Keeping up with the Cadillacs: What Health Insurance Disparities, Moral Hazard, and the Cadillac Tax Mean to The Patient Protection and Affordable Care Act


A major goal of The Patient Protection and Affordable Care Act is to broaden health care access through the extension of insurance coverage. However, little attention has been given to growing disparities in access to health care among the insured, as trends to reduce benefits and increase cost sharing (deductibles, co‐pays) reduce affordability and access. Through a political economic perspective that critiques moral hazard, this article draws from ethnographic research with the United Steelworkers (USW) at a steel mill and the Retail, Wholesale and Department Store Union (RWDSU) at a food‐processing plant in urban Central Appalachia. In so doing, this article describes difficulties of health care affordability on the eve of reform for differentially insured working families with employer‐sponsored health insurance. Additionally, this article argues that the proposed Cadillac tax on high‐cost health plans will increase problems with appropriate health care access and medical financial burden for many families.

Obamacare on the steps of the Supreme Court. Will O'Neill. June 28, 2012.
Obamacare on the steps of the Supreme Court. Will O’Neill. June 28, 2012.

Author Biography

As a medical anthropologist, Rebecca Adkins Fletcher’s research interests are based in health disparities. Her work intersects the anthropology of work and labor studies, the anthropology of finance, activism, gender and women’s studies, and globalization to examine how health disparities and access to resources are tied to economic and social restructuring.

Editorial Footnotes

If you liked this article, you might also be interested in articles previously published in Medical Anthropology Quarterly on inequalities and US health care reform including Louise Lamphere’s (2005) Providers and Staff Respond to Medicaid Managed Care: The Unintended Consequences of Reform in New Mexico, Leslie Lopez’s De Facto Disentitlement in an Information Economy: Enrollment Issues in Medicaid Managed Care, and Gay Becker’s Deadly Inequality in the Health Care “Safety Net”: Uninsured Ethnic Minorities’ Struggle to Live with Life-Threatening Illnesses.

In addition, you might find the Medical Anthropology Quarterly papers on consequences of market-based healthcare systems such as Barbara-Rylko Bauer and Paul Farmer’s (2002) Managed Care or Managed Inequality? A Call for Critiques of Market-Based Medicine, James Ellison’s (2014) First-Class Health: Amenity Wards, Health Insurance, and Normalizing Health Care Inequalities in Tanzania, and Sarah Horton’s (2004) Different Subjects: The Health Care System’s Participation in the Differential Construction of the Cultural Citizenship of Cuban Refugees and Mexican Immigrants of interest.

Finally, regarding the potential role of medical anthropologists have in the US for informing health policy, read the Medical Anthropology Quarterly articles by Carolyn Sargent’s (2009) President, Society for Medical Anthropology Speaking to the National Health Crisis and Sarah Horton, Cesar Abadía, Jessica Mulligan, Jennifer Jo Thompson’s (2014) Critical Anthropology of Global Health “Takes a Stand” Statement: A Critical Medical Anthropological Approach to the U.S.’s Affordable Care Act.

Interview with the Author

1. How did you become interested in US health policy as a research topic?

While the basis of my work lies in health disparities, I was interested in “studying up” to include working and middle class families with employer-sponsored health insurance to expand discussions of access to health care and affordability. I was asking what importance employer-sponsored health insurance held in accessing health care for union families in an urban Central Appalachian community. Through the interviews it became obvious that the differences in health insurance types and overall quality (e.g., network, deductibles, co-pays, exclusions) were a primary cause for concern or ease with how participants negotiated the health care system and understood accessibility to health care. The political discussions and ultimate passage of the Affordable Care Act occurred while I was in the field and writing my dissertation, and it was the culmination of these events and my research that led me to deeper interests in health policy.

2. How did you become interested in work in Central Appalachia?

I believe that if you want to understand disparities in the United States and the processes of globalization, then you have to understand Appalachia. Rather than a region set apart and filled with stereotypical caricatures, Appalachia is a dynamic heterogeneous region that is a mirror of American culture, politics, and economic transition. People in Appalachia have a great deal to teach us about the issues that most directly affect American families and groups today, and this is especially true with respect to health disparities and access to health care.

