Flatlining: Race, Work, and Health Care in the New Economy
216
Flatlining: Race, Work, and Health Care in the New Economy
216Paperback(First Edition)
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Product Details
| ISBN-13: | 9780520300347 |
|---|---|
| Publisher: | University of California Press |
| Publication date: | 07/02/2019 |
| Edition description: | First Edition |
| Pages: | 216 |
| Sales rank: | 637,684 |
| Product dimensions: | 5.50(w) x 8.25(h) x 0.70(d) |
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CHAPTER 1
Health Care, Work, and Racial Outsourcing
Over the course of their careers, black health care workers make many observations, decisions, and choices that have both short- and long-term implications for their work. They choose to specialize in certain areas of health care and decide whether to go into private practice. They take note of the ways that race has an impact on their work, their opportunities for advancement, and the ways they are treated by colleagues and patients. They react to the ways health care has increasingly become more of a business than a service, and assess what that means for their own occupational options. But none of these occur in a vacuum. In this chapter, I examine broad structural changes of the last half century and show how they set the stage for the racial encounters black workers like Randy, Theresa, and Amber experience in professional settings.
ORGANIZATIONS AND WORK IN THE CHANGING ECONOMY
In many ways, the story of contemporary work is a story of "what is" versus "what used to be." We hear laments over the loss of "what used to be" when politicians and policy makers talk about "growing the economy," the importance of "saving middle-class jobs," and of late, the need to "make America great again." When these parties make these claims, they are referring to a time when, for white men, the unemployment rate was low; labor-force participation rates were very high; work was consistent, stable, and pretty readily available; workplaces were hierarchically organized; and companies paid wages that offered a middle-class standard of living (often on only one income). Workers could easily spend their entire careers with one company that provided decent benefits. While there was a disparity between workers' earnings and that of the head of the company, it was typically not astronomical.
Despite what politicians like to tell us, those days are over. Starting in the 1970s, wages began to flatten and ceased to keep pace with productivity. What this means is that even as workers continue to produce results, wages have not kept pace with their efforts. Simultaneously, gains from workers' labor have increasingly gone to very highly placed managers and CEOs (Bivens and Mishel 2015). The US economy, then, is left with record levels of income inequality and limited social mobility (Piketty, Saez, and Zucman 2016). This disparity not only has left a large segment of the population economically insecure but also has helped lay the groundwork for major crises such as the housing crash of 2008, the recession that followed, and the looming student loan debt bubble.
What drives this growing inequality? A significant factor is the neoliberal ideology that became more dominant in the 1970s and 1980s. Neoliberalism, loosely defined, advocates for the primacy of unfettered markets that are neither subject to nor shaped by government regulations. It prizes individualism over collective action, advocates increasing financialization and privatization, and endorses the maximization of profits and shareholder value. Neoliberal agendas encourage limiting the role of the state and promoting austerity measures in order to push for unlimited free market competition. When policy makers decry government regulations, tout the benefits of tax cuts for the wealthy, attempt to prevent workers from collective bargaining, divert corporate profits to stockholders before (or instead of) workers, and seek to shrink or privatize the public sector, this is neoliberalism in action.
With the rise of neoliberalism, major changes in work, organizations, and industry followed. Collective bargaining has taken a massive hit, with clear consequences for workers. Whereas in the early 1970s, a quarter of all workers were unionized, by 2016 just over one in ten were. This is significant because the decline in unionization has had a marked impact on workers' ability to pressure management for greater compensation (Rosenfeld 2013). One result of this wage stagnation and union decline is increased economic inequality between most workers and those at the very top of the economic scale.
Organizations have also changed in ways that facilitate greater inequality. While they once were strictly hierarchical, they now are flatter and allow workers to be more self-directed. These are organizations that have fewer levels of middle management between executives and staff and, thus, require more independent, unsupervised work — think Google, LinkedIn, and other companies in Silicon Valley that encourage employees to work in ways that allow them to be their most productive. This means workers can have greater autonomy and more control over their career paths than was true for employees in the past. Organizations now expect workers to be nimbler and more flexible, to change jobs more frequently rather than devoting their entire career to a company, and to take greater responsibility for moving into and out of jobs, organizations, or even the workforce itself.
In tandem with giving workers more autonomy, however, organizations also assume much less responsibility for employees than they have in the past. In postwar America, organizations would shoulder hefty retirement and medical costs associated with labor, but today these are considered "externality costs" that cut into an organization's bottom line (Acker 2006). Companies now shift these costs back to employees, who are increasingly responsible for greater shares of their own retirement and health care costs. This allows corporations to boost profits and is consistent with broader norms that now cast labor as a cost to be cut rather than an important investment.
