Medicare Part D Beneficiaries’ Experiences with Making Complex Insurance Plan Choices: A Qualitative Interview Study

Abstract

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.

Keywords

Real-world decisions choice complexity choice overload aging decision maker older adults

Introduction

Background

Since 2006, the “Medicare Part D” program has provided government-subsidized prescription drug insurance to US residents aged ≥65 y and those with disabilities.¹ Prescription drugs can be covered by adding a stand-alone Medicare Part D plan to traditional Medicare or by taking a Medicare Advantage plan that combines different types of health insurance.¹ In 2023, 22 million of the 65 million Medicare beneficiaries had a stand-alone Medicare Part D plan.¹

Concern about Choice Complexity

Every year, Medicare Part D beneficiaries have the option to stay with their current plan or switch to one of the many other available plans.² For their 2023 prescription drug coverage, the average beneficiary was offered 24 stand-alone prescription drug plans through private insurers who are contracted with the federal government.³ This large number marks a decline from the average of 56 stand-alone prescription drug plans in 2007, the first year beneficiaries could switch plans.⁴ The decline in offered plans partly reflects 2010 regulations that discouraged duplicative plans and plans with low enrollment, resulting in insurers’ plan cancelations and consolidations.⁴ The average number of options further decreased in subsequent years, to 21 in 2024, and 14 in 2025.⁵

The available plans tend to vary along various features, including premiums, deductibles, co-pays, drugs that are covered, and included pharmacies.³ Detailed information about all available plans is provided in the Medicare Part D booklet, which is more than 100 pages long.⁶ Beneficiaries can also examine available plans through the Medicare plan-finder Web site, after users type in their ZIP code, the prescription drugs they use, and the local pharmacies they frequent.⁷

Economic theory posits that giving beneficiaries many different options should allow them to choose the financially optimal prescription drug plan for them, and the resulting market competition should drive insurers to limit administrative costs and profits.⁷ The financially optimal plan is typically defined as the plan with the lowest overall cost to the beneficiary, assuming that the beneficiary’s prescription drug use and their location will remain unchanged, while considering plan premiums, deductibles, co-pays, and other plan features.^8–13 The financially optimal plan may vary from year to year due to plan changes made by insurers, as well as changes in beneficiaries’ health, location, and other aspects of their situation.⁸

Early analyses of administrative Medicare Part D data showed that less than 25% of beneficiaries were enrolled in their financially optimal plan during 2006 to 2009.⁸ Beneficiaries paid on average $1,000 more than they would have in their financially optimal plan over 2007 to 2009, costing the government $1.3 billion over that same period.⁹ Being enrolled in an overly costly plan can have negative health consequences, because beneficiaries may reduce their medication use to lower their prescription drug costs.¹⁴

The administrative data from 2007 to 2009 also suggested that most beneficiaries tend to stay with their initial stand-alone Medicare Part D plan over the years.⁸ Those who stay in the same plan from year to year are less likely to be in their financially optimal plan, as compared with beneficiaries who do switch (henceforth “stayers” and “switchers”).⁸ Indeed, beneficiaries become more likely to switch as they can gain more from doing so,^9,15,16 such as when insurers drastically increase their plan costs or reduce prescription drug coverage. Nevertheless, the 2007 to 2009 administrative data showed that a majority of both stayers and switchers may not be enrolled in their financially optimal plan, suggesting that both groups may experience challenges with the complexity of their plan choices.⁸

Insights from Behavioral Decision-Making Research about Tackling Complex Choices

“Bounded rationality” refers to the idea that people make choices with limited knowledge, cognitive capacity, and available time.^17,18 As a result of these constraints, choices with many options and complicated features may be too complex for specific individual decision makers.^17,18 Especially older adults and individuals with disabilities may experience such limitations when faced with complex choices, due to cognitive decline or increased preference for spending their time in ways they find more meaningful.¹⁹

