A Call to an Anthropology of Health Policy
2
January 2006 • Anthropology News 33 health policy debates on the impact of higher “cost-sharing” on patient behavior. A bill the House approved in November to slash the Medicaid budget is a good example of policy changes to come. This bill would allow states to gradually increase Medicaid patient copayments to keep pace with inflation and, for the first time in history, would allow states to implement premiums for recipients of Medicaid. Should Medicaid recipients “choose” not to pay such premiums, states would be allowed to drop them from the Medicaid rolls. This bill would make our health care program for the poorest Americans more like the optional insurance offered through employers, and would likely swell the ranks of the uninsured. Through ethnography, then, we should document the effects of such reforms on both Medicaid recipi- ents and the uninsured, exposing the fallacy that “cost-sharing” for the poor will bring about a more efficient health system. Meanwhile, through critical the- ory, we should challenge the very assumptions about human behav- ior and the nature of health care implicit in the economic argu- VIEWS ON POLICY SARAH HORTON UC SAN FRANCISCO LOUISE LAMPHERE U NEW MEXICO A t a time when Con- gress is considering slashing the Medicaid budget, and the legacy of the Great Society has come under increasing scrutiny, it is incumbent upon anthropologists to weigh in on such changes. We suggest that ethnographic perspec- tives are especially needed—and sadly lacking—in the current dis- cussion on reforming our public health care system. Since the 1980s, an emphasis on devolution and the new federalism has changed the landscape of social service provision, dramatically downsizing the social programs of the 1960s. Ethnographers’ analyses could potentially make a significant impact at this crossroads in the his- tory of the American health care sys- tem. Medicaid is currently on the chopping block because, due to increased bureaucratization and the skyrocketing costs of health care, its rate of growth outpaces the rate of inflation. Yet the problems with Medicaid are systemic of a broader dysfunction within our health care system. Many Medicaid recipients receive fragmented, discontinuous care, while an unprecedented 45 mil- lion Americans—15% of the total population—remain uninsured. Anthropologists’ relative neglect of health policy issues may lie, in part, in our tendency to view the realm of policy as outside our disci- plinary scope. Yet in doing so, we have ceded the field of health policy to health economists, who have long held hegemonic sway over the terms in which we discuss and understand the current American health care system. Terms such as the “law of demand” and “cost-effi- ciencies” are commonly used to explain the logic of imposing cost- sharing through premiums and deductibles. Patients are instead portrayed as “consumers of health care,” naturalizing the idea of health care as a commodity whose use must be restricted. As medical anthropologists were once instru- mental in challenging the terms of the rationality debate three decades ago, it is time we dust off our boxing gloves. There are multiple levels of analysis at which anthropologists can make a contribution to debates over health policy—at the levels of individual behavior, institutional policy and public discourse. How Can Anthropology Be of Service? At the level of individual behavior, we need to weigh in on the current ments that currently dominate health policy. The economic princi- ple structuring the recent House proposal is the “law of demand,” which treats health care as a com- modity whose consumption should be limited. The law of demand assumes that patients will consume health services up to the point at which the cost of the good is greater than its value to the indi- vidual, ensuring “system efficien- cies” by discouraging health care use. The premise of this princi- ple, then, is that health insur- ance encourages profligate consumption. In the logic of health economists, the most “efficient” users are, ironically, the uninsured. Yet in practice, this law translates into a high- er economic burden for those who use the health care system the most—the sickest, and frequently poorest, Americans. This economic argument hinges upon the idea of the ration- al, health-maximizing individual, an idea that will be familiar to any med- ical anthropologist. Nearly three decades ago, Marshall Sahlins engaged in a critique of what he called such utilitarian models of health behavior. Not only do such models reduce culture to the sum of the rational, adaptive behaviors of individuals, but they posit a predica- ble and universal model of sick behavior. An individual experiences illness, consults with his or her refer- ral network, reviews the available resources and then rationally choos- es from among them. Yet medical anthropologists have pointed out the ethnocentrism in this model of a universal economic man rationally pursuing the goal of health-maxi- mization. As Byron Good summa- rizes in his 1994 Medicine, Rationality and