Stranded at the Edge: Why Healthcare Hasn’t Crossed the Quality Chasm

The Focus on Access

In 2013, about 270 million Americans—roughly 85.5% of the population—had health insurance through public or private plans. That left approximately 46 million people without coverage. By 2016, following the implementation of the Affordable Care Act (ACA), the number of insured Americans rose to nearly 289 million (91.4%), reducing the uninsured population to about 27 million. Fast forward to 2023, and over 40 million people had enrolled in ACA-related insurance plans¹.

On paper, this looks like progress. But access to care is only part of the equation.

The average American struggles to understand and apply basic health information. According to the Milken Institute, nearly 9 out of 10 adults in the U.S. have limited health literacy². Health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others³. That means millions of people, regardless of insured status, lack the ability to interpret prescription labels, follow discharge instructions, or make informed decisions about their treatment options. The Kaiser Family Foundation (KFF) echoes this concern, showing that even insured individuals with high general literacy levels often lack the tools to navigate the healthcare system effectively⁴.

This disconnect undermines the very principles of patient-centered care outlined in the Institute of Medicine’s Crossing the Quality Chasm⁵:

• Patients as the source of control: Individuals should be empowered with information to make decisions about their care.

• Shared knowledge and free flow of information: Clinicians and patients must communicate effectively and transparently.

• The need for transparency: Patients deserve access to performance data that informs their choices.

But these ideals cannot be realized if the information provided is inaccessible by being buried in jargon, written at a college reading level, or delivered without context.

The SMOG Solution: Making Information Usable

To bridge this gap, we must treat health literacy not as a side issue, but as a core design principle. One practical tool is the SMOG Index, short for Simple Measure of Gobbledygook. Developed by G. Harry McLaughlin in 1969, SMOG estimates the years of education a person needs to fully understand a piece of writing. Unlike other readability formulas that aim for partial understanding (typically 50–75%), SMOG sets a higher bar: it predicts the education level needed for 100% comprehension.

This distinction is critical in healthcare, where misunderstanding can lead to medication errors, missed follow-ups, or poor outcomes. SMOG’s emphasis on complete understanding makes it especially suitable for materials like consent forms, discharge instructions, and public health advisories—documents where clarity is essential.

McLaughlin’s background as both a clinical psychologist and a journalist shaped the formula’s development. His dual expertise in communication and human behavior led to a tool that was scientifically valid yet remarkably simple to use. The name “SMOG” was chosen as a nod to Robert Gunning’s FOG Index and McLaughlin’s London roots—an ironic twist for a formula designed to cut through the haze of confusing language.

When SMOG was first published in the Journal of Reading, its simplicity raised eyebrows. One statistician reportedly thought it was a joke. But validation studies, especially in healthcare, have proven its reliability. A 2010 study in the Journal of the Royal College of Physicians of Edinburgh established SMOG as the preferred readability measure for evaluating healthcare materials, citing its superior accuracy compared to other formulas⁶.

SMOG focuses on polysyllabic words (three or more syllables) and uses a straightforward formula to calculate the reading level. The result is a consistent, evidence-based estimate of how accessible a text is to the average reader. And unlike more opaque metrics, SMOG is transparent and easy to apply, making it a practical tool for clinicians, educators, and health communicators alike.

From Theory to Practice: SMOG in Action

Today, SMOG is widely used across healthcare institutions to ensure that patient education materials are truly accessible. Whether it’s a pamphlet on managing diabetes or a webpage explaining insurance benefits, SMOG helps writers and reviewers tailor content to the audience’s actual health literacy level.

This matters because health information isn’t just about facts. It’s about function. If a patient can’t understand how to take their medication or when to follow up, the information fails its purpose. If a consent form is written at a postgraduate level, it alienates instead of empowers. And if public health messaging is too complex, it risks being ignored altogether.

By applying SMOG, organizations can move beyond the illusion of access and toward true usability. It’s a way to honor the intelligence and dignity of every patient, regardless of their educational background. It’s also a practical step toward fulfilling the edict of Crossing the Quality Chasm: to make the patient the source of control, to foster shared decision-making, and to ensure transparency that’s available and understandable.

Conclusion: Access Must Be Comprehensible to Be Meaningful

Coverage statistics may signal progress, but they don’t tell the whole story. True access means more than enrollment in coverage. It means engagement. It means recognizing that health literacy is the bridge between policy and patient outcomes. And it means committing to communication strategies that honor the diversity, complexity, and humanity of every patient.

The SMOG Index is a reminder that clarity is a form of care. In a system striving to be patient-centered, that clarity is not optional. It’s foundational.

Sources

KFF Health Insurance Status. Data Source:  US Census Bureau, https://www.census.gov/data/developers/data-sets/acs-1year.html 2023.

Lopez, Claude, Bumyang Kim, and Katherine Sacks. "Health literacy in the United States: Enhancing assessments and reducing disparities." Available at SSRN 4182046 (2022). https://milkeninstitute.org/sites/default/files/2022-05/Health_Literacy_United_States_Final_Report.pdf

Center for Disease Control, HHS. Health Literacy in Healthy People 2030. https://odphp.health.gov/healthypeople/priority-areas/health-literacy-healthy-people-2030

Pestaina, K., Long, M., Salaga, M., & Wallace, R. (2025, March 3). Health Insurance Complexities and Consumer Protections | KFF. KFF. https://www.kff.org/private-insurance/navigating-the-maze-a-look-at-health-insurance-complexities-and-consumer-protections/  

Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: a new health system for the 21st century. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK222274/pdf/Bookshelf_NBK222274.pdf#page=20.00

Fitzsimmons PR, Michael BD, Hulley JL, Scott GO. A readability assessment of online Parkinson's disease information. J R Coll Physicians Edinb. 2010 Dec;40(4):292-6. doi: 10.4997/JRCPE.2010.401. PMID: 21132132. https://pubmed.ncbi.nlm.nih.gov/21132132/

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