How emotions affect health care coverage decisions

We both lost our jobs as public health diplomats with the U.S. Agency for International Development last summer. Our termination from federal service also meant that both of us lost our health insurance coverage. The complex process of finding coverage outside of employer-provided plans was chaotic, distressing, and illuminating of our cognitive biases. And these challenges compounded the already painful experience of an unexpected loss of both a job and professional identity.
Lamentably, over the coming months and years, our individual experiences are set to replicate themselves on a national scale.
Advertisement
The government spending bill passed days after we were laid off will make significant cuts to federal funds supporting Medicaid and subsidizing the Affordable Care Act marketplace. Paired with premium tax credits set to expire at the end of this year, the cumulative impact will cause an estimated 17 million Americans to lose their health insurance coverage in the coming decade. This constitutes the single largest cut to federal health benefits in U.S. history.
Losing access to affordable health coverage, of course, comes with negative health consequences. But Americans face another, more insidious problem, too: People will find themselves navigating an increasingly complex insurance landscape. Health insurance companies are notorious for designing plans that are intentionally obscure even for those with high levels of health literacy. The lack of transparency around pricing and the inherent uncertainty around future health needs make rational approaches to these questions largely ineffective. Where logic and reason fail us, emotion takes over.
For the two of us, our first instinct was to seek information on Continuation of Health Coverage (COBRA) costs and benefits. This information never arrived in the mail as it should have, and customer service representatives at our health insurance plans were bewildered to find that the federal government’s Office of Personnel Management had not uploaded this information into their systems. Our anger at the dysfunction and inaccessibility of continued coverage quickly turned to anxiety as we each sought coverage through the ACA marketplace, waited for a spouse’s insurance to begin on Sept. 1, experienced gaps in coverage, and altered life plans out of fear of potential uncovered health expenses.
Advertisement
Reflecting on our experience brought us to lessons from behavioral science. We explored the cognitive biases that clouded our thinking despite our professional backgrounds in medicine, health economics, and public health.
But we soon realized that there was more to learn from affective science, which is the study of emotions, mood, and feelings. Uncertainty about the extent of coverage benefits, bureaucracy in claims processing, and friction induced throughout the experience led to fear, anxiety, and avoidance. These emotions in turn influenced our health beliefs, decision-making, and ultimately, outcomes.
Staying healthy while navigating health coverage instability will challenge the millions of Americans who will go through similar experiences in the coming months and years. Managing emotions will be a key factor of success.
Past efforts to increase health insurance coverage provide a window into what we’re up against. During an expansion of Medicaid access in Oregon in 2008, researchers were able to compare outcomes between those enrolling and those who did not participate. Enrollees in what became known as Oregon’s health insurance experiment had lower out-of-pocket medical expenditures, lower levels of medical debt, and better self-reported health than those who were not enrolled. Adults without health insurance were less likely to access care, often delaying or forgoing necessary care because of cost. This matches our lived experience: When we had coverage, we sought care more regularly and paid less for the care we received.
Everyone who relies on the U.S. health care system has experienced fear of a poor health outcome, anxiety around an unknown health care bill, and general frustration. These emotions are deeply amplified by gaps in insurance coverage and subsequent untreated or undertreated illness. We each had our own experience with these coverage gaps, and since the U.S. system leans heavily on employers to provide health insurance, we faced them at the same time we were processing the emotions around our unexpected job losses.
Advertisement
As millions lose their Medicaid or subsidized health coverage over the coming years, they will need to weigh the cost of insurance available on the market against their personal risk tolerance, perceived benefits, and ongoing health needs. In the absence of perfect knowledge of the future, this process is heavily skewed by cognitive biases and emotional responses. A lesson from behavioral science highlights our collective tendency towards a “present bias:” immediate costs are overemphasized, while future potential benefits are undervalued (“hyperbolic” time discounting). From affective science, the “affect heuristic” describes how emotional impressions like anxiety, fear, and avoidance override the ability to evaluate opaque statistical or actuarial models.
We each saw these cognitive biases and emotional drivers in action in our own experiences. True to form from the affect heuristic, our fear of choosing a bad insurance plan led to delays in enrollment, despite the reality that some coverage is better protection than no coverage. Our desire to pay a lower premium now will likely result in higher overall costs when seeking health care in the future, a classic example of a present bias and hyperbolic time discounting.
While it is easy to imagine examples of negative emotions influencing health decision-making (fear, anger, avoidance, etc.), positive emotions can drive healthy behaviors with equal force. When people experience relief after learning a mole was caught early and can be easily removed, they are motivated to keep up with annual dermatology appointments. When someone feels joy chasing after their grandchildren, they will focus more on healthy living and preventive healthcare utilization. Belonging can be a powerful health motivator for both positive and negative health outcomes, as revealed by Covid-19 vaccine uptake: Family decision-makers’ hesitation to vaccinate children influenced other family members’ hesitation, and health behaviors including vaccination status spread through social groups.
Advertisement
Lessons from behavioral and emotional science for health policymakers are relatively simple and extend beyond congressional efforts to extend premium tax credits before they expire this year. Reduce complexity of coverage options, expand subsidies, and minimize obstacles to enrollment like work requirements. The result will be a healthier population and lower medical debt. Insurance navigators can support individuals with low levels of health or financial literacy to access Medicaid or subsidized coverage.
There is also an opportunity to integrate training in emotional science into medical education for physicians, advanced practice providers, and nurses. Health care providers who understand the emotional underpinnings of health decision-making are better positioned to foster patient trust, improve adherence to treatment plans, and achieve better health outcomes. This educational approach also reinforces the role of community health workers who can serve as health system liaisons, assisting in the physical and emotional navigation of health for their own communities.
Recognizing how biases and emotions influence our decisions is an essential skill for all of us navigating the impending changes in the health insurance landscape. By understanding and anticipating how both positive and negative emotions shape our choices, we can approach health decisions with greater awareness and confidence. This means acknowledging our emotional experience without being caught up by the affect heuristic or hyperbolic time discounting.
For the two of us, identifying our own hesitations and fears helped focus our energy on getting cost clarity, recognizing cognitive biases, and ultimately seeking needed care. Over recent weeks, we each found new health care plans that provide adequate coverage, marking a resolution to an emotionally fraught process. We will be wishing similar resolutions for the 17 million Americans expected to confront this ordeal over the next decade.
Amit Chandra is an emergency physician and global health policy specialist. As a public health diplomat at USAID from 2019-2025, he supported the integration of behavioral science into urban resilience, pandemic response, and digital health programming. Alison Hoover is a former federal worker, sociobehavioral researcher, and global health technical specialist.