Experience, “The model of the rational, autonomous care-seeker … serves best when used to study mid- dle-class Americans who have health insurance and are seeking care for rel- atively minor problems.” What Can Ethnography Tell Us? Finally, as ethnographers, we should continue to document how such reforms play out in our tattered health care safety net. Perhaps nowhere else are the effects of such reforms more visible to the ethnographic eye. Our University of New Mexico-based study of the effects of privatization on the health care safety net in New Mexico has shown that privatization itself result- ed in a form of “cost-sharing” for both institutions and individuals. Medicaid managed care added an intermediate layer of Managed Care Organizations between the state and health care providers, reducing Medicaid reimbursements to safety net providers by as much as 70%. To compensate for such reduced reim- bursements, health care safety net institutions found that they had to implement higher “user fees” for patients or rely upon insured fund- ing streams. One rural health care clinic, for example, attempted to draw pri- vately-insured patients through new cosmetic dentistry services in order to help subsidize the care they provided the poor. Meanwhile an urban clinic affiliated with a public hospital implemented a pay-up- front policy for care for the undoc- umented, charging $50 for a first visit or half the cost of inpatient care. Both these strategies qualified the charity-oriented mission of safety net institutions as established by the Great Society programs of the 1960s. These changes passed the cost of the reform onto safety net institutions, which in turn passed the cost on to their patients. Ethnography was able to reveal these obstacles to care at the institu- tional level that were otherwise invis- ible from a bird’s-eye, or policy, per- spective. In capturing the effect of reforms of Medicaid at the organiza- tional level, we were able to highlight a steady down-shifting of responsi- bility for shouldering the burden of health care costs. While proponents of privatization argue that corporate management will make the health care system more efficient, the reform in fact passed hidden costs onto the most vulnerable Americans. As Arachu Castro and Merrill Singer wrote in their 2004 Unhealthy Health Policy, an anthropology of policy would view such an ethno- graphic finding as one piece of a broader hegemonic system—“as a reflection of the reigning structure A Call to an Anthropology of Health Policy Since the 1980s, an emphasis on devolution and the new federalism has changed the landscape of social service provision, dramatically downsizing the social programs of the 1960s. See Health Policy on page 36
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Transcript of A Call to an Anthropology of Health Policy
January 2006 • Anthropology News
33
health policydebates on the impact of higher“cost-sharing” on patient behavior.A bill the House approved inNovember to slash the Medicaidbudget is a good example of policychanges to come. This bill wouldallow states to gradually increaseMedicaid patient copayments tokeep pace with inflation and, for thefirst time in history, would allowstates to implement premiums forrecipients of Medicaid. ShouldMedicaid recipients “choose” not topay such premiums, states would beallowed to drop them from theMedicaid rolls. This bill would makeour health care program for thepoorest Americans more like theoptional insurance offered throughemployers, and would likely swellthe ranks of the uninsured.Through ethnography, then, weshould document the effects of suchreforms on both Medicaid recipi-ents and the uninsured, exposingthe fallacy that “cost-sharing” forthe poor will bring about a moreefficient health system.
Meanwhile, through critical the-ory, we should challenge the veryassumptions about human behav-ior and the nature of health careimplicit in the economic argu-
V I E W S O N P O L I C Y
SARAH HORTON
UC SAN FRANCISCO
LOUISE LAMPHERE
U NEW MEXICO
A t a time when Con-gress is consideringslashing the Medicaidbudget, and the legacy
of the Great Society has comeunder increasing scrutiny, it isincumbent upon anthropologiststo weigh in on such changes. Wesuggest that ethnographic perspec-tives are especially needed—andsadly lacking—in the current dis-cussion on reforming our publichealth care system.
Since the 1980s, an emphasis ondevolution and the new federalismhas changed the landscape of socialservice provision, dramaticallydownsizing the social programs ofthe 1960s. Ethnographers’ analysescould potentially make a significantimpact at this crossroads in the his-tory of the American health care sys-tem. Medicaid is currently on thechopping block because, due toincreased bureaucratization and theskyrocketing costs of health care, itsrate of growth outpaces the rate ofinflation. Yet the problems withMedicaid are systemic of a broaderdysfunction within our health caresystem. Many Medicaid recipientsreceive fragmented, discontinuouscare, while an unprecedented 45 mil-lion Americans—15% of the totalpopulation—remain uninsured.