Behavioral decision-making research has found that decision makers apply various decision strategies to tackle choices with many complex options (Table 1). Decision makers who feel that a specific task is too difficult for them may seek out decision-support tools or advice.^20,21 It is also possible to apply simple heuristics that reduce the need to look at all of the presented features of all of the available options.^22,23 If the number of options is larger than two, decision makers become more likely to eliminate options from their choice set by prioritizing specific features.²⁴ In addition, choice deferral is a common response to choices that feel complex or time-consuming due to a large number of options or administrative burden (“sludge”).^25–27 Indeed, a meta-analysis of behavioral decision-making research has suggested that people may stick with their initial option when choices are complicated by a large number of options and attributes, especially when they feel uncertain or unmotivated.²⁸

Table 1

Examples of Choice Strategies in the Face of Limited Knowledge, Cognitive Capacity, and Time

Strategy	Definition in context of Medicare Part D
Decision support	Get help from a decision-support tool such as the Medicare plan-finder Web site
Advice seeking	Get help from a trusted expert
Heuristics	Consider only a limited number of plans
Choice deferral	Stay in current plan until action is needed due to plan changes or negative experiences

In line with strategies that have been identified in the behavioral decision-making research literature (Table 1), a 2021 survey of Medicare Part D beneficiaries suggested that they used decision-support tools such as the Medicare booklet (54%) and the Medicare plan-finder Web site (42%).² In addition, a 2023 survey found that especially switchers tend to report help from advisors as well as family and friends.²⁹ A survey from 2014 found suggestive evidence of the use of simplifying heuristics, with about 60% of switchers and 80% of stayers indicating that they had not fully processed the alternative options.³⁰ Administrative data analyses from 2011 additionally suggested that beneficiaries may be applying heuristics that prioritize plans with low premiums.¹¹

Moreover, the 2021 and 2023 surveys found that more than half of beneficiaries made no plan comparisons at all and ended up staying enrolled in their current plan by default.^2,29 Thus, while some beneficiaries may not switch plans because they are postponing plan choices until necessary, others may not switch plans because of difficulties with making plan choices.²⁹ Indeed, the 2023 survey reported that stayers who did not make plan comparisons were more likely than stayers who did make plan comparisons to report not knowing how to go about making a switch, in addition to not using the plan-finder Web site and not having help.²⁹ A 2022 survey also found expressions of frustration, confusion, uncertainty, and feeling overwhelmed, in response to an open-ended question asking Medicare beneficiaries if there is anything “you would like to share about your experiences selecting a Medicare Part D insurance plan.”³¹

The Need for Current Qualitative Research

While administrative data and surveys can give an indication of the prevalence with which beneficiaries may be using various choice strategies, these methods provide limited insights about people’s experiences with applying those strategies. The finding that many stayers and switchers are not in their financially optimal plan suggests that both may potentially be facing challenges when making their choices. Qualitative research may be more suitable for obtaining an in-depth understanding of people’s real-world experiences.³²

In qualitative interviews conducted before the first open enrollment period for 2007, beneficiaries explained that they perceived switching as a tedious process that they may not be able to navigate successfully; therefore, they wanted fewer options, better decision-support tools, and access to reliable unbiased advisors.³³ Focus groups with stayers conducted in 2014 suggested large variation in their information processing, with some limiting their choice set by focusing only on plans from one provider, while others made no plan comparisons at all.³⁰ Focus groups from 2017 found that Medicare Part D beneficiaries found plan selection confusing due to too many options, preferred to defer switching until facing plan discontinuations, and wanted access to advisors and simplified decision-support tools.³⁴

While insightful, these qualitative research studies were mostly focused on beneficiaries who stayed with their plans rather than on switchers. Moreover, they highlighted challenges these stayers had more than a decade ago, before the implementation of various Medicare Part D reforms, the reduction of the number of plans, and an update of the Medicare Part D plan-finder Web site.^35,36

The Current Study

Here, we report on interviews conducted in 2023, in which we aimed to obtain a more in-depth understanding of beneficiaries’ experiences with making their Medicare Part D choices. Because the literature on Medicare Part D choices distinguishes between beneficiaries who have stayed with their initial plan and those who have switched,^8,29,30 we present findings from “stayers” and “switchers.” We subsequently discuss them in light of the behavioral decision-making literature (Table 1) and recommend policies to help beneficiaries with simplifying plan choices.

