Group Healthcare Narrative Template

 

Title (bold)

• Opening Vignette setting the mood and introducing your audience to an iconic scene in your fieldsite 
• make sure at least one of your themes is illustrated in the vignette
• quotations should be minimal in a vignette if at all

• Providers' perspectives
• begin with a short evocative quote (single sentence) --name (heading), or a mini vignette
• Introduce your analysis of the provider's perspective on challenges to access 
• Illustrate your analysis with quotations and interspersed thick descriptions which introduce your "characters"
• analyze each illustration  and support your analysis with citation from text or your research if appropriate. Cite this in Chicago style.
• Make sure you 

• Clients' perspectives (repeat)

• Concluding analysis
• summarize your themes
• summarize your analysis
• Make sure that you utilize the TEXT especially in this section.
• conclude with a powerful quote that sums up the issue of unequal access to healthcare at your site.

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General principles for writing ethnography to remember:

1. We are not writing ABOUT our fieldwork or OUR experiences or what WE learned. We are using our fieldwork as data to illustrate our findings in evocative ways that promote both EMPATHY and understanding.
2. DESCRIBE things so that your reader can EXPERIENCE the cultural scene as you did. The idea is to have your audience have an EXPERIENCE not that you tell them what is going on. (Show me don't tell me)
3. Remember when you can to use the paralinguistic information in your quotations (not in transcription form but in description). This is a way to keep your thick description throughout the text and not just in vignettes. Make the writing flow.
4. Develop you CHARACTERS. Use thick description to do this and introduce them in action (what they are doing in the fieldsite). These descriptions should reveal important facts about the individual that help the reader both empathize with them, and understand their place in the cultural scene.
5. Tell a story from the perspective of your informants. You are simply the tour guide.
6. Cite supporting research in Chicago style.

Unequal Access: Conclusions

 

Trump tapped into and fueled the revulsion toward the ACA-already the political divisions as a backlash against Obama.

• beliefs
• resentment of the law rather than the technocrats who fought to implement it
• belief that others are benefitting but not themselves
• deductibles were too high
• bureaucratic hurdles to enrollment
• doctors not accepting coverage
• disagreed with tax implications
• website too difficult to navigate
• took country in wrong direction
• increased health costs
• too big a role for government

-Law became a flashpoint for battles over inequality, fairness, and the role of government

-Became a vehicle for generating hostility against women, immigrants, the poor, and racialized minorities

-politicians used public resentment against the implementation of the law

• The truth?
• some people argue that we are in a post truth culture where facts dont matter, but the authors conclude that facts do matter, and that people are just relying on facts that people they trut tell them. It is more about a rejection of the educated elite rather than facts. They will believ science when it is convenient. -the eclipse will happen at this time- but not when it is associated with the educated "elites" they resent.
• Discourses of truthiness are widespread
• Lessons
• people need and want affordable healthcare
• people need comprehensive, integrated health systems, but we have yet to define what these are
• Oral health (dentisty) is not ever included...why?
• Every other economically advanced country provides universal healthcare
• stratification leads to POOR healthcare
• Stratified approaches to expanding Access generate resentment
• seems unfair
• dont understand how decisions are made
• some fall through cracks
• geography matters
• Enrollment should not be so hard
• poor already have so much surveillance and barriers that constant need to reenroll becomes burdensome
• proposals to add work requirements etc. would increase this burden
• costs more to AUDIT than deliver healthcare
• Anti immigrant polices are anti health
• emergency room cost skyrocket
• Conclusion
• too modest
• did not change for profit structure
• lacked shared social purpose (like Article 54)

Movie

in Hospitable

Increasing Access, Increasing Responsibility: Activating the Newly Insured

Discourses of Co-Responsibility and Patient Engagement

Based on the ACA credo of joint responsibility. The health care providers would do their part, but it was ultimately the responsibility of the patients for their own healthcare. This essay looks again at this issue in New Mexico.

