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

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  • Mulligan, Jessica

Abstract

This article takes a genealogical and ethnographic approach to the problem of choice, arguing that what choice means has been reworked several times since health insurance first figured prominently in national debates about health reform. Whereas voluntary choice of doctor and hospital used to be framed as an American right, contemporary choice rhetoric includes consumer choice of insurance plan. Understanding who has deployed choice rhetoric and to what ends helps explain how offering choices has become the common sense justification for defending and preserving the exclusionary health care system in the United States. Four case studies derived from 180 enrollment observations at the Rhode Island health insurance exchange conducted from March 2014–January 2017 and interviews with enrollees show how choice is experienced in this latest iteration of health reform. The Affordable Care Act (ACA) of 2010 created new pathways to insurance coverage in the United States. Insurance exchanges were supposed to unleash the power of consumer decision-making through marketplaces where health plans compete on quality, coverage, and price. Consumers, however, contended with confusing insurance terminology and difficult to navigate websites. The ethnography shows that consumers experienced choice as confusing and overwhelming and did not feel “in charge” of their decisions. Instead, unstable employment, changes in income, existing health needs, and bureaucratic barriers shaped their “choices.”

Suggested Citation

  • Mulligan, Jessica, 2017. "The problem of choice: From the voluntary way to Affordable Care Act health insurance exchanges," Social Science & Medicine, Elsevier, vol. 181(C), pages 34-42.
  • Handle: RePEc:eee:socmed:v:181:y:2017:i:c:p:34-42
    DOI: 10.1016/j.socscimed.2017.03.055
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    References listed on IDEAS

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    1. Lee, Nancy S., 2015. "Framing choice: The origins and impact of consumer rhetoric in US health care debates," Social Science & Medicine, Elsevier, vol. 138(C), pages 136-143.
    2. Hoffman, Beatrix, 2012. "Health Care for Some," University of Chicago Press Economics Books, University of Chicago Press, number 9780226348032, April.
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    Cited by:

    1. Lee, Amanda A. & James, Aimee S. & Hunleth, Jean M., 2020. "Waiting for care: Chronic illness and health system uncertainties in the United States," Social Science & Medicine, Elsevier, vol. 264(C).
    2. Schwarz, Carolyn, 2021. "Freed from insurance: Health care sharing ministries and the moralization of health care," Social Science & Medicine, Elsevier, vol. 268(C).
    3. Ihlebæk, Hanna Marie, 2021. "Time to care - An ethnographic study of how temporal structuring affects caring relationships in clinical nursing," Social Science & Medicine, Elsevier, vol. 287(C).
    4. Dao, Amy, 2020. "What it means to say “I Don't have any money to buy health insurance” in rural Vietnam: How anticipatory activities shape health insurance enrollment," Social Science & Medicine, Elsevier, vol. 266(C).

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