Theses Doctoral

The Patient as Consumer: In Whose Interest? The Role of Health Consumer Rhetoric in Shaping the U.S. Health Care System, 1969-1991

McMahon, Caitlin Elizabeth

In 1969, President Richard Nixon declared that the “spiraling costs” of medical care constituted a “crisis.” Medicare and Medicaid had been passed only four years previously, and had dramatically changed the way Americans accessed and paid for medical care. The ensuing three decades ushered in a renewed period of advocacy for health care reform with costs remaining a consistent focus. Proponents for national health insurance framed health as a human right emphasizing equitable access. Those advocating for private health insurance touted the power of the marketplace to contain costs through competition and freedom of choice. Throughout the debates, health reform advocates, insurance industry representatives, medical providers, and legislators repeatedly referred to the “health consumer” as the potential benefactor of such reforms. But this ubiquitous term remained ambiguous. Who exactly was the “health consumer”?

The contests over the rhetoric of the health consumer as an identity, its uses and political alignments, were engaged through print, in research, in organized campaigns, and in discrete individual interactions with health insurance and the health care system. These interconnected systems of power informed and were informed by the language used to describe them, in the sense of “structuring structures,” extending to economics and the consumer movement, social movements and civil rights. Thus the ideological orientations of the terms of the debate, focused on the “health consumer,” have shifted often and have continued to be contested in a dialectic relationship.

This analysis therefore takes place at those intersections where health consumers as individuals have confronted the private, for-profit sphere by making claims for health consumer rights. The utility and ethical implications of commodification versus rights language have consistently been at the center of these opposing views. This dissertation examines the evolution of the dialectic dynamic of these two approaches to better understand how health consumer rights advocates have confronted challenges to include their voices in health care debates from the 1970s to the late 1980s at the local, state, and national levels. Specific sites include the Office of the Commissioner of Insurance and the Center for Public Representation, both located in Wisconsin, as well as the national grassroots organization Citizen Action and the local chapter Massachusetts Fair Share. Moving beyond binary understandings such as "patients" and "non-patients," or even the "patient/consumer," the health consumer identity blurs distinctions of inclusion and exclusion and dramatically expands the framing of "who counts" in health social movements.

The health consumer thereby has remained a locus of contestation and potential rhetorical power that can inform the more political use of the term for making rights claims, as well as the more economic approach that advocates for free market principles. As such, it is readily co-opted in movement/counter-movement shifts in language and political alignment. Such contests and co-optation frame each chapter in this dissertation. Ultimately, health social movements and the dynamic, even equivocal orientation of the “health consumer” identity may play a determinative role in how to move forward with health care policy reform that seeks to provide all Americans with equitable access to wellness, rather than vying to purchase health.

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More About This Work

Academic Units
Sociomedical Sciences
Thesis Advisors
Chowkwanyun, Merlin
Ph.D., Columbia University
Published Here
July 16, 2021