• Co-responsibility and Latin American poverty alleviation & patient responsibility in healthcare in the US
• the idea that both the patient and healthcare providers have a responsibility to make sure that goals are met
• patients are required to improve their health through various measures
• providers are required to assist them
• Clients are perceived as active participants in the improvement of their lives rather than recipients of welfare
• Oportunidadas (example)
• program gives funds and workshops to mothers who are to use the training and money to improve the education and health of their children
• thought to break the cycle of poverty through active responsible behavior
• used today in association with ACA (perspective)
• Patient engagement is defined as: "the relationship between patients and health care providers as they work together to promote and support active patient and public involvement in health and healthcare and to strengthen their influence on healthcare decisions at both the individual and collective levels.
• relies on SHARED RESPONSIBILITY and COLLABORATION among patients, providers, health care  administrators and communities
• motivating patients to increase their involvement in their own healthcare
• primary tool for achieving the triple aims:
• reduced cost
• improved patient experiences
• improved health outcomes
• while there is often a recognition of vulnerable populations who lack the ability to participate fully in this process, nothing is done to address the structural inequalities. Instead, modified interventions are suggested to help these vulnerable populations better engage.
• The Affordable Care Act in Action
• Ongoing Barriers to Access
• lack of documentation
• Being just over the income limit for medicaid
• lack of awareness to apply for medicaid
• difficulties with requirements for HMOs
• lack of education about healthcare alternatives
• lack of funding to support patients in getting documentation
• permanent address- homeless
• birth certificate- especially for immigrants

Focus remains on individual patients and their responsibility rather than the structural barriers to access insurance and healthcare

Outsourcing Responsibility: Behavioral Health Care Services

This chapter looks at the behavioral healthcare crisis in New Mexico, and how systematic failure,  top down healthcare reform, and corporate profit, culminated in the use of FEDERAL FRAUD PROTECTION (in the patient protection clause in ACA) to CURTAIL availability of and access to services.

• these actions have adversely affected groups of citizens who do not have access to the social capitol and political clout to advance meaningful change in how their services are structured, financed, or delivered.
• New Mexico has one of the worst behavioral health systems in the countries with the highest levels of addiction and untreated mental health issues
• 87% of services were offered by the nonprofit sector (before they were forced to close because they were accused of fraud and could not afford to fight the audits)

Total bureaucratization, transparency, and "Truthiness"

• Premised on the adoption of neoliberal ideology and marketization of healthcare
• Assumption: Health care costs are the result of inefficient government management
• Solution: Privatization
• dismantling of social welfare programs- gives people choices!
• marketization- partnership between government and profit-driven private entities
• accompanied by new standards of management and accounting, and technologies of supervision = "total bureaucratization" (David Graeber)
• ultimate goal is to extract profits from the social programs
• audit system devised to promote accountability
• nonprofit system in NM was deemed nontransparent and corrupt (although they were cleared of all charges-damage was already done)
• accusations become shrouded in an aura of "truthiness"- where absent evidence we still feel that it is true in our gut-the appearance of truthfulness.
• 1997- NM institutes MANAGED CARE for behavioral and mental health services
• address public sector accountability and decrease costs
• in practice, diverted funds from care to corporate administration and created financial hardship for providers
• more than 60 programs closed reducing services dramatically
• specialty clinics stopped accepting medicaid patients
• 2005- "Transformation" reforms led to the contracting with the for profit ValueOptions a behavioral health subsidiary of United Healthcare, Inc. (headed by a former governor)
• subject to recurring implementation problems and although they were implemented because of the need for transparency and accountability, they never produced data (either) that showed their performance (which was dismal)
• frequent billing and coverage changes
• higher overhead and labor cost for providers
• long waits for reimbursement and survival dependent of unaccounted "prepayments" which were later subject to "reconciliations" costing providers even more
• created an adverse relationship with service providers
• sold as "modernizing behavioral healthcare"- providers accused of not adjusting and being greedy
• 2014- together, called CENTENNIAL CARE

