The problem of choice: From the voluntary way to Affordable Care Act health insurance exchanges

Mulligan, Jessica

doi:10.1016/j.socscimed.2017.03.055

Cited by 23 publications

(19 citation statements)

References 8 publications

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“…Consistent with our psychiatry utilization ndings, this study found worse access to primary care among those with private coverage purchased on exchanges compared to private coverage purchased individually [31]. Another study found that patients often felt overwhelmed by the array of choices offered on the exchanges and were confused by terminology and websites [32]. The reason for the effects of enrollment through the Exchange on psychiatry utilization in our sample could also be due to higher cost-sharing in Exchange plans (apart from deductibles) or to unexamined group differences such as nancial constraints or fewer mental health problems among Exchange vs. non-exchange enrollees.…”

Section: Discussionsupporting

confidence: 81%

Health care utilization and HIV clinical outcomes following Affordable Care Act implementation in California: A longitudinal study

Satre¹,

Parthasarathy²,

Silverberg³

et al. 2020

Preprint

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Background: The Affordable Care Act (ACA) increased insurance coverage for people with HIV (PWH) in the United States, yet post-ACA health care utilization and HIV outcomes have rarely been examined. Methods: Among PWH newly enrolled in an integrated health care system (Kaiser Permanente Northern California) in 2014 (N=880), we examined use of health care and modeled associations between enrollment mechanisms (enrolled in a Qualified Health Plan through the California Exchange vs. other sources), deductibles (none, $1-$999 and >= $1000), receipt of benefits from the California AIDS Drug Assistance Program (ADAP), demographic factors, and three-year patterns of health service utilization (primary care, psychiatry, substance treatment, emergency, inpatient) and HIV outcomes (CD4 counts, viral suppression). Results: Health care use was greatest immediately after enrollment and decreased over three years. Those with high deductibles were less likely to use primary care (OR=0.64, 95% CI=0.49 - 0.83, p < 0.001) or psychiatry OR=0.58, 95% CI=0.36, 0.93, p=0.02) than those with low or no deductibles. Enrollment via the Exchange was associated with fewer psychiatry visits (rate ratio [RR]=0.38, 95% CI=0.17 - 0.83; p=0.02), but ADAP was positively associated with number of psychiatry visits (RR=2.22, 95% CI=1.22 – 4.05 p=0.01). There was no association between enrollment mechanism or deductibles and HIV outcomes, but ADAP enrollment was associated with viral suppression (OR=2.23, 95% CI=1.35 - 3.68, p<0.001). Non-white PWH were less likely to be virally suppressed, (OR=0.47, 95% CI= 0.31 - 0.71, p< 0.001). Conclusions: In this sample of PWH drawn from an integrated health care system in California, findings suggest that enrollment via the Exchange and higher deductibles were negatively associated with some aspects of service utilization but did not impact HIV outcomes; support from ADAP appeared to help patients achieve viral suppression; ethnic disparities remain important to address in post-ACA health services for PWH even among those with access to insurance coverage.

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Section: Discussionsupporting

confidence: 81%

Health care utilization and HIV clinical outcomes following Affordable Care Act implementation in California: A longitudinal study

Satre¹,

Parthasarathy²,

Silverberg³

et al. 2020

Preprint

View full text Add to dashboard Cite

show abstract

“…For example, the alternative care options promoted in the media and industry sources of information are mostly taken up by patients from the global north and only those who are able to travel and pay for care, limiting this empowerment to a particular population which does not include the most vulnerable patients struggling to access care [ 10 ]. Furthermore, by presenting choice in health care as necessarily empowering [ 8 ], media coverage on medical tourism and industry discourse ignores and dismisses the myriad ways in which more choice for patients and providers can be “stressful, confusing, time consuming, and impossible to do well” ([ 16 ], p. 41). Researchers suggest choice rhetoric might be taken up in media discourse and health system planning in ways that assume more choice is always good while dismissing or ignoring the unintended consequences of policies focused on enhancing patient and provider choice.…”

