Shadow Standards and the Logic of Costs: Care, Stewardship, and Data in U.S. Community Health
type: CreativeWork
description: This dissertation examines the delegation of responsibility for providing health care to particular categories of marginalized populations in the United States in the absence of a uniform and universal health care system. It explores how the U.S. federal government governs patient populations at a distance by mandating that healthcare providers collect, produce, and report on patient data. Drawing from eighteen months of ethnographic research in Massachusetts clinics for the homeless and the frail elderly between 2014-2015, I argue that when marginalized patients are unable to satisfy the neoliberal ideal of self-governance to maintain their health in cost-effective ways, providers are activated to bring them into compliance. Through the lens of political economic, science and technology studies, and critical medical anthropologies, I identified how reimbursement models and government funding requirements redesigned under the 2010 Affordable Care Act obligate health care providers to reframe the care they provide. Providers cultivate what I term the “logic of costs,” a budgetary lens for making care decisions that frames management of costs as essential to care. Data creation and reporting practices require providers to adopt a logic of costs, as such data informs whether their clinics will be deemed effective and the clinics’ funding reauthorized. I trace the incongruities between actual care practices and the metrics that clinics end up recording and submitting to represent their work and their patients. I argue that this work is made possible through the creation of “shadow standards,” unofficial, undocumented, and yet routinized healthcare practices that make the creation and reporting of health data possible, even when providers do not have the resources to comply.
abstract: This dissertation examines the delegation of responsibility for providing health care to particular categories of marginalized populations in the United States in the absence of a uniform and universal health care system. It explores how the U.S. federal government governs patient populations at a distance by mandating that healthcare providers collect, produce, and report on patient data. Drawing from eighteen months of ethnographic research in Massachusetts clinics for the homeless and the frail elderly between 2014-2015, I argue that when marginalized patients are unable to satisfy the neoliberal ideal of self-governance to maintain their health in cost-effective ways, providers are activated to bring them into compliance. Through the lens of political economic, science and technology studies, and critical medical anthropologies, I identified how reimbursement models and government funding requirements redesigned under the 2010 Affordable Care Act obligate health care providers to reframe the care they provide. Providers cultivate what I term the “logic of costs,” a budgetary lens for making care decisions that frames management of costs as essential to care. Data creation and reporting practices require providers to adopt a logic of costs, as such data informs whether their clinics will be deemed effective and the clinics’ funding reauthorized. I trace the incongruities between actual care practices and the metrics that clinics end up recording and submitting to represent their work and their patients. I argue that this work is made possible through the creation of “shadow standards,” unofficial, undocumented, and yet routinized healthcare practices that make the creation and reporting of health data possible, even when providers do not have the resources to comply.
author: Whitten, Margarite J
keywords: Community Health and Preventive Medicine, Health Policy, Inequality and Stratification, Medicine and Health, Science and Technology Studies, Social and Cultural Anthropology, Work, Economy and Organizations, medical anthropology, care work, United States, homelessness, elder care
date published: 2020-06-01T07:00:00Z
date modified: 2026-07-24T01:59:21Z
provider: City University of New York - Graduate Center
publisher: Networked Digital Library of Theses and Dissertations
type: WebPage
source organization: The Graduate School and University Center of The City University of New York