Method

Sample

Our sample consisted of 20 interviewees who were members of the nationally representative Understanding America Study.³⁷ This sample size is typically sufficient for qualitative interviews, because no new topics tend to arise after 15 to 20 interviews.³⁸ Indeed, all reported topics were uncovered by the 10th interview, thus reaching saturation. Members of the Understanding America Study were originally recruited through random address-based sampling while adjusting sampling probabilities to include underrepresented groups.

The median age of the interviewees was 73 y (range 57–86 y), with 13 identifying as women and 10 having at least a bachelor’s degree. They had been Medicare beneficiaries for a median of 8 y (range 1–20 y) and had held their current stand-alone Medicare Part D plan for a median of 3.5 y (range 1–20 y).

Procedure

Interviews were conducted as part of the Understanding America Study panel. Panel members regularly complete online surveys about household finances, well-being, and related topics.³⁷ To facilitate participation in those online surveys, members of the Understanding America Study receive internet access and a tablet as needed. A total of 570 interviewees who had previously indicated having a stand-alone Medicare Part D plan received an e-mail invitation stating, “We want to interview you for our research about people’s experiences with their stand-alone Medicare Part D prescription drug plans.” Our 20 interview slots were filled on a first-come, first-served basis.

Interviews were conducted by phone in July 2023. The interviewer was Lila Rabinovich, a qualitative research expert at the Understanding America Study experienced in conducting interviews about financial decision making. Here, we report on the strategies beneficiaries described when being asked about their experiences with choosing their current plan as well as reasons for (not) switching (Table 2). Interviews lasted about 45 min. Interviewees received $50.

Table 2

Sample Interview Questions

• How long have you had your current stand-alone Medicare Part D prescription drug plan?

• How did you end up selecting your current stand-alone Medicare Part D prescription drug plan?

• How is your current stand-alone Medicare Part D prescription drug plan working for you?

• Have you ever switched your stand-alone Medicare Part D prescription drug plan? Why (not)?

Coding and Analysis

Each interview was audio-recorded and transcribed. We applied thematic analysis, categorizing interview content through an inductive coding procedure. Specifically, the first 3 authors read through the transcripts to design a coding scheme (Supplementary Table S1). The topics raised by each interviewee, as well as associated quotes, were recorded in an Excel spreadsheet. Two transcripts were independently coded by the second and third author, reaching 92% agreement about the topics interviewees raised. Cohen’s Kappa,³⁹ which corrects for chance agreement, was sufficient at 0.74. Disagreements were resolved through discussion. The remaining interviews were coded by the second author. All coding was reviewed by the first author.

Results

Nine interviewees indicated only ever having had 1 plan and, in line with previous research, will therefore be referred to as “stayers.”⁸ Another 2 were referred to as “stayers” because they were defaulted into another plan by their insurer after their original plan was discontinued. The remaining 9 were “switchers,” since they reported changing plans at least once. Below, we share 4 key findings. Where possible, we present at least 1 quote from a stayer and a switcher. Generally, similar issues were raised by stayers and switchers.

Finding 1: Using Decision-Support Tools, Such as the Medicare Plan-Finder Web Site, Booklet, and Mailers, Could Be Time-Consuming and Confusing

Seven interviewees mentioned comparing plans on the Medicare plan-finder Web site,⁶ although this took time and effort. A stayer explained: “I went online several times and went through ‘em all” but noted “it’s not easy to make that decision because you’re overloaded with options” (interview 4). A switcher mentioned the large number of plans: “You put in what medications you take and how often you take them and where you live, and then it would come up with 20 [but] that’s too much for me” (interview 18).

Three interviewees mentioned looking over the plans listed in the Medicare Part D booklet⁵ to compare the available plans, which also required time and effort. One stayer explained: “It takes a long time [but] it’s easier to use the Medicare and Me book than it is to use the Web site” (interview 17). A switcher expressed confusion: “I would get one of their books in the mail and sit down and try to read it, and it just would go right over my head” (interview 20).

