A Eulogy for Jane Robinson: A Social Autopsy of Uncare Policies.

Shortly after losing her health insurance in 2018, Jane Robinson died of a treatable respiratory infection. This article argues that Jane's death occurred at the nexus of two different approaches to care: the necropolitics of uncare and the micropolitics of generative care labor. Both of these approaches to care increased Jane's health and social vulnerability, in turn quickening her death. We adopt the necropolitics of uncare framework to identify and name the harmful policies and attitudes of disregard that control access to life saving medical care. In the micropolitics of care in Jane's life, she became the safety net for others, which left little over when her health began to deteriorate. This social autopsy reveals that her care networks were insufficient to undo the uncare enshrined in state policy. Jane's unnecessary death foreshadowed the excess mortality that the United States has experienced from COVID-19.

Instability in Insurance Coverage: The Impacts of Churn in Rhode Island, 2014-2017.

Churn, defined as a change in plan or a gap in insurance, is a problem in the United States that usually occurs as the result of changing life circumstances. Recent health reform perpetuates - rather than alleviates - churn because low- and middle- income individuals experience frequent changes in eligibility status. Our research asked: how common is churn in the non-group market and what are the health, financial, and emotional impacts on Rhode Island residents? This article draws examples from 31 life-history interviews and 188 enrollment observations conducted at Rhode Island's health insurance exchange from 2014-2017. The findings demonstrate that churn persists, despite state efforts to maximize enrollment, and causes poor health outcomes, financial insecurity, and increased stress. We argue that efforts to reform health insurance enrollment policies should be grounded in qualitative understandings of why people lose coverage and should seek to minimize barriers to maintaining continuous coverage.

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

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."

Mere Mortals: Overselling the Young Invincibles.

This article traces the emergence of the term "young invincible" in health policy literature, the health insurance industry, and popular media. Young invincible is the label given to adults under thirty-five who opt not to purchase health insurance because they perceive that they will not need it and would rather spend their money elsewhere. As uninsurance rates climbed, policy makers tried to figure out who the uninsured were and why they lacked coverage. Young adults rightly assumed importance in these conversations because they were disproportionately represented among the uninsured and their numbers were growing. However, the term "young invincible" had the contradictory effect of centering a white, male, high-income chooser as the subject of health policy discourses rather than the far more diverse mix of people who make up the uninsured. This character was imputed preferences and tastes based in economic theory and in long-standing cultural ideals: he was a risk taker, overly optimistic, and preferred cash now to security later. We argue that this heightened concern over young invincibles distorts understanding of the demographics of people who do not have health insurance. It also stokes intergenerational conflict, and frames structural constraints and high prices as a simple consumer "choice."

Insurance Accounts: The Cultural Logics of Health Care Financing.

The financial exuberance that eventually culminated in the recent world economic crisis also ushered in dramatic shifts in how health care is financed, administered, and imagined. Drawing on research conducted in the mid-2000s at a health insurance company in Puerto Rico, this article shows how health care has been financialized in many ways that include: (1) privatizing public services; (2) engineering new insurance products like high deductible plans and health savings accounts; (3) applying financial techniques to premium payments to yield maximum profitability; (4) a managerial focus on shareholder value; and (5) prioritizing mergers and financial speculation. The article argues that financial techniques obfuscate how much health care costs, foster widespread gaming of reimbursement systems that drives up prices, and "unpool" risk by devolving financial and moral responsibility for health care onto individual consumers.

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.

Overutilization, overutilized.

Overutilization is commonly blamed for escalating costs, compromising quality, and limiting access to the US health care system. Recent estimates suggest that nearly one-third of health care spending in the United States is a result of unnecessary care. Despite the surge of exposés that purport to uncover this "new" problem, narratives about overutilization have been circulating in health policy debates since the beginnings of the health insurance industry. This article traces how the term overutilization has spread in popularity from a relatively small community of mid-twentieth-century insurance experts to economists, physicians, epidemiologists, and eventually the news media of the early twenty-first century. A quick glimpse at the history of the term reveals that there has been constant disagreement and debate over the meaning and impact of overutilization. Moreover, the term has been put to very different uses, from keeping socialism at bay to preserving the fiscal integrity of Medicare to protecting the health of patients. The overutilization narrative, seductive in its promise of cutting costs without sacrificing access to quality care, too often drowns out other difficult conversations about social welfare, health equity, prices, and universal coverage.

