Can moral framing drive insurance enrollment in the United States?

Abstract

To encourage health insurance uptake, marketers and policymakers have focused on consumers' economic self-interest, attempting to show that insurance is a good deal or to sweeten the deal, with subsidies or penalties. Still, some consumers see insurance as a bad deal, either because they rationally exploit private risk information (“adverse selection”), or irrationally misperceive the value due to cognitive biases (e.g., optimism). As a result, about 30 million Americans remain uninsured, including many who could afford it. At the same time, polling suggests that Americans view health insurance through a moral lens, seeking to protect those with pre-existing conditions especially. In other markets, “green halo” and “noble edge” frames have been shown effective. As part of a broader research agenda on private law solutions to healthcare policy, we test whether moral framing could support insurance uptake. We report four phases of research. First, to understand current health insurance marketing in America, we collected the universe of advertisements from the state and federal exchanges and coded a 10% sample for themes of economic self-interest versus three moral themes: helping others, helping community, or responsibility. In the 199 ads in which any theme appeared, 191 ads centered on economic self-interest. Second, we enrolled 344 uninsured Americans in an online, vignette experiment where we offered various insurance plans. Over a baseline where 43.6% were willing to purchase insurance, we found that framing an economically identical plan around generosity yielded an 11.8% higher uptake. Third, we conducted five focus groups with 32 adults, including two groups in Spanish. We explored variations in the frames and probed for resistance, to prepare for the next phase of research. Fourth, using an online advertising platform (Google), we purchased 5.6 million advertising impressions in English and Spanish, targeting higher-income Americans nationwide during the 2021 open-enrollment period. Consumers saw advertisements from a control group (highlighting economic self-interest, with real ads collected from the field) versus three experimental groups (helping others, helping community, or responsibility). We measured whether consumers clicked to “shop now” on the HealthCare.gov website (1.01% click-through rate [CTR] in English and 1.38% CTR in Spanish at baseline). Helping community ads increased CTR over the control by 14.5% in English and by 33.7% in Spanish. Ads emphasizing responsibility increased CTR by 30.3% in English, though reduced CTR by 14.7% in Spanish. Helping others ads increased CTR by 9.8% in English but decreased CTR by 13.9% in Spanish. All of these results were significant at the 0.01 level and were robust to demographic controls and subgroup analyses, using individual and county-level covariates. Although the optimal approach varies, the status quo self-oriented message of economic rationality was not the top-performing approach for either language group. Scaled up to real-world advertising budgets, back-of-the-envelope extrapolation suggests that under moral framing, millions of additional Americans could be driven to shop for health insurance.