Fraud and Transparency Under Centennial Care

• 5 months prior to enacting CC, the HSD accused 20 nonprofit organizations of fraud. 
• New govt. rules required that "credible allegations" mandated the halting of payments by OptumHealth 
• meanwhile they made a 3$ contract (in secret) with PCG to conduct audits on the nonprofits - agreeing that any violations founds would send those monies to OptumHealth (profit)
• Accused nonprofits of mishandling services (like failure to provide hospitalization) for services they didn't even provide-- even though previous audits had given all the nonprofits high marks
• ACA had empowered the state agencies to aggressively crack down on fraud and waste, and although they were offered a half dozen other alternatives to halting payments, they didn't take advantage of them
• implement other remedies to protect medicaid funds
• allow the organizations to provide written evidence to the contrary
• allow some services that are not deemed compromised to continue
• conclude that the payment suspension is not in the best interest of medicaid
• OptumHealth portrayed as the hero- rooting out fraud and providing modern services
• Choices
• shut down their nonprofits
• allow 5 other for profit companies already selected from AZ to take over their facilities, internal operations, and clinical care. (most took the hostile takeover option)
• 2016- All accused nonprofits were exonerated after it was shown that 35,000 patients had lost care, resulting in increased rates of suicide and incarceration, and homelessness. 
• also uncovering of fraud and corruption, political payoffs by journalists
• Of the cleared, most were already out of business
• 2018- When money was no longer available, 4 of the 5 Arizona companies pulled out of the state, creating a huge service gap
• Optumhealth was accused of fraud (and falsifying fraud claims of others to benefit) but was continually paid by the state during this time
• OptumHealth covered up false medicaid claims to get larger reimbursements.

New Mexico still has the worst behavioral health system in the country.

Responsibility: Pharmaceutical Regulation of Chronic Disease Among the Poor

This chapter explores the ways in which patients and healthcare providers at a Massachusetts Health Clinic were made accountable through the private sector rationales of:

• Transparency
• Individual Responsibility
• Cost Effectiveness

that are meant to manage chronic disease under healthcare reform.

Problem:

• many of the reforms with ACA went less far than Article 5 Had.
• federal subsidies for low to moderate income were lower under ACA
• Payments to safety net hospitals were lower (Lost 1/2 billion dollars in 10 years)
• Mass. had appealed to the ETHICAL principles of redistributive justice in an effort to get people to buy into article 54
• linked ethical claims and  economic justifications to notions of ACCOUNTABILITY (application of the business model)
• cost control
• transparency
• good business practices
• return on investment

ANTHROPOLOGY OF ACCOUNTABILITY

• the ethical injunction to take responsibility for , or be held responsible for wrongdoing
• the "new managerialism": transparency and cost control
• discipline  and accountancy, financial and human accountability were merged. 
• Neoliberal "privatized actuarialism" 
• apply to your individual private lives the same principles applied to audit corporations and bureaucracies. 
• individual responsibility and risk minimization
• increased burden of documentation and verification

How do poor patients with chronic diseases manage their health considering the contradictory policies of expanded access and cost control?

• Techniques of Cost Control
• bureaucratic disentanglement
• prevents "rights" from being translated into benefits in many cases
• deferral, disinformation, delay in enrollment processes
• Cost control measures ACA
• limited application periods
• slashed number of healthcare guides
• need to re-qualify and reapply each year
• RITUAL OF CERTIFICATION
• All led to a distrust of the medical system

Controlling Pharmaceuticals for the Chronically Ill (techniques)

• Three ways for patients to experience Accountability"
• Changing Formularies
• Constantly changing medications which are paid for by insurance companies or subsidized by the federal government
• third party payers become the locus of cost control (if the govt. does not negotiate, as with drug companies-as with medicare/caid)
• generic drug requirements
• tiered formularies with higher copays for name brand drugs
• associated with decreased compliance in chronically ill patients, and increased emergency room and inpatient care
• disrupted relationships with physicians and familiarity with drug protocols
• different brands may affect patients differently
• physicians may get around this by giving their patients drug samples given to them by the pharmaceutical companies when a drug is no longer preferred.
• dependent of varying supplies
• creates immense insecurity in patients
• lose faith in doctors and their knowledge
• more stringent authorization and review strategies
• better management of small number of high cost medicaid patients and prescription drug benefits
• Transparency-see the cost of their care- their share and the governments
• cost sharing statements served NOT to make assistance recipients feel better, but to stigmatize them because they received assistance.
• meant to foster personal responsibility -- but why? Business model.
• Struggle to pay high out of pocket expenses
• Even those with good insurance had trouble paying for copays for drugs. 32% reported not taking drugs properly because of cost
• depending on who is working, they may get a waiver-unequal application by pharmacies- even though policies were intended to be transparent, but people saw them as arbitrarily applied
• coping strategies
• decide which are the MOST IMPORTANT DRUGS to take and don't take all that they should everyday
• hoarded pills
• share medications with others

Actuarial techniques are indicative of the decline of public trust and increased need for transparency and visibility. has led to tripling of cost of administration

• increased demands for evidentiary support ($$$)
• entail massive time consuming busywork by institutions and providers ($$$)
• ceaseless reviews of performance, productivity, and efficiency ($$$)

Texans Don't Want Health Insurance

This article looks at the way Texans view healthcare. It surprised the author that many Texans who hand the means decided to remain uninsured. This study looked at why, and the importance or lack of importance of social class.