Critical Anthropology of Global Health "takes a stand" statement: a critical medical anthropological approach to the U.S.'s Affordable Care Act.

The Affordable Care Act (ACA) of 2010--the U.S.'s first major health care reform in over half a century-has sparked new debates in the United States about individual responsibility, the collective good, and the social contract. Although the ACA aims to reduce the number of the uninsured through the simultaneous expansion of the private insurance industry and government-funded Medicaid, critics charge it merely expands rather than reforms the existing fragmented and costly employer-based health care system. Focusing in particular on the ACA's individual mandate and its planned Medicaid expansion, this statement charts a course for ethnographic contributions to the on-the-ground impact of the ACA while showcasing ways critical medical anthropologists can join the debate. We conclude with ways that anthropologists may use critiques of the ACA as a platform from which to denaturalize assumptions of "cost" and "profit" that underpin the global spread of market-based medicine more broadly.

Take a stand commentary: how can medical anthropologists contribute to contemporary conversations on "illegal" im/migration and health?

Of the estimated 214 million people who have migrated from poorer to richer countries in search of a better life, between 20 and 30 million have migrated on an unauthorized, or "illegal," basis. All have health needs, or will in the future, yet most are denied health care available to citizens and authorized residents. To many, unauthorized im/migrants' exclusion intuitively "makes sense." As scholars of health, social justice, and human rights, we find this logic deeply flawed and are committed to advancing a constructive program of engaged critique. In this commentary, we call on medical anthropologists to claim an active role in reframing scholarly and public debate about this pressing global health issue. We outline four key theoretical issues and five action steps that will help us sharpen our research agenda and translate ourselves for colleagues in partner disciplines and for broader audiences engaged in policymaking, politics, public health, and clinical practice.

Myoclonic astatic epilepsy and the role of the ketogenic diet.

The ketogenic diet remains one of the most effective treatments for medically refractory childhood epilepsy. In spite of the long history of its use, relatively little is known about the mechanism of action. The diet's efficacy in a wide range of epilepsy syndromes suggests that it may have multiple mechanisms of action, each of which may be more relevant to a specific disease state. Further research is necessary to define the mechanism of action, which may, in turn, lead to easier means to provide the therapeutic benefit.

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.

Sources of folate and serum folate levels in older adults.

This study examined dietary folate intake in 173 older adults. A subsample (n=128) also provided data about folic acid from vitamin/mineral supplements and serum folate. Subjects were community-dwelling men and women 60 years of age and older. Overall, this sample had healthful dietary patterns with adequate dietary folate. Mean dietary intake converted to dietary folate equivalents (DFE) was 464 microg DFE/day. However, 20% (n=36) had inadequate and 2% (n=3) had high dietary DFE (>1,000 microg DFE/day). A subsample (n=128) completed a dietary supplement questionnaire and biochemical assessment of folate. Adding folic acid from vitamin/mineral supplements to dietary folate (total DFE), intake increased to 766 microg DFE/day; 13% (n=16) had inadequate, 75% (n=95) had adequate, and 13% (n=13) had high total DFE. No subject with low total DFE reported supplement use, but 94% (n=39) with high total DFE intake did so. In the subsample, all subjects had acceptable serum folate levels (mean serum folate=28.0+/-13.8 ng/mL [63.5+/-31.3 nmol/L]). In conclusion, vitamin/mineral supplements should be included in nutrition assessment of older adults. Older adults may be at risk for inadequate folate intake if their energy intake is low, they do not take a vitamin/mineral supplement, or are not consuming fortified cereals. However, older adults may be at risk for excess folic acid intake if they consume both a supplement and fortified cereals.