Social Science & Medicine 63 (2006) 2702–2714

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

of health care in the US

Sarah Horton�

University of California, San Francisco, CA, USA

Available online 5 September 2006

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.’

r 2006 Elsevier Ltd. All rights reserved.

Keywords: Health disparities; Health care safety net; Private sector reforms; Street-level bureaucrats; Clinician productivity; Latinos;

USA; Privatization

Introduction

It is a Friday afternoon and Ana,1 a clinicianworking at Bienestar, a Latino mental health clinic

in the northwestern US, is wrapping up a typicalday. She is writing her case notes and preparing togo home when the front-desk worker calls her onthe phone. She has received an urgent call fromPilar, a Bienestar patient who has finally made thedecision to leave her abusive husband after monthsof therapy. Pilar wants to leave the house before herhusband returns from work. Yet she has notransportation, nowhere to go, and does not speakEnglish. Moreover, having left El Salvador 2 years

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0277-9536/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.

doi:10.1016/j.socscimed.2006.07.003

�Tel.: +1 510 883 9435.

E-mail address: HortonSarah@msn.com.1All names are pseudonyms so as to protect the identity of

Bienestar clinicians and patients. In cases where it would not

jeopardize the meaning, I have changed personal details to

protect confidentiality.

ago to move to the US, she has no knowledge of thesupport system for battered women.

Ana calls Pilar a cab to bring her and her childrento the clinic and then calls the one women’s shelter inthe city that has Spanish-speaking staff. Due to Ana’shelp, Pilar and her children move into the shelter thatnight. A year later, Pilar has left her husband andfound her own apartment, also with Ana’s help.

This vignette illustrates that clinicians caring foran underserved population frequently assume a dualrole—not only as mental health workers but also asadvocates for patients attempting to negotiate anunfamiliar welfare and social services system. Whilethis dual role is especially true of clinicians serving aSpanish-speaking immigrant population, it is char-acteristic of workers in a variety of safety net sites—or sites that serve low-income and uninsuredpatients (Boehm, 2005; Horton, McCloskey, Todd,& Henriksen, 2001; Kuttner, 1988; Lamphere,2005). While safety net clinicians perform vitalsocial service advocacy, they often work in hospitalsfeeling the brunt of the impact of cuts in Medicaidand reduced funding for public health care. Over thepast decade, such hospitals have implemented newmanagerial measures emphasizing clinician ‘‘pro-ductivity’’ and ‘‘efficiency’’ that do not takeclinicians’ work as advocates into account. Thisleads to an unacknowledged double burden onclinicians serving the underserved: balancing rolesas therapists and advocates with the hospital’sincreasing demands for ‘‘billable hours.’’

In this paper, I show that hospital ‘‘productivity’’requirements attempt to make clinicians’ charitymission conform to new cost-cutting administrativeimperatives, taking a toll on both the minoritywomen whose invisible work subsidizes the systemas well as on the uninsured and patients with seriouspsychosocial issues. Analysis of the heavier burdenof safety net providers helps fill a gap in the existingliterature on health disparities, which tends to focuson clinician stereotyping as though divorced fromthe institutional context within which providerswork. By placing disparities in care for low-incomeimmigrants against the backdrop of the financialpressures buffeting safety net institutions, I illus-trate the systemic and institutional policies thatdiscourage ‘‘equal treatment.’’

The narrow focus of health disparities research

The Institute of Medicine’s report, Unequal

Treatment (Smedley, Stith, & Nelson, 2003) has

been influential in highlighting the importance ofunconscious bias in contributing to the unequalclinical disposition of minority patients, claimingsuch covert racism is an even more important factorthan obstacles to minorities’ access to care.

Yet while the report acknowledges the role thathealth care financing plays in intensifying thepressures health care providers face, it—and manyof the studies that have followed it—focus primarilyon how clinicians may rely on stereotypic assess-ments of minorities during the fraught process ofmedical decision-making. In training their lensnarrowly on the snap judgments providers make,these studies portray them as largely divorced fromthe very specific institutional contexts that create theneed for such shortcuts (Van Ryn & Burke, 2000;Van Ryn & Fu, 2003; as an exception, see forexample, Good, James, Good, & Becker, 2003). Inkeeping with such research, proposed solutions alsoattempt to eliminate bias from the process ofmedical decision-making through better trackingand monitoring of the use of procedures by patientrace (Nerenz, 2005), the implementation of qualityassurance protocols (Aaron & Clancy, 2003; Fiscel-la, Franks, Gold, & Clancy, 2000; Lurie, Jung, &Lavizzo-Mourey, 2005; Nerenz, 2005), and clini-cians’ cultural competency training (Betancourt,Green, Carrillo, & Park, 2005; Cain, 2003). Whilethese are important avenues for investigation andintervention, they devote less attention to the role ofinstitutionalized discrimination—rather than indivi-dual discrimination—in contributing to healthdisparities. While many valuable studies continueto examine systemic forms of inequalities, few, ifany, examine the effects of changes in health carefinancing on minorities’ disparate treatment. Ethno-graphic analyses, then, are essential to remedyingthis gap by placing clinical decision-making againstthe backdrop of the new federalism, examining howreduced funding for public health leads to heigh-tened institutional demands on providers.