Three interviewees mentioned being overwhelmed by mailers, including a stayer who said, “The minute you turn about 64, you get something in the mail almost every day from an insurance company [and it] was just kind of overwhelming for me” (interview 3). Another stayer added, “[We get] pamphlets, yeah, in the mail. But it’s pretty confusing” (interview 5).

Finding 2: Recommendations Were Taken from Insurance Brokers, Agents, and Pharmacists, Often without Questioning Their Advice

Ten interviewees mentioned choosing their current plan after getting advice from a recommended insurance agent or broker, often after an attempt at making the choice on their own. A stayer said, “[I looked on] the Internet [but] I ended up disregarding it. I just went with [my broker’s] recommendation. I happened to talk to my brother in law and he recommended this broker” (interview 2). A switcher explained, “I didn’t like going online because I’d rather talk to somebody in person” (interview 8). Although experiences with these advisors were largely positive, there was uncertainty about their affiliation. A stayer questioned, “She must have been working with Medicare and insurance. I don’t know exactly how it all worked” (interview 5). A switcher had a negative experience: “Someone I knew that worked in insurance told me to call this person to help me [and] now she left and there’s another guy [who] helps me now. [He] suggested I switch [but] I’m not liking how that’s working out” (interview 9). A stayer therefore recommended: “If you get some person from [an insurance company], of course, you’re going to get a biased idea. So if there were some public agency that would help older people work their way through Part D, I think that might be advantageous” (interview 15).

Two interviewees mentioned following recommendations from their pharmacy. A stayer said, “They recommended is what they did [and] I’m fine with it” (interview 12). A switcher explained, “I discussed all of it with the pharmacy, and they recommended it. They figured it would be the best for me” (interview 10).

Finding 3: Beneficiaries 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

Fifteen interviewees indicated considering a limited number of the available options either on their own or with a broker, with 13 quantifying their choice set as between 2 and 6 plans. A stayer who worked with a broker explained, “I just sometimes get overwhelmed with a lot of choices [so] the broker that we were working with [showed only] a couple of different plans. So, I did have choices there but it wasn’t overwhelming” (interview 3). A switcher who used the Medicare plan-finder Web site said, “For me 3 was enough. After that it just gets kind of confusing” (interview 6). Choice sets were reduced by applying heuristics that prioritized specific features. A stayer who used the Medicare Web site narrowed down on coverage: “Some [plans] didn’t have a large coverage at all. And so those we sort of eliminated and looked at what we considered the top six. . . . I won’t say we thoroughly analyzed it, but we were comfortable with our choice” (interview 15). A stayer who used the Medicare booklet considered plans from only 1 insurer: “I didn’t look at any other company. AARP was the only drug plan that I looked at” (interview 17).

Four interviewees considered only a single option that was recommended to them. A switcher who worked with a broker said, “I think she just advised me that was a good thing to do, and it would cost me a little more in premiums but the coverage would be good. I just took her word for it” (interview 20). A switcher who relied on their pharmacist’s guidance said, “I just went with what they said [because] I trusted them to do what was best for me” (interview 10).

Finding 4: Few Beneficiaries Made Annual Plan Comparisons, and while Some Deferred Choices until Necessary, Others Did Not Act Even after Being Confronted with Negative Experiences or Plan Changes – due to Knowledge and Time Constraints

Only 5 interviewees explicitly mentioned making annual plan comparisons, using different types of advice and decision support. One stayer made annual plan comparisons with the help of an advisor: “We have a guy that we go to, we compare different plans, it’s always been this one [plan] has been the best for the medications I’m on” (stayer 19). A switcher who used the Medicare plan-finder Web site said, “I actually look at it every year to see if there’s a better plan for the needs that I have [and] this year I did decide to switch” (interview 13).

Ten interviewees explicitly described a choice-deferral strategy. Three stayers used the exact phrase “if it ain’t broke don’t fix it” (interviews 5, 7, and 17). A stayer explained, “If I have incidents where they’re not covering more stuff that I need, then I’ll look around” (interview 3). In line with this strategy, switchers reported changing plans after negative experiences or plan changes. A switcher explained, “There was some snag with [my former plan] so that’s when I switched” (interview 18). Another switcher added: “I got a letter saying that . . . the plan you have now is going to be called something different next year. The price was going to go up. The coverage was changing. It was going to be a totally different plan. That’s why I found something different” (interview 14).

