One source of the cognitive dissonance we feel these days comes from the near-constant demands for individual freedom juxtaposed with the equally pervasive evidence of deep craving for community. Voices from inside and outside the reactionary right invoke autonomy against masking, personal choice in vaccination, and the right to fend off others with guns. This exhausted political rhetoric of liberty disavows any obligations toward one another and threatens bitter backlash against any pro-social claim. This is the discourse we hear, the words on the surface. However, when we look at people’s revealed preferences, we see a different picture. And that is exactly what Wendy Epstein, Christopher Robertson, and their coauthors in their new article, Can Moral Framing Drive Insurance Enrollment in the United States, call us to attend to in health insurance markets. Instead of defaulting to the assumption that we must speak to our selfish fallen selves, we may do better to assume each others’ better generous selves when it comes to, of all things, advertising insurance.
Indeed as the anxieties of this atomized, isolated, every-tub-on-its-own-bottom mentality yawn before us, I find it curious that we don’t see Americans scattering to the winds, toward various individual, idiosyncratic courses of action. If anything, we are all gravitating toward our tribes—ever more polarized communities to be sure, but communities nonetheless. I’m reminded of an earlier quote about the Trump political phenomenon: “It’s Möbius strip politics, Trumpism’s defining oxymoron: a populist elite, a mass movement of “free thinkers” all thinking the same thing.”
The push-pull cognitive dissonance between self and other has everything to do with health policy. The market for health insurance, characterized by collective action dynamics, information asymmetries, externalities, and the problem of public goods, is canonically ill-suited for examination from an individual preference-maximization lens without regard for social solidarity. Health law scholars know all-too-well the adverse selection problems that plague the health insurance market. These dynamics render medical care increasingly unaffordable for those who have preexisting or other health needs as low-risk individuals like the “Young Invincibles” overwhelmingly opt out of buying insurance. For health insurance to be offered at a moderate pooling price depends on getting a balanced population of insureds to enroll in health care. Thus, for health insurance perhaps more than for any other product, any given person’s decision to purchase both affects and is affected by others; the purchase of health insurance is an ineluctably social act.
And yet, as Wendy Epstein, Christopher Robertson and their co-authors show, our practical messaging to get people insured draws overwhelmingly from the surface rhetoric of individual economic rationality. These authors have undertaken an ambitious Robert Wood Johnson-funded project on what drives insurance enrollment in the U.S., and their findings thus far warn against falling for the surface rhetoric without attention to the undertow pulling in the opposite direction, expressing our strong underlying desires to participate in a broader community with ties to others.
Epstein and Robertson have already completed four phases of the project and I eagerly await their findings from the fifth.
In the first phase, they reviewed a large sample of existing advertising for health insurance only to find that it is now sold overwhelmingly using an economic rationality frame with appeals to the affordability of coverage.
In the second phase, they presented online survey takers with hypothetical vignette conditions, and asked their likelihood of enrolling in health insurance. They found that when survey respondents were approached with a “generosity” frame, emphasizing the benefits of buying health insurance not just for the individuals themselves, but for its availability to others, the respondents were nearly 12 percent more likely to say they would enroll! This boost in enrollment propensity exceeded even that achieved if respondents were told they would get $500 more in premium subsidy.
I found the generosity condition quite cleverly and appealingly worded. Respondents were told that “for every healthy person who purchases a policy, the insurer will offer a health plan to an individual with a preexisting condition for the same price.” They also explained that “buying a policy not only insures you against future risk…you would [also] be funding health insurance coverage for a sicker person.”
In the third phase, Epstein and Robertson explored these leads in a more granular way through focus groups, finding receptiveness amongst participants when presented with the concept that “to make insurance affordable for sick people, healthy people need to buy it too.”
In their most recent phase, the authors further implemented these ideas through a field marketing experiment. The authors bought $34,000 worth of Google ads that would randomly show one of four different types of health insurance advertisements. Only one type appealed to the self-oriented frame. The three other ad types emphasized helping others, helping community, and the responsibility to ensure that your costs when you fall sick do not burden others. They could then measure which ad type prompted more click-throughs to “Shop Now” at healthcare.gov. Lo and behold, the messages that appealed to the three other-directed frames got more click-throughs than the self-oriented messages did. Their data yields noteworthy nuggets. For instance appeals to “helping community” somewhat outperformed generic appeals to “helping others” among Spanish-speakers, an especially crucial population to reach for increased health insurance uptake.
And while this stage could only measure click-throughs without access to the numbers of who actually purchased health insurance after shopping, the fifth phase of that project is geared to supply that answer. The research team is set to run an experiment in partnership with a number of state ACA marketplaces, including Colorado’s and Maryland’s, where they deploy the experimental “helping others” and “helping community” messages to see whether they can boost ACA coverage in these states.
I can’t do this sweeping project justice in just the space here, so I encourage you to read it yourself. The findings suggest a glimpse into a hopeful truth about people’s subjectivities, even in our forsaken times. As one of the subjects of Arlie Russell Hochschild’s Strangers in Their Own Land laments, “Is it just me or does it seem like the only thing ANYONE cares about is themselves and their immediate circumstances?” It turns out the answer is no: what may motivate people even more is a sense of belonging, and a connection to the flourishing of others.
