What it means to say "I Don't have any money to buy health insurance" in rural Vietnam: How anticipatory activities shape health insurance enrollment.

Abstract

Abstract Cost is a well-established barrier to health insurance uptake. Although iterations of the phrase “I don’t have any money to buy health insurance” are pervasive in research on the determinants of health insurance enrollment, its meaning is not universal. Through ethnographic immersion in Vinh Long Province and 34 semi-structured interviews collected from August 2015-September 2016, I show that being uninsured is not merely about the financial cost of an insurance card. Instead, the use of money in this phrase signals “anticipatory activities,” which refer to projects undertaken in the service of a projected future. If participation in insurance is fundamentally about planning for the future, then people weighed the risk management aspect of insurance against other more pressing anticipatory activities. Cash was key as it facilitated one’s ability to adjust to rapidly changing circumstances engendered by Vietnam’s ongoing marketization and global integration. For informal sector workers in this rural district, the value of health insurance was judged against five primary anticipatory activities where cash had instrumental and cultural dimensions: anticipating care responsibilities following the life course, anticipating changing economic and environmental risks, cultivating relationships as a form of anticipation, anticipating uncertain health vulnerabilities, and anticipating the inequalities of the health care system. By bringing attention to how anticipation is articulated in financial and health-seeking practices, I show how my interlocutors view their decision to remain uninsured as morally worthwhile. This study moves beyond utilitarian frameworks for understanding the uninsured. It also advances the anthropological agenda to study the “social life of health insurance” across the globe.