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  From the January 2006 Anthropology News

A Call to an Anthropology of Health Policy

Sarah Horton
UC San Francisco

Louise Lamphere
U New Mexico

At a time when Congress 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 perspectives are especially needed—and sadly lacking—in the current discussion 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 history of the American health care system. 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 million 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 disciplinary 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-efficiencies” 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 instrumental 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 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 recipients and the uninsured, exposing the fallacy that “cost-sharing” for the poor will bring about a more efficient health system.

Meanwhile, through critical theory, we should challenge the very assumptions about human behavior and the nature of health care implicit in the economic arguments that currently dominate health policy. The economic principle structuring the recent House proposal is the “law of demand,” which treats health care as a commodity 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 individual, ensuring “system efficiencies” by discouraging health care use. The premise of this principle, then, is that health insurance 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 higher 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 rational, health-maximizing individual, an idea that will be familiar to any medical 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 predicable and universal model of sick behavior. An individual experiences illness, consults with his or her referral network, reviews the available resources and then rationally chooses 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-maximization. As Byron Good summarizes in his 1994 Medicine, Rationality and Experience, “The model of the rational, autonomous care-seeker … serves best when used to study middle-class Americans who have health insurance and are seeking care for relatively 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 resulted 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 reimbursements, health care safety net institutions found that they had to implement higher “user fees” for patients or rely upon insured funding streams.

One rural health care clinic, for example, attempted to draw privately-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 undocumented, 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 institutional level that were otherwise invisible from a bird’s-eye, or policy, perspective. In capturing the effect of reforms of Medicaid at the organizational level, we were able to highlight a steady down-shifting of responsibility 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 ethnographic finding as one piece of a broader hegemonic system—“as a reflection of the reigning structure of social inequality.” Far too often our discipline has prioritized studies of quaint “health beliefs” over documenting the tangible effects of such policies, allowing the views of health economists to prevail. At this critical juncture in our health care system, ethnographers need to both interrogate the material effects of recent reforms as well as the ideological premises that make them appear common-sense. It is time we take up the gauntlet that policymakers have thrown down, and join the debate.

Sarah Horton is a medical anthropologist at the University of California, San Francisco, and has written on the ethnography of health policy for the American Anthropologist and Medical Anthropology Quarterly. Louise Lamphere is Distinguished Professor of Anthropology at the University of New Mexico and a AAA past-president. She has written on issues of public anthropology for Human Organization and Social Anthropology.

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