"Health Care Off the Books: Poverty, Illness, and Strategies for Survival in Urban America" by Danielle T. Raudenbush (review)

Danielle T. Raudenbush's Health Care Off the Books provides a window into the processes by which an extremely disadvantaged population obtains health services in the face of an insufficient social safety net and an American healthcare system built around exclusion. Raudenbush draws on participant observation, focus groups, and resident interviews in a public housing development called "Jackson Homes," located in a high-poverty urban community in the United States. She also interviews providers who work at local clinics and hospitals. She traces the structural barriers that residents face as well as the social strategies residents use to access care, calling attention to the not insignificant population of poor households for whom a $15 copay represents a prohibitive expense. In this way, her book is a unique work of qualitative medical sociology in that it takes place almost entirely outside the doctor's office.

The inflexibility of the formal healthcare system presents challenges for those living on a few dollars a day. Raudenbush skillfully contextualizes the problem of health care inequities within the broader structure of racial and urban inequality—a mother must decide between a stable job with health benefits or providing needed care for her children. An adult facing new symptoms must choose between obtaining medications from less-than-reputable sources or braving the emergency room with uncertain consequences.

The setting—the Jackson Homes housing project—provides an important backdrop, by illuminating the dynamics of urban poverty as well as highlighting the social networks and support systems that develop in public housing. Despite the concentration of disadvantage in public housing developments, residents have long developed ingenious informal relationships to replace the necessities of life that are not provided equitably by the market. Indeed, many of the book's participants already rely on informal structures to provide other necessities, including food, emotional support, transportation, and child care.

Residents of the Jackson Homes vary significantly in their basic level of access to the formal healthcare system. Some have insurance, some do not. Some can afford basic services, others cannot. This variation creates the precise conditions necessary for the development of informal means to access care. Raudenbush provides a compelling assessment of the strategies poor residents use to navigate the process of informally exchanging health care services, medications, and information. The beneficial effects of social relationships on health are well-documented, but high-poverty communities are often assumed to be lacking social support and social ties. Raudenbush critiques this point of view, detailing how residents of Jackson Homes engage in Selective Solidarity, the development of informal exchange relationships that are limited to a small number of trusted individuals (p. 94).

Raudenbush notes that residents implicitly connect their own health experiences to those of others in the development—linked health fate. This shared sense of collectivism helps to normalize the use of informal strategies to access care; residents turn to two primary groups: (1) Friends and family and (2) Street entrepreneurs. For instance, one younger, relatively healthy woman with health insurance would often seek extraneous care and medications specifically to provide them to friends and family members (p. 63). In other cases, uninsured individuals may purchase medications off the street from those with insurance (pp. 64–65).

Notably, the informal strategies for healthcare access are not limited to the residents of Jackson Homes. Indeed, Raudenbush discovers that the physicians themselves often resort to informal efforts to provide needed care when the formal structures of the healthcare system fail. This includes providing unauthorized medications to patients in need, or prescribing medications to families with similar health issues, providing direct financial support, or writing prescriptions without specifying a patient (p. 111). While doctors are often feel devoted to their high-need patients, many of the challenges they are seeking to address might be better handled outside the healthcare system.

The book would have benefitted from...