3. What were some challenges you faced while completing your fieldwork?

While I had intended to utilize snowball sampling (as one method) for participant recruitment within the unions, this did not work well within this setting. Actually, rank-and-file union members, both male and female, were very reluctant to recommend others to talk to me. I believe this to be due, in part, to the demanding work schedules at the food processing plant and the steel mill combined with other family and social obligations, and people were simply reluctant to recommend (and obligate) others. However, and maybe more importantly, participants appeared uncomfortable with asking a fellow union member to talk with me, as this was “asking a favor” of their union brother or sister. As a result, the majority of interview participants from both unions were recruited to this study by union representatives and not through snowball sampling. Ironically, my inability to utilize snowball sampling as intended for recruitment assisted in social network analysis among the union members, which is another benefit of this sampling methodology. Although problematic, the union tradition that encourages members to look out for each other made this sampling bias unavoidable, and I worked in other ways to reduce this potential bias in the study. It goes to show that sometimes we learn as much from what does not work as intended in the field as from what does.

Anti-McCain Protest Rally in Washington County. Molly Theobald. August 30, 2008.
Anti-McCain Protest Rally in Washington County. Molly Theobald. August 30, 2008.

4. You worked with representatives of two unions of different industries (steel workers and a food processing plant).What led you to choose these two groups? Did you find that the type of labor performed or the fact that they were unionized specifically influence people’s relationships with the government or insurance companies?

I was interested in understanding access to health care issues from the perspective of insured working families in the region and working with unions that are involved in “new” unionism activism strategies. The United Steel Workers and Retail, Wholesale and Department Store Union locals were both extremely generous with their time and supportive of my research efforts. In addition to these two unions, I did participant-observation with a labor council that included union representatives from many different sectors, including industrial, trades, and service unions to better understand the broader community, labor, and political issues from their perspective. The union representatives, as well as many rank-and-file members, were very politically informed, and the labor council was active, especially on the community and state level. This included GOTV member-to member political canvassing, phone banks, staying informed on state legislative efforts, and contact with political representatives. In terms of the union’s relationship to health insurance, these two unions had different types and qualities of coverage that was directly related to the size of the industries and each union’s bargaining power. Representatives from both unions cited negotiations regarding health insurance benefits as one of the most critical aspects of contract negotiation, with these benefits highly valued by members.

5. In your article, you discuss that part of the goals of your research is to answer a specific call for medical anthropologists to contextualize the PPACA on the ground. What significance do you think this project could have overall and for anthropologists? How can it help us better understand the government’s role in the everyday, and how the everyday can influence how our government works?

It is important to remember that public policies differentially affect the quality of life for many people and groups. This is certainly true with health policy. As there is often a difference between ideal and real culture, one place anthropologists can effectively apply our skills is in making this differential obvious in ways that get beyond the political rhetoric and document what actually happens in the spaces of everyday life. This is a contribution toward public accountability across many levels, and in this case, for government, policy makers, insurance companies, and health care providers. Regardless of the intentions and the need behind a health policy intervention, it is important to understand how policies are interpreted, implemented and experienced. Anthropologists are uniquely qualified to follow on-the-ground actions and intended and unintended consequences across a community to give informed understanding to the public and policy makers. This article represents but one piece of the puzzle and, I hope, demonstrates the importance of following health policy and the finance of health care and health insurance among many groups.

Questions for Classroom Discussion

  1. How does Adkins Fletcher’s ethnography call into question the economic notion of moral hazard?
  2. How might workers’ relationship with their health care differ if, instead of seeing insurance as a business, they saw access to care as a right?
  3. What would it mean for your personal finances if your health care expenses met the maximum out-of-pocket affordability rate of 9.5% of your total living expenses as set by the Affordable Care Act for one year? For five years? For ten years? How does the amount of money you would spend on health care compare with your other living expenses?

Additional Resources

Campbell, D. (2011). Anthropology’s Contribution to Public Health Policy Development. McGill Journal of Medicine, 13(1), 76.

UC Berkley Labor Center. The Affordable Care Act: A Guide for Union Negotiators.

Politico. 5 questions about the unions’ beef with Obamacare.

NBC Nightly News. Employers cut health benefits to prepare for ‘Cadillac’ tax. (video)