An ethnographic study of enrollment obstacles in Rhode Island, USA: struggling to get covered on an Affordable Care Act insurance marketplace

ABSTRACTThe Affordable Care Act (ACA) of 2010 expanded access to health insurance coverage in the United States through online marketplaces that provided subsidized insurance coverage. Nonetheless, many obstacles made it difficult to enroll in and maintain ACA insurance coverage. In this article, we analyze obstacles to enrollment and continuous coverage based on an ethnography of ACA insurance enrollment in Rhode Island. We foreground consumers’ experiences and highlight the time and effort that people invested into getting covered. Unlike studies that focus on individual choices and employ a deficit perspective to understand gaps in coverage, this article argues that structural problems related to the organization of the American health insurance system, economic instability and bureaucratic eligibility criteria shaped the experiences of individuals and families seeking coverage. We found that people actively and intensely struggled to enroll and were met with multiple obstacles, most of which were beyo...