, participants had the most difficulty with knowing the cost of an emergency room visit ahead of time (mean 2.19 [SD 0.98]) and found it easiest to know the out-of-pocket cost of a prescription drug ahead of time (mean 2.60 [SD 0.87]). Participants with high-HCL, defined as those with&gt;median HCL score of 2.42, were more likely to be older, have greater health literacy, and be more confident in managing their healthcare (all p\u2009&lt;\u2009.001). They were more likely to have visited a doctor in the last year and were more knowledgeable about cancer screening guidelines (both p\u2009&lt;\u20090.001).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec005\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Levels of HCL are varied among the adult population, with wide knowledge gaps in understanding hospital bills and insurance-related costs. Efforts to bolster levels of HCL may help patients\u2019 ability to anticipate, manage, and navigate healthcare expenses.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0354341","type":"journal-article","created":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T17:23:30Z","timestamp":1787160210000},"page":"e0354341","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Healthcare cost literacy in the united states: Cross-sectional estimates from a representative national sample"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3633-9124","authenticated-orcid":true,"given":"Alexandra","family":"Guttentag","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Smrithi","family":"Sukumar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeroen","family":"van Meijgaard","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khurram","family":"Nasir","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harlan","family":"Krumholz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haider J.","family":"Warraich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,8,19]]},"reference":[{"key":"pone.0354341.ref001","unstructured":"The burden of medical debt in the United States. Peterson-KFF Health System Tracker. https:\/\/www.healthsystemtracker.org\/brief\/the-burden-of-medical-debt-in-the-united-states\/. Accessed 2022 November 10."},{"key":"pone.0354341.ref002","unstructured":"Sparks G, Kirzinger A, Montero A, Valdes I, Published LH. Public Opinion on Prescription Drugs and Their Prices. KFF. https:\/\/www.kff.org\/other\/poll-finding\/public-opinion-on-prescription-drugs-and-their-prices\/. 2024. Accessed 2025 July 21."},{"issue":"2","key":"pone.0354341.ref003","doi-asserted-by":"crossref","first-page":"384","DOI":"10.2337\/diacare.27.2.384","article-title":"Problems paying out-of-pocket medication costs among older adults with diabetes","volume":"27","author":"JD Piette","year":"2004","journal-title":"Diabetes Care"},{"issue":"6","key":"pone.0354341.ref004","first-page":"553","article-title":"Unfilled prescriptions of medicare beneficiaries: prevalence, reasons, and types of medicines prescribed","volume":"14","author":"J Kennedy","year":"2008","journal-title":"J Manag Care Pharm"},{"key":"pone.0354341.ref005","unstructured":"Foster S. Survey: As coronavirus spreads, nearly 1 in 3 Americans admit to not seeking medical care due to cost. https:\/\/www.bankrate.com\/surveys\/health-care-costs\/. Accessed 2022 November 10."},{"key":"pone.0354341.ref006","unstructured":"Board of Governors of the Federal Reserve System. Report on the Economic Well-Being of U.S. Households in 2021 - May 2022. 2022. https:\/\/www.federalreserve.gov\/publications\/2022-economic-well-being-of-us-households-in-2021-executive-summary.htm"},{"key":"pone.0354341.ref007","unstructured":"Survey 2022. PatientRightsAdvocate.org. https:\/\/www.patientrightsadvocate.org\/survey-2022. Accessed 2025 July 21."},{"key":"pone.0354341.ref008","article-title":"Health literacy","volume":"2000","author":"S Ratzan","year":"2000","journal-title":"Natl Libr Med Curr Bibliogr Med"},{"key":"pone.0354341.ref009","unstructured":"Survey: Many Americans have trouble estimating the cost of their healthcare. GoodRx. https:\/\/www.goodrx.com\/healthcare-access\/research\/many-americans-have-trouble-estimating-cost-healthcare. Accessed 2025 July 21."