Any analysis of disparities must take into accountthe settings within which minorities disproportio-nately receive treatment—the health care safetynet—as well as the financial and organizationalchanges that affect it. Two-thirds of those whoreceived inpatient care in safety net hospitals in 2002were minorities (Regenstein & Huang, 2005, p. 6).Hispanics utilize community health centers at a rate700% higher than that of whites, and AfricanAmericans at a rate 550% higher than whites(Smedley et al., 2003, p. 112). Yet such sites are

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also those disproportionately affected by reducedfunding for public health, state budget cuts, and therising volume of the uninsured. Obstacles to theprompt access to care may in turn exacerbateuntreated illnesses, leading to a disproportionateshare of illness (Sue & Chu, 2003).

Medicaid, the federal program that provideshealth insurance to the low-income, has becomethe single largest source of support for the healthcare safety net. Medicaid provides the safety net40% of its funding (Regenstein & Huang, 2005, p.4), and it has become essential in offsetting thedeclining proportion of health centers’ overallrevenue attributable to federal grants. Since 1985,federal funding as a proportion of health care safetynets’ overall budgets has declined, but the propor-tion of revenues attributable to Medicaid has morethan doubled (Rosenbaum, Shin, Markus, &Darnell, 2004, p. 8).

Yet due to the government’s increasing privatiza-tion of Medicaid, and recent state budget crises, thisstaple of the safety net has been threatened. AsMedicaid reimbursements no longer allow safety netinstitutions to ‘‘cost-shift’’ (Cunningham, Gross-man, St. Peter, & Lesser, 1999)—i.e., help subsidizethe care they provide the indigent—they havebecome more dependent upon ‘‘private-sector’’strategies, such as attracting insured populationsor cutting costs (Horton et al., 2001). This goal hasbecome more urgent as the rise in volume of theuninsured has outpaced recent modest increases infederal funding (Rosenbaum, Shin, Markus, &Darnell, 2000). Safety net hospitals like the one Iexamine here have been particularly hard-hit, withaverage margins below 2% each year since 1998(Regenstein & Huang, 2005).

The privatization of the health care safety net hascoincided with a movement towards the intensifiedscrutiny of public governance and of public agencyperformance. Heightened performance measure-ment of public agencies and providers is an attemptto reconcile the demand for ‘‘smaller government’’with the demand for improved health care quality.Hospitals’ reporting of performance measures suchas clinician ‘‘productivity’’ is frequently tied to thedictates of managed care organizations and to theiraccess to federal funds. (The 1993 GovernmentPerformance and Results Act, for example, requiredall agencies receiving public funding to implementperformance goals and monitor their progresstowards documentable outcomes; Caudle, 2001.)In general, the heightened monitoring of public

agencies has led to intensified consumer awarenessof agency performance (Hibbard, Stockard, &Tusler, 2005) as well as to notable improvementsin clinical performance and reduced mortality ratesin cardiac surgery (Hibbard et al., 2005; Marshall,Shekelle, Davies, & Smith, 2003, p. 141). Yetanalysts have noted the complexity of implementingaccurate performance measures and their occasionaltangential relationship to tangible health outcomes(Eddy, 1998, p. 16; Fernandopulle et al., 2003).While public agency performance may be easier toquantify in terms of improving access and specifichealth indicators (DoBias, 2005), the ‘‘perfor-mance’’ of individual human service workers isfrequently more difficult to quantify. In implement-ing quantifiable measures of provider ‘‘productiv-ity,’’ for example, provider efficiency may beelevated as an end in itself, displacing the goal ofimproving the quality of services rendered (Clarke,2004, p. 128; Lipsky, 1983).

Stereotypes and shortcuts: how ‘‘street-level

bureaucrats’’ can create disparities

This analysis of the effect of performancemeasures on mental health providers fits within abroader social science literature on human servicebureaucracies suggesting that an examination of theactions of frontline providers is key to the study ofhow public policy is produced. This work takesseriously Lipsky’s proposition (1983) that such‘‘street-level bureaucrats’’ not only implement butproduce public policy, as de facto policy iscomprised of the sum of their individual decisionsand actions. Human service workers are caughtbetween competing loyalties to management’s de-mand for speed in ‘‘people-processing’’ and theirindividual clients, who require the ‘‘discretion’’ ofbeing treated as individuals rather than as masscategories. As Lipsky suggests, the circumstances ofwork in such bureaucracies explains why humanservice workers engage in disparate treatment,‘‘despite official regulations to the contrary’’(1983, p. xi).

Anthropologists such as Kingfisher (1996) andMorgen (2001) have extended Lipsky’s analysis tothe behaviors of welfare workers under the pres-sures of welfare reform. Confronted with heavycaseloads, unrealistic agency expectations, andlimited resources, street-level bureaucrats may en-gage in stereotyping of clients as a form of ‘‘short-cut’’ that simplifies their workload. Faced with their

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own powerlessness in the institutional hierarchy,such workers may justify their own inaction onbehalf of their clients through ideologies of victim-blaming (Kingfisher, 1996, pp. 96–129). Thesescholars thus follow Lipsky in examining how workrequirements lead to ‘‘favoritism, stereotyping, androutinizing—all of which serve private or agencypurposes’’ (1983, p. xii).