However, 4 interviewees had not switched despite having negative experiences or plan changes, due to knowledge and time constraints. A stayer explained that it had not occurred to them to switch: “I hadn’t really given all that much thought ma’am, about switching to another D plan . . . [but] that’s a lot of money [I] pay every month, especially when you on a fix[ed] income” (interview 11). Another stayer said that they did not know how to switch: “If they continued to raise the premiums and raise the deductibles, then yeah, clearly I’ll look for somebody else. [But] I don’t even know if I have to go to there or whether they have an open season for Part D” (interview 15).

A switcher had previously lacked time: “I kept with the status quo even though I really wasn’t happy with it, [because] I was busy” (interview 6).

Moreover, 4 interviewees might have failed to switch if they had not been warned by someone that there was a better alternative available. For example, one switcher described the intervention of a new agent: “I made the mistake of not telling [my previous insurance man] what drugs I was on. [So] I just went with Blue Cross basically. And that was an expensive plan. [Two years later] somebody else took over [and] he said tell me what drugs you’re on and I did. He said [you] need to change your plan. So then I changed to another one and it was so much cheaper” (interview 8).

Another switcher said, “[My pharmacy] noticed it first and then brought it to my attention. [My insurer was increasing] the amount that I had to pay for the membership [premium], and some of the prices also on some of the medicines” (interview 10).

Discussion

By conducting qualitative interviews, we aimed to understand Medicare Part D beneficiaries’ experiences with choosing between the large number of available drug insurance plans. We uncovered real-world examples of strategies that have been proposed in the behavioral decision-making literature for tackling such complex choices, including using decision support, advice seeking, heuristics, and choice deferral (Table 1). However, interviewees appeared to be using these 4 strategies with mixed success (Table 3), describing some of the same challenges that were previously uncovered in qualitative research that was conducted more than a decade ago, before the implementation of various Medicare Part D reforms, the reduction of the number of plans, and an update of the Medicare Part D plan-finder Web site.^35,36

Table 3

Key Findings and Associated Recommendations

Key Finding		Recommendation
1.	Using decision-support tools such as the Medicare plan-finder Web site, booklet, and mailers could be time-consuming and confusing	Simplify decision-support tools
2.	Recommendations were taken from insurance brokers, agents, and pharmacists, often without questioning their advice	Provide independent advisors
3.	Beneficiaries 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	Reduce the number of options and highlight the recommended plan given beneficiaries’ current medication use and location
4.	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	Reduce frequency of choices, send alert when plan stops being financially optimal, auto-enroll into recommended plan given medication use and location

Specifically, our interviewees used decision-support tools such as the Medicare plan-finder Web site,⁷ booklet,⁶ or mailers, which required time and effort, partly due to the large number of plans and plan features. Some therefore sought help from advisors, who were often recommended to them. While experiences with advisors were largely positive, there was some uncertainty about their affiliations and whether they provided unbiased recommendations. To simplify their plan choice, beneficiaries used heuristics to reduce their choice set on their own or with an advisor or just opted for a recommended option without making any comparisons at all. Many additionally used an “if it ain’t broke don’t fix it” strategy, allowing them to defer choices until after plan changes or negative experiences. Stayers who did not act despite unfavorable plan changes and experiences indicated barriers to switching, which some did overcome due to the intervention of an advisor or pharmacy.

