Health Insurance Reform and Intimations of Citizenship

This article considers the implications of the Patient Protection and Affordable Care Act (PPACA) for social meanings of civic belonging in American society and for possible new forms of individual engagement with the health care system. Once fully implemented, PPACA will have many of the governance characteristics of other social insurance systems, in that it will define membership in a collective undertaking, establish a mechanism for collective security against a shared risk, and channel, incentivize and penalize specific behaviors. The article considers the extent to which PPACA has the potential to also produce new narratives and understandings of social solidarity and a heightened degree of participation in the politics of health care. An underlying premise is that the law’s structural and normative realms are mutually constitutive. As a new conceptual lens for approaching these questions, the article introduces and defines the idea of “citizenship practices.” “Citizenship practices” is intended to signify regularized behaviors and interactions with a system of governance and a coherent (although not necessarily universal) set of beliefs about the meaning of those behaviors. The concept of “citizenship practices” could be used in many contexts in which “citizenship” is now overused as a metaphor, and its use would help clarify the scholarly literature on how individuals relate to real or imagined communities. Using the concept of citizenship practices, the article deconstructs the ongoing debates about the constitutionality of PPACA. It does not address the doctrinal arguments at issue, but instead focuses on the impact of the law and debates about the law on understandings of the obligations of citizenship and the possibilities for participation in decision-making. Inexact historical antecedents can be found in the constitutional challenge to Social Security and in participatory consumer citizen administrative bodies. It is impossible to know at this early date exactly what constellation of social meanings will emerge from PPACA, but one component of them will surely be a more explicit sense of who we are as a national community and what we expect of each other