While the ethnographic literature has illustratedhow ‘‘unequal treatment’’ may originate in welfareoffices, only recently have anthropologists begunextending Lipsky’s insights to health care workers inthe context of health care reform. At issue, then, ishow (and whether) safety net providers dischargetheir charity missions in a context of heightenedpressures on their time and resources. New ethno-graphies of managed care illustrate that an exam-ination of frontline providers is key to how suchreforms play out, as the informal and unrecognizedwork of health care providers, clerks, and casemanagers subsidizes the overall system (Boehm,2005; Lamphere, 2005; Lopez, 2005; Waitzkin et al.,2002). Espousing an ‘‘ethic of care’’ (Lamphere,2005, p. 5), such workers may attempt to protecttheir patients from administrative cost-cuttingstrategies, stretching their time and resourcesfurther to continue to deliver charity care. Thus,as Lamphere (2005) suggests, the ‘‘success’’ ofprivate sector reforms has relied upon the invisibleand unpaid work of largely female and minoritymid-level professionals, who have disproportio-nately borne the brunt of health care restructuring.

In this paper, I examine the effect of one private-sector reform—heightened institutional controls ofprovider ‘‘productivity’’—on both Latina cliniciansand the underserved Latino immigrant patients theyserve. Following Kingfisher’s (1996) work, I examinehow the service bureaucracy positions Latina clin-icians vis-a-vis their Latino clients to discover whysuch mid-level professionals, unlike welfare workers,continue to espouse an ‘‘ethic of care.’’ Previousresearch on the restructuring of the health careeconomy in both the American and Canadiancontexts has suggested that such methods maydiscourage providers from delivering quality care tovulnerable groups (Good et al., 2003; Rice, 2003;Spitzer, 2004). Forced to ration both attention andresources, providers may unintentionally underservegroups whose cultural differences or life circumstancesmay appear to require special attention (Balsa &McGuire, 2001). How, then, does the monitoring of‘‘productivity’’ affect care for underserved minorities?

The ethnographic context

Given both the increased rationalization of healthcare delivery in the US and the mounting concern forthe security and privacy of patient health informa-tion, culminating in the Health Insurance Portabilityand Accountability Act (HIPAA) of 1996,2 conduct-ing ethnography in a clinical setting in the US is anincreasingly fraught and encumbered process. To beable to conduct research on disparities in treatmentfor Latino immigrant patients, I had to first submitextensive paperwork for approval from both myacademic institution’s and Bienestar’s parent hospi-tal’s Institutional Review Board. Even with thisapproval, my entree would have been all butimpossible without a prior existing arrangementbetween these two institutions. I was given accessto Bienestar clinic staff meetings with the sole caveatthat I was not privy to patient names so as not toviolate HIPAA rules. Thus when individual patientswere discussed or identifying information wasdivulged, I was led out of the room. While staffwere very cautious about violating HIPAA rules, myresearch was aided by their cooperation due tomounting concern about administrative rules theyviewed as impeding their professional autonomy aswell as the hospital’s charity mission.

This paper is based on two periods of intensiveethnographic fieldwork at Bienestar. First, fromNovember 2003 until June 2004, I conductedparticipant observation at Bienestar, interviewedstaff, and attended staff meetings. One year later, Ireturned to conduct follow-up interviews andobservations with clerical workers from January2005 until April 2005. During these two periods ofresearch, I conducted interviews with a range ofclinic staff: two front-desk clerks, one clinicmanager, six psychologists, four psychiatrists,and one social worker, as well as with onesenior official in the hospital administration.Interviews ranged from 1 to 3 h, spread over severalvisits to accommodate staff’s need to meet demandsfor ‘‘billable hours.’’ Topics included staff’s

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2The US Health Insurance Portability and Accountability Act,

although passed in 1996, first went into effect in April 2003.

HIPAA specifies a set of rules that health care providers must

follow to ensure the privacy and security of patient health

information. While HIPAA was intended to protect patient

privacy in an era of a health care system increasingly linked via

the electronic exchange of patient information, it has arguably

had a dampening effect on hospital and clinic-based research in

the US.

S. Horton / Social Science & Medicine 63 (2006) 2702–2714 2705

observations regarding ethnic disparities, theirmethods of coping with institutional pressures, theirobservations of barriers to patient access and equalcare, and their opinions regarding what factorsmade patients particularly difficult to serve.

Both Bienestar Clinic and its parent hospital,Bradford Hospital, are traditional providers of careto the uninsured and low-income. While thehospitals’ patient base makes it representative of‘‘the hub of the safety net’’ (Regenstein & Huang,2005), it is perhaps exceptional among safety nethospitals in its commitment to providing care to theunderserved. Bradford Hospital is currently thelargest proportional provider of care for theuninsured in the area3 and has a national reputationfor delivering community-based medicine to amulticultural and low-income patient base. It haswon numerous awards, including several Safety NetAwards from the National Association of PublicHospitals and Health Systems—one for cultural andlinguistic competency. Like all safety net hospitals,the majority of Bradford’s patient base is uninsuredor on Medicaid; over 80% of its annual revenuederives from government sources.