Perhaps surprisingly, our interviews revealed few qualitative differences between the experiences of stayers and switchers. Administrative data analyses have suggested that switchers are more likely than stayers to be in their financially optimal plan,⁸ and surveys have suggested that switchers are more likely than stayers to use decision-support tools, have help from advisors, process information about alternative plans, and make plan comparisons.^29,30 However, these quantitative group differences may have obscured how stayers and switchers may face some of the same challenges over time, when attempting to use decision-support tools, relying on advisors, and implementing choice-deferral strategies. Possibly, this is part of the reason why many stayers and switchers are not enrolled in their financially optimal plan.⁸

Limitations

Like any study, ours has limitations. First, we were unable to evaluate the effectiveness of interviewees’ choice strategies, because we lacked the information needed to evaluate their plans. Second, like any interview study, our sample was small and therefore not representative despite reaching saturation. Third, the most confused and inactive beneficiaries may have avoided our interviews, thus leading us to underestimate difficulties with plan choices. Fourth, qualitative interviews can provide in-depth insights into beneficiaries’ experiences, but surveys are needed to identify the prevalence of those experiences and how it varies between stayers and switchers. Fifth, our interviews focused on beneficiaries who were enrolled in stand-alone Medicare Part D plans and examined how they tackled the choice between these plans. However, beneficiaries also have the option to switch to a Medicare Advantage plan that bundles their medication coverage with other types of health insurance, thus adding even more complexity.³

Policy Recommendations

Our findings suggest that beneficiaries may welcome the help to overcome challenges to make their Medicare Part D plan choices. Table 3 suggests policy interventions that may be beneficial, given some of the challenges beneficiaries may be facing. Below, we explain how these policy interventions are grounded in the decision-making literature while recognizing potential challenges in their implementation.

First, to overcome difficulties using the Medicare plan-finder Web site⁷ and booklet,⁶ the presented information and the choice itself could be simplified. Research on effective patient communications suggests that outreach materials should be written at the seventh- to eighth-grade reading level.⁴⁰ There are different formulas for measuring readability, which generally agree that longer words and longer sentences are harder to read.⁴¹ In contrast, the 2008 Medicare booklet was written at the 10th-grade reading level.⁴² The 2006 Medicare booklet and plan-finder Web site were also criticized for being poorly designed.⁴³ A 2018 article found that older adults were better able to identify the financially optimal plan if the Medicare plan-finder Web site focused on presenting total costs, rather than overwhelming them with additional financial information about premiums and out-of-pocket spending,^44,45 in line with findings that focusing on main points benefits older adults with low numeracy.⁴⁶ The Medicare plan-finder Web site received a large update in 2019, for the first time in a decade, including a greater focus on total costs.³⁶ Yet, even the updated Web site was easier for older adults to use if they had the help of an advisor.⁴⁷

Second, beneficiaries seem to want advisors. Evidence suggests that giving beneficiaries unbiased expert advice can improve their plan choices.^48–50 State Health Insurance Assistance Programs (SHIPs) have unbiased volunteers offer free one-on-one meetings with beneficiaries about Medicare, including to compare and choose plans.⁵¹ To avoid driving beneficiaries to advisors who have a conflict of interest, greater investments in and advertising of SHIPs is needed.⁵¹ It has also been suggested to incentivize agents for giving appropriate disclosures, provide performance ratings for agents, and boost not-for-profit educational efforts.⁵² However, many beneficiaries may not take the initiative to work with an advisor, especially if they are habitually avoiding their annual plan choices.²⁹

Third, the number of plans could be further reduced to meet beneficiaries’ desire to review fewer options, perhaps with the recommendation of a financially optimal plan. Our interviewees considered 2 to 6 plans either on their own or with an advisor or chose a recommended option without making comparisons. A 2008 survey suggested that older adults want on average 4 options for their drug insurance plans—even fewer than the 5 to 6 options they might want when choosing cars or apartments.⁵³ Beneficiaries may therefore have still felt overwhelmed when facing on average 14 plan options in 2025, despite this marking a large decline from the average of 56 in 2007.⁵ It may be legally difficult to enforce a lower number of plans, but perhaps it would be possible to build on 2010 regulations that discouraged duplicative plans and plans with low enrollment.⁴ Although some have expressed the concern that reducing the number of plans will undermine plan competition and increase prices,⁵⁴ beneficiaries’ hesitance to switch may increase what they pay as well.⁸ Moreover, if policies focus on removing particularly costly plans, then prices may not be affected. A more serious challenge pertains to the recommendation of a financially optimal plan, because its identification tends to be based on the assumption that beneficiaries’ medications and location will remain unchanged and may ignore features such as quality of service or preferred pharmacies. The question therefore arises if the recommended plan should also incorporate star ratings and preserve beneficiaries’ relationships with their pharmacies.⁵⁵ Meanwhile, advisors do already seem to be tailoring the number of options they present to the needs and wants of their clients and go so far as to recommend just 1 plan to beneficiaries who want to make no comparisons.

