’Tis the season — open enrollment season, that is. Since before the Nov. 1 start to the annual open enrollment period, the advertising engines for state health insurance marketplaces, and the federal exchange, healthcare.gov, have been revving up. The nation’s uninsurance rate is down to 7.7% — the lowest it has ever been. While the celebrations of this success are merited, more than 25 million Americans are still uninsured.
The woes of the uninsured are well-documented. They are three times as likely to go without needed care due to cost and are more likely to suffer from the weight of high rates of medical debt. Mary Lou Retton, the gold-medal winning Olympic gymnast recently released from the hospital after fighting for her life in the ICU, doesn’t have health insurance. Her family had to crowdfund to raise money to pay for her care. But unlike Mary Lou Retton, most are not able to raise hundreds of thousands of dollars from admiring fans when illness strikes.
In the U.S., insurers and the government pitch buying insurance as a rational economic choice. They tell people that health insurance is affordable, and folks should get covered to protect themselves and their families. We know, because we reviewed a sample of marketplace ads from the past five years, and a whopping 96% of them were centered around themes of economic self-interest.
But for some, including many who are currently healthy, that narrative doesn’t ring true. One-fifth of uninsured adults report not needing or not wanting coverage. Younger adults in particular may perceive little value from being insured. Some may be wrong about that, unreasonably optimistic in their continuing good health. Mary Lou Retton may have been one such person.
But others may well be right in thinking that paying health insurance premiums is a bad deal for them. In order for insurance to cover people with pre-existing conditions and not charge them more than healthy people — Affordable Care Act protections that are widely popular across the political spectrum — healthy people end up subsidizing the cost of sicker ones. That is the whole point of insurance, to spread risk.
As health policy researchers, we wondered what would happen if we changed the script on why people (and particularly those who can afford it) should purchase health insurance. What if, instead of trying to appeal to economic self-interest, we appealed to Americans’ value commitments, talking about the moral reasons to buy health insurance? After all, Americans widely support the idea that sicker folks should be covered at the same rate as healthier ones.
Many Americans choose green products because they care about the environment. Could Americans buy health insurance because they care about each other? Or at least buy health insurance so they do not unfairly exploit others or need to rely on charity when they get sick?
In a series of experiments, we tested whether uninsured Americans would be more likely to enroll in a policy if we explained that doing so was actually a way to help others, help their community, or a matter of individual responsibility.
The results were surprising. In one experiment, we purchased 5.6 million advertising impressions on Google during the 2021 open-enrollment period. We found ads that used a “helping community” frame were more popular than traditional ads focusing on cost-effectiveness. This was true across the political spectrum of voters, in Democratic strongholds as well as in Republican counties. We also found that, particularly among English speakers, ads emphasizing individual responsibility — another moral theme — were clicked on 30% more often than the economic-oriented ads. This experiment suggests that switching to moral frames could drive millions of Americans to begin shopping for insurance.
In a follow-up experiment, we sent postcards and emails to over 16,000 uninsured individuals, but we varied the messages that individuals received. We then tracked to see which messages resulted in the highest enrollment rates. We found that any outreach substantially improved enrollment, suggesting that exchanges may not be doing enough. As with the online experiment, we found that individual responsibility and community messages were the most effective (an 18.5% change over no outreach), in prompting people to enroll in an insurance policy. Extrapolating our results to the larger uninsured population, using moral messaging could result in 250,000 more families becoming insured.
Even those who are already insured have a stake in the uninsurance problem. Public funding offsets providers’ uncompensated care costs for the uninsured, so the higher the uninsured rate, the more of your tax dollars are going to providers to pay for the uninsured when they get care they can’t pay for. The more people who get insured, the lower the premium rates for everyone.
Maybe it is time for those who market health insurance to just be honest. Not everyone should buy insurance because it is a good deal. If you are younger and healthier, you might be subsidizing the cost of health insurance for someone who is older and sicker. But maybe, in appealing to our morals rather than just our pocketbooks, more folks will get covered anyway.
Wendy Netter Epstein is professor of law and associate dean of research at the DePaul University College of Law. She is also co-faculty director of the Mary and Michael Jaharis Health Law Institute at DePaul. Christopher Robertson is professor of law and associate dean for strategic initiatives at the Boston University School of Law, professor of health law, policy and management in the Boston University School of Public Health, and author of the book “Exposed: Why Our Health Insurance is Incomplete and What Can be Done About It.”