Bienestar follows in its parent hospital’s charitymission; roughly 65% of its clinic base is uninsured,25% is on Medicaid, and 10% has privateinsurance. Bienestar has established a reputationin the region for providing quality mental healthcare to Spanish-speaking immigrant patients. Theclinic integrates therapy with attention to patients’broader contextual issues—the social, economic andpolitical factors that affect mental health. Due toboth Bradford and Bienestar’s exceptional commit-ment to serving the low-income, the clinic offers anideal site in which to examine how institutionalpressures may help explain the Institute of Medi-cine’s conundrum—why, despite their best inten-tions, providers may wind up delivering sub-optimalcare to minorities (Smedley et al., 2003).

The culture of the clinic and the patient– provider

relationship

Recent anthropological studies of ‘‘street-levelbureaucrats’’ have focused on the conflictive and

sometimes antagonistic relations between welfareworkers and their ‘‘clients.’’ (Kingfisher, 1996;Morgen, 2001). This work examines how, despitecongruence in their structural locations—particu-larly of gender and class—the welfare systemprecludes any form of solidarity between womenexperiencing a similar class oppression (Kingfisher,1996, pp. 131–156). While the clinicians I examinehere experience a sense of increasing powerlessnessin the face of bureaucratic edicts, they do notperform a low-status job (p. 83) and typically do notserve as gate-keepers who control the disbursementof scarce social benefits. Thus unlike welfareworkers, Bienestar clinicians—like many healthcare workers described elsewhere (Boehm, 2005;Lamphere, 2005)—enjoy relatively greater autonomyand less conflictive relationships with their patients.

An examination of the patient–provider relation-ship and the ‘‘culture of the clinic’’ (Santiago-Irizarry, 2001) will help illuminate the context ofhealth care delivery at Bienestar. Bienestar patientstend to come from predominantly low-incomeimmigrant Latino backgrounds. The majority isfrom Latin America, with the heaviest concentra-tions from the Dominican Republic, El Salvador,and Puerto Rico; most are from rural backgrounds.As poor, recent, immigrants, many have contextualissues—such as the lack of housing or of jobs—thatcompound their mental health problems. Many areilliterate. Roughly 90% are primarily Spanish-speaking, and between 50% and 60% are mono-lingual in Spanish. Nearly 60% of the clinic’spatients are first-generation immigrants, with sec-ond-generation immigrants comprising another30%. A majority of patients have been in the USfor less than 10 years, and thus are unfamiliar withthe American health care and welfare systems.

The opportunity to serve an underserved Latinoimmigrant population has attracted primarily Lati-no clinicians. Nine of twelve Bienestar cliniciansself-identify as Latino. (Three of four psychiatristsare Anglo Americans who speak Spanish andemphasize their commitment to serving an under-served population.) All Latino clinicians are bicul-tural, and all but one had been both raised andtrained in Latin America. All are fluent in Spanish.Reflecting the gendered nature of clinical work, 14of 15 Bienestar staff are female.

Bienestar staff—from the front-desk workers tothe psychologists and psychiatrists—generally saythat they came to Bienestar specifically to serve adisadvantaged immigrant population, professing a

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3Bradford Hospital is heavily reliant on public revenues—33%

of its revenues are from the uninsured, 24% from Medicaid

funding and another 24% from Medicare. Yet funding for the

uninsured and Medicaid recipients has not kept pace with the

volume of patients seen.

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‘‘social orientation’’ (Kuttner, 1988, p. 1588) notuncommon for workers in nonprofit organizations.Indeed, Bienestar clinicians tended to identify withtheir patients and to view themselves and theirimmigrant patients as occupying structurally homo-logous positions as ‘‘foreigners’’ in the UnitedStates.

Although clinicians typically come from moreprivileged Latin American backgrounds, they tendto identify with the feelings of culture shock anddisorientation of their patients. In interviews, stafffrequently cited their being an immigrant or‘‘having roots in two cultures’’ as a source ofcommon experience with their patients. A Venezue-lan born of European Jewish immigrant parentsexplains her feeling of ‘‘dislocation’’ in bothVenezuela and the US: ‘‘The issue of belonging,and of never feeling homogeneous in any onesetting. It’s something I live with.’’ Meanwhile, aPeruvian immigrant who came of age in a smalltown in the South puts it: ‘‘Yes, I know what it feelslike to be an immigrant and I know what it’s like tobe different.’’ Like minority clinicians in otherethnically specific clinics, Bienestar clinicians tendto view themselves as fellow minority patients’stewards in adapting to an alienating, and some-times hostile, new culture (Ito & Maramba, 2002).