Section: Introductionmentioning

confidence: 99%

A critical examination of empowerment discourse in medical tourism: the case of the dental tourism industry in Los Algodones, Mexico

et al. 2018

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BackgroundMedical tourism is a term used to describe the phenomenon of individuals intentionally traveling across national borders to privately purchase medical care. The medical tourism industry has been portrayed in the media as an “escape valve” providing alternative care options as a result of vast economic asymmetries between the global north and global south and the flexible regulatory environment in which care is provided to medical tourists. Discourse suggesting the medical tourism industry necessarily enhances access to medical care has been employed by industry stakeholders to promote continued expansion of the industry; however, it remains unknown how this discourse informs industry practices on the ground. Using case study methodology, this research examines the perspectives and experiences of industry stakeholders working and living in a dental tourism industry site in northern Mexico to develop a better understanding of the ways in which common discourses of the industry are taken up or resisted by various industry stakeholders and the possible implications of these practices on health equity.ResultsInterview discussions with a range of industry stakeholders suggest that care provision in this particular location enables international patients to access high quality dental care at more affordable prices than typically available in their home countries. However, interview participants also raised concerns about the quality of care provided to medical tourists and poor access to needed care amongst local populations. These concerns disrupt discourses about the positive health impacts of the industry commonly circulated by industry stakeholders positioned to profit from these unjust industry practices.ConclusionsWe argue in this paper that elite industry stakeholders in our case site took up discourses of medical tourism as enhancing access to care in ways that mask health equity concerns for the industry and justify particular industry activities despite health equity concerns for these practices. This research provides new insight into the ways in which the medical tourism industry raises ethical concern and the structures of power informing unethical practices.Electronic supplementary materialThe online version of this article (10.1186/s12992-018-0392-3) contains supplementary material, which is available to authorized users.

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“…This suggests that there might be some larger process of "thrifting health care" at work in the post-ACA era. This process could be understood as one response to "rapidly rising health care costs" (Horton et al 2014, 2;Starr 2017) and to the fact that Americans are encouraged to think of themselves more and more as consumers (i.e., as shoppers) making choices in a health care marketplace (Mulligan 2017). For medical anthropologists interested in the wholeness of human lives, the most pressing ethnographic question about thrift, however, is the one I have tried to address in this article-"thrift for what?"…”

Section: Resultsmentioning

confidence: 99%

Thrifting for More: Savings and Aspirations in Health Care Sharing Ministries after the Affordable Care Act

Schwarz

2019

Med Anthropol Q

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The Affordable Care Act (ACA) of 2010 includes health care sharing ministries (HCSMs) on the list of religious exemptions to the individual mandate. HCSMs are non‐profit, faith‐based organizations that share in the cost of medical bills but are not actually insurance. Precisely because HCSMs are not beholden to any of the ACA's insurance reforms, they have the advantage of costing less. Based primarily on in‐depth interviews, I argue that thrift is the preeminent moral discourse that anchors the HCSM world. For members, thrift in health care is understood as a moral good and as a practice that offers possibilities for benefiting connected others and generating life fulfillment, or what Taylor refers to as “fullness.” I suggest that a focus on thrift raises questions about how Americans make determinations about worth in health care and how they construct health care–seeking as deeply attached to their visions of how they want life to be.

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The problem of choice: From the voluntary way to Affordable Care Act health insurance exchanges

Cited by 23 publications

References 8 publications

Health care utilization and HIV clinical outcomes following Affordable Care Act implementation in California: A longitudinal study

Health care utilization and HIV clinical outcomes following Affordable Care Act implementation in California: A longitudinal study

A critical examination of empowerment discourse in medical tourism: the case of the dental tourism industry in Los Algodones, Mexico

Thrifting for More: Savings and Aspirations in Health Care Sharing Ministries after the Affordable Care Act

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