Date of Award

January 2025

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Jennifer Hankenson

Abstract

Website accessibility is essential to ensure equitable healthcare access, especially for individuals with disabilities. This study evaluated the accessibility of health insurance websites for the ten largest Medicare Advantage insurers by market share. Using three free, publicly available automated accessibility checkers—WAVE, Axe-Core, and Skilltide—we systematically identified five URLs per insurer based on specific webpage keywords. These tools adhere to the Web Content Accessibility Guidelines (WCAG) Version 2.1 Level AA, the technical standard referenced in the most recent U.S. legislation.A total of 1,223 accessibility errors were identified across 50 webpages, with Skilltide detecting the most errors (588), followed by WAVE (502) and Axe-Core (133). 98% of webpages contained at least one error, and over half had 20 or more errors. A one-way ANOVA revealed a statistically significant difference in total errors by company (F (9, 40) = 8.71, p < 0.001), with Tukey’s HSD identifying significant differences between 16 company pairs. Highmark had the highest total errors (283), while Humana had the lowest (23). A two-way ANOVA evaluating the effects of webpage URL and tool type on error detection found a statistically significant effect of tool type (F (2,135) = 9.77, p < 0.001), but no significant effects of webpage type (F (4,135) = 0.75, p = 0.562) or tool performance across webpage URL type (F (8,135) = 0.24, p = 0.982). Analysis of WCAG categories showed that WAVE and Axe-Core mapped errors to multiple WCAG criteria 72 and 3 times, respectively. Most errors (75%) fell under Level A, the most basic accessibility standard, and 96% of webpage URLs contained at least one Level A error. Additionally, error counts varied by webpage type. The Website Accessibility page had the fewest average errors (mean = 8.7, SD = 12.7), while the Homepage had the most (mean = 15.3, SD = 16.3). This is concerning as many users may start their searches on Homepages. Despite new rulings under Title II, Subpart H of the Americans with Disabilities Act, these findings highlight persistent and variable gaps in website accessibility across major insurers. Achieving meaningful progress will likely require a multifaceted approach, integrating automated and manual testing and involving individuals with disabilities in the process of website creation and evaluation. Our results provide actionable insights for insurers, policymakers, and developers aimed to improve website accessibility and to promote equitable healthcare access for all persons, regardless of disability status.

Comments

This is an Open Access Thesis.

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