In keeping with this view of their role, clinicianssay they intend the clinic to serve as a refuge froman alienating and Anglo-centric public environment.They describe the clinic as a ‘‘safe haven’’ forimmigrant patients with multiple contextual issues,a space where patients can feel ‘‘welcomed’’ and ‘‘athome.’’ They emphasize that they intend the clinicto serve as a space that is linguistically andculturally familiar to patients (Santiago-Irizarry,2001, p. 4, 101). One clinician, for example, refers toa patient who had made multiple visits to bothherself and to a front-desk worker simply to ‘‘visit’’in Spanish. ‘‘She was just so relieved—to findsomebody who spoke Spanish,’’ she says. Mean-while, another describes the bewilderment a patienthad felt in finding herself in a foreign country, ‘‘Shecalls herself ‘illiterate in another culture.’’

Yet clinicians view the clinic not only as a refugefrom both a foreign and hostile public sphere, butalso as a ‘‘safe haven’’ from a dysfunctional privatesphere. For example, one clinician describes theclinic’s therapy groups for women suffering domes-tic violence in the following way: ‘‘It becomes like asafe haven to discuss something. Sometimes theycome hours ahead of time to discuss things.’’ A

front-desk worker reiterates this ethic when explain-ing the extra measures she took to insulate patientsfrom encroaching, and possibly violent, boyfriends:

Once I was working here and this guy came inand asked if his girlfriend was there. Well [that’s]confidential. So I turned him away. Hours later, Iwas working late at nighty and he was pacingoutside the doorway. Waiting. I was facing thecomputer and I could see in the screen that hehad come in through the doorway behind me. SoI called Security and they escorted him out.

In this way, clinicians and staff intend the clinic toserve as an idealized liminal space in between bothhostile public spheres and possibly violent privatespheres; a ‘‘second home’’, culturally Latino, whiledysfunction-free.

In treating Bienestar patients with significantcontextual issues, clinicians find their job consistsof serving simultaneously as therapist and patientadvocate. It is common for clinicians to assistpatients in navigating the American social service,legal, and welfare systems—writing legal briefs insupport of patients’ US Citizenship & Immigrationhearings, mediating between patients and thecourts, even writing letters to help mentallydistressed patients maintain their utility servicedespite late payments. As one clinician, Ana,describes:

We can’t just do psychotherapy. We spend ourtime calling attorneys, calling agencies ourselves,setting appointments up—we don’t have thatkind of support herey. We help patients withrent insurance, heating, utilities, even donationsfor basics [baby carriages, etc.]. We accompanythem to legal and housing authority meetings.

Thus Bienestar clinicians hold a ‘‘social orienta-tion’’ not atypical of workers in the health caresafety net (Kuttner, 1988) that makes their relation-ships with patients significantly different from thatof welfare workers. Clinicians serve as advocates or‘‘cultural brokers’’ for patients navigating anunfamiliar new system, performing tasks that areincidental to the task of therapy itself.

Profiles in clinician advocacy: subsidizing the

hospital’s charity mission

To illustrate the types of contextual issuesBienestar clinicians address on top of actualtherapy, I offer two profiles in clinician advocacy.

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In each case, each clinician performs tasks thatgreatly enhance patient health but are neitherrewarded nor institutionally supported by thehospital administration. Such advocacy addressesthe multiple social needs of Bienestar patients, needswhich are not served by the city’s largely mono-lingual social service agencies. This work also fills agap in the hospital’s own services, as the hospitalitself lacks Spanish-speaking services in importantspecialty mental health services such as inpatientpsychiatric hospitalization, day treatment, partialhospitalization, behavioral medicine, elder services,and alcohol treatment. While such services may beavailable through an interpreter, patients often shyaway from filtering their intimate mental healthneeds through a third party. Thus clinicians’advocacy work both subsidizes the Hospital’smission of providing community mental healthwhile filling in gaps in a broader Anglophonemedical and social service system in the city.

Alba—the advocate for political asylees

Among Bienestar clinicians, Alba is referred to asthe ‘‘backbone’’ of the team. Not only is she one ofthe clinic’s longest-serving employees, but sheexemplifies the ‘‘ethic of care’’ (Lamphere, 2005)that Bienestar clinicians hold as an ideal. Over thedecade that Alba has worked at Bienestar, she hasserved as a pro bono advocate for at least 65 victimsof political violence facing possible deportation, inaddition to her regular job as their therapist.

For each patient, Alba prepares a 15–45-pagereport detailing the patient’s traumatization andexplaining the possible psychological sequelae ofreturn. She regularly meets with patients’ lawyersand attends patients’ court hearings. She assists theattorneys of her patients by providing clinicaltraining to deal with issues of trauma and itspsychological implications. In addition, she helpsprepare humanitarian pleas for battered womenwho received their legal status from their husbandsand might forfeit that status in seeking separation.

Alba writes about four detailed psychologicalassessments a year. The reports often take her manyhours to write, not counting the time she spendsinterviewing and accompanying patients to court orto meet with attorneys. Yet Alba cannot count anyof these hours towards her ‘‘billable hours.’’ Norcan she bill for the time she spends in courttestifying as an expert witness; only if the patientsigns in the clinic can she count 1 h towards her

‘‘productivity.’’ ‘‘I have to take days off to go tocourt, to meet with attorneys, to provide expertwitness in court, to help prepare my patients forthat. It is many, many hours, and it varies fromweek to week,’’ she says.

