Thrifting for More: Savings and Aspirations in Health Care Sharing Ministries after the Affordable Care Act

Like a Grinding Stone: How Crowdfunding Platforms Create, Perpetuate, and Value Health Inequities

This article explores how inequities are reproduced by, and valued within, the increasingly ubiquitous world of medical crowdfunding. As patients use platforms like GoFundMe to solicit donations for health care, success stories inundate social media. But most crowdfunders experience steep odds and marginal benefits. Drawing on the problematic figure of the "black box" in health disparities research and technology studies, I offer ethnography as a tool for unpacking often inscrutable and complex pathways through which online platforms amplify inequities. By leveraging both online and traditional research strategies-a platform analysis and paired narratives of crowdfunders' disparate experiences, drawn from open-ended interviews-this article explores how inequities are created and experienced by users. The analysis highlights how inequities are simultaneously central to the functioning of this marketplace and occluded by its platform design. Consequently, crowdfunding is concealing health inequities while shifting public values about who is entitled to health care, and why.

Design principles for risk-pooling systems

In times of crisis, risk pooling can enhance the resilience of individuals, households and communities. Risk-pooling systems are most effective when their participants adhere to several principles: (1) participants should agree that the pool is for needs that arise unpredictably, not for routine, predictable needs; (2) giving to those in need should not create an obligation for them to repay; (3) participants should not be expected to help others until they have taken care of their own needs; (4) participants should have a consensus about what constitutes need; (5) resources should be either naturally visible or made visible to reduce cheating; (6) individuals should be able to decide which partners to accept; and (7) the scale of the network should be large enough to cover the scale of risks. We discuss the cultural and evolutionary foundations of risk-pooling systems, their vulnerabilities and their relationship to commercial insurance.

Freed from insurance: Health care sharing ministries and the moralization of health care

Since the Affordable Care Act (ACA) was passed in 2010, health care freedom has become a kind of mega-narrative trumpeted by Republicans leaders who decry government overreach. I turn to faith-based, non-profit organizations called "health care sharing ministries"(HCSMs) to consider the work that this mega-narrative does in everyday health care lives. While HCSMs are not insurance, HCSMs share in the payment of medical bills and are written into the ACA as one religious exemption to the individual mandate. Based on ethnographic interviewing done with 31 people in Maryland, Ohio, Virginia, and Pennsylvania between 2015 and 2020, I examine the ways that Americans who belong to HCSMs take up freedom as a guiding frame to reflect on and moralize their health care. I argue that articulations of freedom in HCSMs involve freedom from the constraints of bureaucratic care and governmental control and are tethered to a single, overarching moral discourse that presents freedom as the freedom of choice. I suggest, therefore, that being a part of an HCSM is about getting health care-including getting it cheap-but it is also about how the health care makes people feel as moral persons in the current political climate of U.S. life.

Crowdfunding and global health disparities: an exploratory conceptual and empirical analysis

BACKGROUND

The use of crowdfunding platforms to cover the costs of healthcare is growing rapidly within low-, middle-, and high-income countries as a new funding modality in global health. The popularity of such "medical crowdfunding" is fueled by health disparities and gaps in health coverage and social safety-net systems. Crowdfunding in its current manifestations can be seen as an antithesis to universal health coverage. But research on medical crowdfunding, particularly in global health contexts, has been sparse, and accessing robust data is difficult. To map and document how medical crowdfunding is shaped by, and shapes, health disparities, this article offers an exploratory conceptual and empirical analysis of medical crowdfunding platforms and practices around the world. Data are drawn from a mixed-methods analysis of medical crowdfunding campaigns, as well as an ongoing ethnographic study of crowdfunding platforms and the people who use them.

RESULTS

Drawing on empirical data and case examples, this article describes three main ways that crowdfunding is impacting health equity and health politics around the world: 1) as a technological determinant of health, wherein data ownership, algorithms and platform politics influence health inequities; 2) as a commercial determinant of health, wherein corporate influence reshapes healthcare markets and health data; 3) and as a determinant of health politics, affecting how citizens view health rights and the future of health coverage.

CONCLUSIONS

Rather than viewing crowdfunding as a social media fad or a purely beneficial technology, researchers and publics must recognize it as a complex innovation that is reshaping health systems, influencing health disparities, and shifting political norms, even as it introduces new ways of connecting and caring for those in the midst of health crises. More analysis, and better access to data, is needed to inform policy and address crowdfunding as a source of health disparities.