Anthropologists’ relative neglectof health policy issues may lie, inpart, in our tendency to view therealm of policy as outside our disci-plinary scope. Yet in doing so, wehave ceded the field of health policyto health economists, who havelong held hegemonic sway over theterms in which we discuss andunderstand the current Americanhealth care system. Terms such asthe “law of demand” and “cost-effi-ciencies” are commonly used toexplain the logic of imposing cost-sharing through premiums anddeductibles. Patients are insteadportrayed as “consumers of healthcare,” naturalizing the idea ofhealth care as a commodity whoseuse must be restricted. As medicalanthropologists were once instru-mental in challenging the terms ofthe rationality debate three decades
ago, it is time we dust off our boxinggloves. There are multiple levels ofanalysis at which anthropologistscan make a contribution to debatesover health policy—at the levels ofindividual behavior, institutionalpolicy and public discourse.
How Can Anthropology Be of Service?At the level of individual behavior,we need to weighin on thecurrent
ments that currently dominatehealth policy. The economic princi-ple structuring the recent Houseproposal is the “law of demand,”which treats health care as a com-modity whose consumption shouldbe limited. The law of demandassumes that patients will consumehealth services up to the point atwhich the cost of the good isgreater than its value to the indi-vidual, ensuring “system efficien-cies” by discouraging health care
use. The premise of this princi-ple, then, is that health insur-
ance encourages profligateconsumption. In the logic
of health economists,the most “efficient”users are, ironically,the uninsured. Yet inpractice, this lawtranslates into a high-er economic burdenfor those who use the
health care system themost—the sickest, and
frequently poorest,Americans.This economic argument
hinges upon the idea of the ration-al, health-maximizing individual, anidea that will be familiar to any med-ical anthropologist. Nearly threedecades ago, Marshall Sahlinsengaged in a critique of what hecalled such utilitarian models ofhealth behavior. Not only do suchmodels reduce culture to the sum ofthe rational, adaptive behaviors ofindividuals, but they posit a predica-ble and universal model of sickbehavior. An individual experiencesillness, consults with his or her refer-ral network, reviews the availableresources and then rationally choos-es from among them. Yet medicalanthropologists have pointed outthe ethnocentrism in this model of auniversal economic man rationallypursuing the goal of health-maxi-mization. As Byron Good summa-rizes in his 1994 Medicine, Rationalityand Experience, “The model of therational, autonomous care-seeker …serves best when used to study mid-dle-class Americans who have healthinsurance and are seeking care for rel-atively minor problems.”
What Can Ethnography Tell Us?Finally, as ethnographers, we shouldcontinue to document how suchreforms play out in our tatteredhealth care safety net. Perhaps
nowhere else are the effectsof such reforms more visible to theethnographic eye. Our University ofNew Mexico-based study of theeffects of privatization on the healthcare safety net in New Mexico hasshown that privatization itself result-ed in a form of “cost-sharing” forboth institutions and individuals.Medicaid managed care added anintermediate layer of Managed CareOrganizations between the state andhealth care providers, reducingMedicaid reimbursements to safetynet providers by as much as 70%. Tocompensate for such reduced reim-bursements, health care safety netinstitutions found that they had toimplement higher “user fees” forpatients or rely upon insured fund-ing streams.
One rural health care clinic, forexample, attempted to draw pri-vately-insured patients throughnew cosmetic dentistry services inorder to help subsidize the care theyprovided the poor. Meanwhile anurban clinic affiliated with a publichospital implemented a pay-up-front policy for care for the undoc-umented, charging $50 for a firstvisit or half the cost of inpatientcare. Both these strategies qualifiedthe charity-oriented mission ofsafety net institutions as establishedby the Great Society programs ofthe 1960s. These changes passedthe cost of the reform onto safetynet institutions, which in turnpassed the cost on to their patients.
Ethnography was able to revealthese obstacles to care at the institu-tional level that were otherwise invis-ible from a bird’s-eye, or policy, per-spective. In capturing the effect ofreforms of Medicaid at the organiza-tional level, we were able to highlighta steady down-shifting of responsi-bility for shouldering the burden ofhealth care costs. While proponentsof privatization argue that corporatemanagement will make the healthcare system more efficient, thereform in fact passed hidden costsonto the most vulnerable Americans.
As Arachu Castro and MerrillSinger wrote in their 2004 UnhealthyHealth Policy, an anthropology ofpolicy would view such an ethno-graphic finding as one piece of abroader hegemonic system—“as areflection of the reigning structure
A Call to an Anthropology of Health Policy
Since
the 1980s, an
emphasis on devolution
and the new federalism
has changed the landscape
of social service provision,
dramatically downsizing
the social programs of
the 1960s.
