Joachim Winter

Background. The Medicare Part D program provides stand-alone prescription drug insurance to US residents aged ≥65 y and those with disabilities. Annually, they can choose to stay with their plan or to switch to one of the many alternative plans. Behavioral decision-making research has proposed various strategies for tackling such complex choices. Here, we interviewed Medicare Part D beneficiaries to understand their real-world experiences with making their plan choices and examined quotes from those who stayed with their first plan and those who had switched. Method. In July 2023, we conducted phone interviews with 20 Medicare Part D beneficiaries aged 57 to 86 y who were recruited through the US-wide Understanding America Study. Results. Eleven interviewees had stayed with their first plan, and 9 had switched. Stayers and switchers applied similar strategies, with mixed success. Using decision-support tools such as the Medicare plan-finder Web site, booklet, and mailers could be time-consuming and confusing. Recommendations were taken from insurance brokers, agents, and pharmacists, often without questioning their advice. Interviewees varied widely in the amount of information they considered, with some using heuristics to reduce their choice set and others considering only 1 recommended option. Few beneficiaries made annual plan comparisons, and while some deferred choices until necessary, others did not act even after being confronted with plan changes or negative experiences – due to knowledge and time constraints. Discussion. Medicare beneficiaries use various strategies known from the behavioral decision-making research literature for tackling complex choices between Medicare Part D stand-alone plans. Each strategy posed its own challenges. We discuss our findings in light of the behavioral decision-making literature and recommend policies for helping beneficiaries with their plan choices. Highlights: We interviewed Medicare Part D beneficiaries about how they tackled drug insurance plan choices with many options and complicated features. Interviewees reported using decision-support tools, seeking help, applying heuristics, and relying on choice deferral, but with mixed success. Qualitatively, similar experiences were described by interviewees who stayed with their initial plan and those who had switched. We recommend policies for addressing the difficulties beneficiaries had in applying these strategies.

In the United States, individuals with disabilities and those aged ≥65 can supplement their Medicare with so-called stand-alone Medicare Part D prescription drug plans. Beneficiaries can switch their stand-alone prescription drug plans annually, but most do not. Indirect evidence has raised concerns that non-switchers do not even make plan comparisons (labeled “inattention”), but direct evidence is scarce. Therefore, we surveyed 439 beneficiaries of Medicare Part D plans from a nationally representative adult sample after the 2024 open-enrollment period. Overall, 53% self-reported making no comparisons. Of those who did not compare, 98% did not switch (vs 67% of those who did compare). Multinomial regressions revealed that beneficiaries who neither compared nor switched were more likely than switchers to report difficulties with comparing and switching, experiencing no plan-related discontinuation, changes, or dissatisfaction, not using advisors or the plan-finder website, and receiving potentially confusing mailings. Non-switchers who did compare were similar to switchers in reporting few difficulties and relying on advisors and the plan-finder website, but they were less likely than switchers to report plan-related changes, discontinuation, or dissatisfaction, while being more likely to report receiving mailings and having no college degree. We discuss insights for policy-making.

Significance: From 1990 to 2018, the Black–White American life expectancy gap fell 48.9% and mortality inequality decreased, although progress stalled after 2012 as life expectancy plateaued. Had improvements continued at the 1990 to 2012 rate, the racial gap in life expectancy would have closed by 2036. Despite decreasing mortality inequality, income-based life expectancy gaps remain starker in the United States than in European countries. At the same time, European mortality improved strongly and even those U.S. populations with the longest life spans–White Americans living in the highest-income areas–experience higher mortality at all ages than Europeans in high-income areas in 2018. Hence, mortality rates of both Black and White Americans could fall much further in both high-income and low-income areas.

Risk attitudes influence decisions made under uncertainty. This paper investigates the association of risk attitudes with the utilization of preventive and general healthcare services, work absence and resulting costs to explore their contribution to the heterogeneity in utilization. Data of 1823 individuals (56.5 ± 9.5 years), participating in the German KORA FF4 population-based cohort study (2013/2014) were analyzed. Individuals’ general and health risk attitude were measured as willingness to take risk (WTTR) on 11-point scales. Utilization of preventive and medical services and work absence was assessed and annual costs were calculated from a societal perspective. Generalized linear models with log-link function (logistic, negative-binomial and gamma regression) adjusted for age, sex, and height were used to analyze the association of WTTR with the utilizations and costs. Higher WTTR was significantly associated with lower healthcare utilization (physician visits, physical therapy, and medication intake), work absence days and indirect costs. Regarding preventive services, an overall negative correlation between WTTR and utilization was examined but this observation remained non-significant except for the outcome medical check-up. Here, higher WTTR was significantly associated with a lower probability of participation. For all associations mentioned, Odds Ratios ranged between 0.90 and 0.79, with p < 0.05. Comparing the two risk attitudes (general and regarding health) we obtained similar results regarding the directions of associations. We conclude that variations in risk attitudes contribute to the heterogeneity of healthcare utilization. Thus, knowledge of their associations with utilization might help to better understand individual decision-making – especially in case of participation in preventive services.

We study the impact of financial education on intertemporal choice in adolescence. The educational program was randomly assigned among high school students, and choices were measured using an incentivized experiment. Students who participated in the program make more time-consistent choices; are more likely to allocate payments to a single payment date, as opposed to spreading payment across two dates; and display increased consistency of choice with the law of demand. These findings suggest that financial education increases the quality of intertemporal decision-making and decreases narrow bracketing. (JEL C93, D14, D15, I21, J13)