These organizational changes have dramatically restructured the way work is done. It now is much more insecure and contingent. As a result, employees switch jobs more frequently. In the absence of middle-management layers, teamwork is more prevalent, and routes to upward mobility are rarely as hierarchically organized as they were in the past (Williams, Mueller, and Kilanski 2012). Workers are also more likely to find jobs through networking, which can become essential to the hiring process, particularly for securing professional, high-status work (Rivera 2014). On the face of it, these organizational changes might seem to provide employees with more control over when, how, and where they work, attributes that are especially valuable in a neoliberal economy, where individualism is prized. But there is a downside to this, particularly for workers of color in contemporary organizations.
HEALTH CARE IN THE NEW ECONOMY
The aforementioned changes certainly apply to the health care industry. Table 1 shows the way health care has changed over the course of the twentieth century. Debates about the role of the public sector, insurance costs and coverage, and the integration of private industry have long shaped the ways health care is organized and how it has changed over time, leading to a current system that is highly stratified and sharply tiered.
The American Medical Association, the main lobbying group and organization representing doctors, launched in the early 1900s. The timing was important, as this move allowed doctors to represent their interests when reformers and forces in government pushed for insurance as a means of addressing health care costs. Though physicians fought health insurance in the early part of that century, they eventually lost this battle in the post-Depression era, when economic collapse brought more attention to and support for insurance and benefits that could protect citizens. However, physicians' opposition to President Harry Truman's proposal for a single-payer health care system in the 1940s helped defeat this initiative. Doctors' collective power, status, and prestige also increased in this period.
Around this time, employers began to assume more of the burden of rising health care costs. Because of wage controls that limited what they could offer in financial compensation, companies began to offer health benefits to attract workers. This began the trend of linking health care to employment, but it is important to reiterate that these benefits were not widely shared. Organizations began to assume some responsibility for the increasing costs of health care at a time when the workers who could take advantage of this were, owing to employment discrimination, mostly white men. Women of all races, and particularly women of color, faced overt, systemic discrimination that left them underrepresented in jobs that included health care benefits, forcing them to shoulder these costs on their own or rely on a partner's coverage if available (Branch 2011).
Problems with the health care system continued over the latter half of the twentieth century. By the 1950s, health care expenditures had risen to almost 5 percent of the gross national product. Additionally, elderly populations faced increasing difficulty accessing health care. These concerns over cost and access contributed to success in passing Medicare and Medicaid, though they did not lead to the same levels of widespread support for comprehensive, national health insurance. However, worries about a projected practitioner shortage led to federal measures designed to expand training and health education that would widen the pipeline for those interested in health care work. Thus, lawmakers were able to pass legislation intended to expand access to care, address rising costs, and increase the number of providers trained to give care. Unfortunately for many Americans, health care still remained tied to work.
These changes helped but did not provide a panacea. In the 1970s, factors like inflation, high Medicare costs, and the growing use of technology in medicine meant that costs continued to spiral. At the same time, the number of the uninsured also continued to grow. The population of health care practitioners began to change somewhat as the number of (mostly white) women in the profession increased rapidly; but at this point, "American medicine [was] now seen as in crisis."
Through the 1980s and 1990s, an increasing push toward privatization meant that health care became more and more bureaucratized. This limited doctors' interactions with patients and shortened the time they spent actually dispensing care. It also positioned insurance companies between patients and practitioners. Privatization has also reduced available public funding that can subsidize the high costs associated with education and training required for health care careers. Neoliberal principles of free markets, deregulation, and profit maximization pushed health care further and further under the control of private industry, making care itself a commodity rather than a basic right available to all. Government attempts to rein in costs and modify health care during this period were unsuccessful, as evidenced by the failure of then-president Bill Clinton to persuade Congress to pass health care reform in 1993.
Fixing Health Care: Race and the Two-Tiered System
Today, health care has morphed into a sharply tiered system that is profoundly unequal and in which care is highly commodified. For those who are well off and can afford private insurance, there are extensive treatment options, preventative care, and highly sought-after specialists. For those who cannot afford this, care in the poorly funded, under-resourced public sector is often the only option.
