Can Consumers Make Affordable Care Affordable? The Value of Choice Architecture

Tens of millions of people are currently choosing health coverage on a state or federal health insurance exchange as part of the Patient Protection and Affordable Care Act. We examine how well people make these choices, how well they think they do, and what can be done to improve these choices. We conducted 6 experiments asking people to choose the most cost-effective policy using websites modeled on current exchanges. Our results suggest there is significant room for improvement. Without interventions, respondents perform at near chance levels and show a significant bias, overweighting out-of-pocket expenses and deductibles. Financial incentives do not improve performance, and decision-makers do not realize that they are performing poorly. However, performance can be improved quite markedly by providing calculation aids, and by choosing a “smart” default. Implementing these psychologically based principles could save purchasers of policies and taxpayers approximately 10 billion dollars every year.当前已有数千万民众通过州级或联邦级健康保险交易所（health insurance exchange）选择医保保障计划，此类医保选择均为《患者保护与平价医疗法案》（Patient Protection and Affordable Care Act）框架下的实施内容。我们考察了民众在这类决策中的实际表现、自我认知的决策准确度，以及可优化此类决策的可行路径。我们开展了6项实验：让受试者基于复刻当前交易所的官方网站界面，挑选性价比最优的医保保单。实验结果显示，当前民众的医保选择存在显著的优化空间。若无干预措施，受试者的决策表现仅略优于随机猜测水平，且存在显著偏差：过度重视自付费用与免赔额。经济激励并未改善决策表现，且决策者也未意识到自身决策质量不佳。但通过提供计算辅助工具、设定“智能”默认选项，可显著提升决策表现。落实这些基于心理学的决策原则，每年可为医保保单购买者与纳税人节省约100亿美元。