Over her years at Bienestar, Alba has not had apatient lose a case. While she receives routine praisefrom the Hospital administration for her advocacywork, in practice her work is not institutionallysupported. She still must bill as many ‘‘billablehours’’ as providers who do not perform suchadvocacy work. In the course of providing suchservices for her patients pro bono, however, Albahas been subsidizing the Hospital’s mission ofproviding charity care and community-based men-tal health services.

Luisa—the social services advocate

The clinic supervisor routinely praises Luisa’swork with a particular patient, Raquel, as repre-sentative of the clinic’s approach integrating mentalhealth treatment with the socioeconomic concernsthat patients face. In this case, Luisa not onlytreated Raquel for psychotic depression, but alsoaddressed the profoundly social causes for Raquel’scrisis—the Department of Social Services’ (DSS)unfair removal of her children.

Raquel, a Spanish-speaking Colombian womanin her 30s, had come into the clinic in December of2002 after a suicide attempt. She was diagnosedwith psychotic depression and began seeing Luisa.As Luisa saw her, she began to realize that aprimary cause of Raquel’s depression was theremoval of Raquel’s three children. Raquel’ssiblings, blaming Raquel for the death of theirmother, had reported Raquel to DSS for a numberof false allegations of child neglect. DSS placedRaquel’s children in a foster home, and shortlyafterwards Raquel became suicidal.

In dealing with Raquel’s case, Luisa soon realizedthat part of Raquel’s feeling of hopelessnessstemmed from facing an insurmountable andseemingly hostile legal system. ‘‘There’s a bigdifference in ability to access care and function ina system that people who aren’t native don’tunderstand. [Raquel] didn’t feel confident abouther ability to get her side of the story out. She felt akind of helplessness that confirmed all the negativethings that people had assumed,’’ Luisa explains. AsLuisa describes, Raquel had not received a fair trialin the courts. Raquel’s court-appointed lawyer,

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having heard stories about Raquel’s presumedabuse, had presumed her guilty and had never evenopened Raquel’s file. Raquel had been appointed asocial worker who only spoke English, and Raquelonly spoke Spanish. Raquel had also been orderedto take a parenting class that was offered only inEnglish, and understandably never attended. This inturn further jeopardized her case.

Luisa thus adopted the role of Raquel’s ‘‘culturalbroker’’ as well as her therapist. ‘‘I find myself intwo modes: doing therapy and case management,making sure that she understands everything that ishappening,’’ she explains. She intervened to haveRaquel appointed a new lawyer, whose interviewswith Raquel’s children’s day care providers andteachers led to Raquel’s children being returned toher. With her children back in her house, Raquelbecame again the picture of sound mental health.

Luisa’s active role in Raquel’s case exemplifies theintegrated approach of Bienestar clinicians toaddressing their patients’ problems. While Luisaprovided Raquel with therapy for her depression,this treatment would hardly have been as effectivewithout the advocacy that Luisa also provided.Luisa’s advocacy moreover filled in major gaps inan Anglophone legal and social service system thatoffered few resources for immigrant parents such asRaquel.

‘‘The system relies on the goodwill of minority

clinicians:’’ flexible women in the new health care

economy

Although the work of Alba and Luisa is vital totheir patients’ mental health and to the Hospital’scharity mission, it is incidental to the administra-tion’s goals of ‘‘productivity.’’ As Alba says, ‘‘Wehave the same productivity requirements as anyother place and I don’t get any credit for this kind ofadvocacy. The system relies too heavily on thegoodwill of minority clinicians.’’ The Hospital’s newmonitoring of clinicians’ ‘‘billable hours’’ thusestablishes a double standard in which the unac-knowledged work of its clinicians subsidizes itscontinued reputation for charity care.

These vignettes illustrate that providers for theunderserved frequently bear the brunt of providingadequate care in an underfunded public healthsystem (Alegrıa et al., 2001; Boehm, 2005; Lam-phere, 2005; Waitzkin et al., 2002). Demands forgreater system ‘‘efficiencies’’ depend upon theuncompensated and unseen work of mid-level

professionals who are often disproportionatelyfemale and minority. While their ‘‘roles have oftenbeen overlooked in the analysis of health carereform’’, the restructured health care economydemands that such mid-level professionals performthe role of ‘‘flexible woman’’ (Lamphere, 2005, p. 4;Susser, 1997). ‘‘I work here, I make calls fromhomey I mean, I don’t want it to be that way butfor now it has to be that way,’’ Ana says. Bienestarclinicians continue to perform the ‘‘emotionallabor’’ inherent in the service occupations (Lam-phere, 2005; Leidner, 1999) while attempting tomeet the ever-faster pace of health care production.Yet restrictions in public health care financing notonly take their toll on female minority providers butalso on minority patients; providers cannot com-pletely insulate patients from the cost-cuttingimperatives of their managements.

