Paper short abstract:

This paper examines how the misleading neologism “consumer directed healthcare” plays out in two U.S. settings: a dental “safety net” and an electronic insurance marketplace. Patients are obligated to act, and even feel, like consumers despite the reality that their “choices” are highly constrained.

Paper long abstract:

Consumers want choices. They want their pick of provider, to only pay for the care that they want, and to avoid being over-insured. These assumptions underwrite "consumer directed healthcare", the most recent pro-privatization, pro-competition ideology to take hold in the $2.9Tril U.S. health care industry. This misleading neologism places consumer "choices" at the center of health policy priorities, even though most innovations offered by this model result in a retraction of benefits and cost-shifting away from employers and public payers and onto consumers themselves. In this paper, we examine how "choice" plays out on-the-ground in two very different settings. In one site, low-income Appalachians' efforts to obtain dental care within a fragmented and hybridized public-private dental "safety net" are gatekept and otherwise shaped by individual providers. In the other site, uninsured residents of Rhode Island try to purchase insurance coverage on electronic insurance marketplaces, but find they need considerable help in navigating the choices they are compelled to make by new legal mandates. "Consumer-directed" health care obligates patients to act, and even feel, like consumers despite the reality that, for many, their health care "choices" are highly constrained.