The Financial Risks of Living Wellness: Contextualizing the Affordable Care Act Wellness Incentives through the Political-economy of Health Risk Management and Health Insurance Governance

Numerous Medical Anthropological accounts describe disparities in accessing health care in broad relation to neoliberal market transformations and state governance. It is in the intersections of political-economy and biomedicine that we see the ways in which individual abilities to maintain health are determined by ties to the global job market that regulate access to resources, including health insurance and health care. Within this framework, the ability to manage one’s health is increasingly tied to market principles that increase vulnerability regarding access to an assembly of resources that affect health status. However, belying the consequences of neoliberal economic policies and transformations that decrease security for individuals and families, public health paradigms largely focus on health behaviors and individual lifestyle choices to explain health disparities. This paper describes the financial links to health behaviors that emerged through ethnographic participant-observation and semi-structured interviews in an urban Central Appalachian community in 2007-2008. While my research broadly asked how union members of the United Steelworkers (USW) and Retail, Wholesale, and Department Store Union (RWDSU) unions in this community described the links between health insurance, access to health care, and union membership, this paper relocates health behaviors within a political economic framework to showcase the complexities of cultural and economic factors (e.g. changing employment statuses, wage differentials, social location, and health insurance status) that influence individual and family choices for maintaining health. Theoretically, this paper utilizes political-economy, health risk behavior, and health insurance governance perspectives to contextualize the ways in which differentially insured individuals and families seek to mitigate the financial burden of health risk, including health risk avoidance and prevention. In so doing, I discuss instances of “job lock” in terms of health insurance access and draw upon recent reevaluations of fatalism to reassess how negative health and lifestyle behaviors are sometimes rational responses in the form of risk management regarding employment and health insurance governance. Ultimately, I argue that revisiting the actions (agency) individuals take towards securing health and financial security within a health behavior paradigm unmasks the political-economic nature (structure) in which health disparities have expanded from the rewriting of the social contract linking work with culturally appropriate access to health care. I argue here that expanding the health behaviors concept to include a broader array of actions individuals take to better their health and well-being provides a means of placing health disparities into meaningful social context, creating avenues for better public health outcomes. The implications of this research point to the need to re-categorize health behaviors within a framework that acknowledges the political economic shifting of risk management to individuals and families, especially as through increased consumer cost-sharing disincentives (health insurance premiums, deductibles, and co-pays) to health seeking behavior. In so doing, I offer an informed critique of the Wellness programs incentivized in the Affordable Care Act in relation to health behavior risk assessment.