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The double burden on safety net providers: Placing health disparities in the context of the privatization of health care in the US

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  • Horton, Sarah

Abstract

The US Institute of Medicine's (IOM) influential 2003 report has focused attention on disparities in treatment outcomes and health status for American minorities, zeroing in on the role of unconscious bias in the unequal clinical disposition of minority patients. In keeping with the IOM's focus, current examinations of health disparities in the US tend to explore bias in clinical decision-making to the neglect of the political economic trends that buffet health care safety net sites and create the need for financial shortcuts. This paper recontextualizes the study of health disparities in the US by placing it against the backdrop of private sector trends emphasizing fiscal austerity and increased workforce productivity in health care. The social science literature on workers in human service bureaucracies, only recently applied to health care workers, suggests that higher demands for system "accountability" and worker "efficiency" may encourage providers to take shortcuts by treating individuals as mass categories. This ethnography of a Latino mental health clinic in the Northwestern USA shows that new private-sector measures of "productivity" take a toll on both the Latina clinicians whose invisible work subsidizes the system as well as on particular categories of patients--the uninsured and immigrants with serious psychosocial issues. While clinicians attempt to buffer the impacts of such reforms on patients, they also resort to means to increase their productivity such as firing repeated no-show patients and denial of care to the uninsured. This study is relevant for the health care of the poor in all health care systems considering restructuring along managerial principles to increase system 'efficiencies.'

Suggested Citation

  • Horton, Sarah, 2006. "The double burden on safety net providers: Placing health disparities in the context of the privatization of health care in the US," Social Science & Medicine, Elsevier, vol. 63(10), pages 2702-2714, November.
    • Handle: RePEc:eee:socmed:v:63:y:2006:i:10:p:2702-2714
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    2. Closser, Svea & Mendenhall, Emily & Brown, Peter & Neill, Rachel & Justice, Judith, 2022. "The anthropology of health systems: A history and review," Social Science & Medicine, Elsevier, vol. 300(C).
    3. Viladrich, Anahí, 2012. "Beyond welfare reform: Reframing undocumented immigrants’ entitlement to health care in the United States, a critical review," Social Science & Medicine, Elsevier, vol. 74(6), pages 822-829.
    4. Marrow, Helen B., 2012. "Deserving to a point: Unauthorized immigrants in San Francisco’s universal access healthcare model," Social Science & Medicine, Elsevier, vol. 74(6), pages 846-854.
    5. Lo, Ming-Cheng M. & Nguyen, Emerald T., 2021. "Resisting the racialization of medical deservingness: How Latinx nurses produce symbolic resources for Latinx immigrants in clinical encounters," Social Science & Medicine, Elsevier, vol. 270(C).
    6. López-Sanders, Laura, 2017. "Changing the navigator's course: How the increasing rationalization of healthcare influences access for undocumented immigrants under the Affordable Care Act," Social Science & Medicine, Elsevier, vol. 178(C), pages 46-54.
    7. Zuberi, Daniyal M. & Ptashnick, Melita B., 2011. "The deleterious consequences of privatization and outsourcing for hospital support work: The experiences of contracted-out hospital cleaners and dietary aids in Vancouver, Canada," Social Science & Medicine, Elsevier, vol. 72(6), pages 907-911, March.
    8. Mladovsky, Philipa, 2023. "Mental health coverage for forced migrants: Managing failure as everyday governance in the public and NGO sectors in England," Social Science & Medicine, Elsevier, vol. 319(C).
    9. Pillay, Timesh D. & Skordis-Worrall, Jolene, 2013. "South African health financing reform 2000–2010: Understanding the agenda-setting process," Health Policy, Elsevier, vol. 109(3), pages 321-331.

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