See Health Policy on page 36
CALLFOR
PAPERS
Anthropology News • January 2006
36
V I E W S O N P O L I C Y
of social inequality.” Far too oftenour discipline has prioritized studiesof quaint “health beliefs” over doc-umenting the tangible effects ofsuch policies, allowing the views ofhealth economists to prevail. At thiscritical juncture in our health caresystem, ethnographers need to bothinterrogate the material effects ofrecent reforms as well as the ideo-logical premises that make themappear common-sense. It is time wetake up the gauntlet that policy-makers have thrown down, andjoin the debate. �AN
Sarah Horton is a medical anthropolo-gist at the University of California, SanFrancisco, and has written on the ethnog-raphy of health policy for the AmericanAnthropologist and MedicalAnthropology Quarterly. LouiseLamphere is Distinguished Professor ofAnthropology at the University of NewMexico and a AAA past-president. She haswritten on issues of public anthropologyfor Human Organization and SocialAnthropology.
contestation of enduring racial val-ues. Transit racism in the US takesmany forms, including the politics ofresource allocation for highways ver-sus public transit and, within publictransit, rail versus bus. The greeningof urban transit presents both a riskfor remaking racism through new de-sign choices and an opportunity formaking sure that the “back of thebus” does not take new forms in the21st century. �AN
David J Hess is chair of the AAACommittee on Public Policy. Seewww.davidjhess.org/sustlocproject.html toaccess case studies on efforts to improvejustice and sustainability at the grassrootslevel in the US. Hess is now exploring theissue in relation to the CNG/diesel contro-versy comparatively with a colleague inColombia; they are looking for a partnerto examine the controversy in Europe.
Back of the BusContinued from page 34
Health PolicyContinued from page 33
Post-KatrinaContinued from page 32
speech reveal erroneous ideas aboutcontaining a pandemic flu virus.Showing a fortress mentality, the do-cuments falsely reassure that the UScan escape pandemic flu unscathedthrough containing the first clusterof human infections overseas, mon-itoring points of “entry to and egressfrom affected areas” and imposinggeographic quarantines at home. Inhis speech, the president invokes aforest fire image: “If caught early itmight be extinguished with limiteddamage; if allowed to smolder unde-tected, it can grow to an inferno thatspreads quickly beyond our ability tocontrol.”
The virology, epidemiology andsociology of a human influenzapandemic suggest profound faultswith these analogies. Past influenzapandemics have not developed in aslowly mounting linear fashion,but in quick multi-focal bursts.Targeting antiviral drugs and quar-antine at the pandemic’s point oforigin (that is, promptly dousingthe spark in the forest) is simply notfeasible. Mathematical models ofquarantine for flu show that theremust be a nearly perfect degree oflimitation of travel to be effective—another practically unachievablegoal. Lastly, implying a foreignpoint of origin for the pandemicagainst which the country can andmust be secured creates a “geogra-phy of blame” likely to stigmatizeAsia and Asian-American peoples,neighborhoods and commodities.
The September 11 attacks,Hurricane Katrina and now a possi-ble flu pandemic are strung togeth-er in the minds of US politicians,health and safety professionals,journalists, and many citizens bydint of chronological proximity,the need to make sense of humantragedy, and the onus upon every-one to fathom how homeland secu-rity initiatives have made the coun-try any safer. In the meantime, fail-ures of imagination continue toplague US policy regarding com-plex modern disasters. �AN
Monica Schoch-Spana is an assistantprofessor of medicine and infectious dis-eases at the University of Pittsburgh. Shehas worked on public health and biologicalweapons policy for the last seven years.
AN• How do anthropologists understand globalization?
• What does anthropology contribute to studies on globalization that otherfields of study, such as economics, political science and sociology, could miss?
• How do and should anthropologists understand globalization historically?
• How do neoliberal policies impact humans?
• What systems of local, national, regional and international regulations of glob-al markets and trade have existed and are emerging?
• What are the new languages of protest and globalization activism? What roledo new technologies and media play in these protests? What role should anthro-pologists have in these movements as scholars and citizens? And how should orshould not anthropological research inform advocacy?
• What new categories of identity have emerged as a result of neoliberal poli-cies? How are these identities embodied, contested and related to other identi-ties? What new rights and ideas of social justice have emerged in response tothese new identities?
• What role do new technologies play in new forms of global labor (for instance,outsourcing, reconfiguring production practices)?
Send your comments and research reports addressing these questions [email protected] to be considered for a series in Anthropology News.
Deadline: March 1, 2005
Seeing Humans, Society and Culture in Globalization