The drive towards ‘productivity’: ‘‘naming and

shaming’’

We have seen above a variety of ways in whichcity and hospital services themselves do not afford‘‘equal treatment’’ to monolingual Spanish-speak-ers. While safety net providers attempt to redressthis gap and assume a dual role of health careprovider and advocate, this ‘‘double burden’’ is notofficially rewarded nor recognized by hospitaladministrations facing stretched resources. Whilethe Hospital is eligible for supplemental funds dueto its being a disproportionate share hospital,4 thesefunds only cover a small portion of the care itprovides the uninsured. As a result of such financialpressures, the Hospital experienced a budget deficitof $20 million in 2003.

Thus the Hospital, like other safety net hospitalsnation-wide, has implemented new cost-contain-ment strategies such as the heightened monitoringof provider ‘‘productivity.’’ In 2003, the Hospitalbegan requiring that clinicians spend at least 65% oftheir time in the office in ‘‘billable encounters.’’Every Hospital provider is given a monthly reportdetailing the number of hours for which each team

ARTICLE IN PRESS

4The Hospital’s one relative advantage is that as a dispropor-

tionate share hospital, it is eligible for a supplement to the federal

Medicaid program that provides it up to $70 million annually to

help offset uncompensated costs. However, Medicaid Dispropor-

tionate Share Hospital (DSH) payments only finance 23% of the

costs of uncompensated care faced by safety net hospitals nation-

wide (Regenstein & Huang, 2005, p. 10) and are vulnerable to

budget cuts.

S. Horton / Social Science & Medicine 63 (2006) 2702–2714 2709

member has billed, singling out those who fail tomeet hospital quotas. Those who fail to meet the setrequirements—barring personal illness or vaca-tions—are asked to account for their loweredproductivity rates to their clinical team manager,who in turn accounts for it to the Hospitaladministration. As the clinic social worker puts it,‘‘It’s kind of like a public shaming. Like highschool. Gold stars for the good students and sit inthe corner ashamed for those who aren’t.’’ Thecirculation of reports of clinician productivity, then,is part and parcel of a new ‘‘competitive framing ofpublic services’’ (Clarke, 2004, p. 13). Public serviceproviders, like the agencies that employ them, areheld to quantifiable goals, and underperformingentities are ‘‘named and shamed.’’

The Hospital’s new emphasis on productivityillustrates the conflicting priorities of street-levelbureaucracies, reflecting in part the contradictoryimpulses of the society they serve (Lipsky, 1983,p. 165). Thus while the hospital continues topublicly espouse a mission of providing charitycare, this mission has come into increasing conflictwith a growing ‘‘private sector’’ emphasis on fiscalausterity and efficiency. Productivity requirementsmay be seen as an attempt to conform the charitymission of health care workers to the cost-savingimperatives of its management and to ensure‘‘accountability’’ to public taxpayers through quan-tifiable performance measures (Clarke, 2004). Yetproductivity requirements may be related onlytangentially to the agency’s overall objective ofpublic service (Lipsky, 1983, p. 50); they may bemore about what Clarke calls ‘‘impression manage-ment’’ (2004) than about human service delivery.Productivity requirements standardize the discre-tionary work involved in therapy, quantifyinga fundamentally human service (Lipsky, 1983,pp. 165–167). Health care workers, then, must dailynegotiate the conflict between their loyalties toagency objectives and to patients. How, then, dothese productivity requirements affect the care ofunderserved immigrants?

Clinical care in a ‘‘factory setting’’: community

mental health ‘‘on your free time’’

In order to boost clinician ‘‘productivity’’ andHospital revenues, Bradford has encouraged clin-icians to adopt a number of measures to increase‘‘billable hours.’’ These include: (1) implementingnew time limits for appointments; (2) denying care

to uninsured patients; (3) encouraging clinicians toperform ‘‘group therapy;’’ and (4) encouragingclinicians to ‘‘double-book’’ patients.

First, the Hospital implemented new time limitsfor appointments with psychologists and psychia-trists. Whereas psychiatrist appointments previouslytook 30min, the Hospital required that they take nolonger than 20. Psychiatrists may now bill for threeappointments as opposed to two within the space ofan hour. One psychiatrist says: ‘‘There’s a hugepressure on productivity—that’s a big concern ofthe administration—‘keep your numbers high.’ ButI think the standard of care really suffers when yousee patients every 20min.’’ As another psychiatristputs it, these new time limits reduce psychiatry towhat she calls ‘‘medication management.’’

Similarly, whereas appointments with psycholo-gists previously had lasted 1 h, the administrationchanged the allotted time instead to 45min. In theremaining 15min of the hour, psychologists are nowrequired to fill out insurance forms and maintainHospital databases with patient records. Thiseconomizing of time, not to mention clinicians’additional bureaucratic responsibilities, diminishesclinicians’ attention to patients’ psychosocial issues.The new time limits on appointments reducethe human service dimension of being a clinician,causing one psychologist to liken her job to ‘‘work-ing in a factory setting.’’ As the referencesto ‘‘medication management’’ and ‘‘factorywork’’ illustrate, the Hospital’s emphasis onclinician ‘‘productivity’’ is part of a broader trendtowards the commodification of health care pro-vision. Shaped by the administrative mandatesof ‘‘efficiency’’ and ‘‘productivity,’’ the humanprocess of care-giving is instead rendered alienablelabor, measured and quantified in the process ofproduction.

