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.

中文翻译：

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道德框架可以推动美国的保险注册吗？

为了鼓励购买健康保险，营销人员和政策制定者将重点放在消费者的经济自身利益上，试图通过补贴或处罚来证明保险是一笔划算的交易，或者让交易变得更加甜蜜。尽管如此，一些消费者仍然认为保险是一笔糟糕的交易，要么是因为他们理性地利用私人风险信息（“逆向选择”），要么是因为认知偏差（例如，乐观主义）非理性地误解了价值。结果，大约 3000 万美国人仍然没有保险，其中包括许多负担得起的人。与此同时，民意调查显示，美国人通过道德视角看待健康保险，尤其是寻求保护那些已有疾病的人。在其他市场，“绿色光环”和“高贵边缘”镜框已被证明有效。作为关于医疗保健政策私法解决方案的更广泛研究议程的一部分，我们测试道德框架是否可以支持保险的吸收。我们报告了四个阶段的研究。首先，为了了解美国当前的健康保险营销，我们从州和联邦交易所收集了所有广告，并对经济自利主题和三个道德主题的 10% 样本进行了编码：帮助他人、帮助社区或责任。在出现任何主题的199个广告中，有191个广告以经济私利为中心。其次，我们招募了 344 名未投保的美国人参加在线小插曲实验，我们提供各种保险计划。在 43.6% 愿意购买保险的基线上，我们发现围绕慷慨制定经济上相同的计划会产生 11.8% 的高采纳率。第三，我们对 32 名成年人进行了五个焦点小组讨论，其中两个小组使用西班牙语。我们探索了框架的变化并探索了阻力，为下一阶段的研究做准备。第四，我们使用在线广告平台（谷歌）购买了 560 万英语和西班牙语的广告印象，目标是 2021 年公开招生期间全国范围内的高收入美国人。消费者看到的广告来自对照组（突出经济自身利益，使用从现场收集的真实广告）与三个实验组（帮助他人、帮助社区或责任）。我们测量了消费者是否在 HealthCare.gov 网站上点击“立即购物”（基准时英语点击率 [CTR] 为 1.01%，西班牙语点击率为 1.38%）。帮助社区广告将英语的点击率提高了 14.5%，西班牙语的点击率提高了 33.7%。强调责任感的广告将点击率提高了 30。英语的点击率降低了 3%，但西班牙语的点击率降低了 14.7%。帮助他人广告使英语的点击率提高了 9.8%，但西班牙语的点击率降低了 13.9%。所有这些结果在 0.01 水平上都很显着，并且对使用个人和县级协变量的人口控制和亚组分析具有稳健性。尽管最佳方法各不相同，但经济理性的现状自我导向信息是对于任何一个语言组来说都不是表现最好的方法。扩大到现实世界的广告预算，粗略推断表明，在道德框架下，数百万额外的美国人可能会被迫购买健康保险。