Jessica Mulligan

It gets better if you do? Measuring quality care in Puerto Rico.

Quantifying quality is supposed to unite health policy, health plans, and health care consumers in a circuit of constant improvement. In practice, significant gulfs separate how policymakers, health plan administrators, and consumers write and talk about quality. Drawing on policy literature, ethnography inside a managed care organization, and interviews with health plan members, this article examines a quality improvement program at a health plan in Puerto Rico. The findings challenge the assumption underwriting neoliberal health policy that quality measurement leads to quality improvement.

Toward an Anthropology of Insurance and Health Reform: An Introduction to the Special Issue

This article introduces a special issue of Medical Anthropology Quarterly on health insurance and health reform. We begin by reviewing anthropological contributions to the study of financial models for health care and then discuss the unique contributions offered by the articles of this collection. The contributors demonstrate how insurance accentuates--but does not resolve tensions between granting universal access to care and rationing limited resources, between social solidarity and individual responsibility, and between private markets and public goods. Insurance does not have a single meaning, logic, or effect but needs to be viewed in practice, in context, and from multiple vantage points. As the field of insurance studies in the social sciences grows and as health reforms across the globe continue to use insurance to restructure the organization of health care, it is incumbent on medical anthropologists to undertake a renewed and concerted study of health insurance and health systems.

An ethnographic study of enrollment obstacles in Rhode Island, USA: struggling to get covered on an Affordable Care Act insurance marketplace

ABSTRACT The Affordable Care Act (ACA) of 2010 expanded access to health insurance coverage in the United States through online marketplaces that provided subsidized insurance coverage. Nonetheless, many obstacles made it difficult to enroll in and maintain ACA insurance coverage. In this article, we analyze obstacles to enrollment and continuous coverage based on an ethnography of ACA insurance enrollment in Rhode Island. We foreground consumers’ experiences and highlight the time and effort that people invested into getting covered. Unlike studies that focus on individual choices and employ a deficit perspective to understand gaps in coverage, this article argues that structural problems related to the organization of the American health insurance system, economic instability and bureaucratic eligibility criteria shaped the experiences of individuals and families seeking coverage. We found that people actively and intensely struggled to enroll and were met with multiple obstacles, most of which were beyond their control. In some cases, these obstacles resulted in gaps in coverage. In almost all cases, they created additional stress, were time consuming and frustrating. The most significant obstacles to enrolling in coverage were bureaucratic barriers, affordability, changes in personal or family status, and knowledge about health insurance and ACA program rules. We end by questioning the ethical basis of a health coverage system structured on ‘churn’ and offer policy recommendations to design programs that respect people’s time, avoid verification redundancies and are motivated by a mission to expand coverage.