Political attempts to "fix" health care reflect the tug-of-war over this two-tiered system. The Affordable Care Act (ACA), signed into law in 2010, requires everyone to have health insurance and is grounded in the belief that health care is a basic right that should be available to all Americans. Furthermore, it reflects a perspective that all Americans bear some responsibility for each other. By pooling resources, everyone theoretically has access to care that could save lives, thus protecting vulnerable and poorer citizens and ultimately strengthening society. From this standpoint, requiring everyone — even the young and healthy — to purchase insurance means that risks go down for those who are poorer or chronically unwell. In 2015, speaking to the Catholic Health Association in Washington, DC, President Barack Obama himself made this very case: "America is not a place where we simply ignore the poor or turn away from the sick. It's a place sustained by the idea that I am my brother's keeper and I am my sister's keeper. That we have an obligation to put ourselves in our neighbor's shoes, and to see the common humanity in each other." In this telling, the ACA was premised on the assumption that Americans share a common bond of citizenship. That connection was the foundation for a vision in which raising taxes for those in the top income bracket, and mandating that everyone must purchase insurance to create a common pool, was an acceptable trade-off for establishing health care as a right and benefit for all.
This is a sharp contrast to the logic underlying the Republican-sponsored American Health Care Act (AHCA), Better Care Reconciliation Act, and Graham-Cassidy bills, the former of which passed the House while the latter two died in the Senate. These bills were grounded much more firmly in the ideals of individualism, profits, and commodification. During debate over the AHCA, Congressman John Shimkus (R-IL) questioned why he should be required to pay for health care services, such as maternity care, that he personally would never need to use. Representative Mo Brooks (R-AL) argued that the AHCA would "allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool that helps offset all these costs, thereby reducing the cost to those people who lead good lives. They're healthy; they've done the things to keep their bodies healthy." If the ACA was based on the logic that "we're all in this together," the AHCA, Better Care Reconciliation Act, and Graham-Cassidy were driven by the view that "I shouldn't have to pay for your health care."
Though ostensibly race-neutral, these competing arguments illuminate the racial beliefs embedded in the current stratified health care system. In an increasingly multiracial society, the premise of collective responsibility that underlies the ACA means that wealthy white families will be called upon to show some level of economic, political, and social support for poor black, Asian, and Latino communities. Thus, basing this legislation on the belief that "we're all in this together" means, in practice, that whites must see racial minorities as people with whom they share not just a fundamental connection but also a sense of responsibility. Projections that America will become a majority minority nation by 2044 mean that this prospect of mutual connectivity is no longer an abstract hypothetical. Rather, as the US rapidly grows blacker, browner, and more Asian, this collective orientation suggests that these groups are entitled to the benefits of inclusion that they had previously been denied, and that this may call for some sacrifices from white communities.
The racial subtexts of arguments to repeal and replace the ACA are vastly different. Conservative objections to the ACA cast it as a stealth version of reparations, with Obama advancing the legislation as a sneaky way to give undeserved benefits to black Americans. From this standpoint, the ACA was "job-killing Obamacare" that taxed Americans in order to fund health care. By this logic, the ACA hurt "working" Americans by reducing their employment opportunities. Voters with strongly held racial stereotypes, beliefs, and perceptions were less likely to support health-care reform under Obama, indicating that support (or the lack thereof) for health care reform was driven as much by racial attitudes as the actual proposals being put forth (Tesler 2014).
Perhaps no conservative made this case against the ACA and for the AHCA more clearly than former Representative Joe Walsh. In a May 2017 conversation between Walsh and MSNBC commentator Ali Velshi, Velshi pointed out that health care outcomes, as a whole, in the US health care system rank last relative to those of other industrialized nations. Walsh replied, "You can't compare the rest of the world to us. They do not have the big diverse populations that we have. They do not have the inner city populations that we have. ... Sweden does not have our inner city population. Norway, these countries do not have — you're talking about countries the size of India with homogenous populations. You can't compare them to what we have." Contrasting the health care systems of Norway and Sweden, with their predominantly white populations, to the health care system of the US, with its "inner-city populations," Walsh made clear that part of the reason why a more collective orientation to health care would not work is that it would necessarily require whites to be comfortable with their tax dollars paying for a health care system that, in part, supported minority communities. In this framing, then, the ACA involved a black president requiring hardworking white populations to pay for health care for "diverse," "inner-city" populations whose expensive health care outcomes stem from a failure to lead "good lives."
(Continues…)
Excerpted from "Flatlining"
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Copyright © 2019 Adia Harvey Wingfield.
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