Fourth, to allow beneficiaries to defer choices, it has been suggested to require plan choices over multiple years instead of every year.⁵⁶ Moving toward multiyear plans would require plan choices less often and would reduce the burden on older adults who would rather spend their time differently.¹⁹ However, there may be pushback from beneficiaries who do want the option to change plans in the face of changing situations and from providers who want the opportunity to change their plan features. In addition, beneficiaries could be alerted when their plan is changing for the medications they are taking, perhaps while pointing them to their local SHIP for advice.

However, the inactive beneficiaries we interviewed did not act unless someone reached out to switch them to a better option. To address persistent inactivity, it might be helpful to auto-enroll beneficiaries into a financially optimal plan or to send an alert to their local SHIP program so that a volunteer can reach out to beneficiaries who appear to be stuck in costly plans. While defaults have been successfully implemented to simplify and improve some financial choices, there has also been pushback due to potential negative effects on consumer autonomy and consumer welfare.⁵⁷ Moreover, for the reasons indicated above, it is difficult to identify the financially optimal plan to auto-enroll beneficiaries into. Beneficiaries who receive low-income subsidies are already being auto-enrolled into a randomly selected plan from among available plans without premiums.⁵⁸ Sending an alert to the local SHIP program to provide help to beneficiaries who appear to be stuck in financially costly plans may therefore be more feasible but would likely require more funding for SHIP.⁵¹

We discussed several options for helping beneficiaries to make their plan choices (Table 3), each of which has potential drawbacks. Meanwhile, the drawback of not simplifying beneficiaries’ plan choices means that many beneficiaries may be sticking with suboptimal defaults that are costly to them and the federal government while benefiting insurance firms.

Supplemental Material

sj-docx-1-mpp-10.1177_23814683261441269 – Supplemental material for Medicare Part D Beneficiaries’ Experiences with Making Complex Insurance Plan Choices: A Qualitative Interview Study

Supplemental material, sj-docx-1-mpp-10.1177_23814683261441269 for Medicare Part D Beneficiaries’ Experiences with Making Complex Insurance Plan Choices: A Qualitative Interview Study by Wändi Bruine de Bruin, Nathan Hodson, Lila Rabinovich and Joachim Winter in MDM Policy & Practice

Footnotes

Acknowledgements

We thank Jon Blum, Daniel Czarnowske, Florian Heiss, Amelie Wuppermann, and Daniel McFadden for their advice and comments. We thank the team at the Understanding America Study for help with interviewee recruitment. Part of this article has been presented by the first author at the 2025 conference on Current Innovations in Probability-based Household Internet Panel Research (CIPHER) held in Washington, DC, by the University of Southern California’s Center for Economic and Social Research.

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Wändi Bruine de Bruin is a member of the Editorial Board of MDM Policy and Practice. The author did not take part in the peer review or decision-making process for this submission and has no further conflicts to declare. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for this study was provided entirely by a gift from the University of Southern California to the USC Schaeffer Center for Health Policy and Economics. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the University of Southern California: Wändi Bruine de Bruin and Lila Rabinovich.

Ethical Considerations

This study was conducted as part of the Understanding America Study. It received ethical approval from Brany, an external IRB partner that works with the Understanding America Study (protocol 22-030-1044). Participants provided informed consent online, before signing up for their interview.

ORCID iDs

Wändi Bruine de Bruin

Nathan Hodson

Lila Rabinovich

Joachim Winter

Data Availability

Interview transcripts are available upon request from Wändi Bruine de Bruin.

References

KFF. Key facts about Medicare Part D enrollment and costs in 2023. 2023. Available from: https://www.kff.org/medicare/issue-brief/key-facts-about-medicare-part-d-enrollment-and-costs-in-2023/. [Accessed 23 February, 2026].

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