},{"key":"pone.0354341.ref010","doi-asserted-by":"crossref","unstructured":"Wheeler C, Taylor R. New year, new CMS price transparency rule for hospitals. Health Aff Forefr. https:\/\/doi.org\/10.1377\/forefront.20210112.545531","DOI":"10.1377\/forefront.20210112.545531"},{"issue":"1","key":"pone.0354341.ref011","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1215\/03616878-9417470","article-title":"The No Surprises Act: A Bipartisan Achievement to Protect Consumers from Unexpected Medical Bills","volume":"47","author":"J Hoadley","year":"2022","journal-title":"J Health Polit Policy Law"},{"key":"pone.0354341.ref012","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1080\/10810730.2014.938841","article-title":"Health literacy, numeracy, and other characteristics associated with hospitalized patients\u2019 preferences for involvement in decision making","author":"KM Goggins","year":"2014","journal-title":"J Health Commun"},{"issue":"3","key":"pone.0354341.ref013","doi-asserted-by":"crossref","first-page":"499","DOI":"10.1016\/j.pec.2010.12.015","article-title":"Health literacy and decision making styles for complex antithrombotic therapy among older multimorbid adults","volume":"85","author":"AD Naik","year":"2011","journal-title":"Patient Educ Couns"},{"key":"pone.0354341.ref014","article-title":"Healthcare Cost Literacy: Exploration of Concept and Initial Development of a Novel Tool in a Representative U.S. Adult Population","author":"A Guttentag","year":"2023","journal-title":"medRxiv"},{"key":"pone.0354341.ref015","unstructured":"About our panel. https:\/\/today.yougov.com\/about\/panel. Accessed 2025 July 22."},{"key":"pone.0354341.ref016","unstructured":"Methodology. YouGov. https:\/\/today.yougov.com\/about\/panel-methodology. Accessed 2025 July 22."},{"issue":"1","key":"pone.0354341.ref017","doi-asserted-by":"crossref","first-page":"506","DOI":"10.1186\/s12913-018-3275-7","article-title":"Establishing the HLS-Q12 short version of the European Health Literacy Survey Questionnaire: latent trait analyses applying Rasch modelling and confirmatory factor analysis","volume":"18","author":"HS Finbr\u00e5ten","year":"2018","journal-title":"BMC Health Serv Res"},{"key":"pone.0354341.ref018","unstructured":"Ellis GF, Lumley T, \u017b\u00f3\u0142tak T, Schneider B, Krivitsky PN. srvyr:\u2019dplyr\u2019-like syntax for summary statistics of survey data. https:\/\/cran.r-project.org\/web\/packages\/srvyr\/index.html. 2024. Accessed 2025 July 23."},{"issue":"1","key":"pone.0354341.ref019","doi-asserted-by":"crossref","first-page":"75","DOI":"10.12799\/jkachn.2011.22.1.75","article-title":"Influencing Factors on Functional Health Literacy among the Rural Elderly","volume":"22","author":"JY Park","year":"2011","journal-title":"J Korean Acad Community Health Nurs"},{"issue":"3","key":"pone.0354341.ref020","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1080\/08858199209528176","article-title":"The use of illustrations and narrative text style to improve readability of a health education brochure","volume":"7","author":"R Michielutte","year":"1992","journal-title":"J Cancer Educ"},{"issue":"1","key":"pone.0354341.ref021","doi-asserted-by":"crossref","first-page":"2381468318760298","DOI":"10.1177\/2381468318760298","article-title":"Access Is Necessary but Not Sufficient: Factors Influencing Delay and Avoidance of Health Care Services","volume":"3","author":"KT Smith","year":"2018","journal-title":"MDM Policy Pract"},{"key":"pone.0354341.ref022","unstructured":"Surprise medical bills: New protections for consumers take effect in 2022. KFF. https:\/\/www.kff.org\/private-insurance\/fact-sheet\/surprise-medical-bills-new-protections-for-consumers-take-effect-in-2022\/. 2021. Accessed 2025 July 23."},{"issue":"2","key":"pone.0354341.ref023","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1055\/s-0041-1729168","article-title":"Survey of Hospital Chargemaster Transparency","volume":"12","author":"S Arvisais-Anhalt","year":"2021","journal-title":"Appl Clin Inform"},{"key":"pone.0354341.ref024","unstructured":"How New Hospital Transparency Regulations Fall Short. https:\/\/www.goodrx.com\/healthcare-access\/research\/has-hospital-price-transparency-rule-led-to-clarity-or-confusion-on-drug-costs. Accessed 2022 November 10."},{"issue":"3","key":"pone.0354341.ref025","doi-asserted-by":"crossref","first-page":"627","DOI":"10.1111\/j.1475-6773.2004.00248.x","article-title":"The lifetime distribution of health care costs","volume":"39","author":"B Alemayehu","year":"2004","journal-title":"Health Serv Res"},{"issue":"5","key":"pone.0354341.ref026","doi-asserted-by":"crossref","first-page":"901","DOI":"10.1093\/heapro\/dax015","article-title":"Improving health literacy in community populations: a review of progress","volume":"33","author":"D Nutbeam","year":"2018","journal-title":"Health Promot Int"},{"key":"pone.0354341.ref027","volume-title":"The health literacy of America\u2019s adults: Results from the 2003 national assessment of adult literacy","author":"M Kutner","year":"2006"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0354341","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T17:23:33Z","timestamp":1787160213000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0354341"}},"subtitle":[],"editor":[{"given":"Andrej M","family":"Kielbassa","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,8,19]]},"references-count":27,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8,19]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0354341","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,19]]}}}