Sherry Ortner's definition of social classes in the USA:

While movement is theoretically possible between classes, being a particular social class influences the way one thinks and talks about themselves and others and how they act. The differences that stem from this result in the perpetuation of social class. In other words, there is a "sharing of culture" within social classes

• Lower Class- 
• working class
• do not own the means to production
• earn a living through some type of manual labor
• poorest
• often non-white, although the majority of poor are white
• strong element of racism plays into the PERCEPTION of the lower class
• Lower Middle Class-
• working class
• do not own the means to production
• earn a living through some type of manual labor
• Upper Middle Class-
• act as administrators and managers, and do not work in manual labor
• more wealth than lmc
• Upper Class-
• WASPs who have old money
• owners of the means to production

There is no middle class according to Ortner, it is an attractive cultural ideal without merit-- it is the way that most people "identify" and why we may think that America is a classless society.

• the denial of classes leads to the condemning of those whose personal failings are seen as their fault rather than the result of structural inequality.
• only nation not to produce health statistics by social class
• health policy neglects class disparities and instead focuses on race
• dog whistle politics and racism are said to undermine class solidarity and prevent more generous social welfare policies
• some argue that upper class owners of medical services and insurance companies were the real beneficiaries when the single payer system was cast aside in favor of a hybrid that worked within the existing system.

texas and ACA

• before ACA Texas boasted the highest level of uninsurdes and almost 25% or 7 million people.
• texans are knowm for their sense of Texan identity and their loyalty to the state.
• Second largest state with the second largest population.
• political rhetoric
• cost millions of jobs
• raised healthcare costs
• caused people to lose their insurance
• provides support to people that don't deserve it
• still by 2016- decrease in uninsured to 18% (still double the national average)
• coverage gap can be attributed to income levels.
• did not expand access
• coverage for middle and upper class went down 43% in cost. For poor and lower middle class only about 15%.
• coverage gap bu INCOME
• Anna (lower class)
• no knowledge of ACA or how to get it
• receiving stigmatized indigent care
• feeling that she is under surveillence
• no internet or computer so hearing mostly texas govt. rhetoric
• does not qualify for unexpanded medicare
• Beth (lower middle class)
• got insurance coverage through the market place that was subsidized by her husband's employer and the govt.
• was still not a supporter and felt stigmatized for getting Obamacare
• found it too difficult to figure out the marketplace when husband became self employed and Texas did not support a navigator system to help individuals
• Cate: Upper middle class
• tax penalties led to resentment
• chose before not to get healthcare insurance
• want to be free not to have it

Onus of care on WOMEN who took responsibility for finding insurance and caring for their families whether parents or spouse and children. All had forgone employment opportunities which could have offered them health insurance (employment based). 

Social Class and Differeneces in Health Coverage

• ability to gain coverage through ACA
• all concerned about "accidents" which made them feel vulnerable without coverage
• Anna
• felt marginalized
• never really part of the healthcare system
• had any untreated ailments and poor health
• uniformed about ACA
• cited STRUCTURAL BARRIERS that prevented her from getting health insurance
• Beth
• felt irresponsible for not having health insurance
• also felt guilty about obtaining healthcare through obamacare
• too complicated a process and cost too high
• Cate
• personal CHOICE to forgo insurance coverage
• Independence and self reliance as texan and neoliberal values
• Also not able to get employer based insurance
• felt capable of managing her own risk, believed stereotypes about the other uninsured but not herself

Complained but did not take action to change anything even though they felt that it should all be overhauled. LACKED THE CLASS CONSCIOUSNESS to join to take action because of the neoliberal perspective and stereotypes about race (dog whistling) and immigration.

All the same age from the same area but had differenr class-based experiences. 

People without health insurance are much more likely to suffer health issues and premature death