Yet on top of staff’s faster pace of work, theadministration has also unintentionally increasedthe charity work clinicians perform in their freetime. Exacerbating Bienestar clinicians’ already-heavy caseload, in 2004 the administration specifi-cally asked clinicians to stop providing charity careto the uninsured. These patients, for whom there isno public nor private payer, do not count towardsclinicians’ ‘‘billable hours.’’ This edict presented anadditional dilemma for clinicians who wish toensure continuous care, as their patients’ insurancestatus may fluctuate from month to month.Medicaid-eligible patients may lose that eligibilitydue to an unforeseen spike in monthly income,

ARTICLE IN PRESSS. Horton / Social Science & Medicine 63 (2006) 2702–27142710

causing such patients to temporarily become ‘‘un-insured.’’ Clinicians who did not wish to disrupt thecare of their regular patients, then, were forced tosubvert the administrative edict by seeing patientswho were temporarily ‘‘uninsured’’ on their owntime. Others spoke of not providing these patientstherapy, but attempting to redress their ‘‘unin-sured’’ status. As one clinician put it:

We might still try to manage the patients’ needson the phone or try to help them get insurance,and again, that is something we’re not reim-bursed fory

Again, such reforms took a toll first on providers,encouraging clinicians to provide more unreimbur-sable care on their ‘‘own free time.’’

Hospital measures to boost provider ‘‘productivity:’’

new dilemmas for providers

The Hospital’s attempts at increasing clinicianproductivity have run into a significant challenge:Bienestar’s no-show rate of 30%. Since Bienestarpatients face a number of contextual problems—theinability to speak English, the lack of transporta-tion, and unpredictable work schedules with littlecontrol—many find it difficult to regularly makeappointments. To decrease the likelihood of ‘‘no-shows,’’ front-desk clerks make a practice of notonly giving patients cards to remind them of theirnext appointment, but also of calling them toremind them a day in advance. Yet while cliniciansmay be asked to see more patients in the spaceof day, the administration cannot compel patientsto comply with the faster pace of health careproduction.

To solve the problem of ‘‘no-shows’’ and unbill-able clinical hours, the Hospital recently adoptedtwo additional strategies. First, it has begunencouraging clinicians to increase their use of grouptherapy. Group therapy theoretically increases bothpatient access and hospital revenue, as cliniciansreceive more credit towards ‘‘billable hours’’ in asingle visit. Yet while group therapy may beeffective in creating support groups for certainissues, it may be inappropriate for sensitive topicsand for those who are less comfortable discussingtheir mental health issues with strangers. As oneclinician says, ‘‘Sometimes there are constraints—patients are very private, very embarrassed—espe-cially coming from a Latin American culture,they’re not as open about mental illness issues. So

providers are trying to do more group therapy, butsome patients don’t like it.’’

Secondly, the administration has encouragedclinicians to double-book for each appointment. Iftwo patients show up for the same time slot, theyeach receive half the allotted time. Most clinicianshave resisted the practice on principle, but a fewhave adopted it to help meet heightened productiv-ity requirements. Yet this practice sends a messageto patients that their appointments are conditionaland may not be honored. One day, for example, as Iwas observing the work of the front-desk clerks, apatient, Monica, showed up for a first appointmentwith Elisabeta, a clinician. Shortly after she hadchecked in, La Cubana, ‘‘the Cuban,’’ a ‘‘regular’’nick-named by the staff for her imperious ways,came in for her regular therapy appointment withthe same clinician. Alerted to this, Elisabetaemerged to explain the situation to both patients.She could only see each for 20min, half the regularappointed time; she would start with Monica as shehad arrived first. The news did not sit well with La

Cubana, who spent much of her 20-min waitdirecting her criticism at the front-desk clerk.

Elisabeta explained to me later that she hadagonized about the decision to ‘‘double-book’’because La Cubana (who has bipolar disorder) wasa sensitive case. Yet Elisabeta’s productivity waslow for that month and La Cubana was unpredict-able in making her appointments. Unfortunately,La Cubana retaliated by missing her next appoint-ment and failing to return Elisabeta’s phone-calls;her therapy was eventually prematurely terminated.Productivity requirements thus placed Elisabeta in adouble bind, as she must try to ‘‘keep her numbershigh’’ but does not wish to discourage patientaccess. She continues to worry about La Cubana

and whether she is taking her medications. Thusclinicians may ‘‘double-book’’ in attempting toadhere to agency directives, yet this practice mayerode patient trust in their therapists.

‘‘Firing’’ the no-shows: health disparities for

immigrant patients

Finally, clinicians have adopted a strategy of theirown to increase ‘‘productivity’’—that of ‘‘firing’’patients who ‘‘no-show’’ three times, a practice byno means limited to Bienestar (Borglum, 2003;Izard, 2005). Most Bienestar clinicians say theyavoid doing this to the most vulnerable patients. Yetin order to meet administrative quotas, some

ARTICLE IN PRESSS. Horton / Social Science & Medicine 63 (2006) 2702–2714 2711

clinicians at risk of lowered ‘‘productivity’’ haveadopted the practice. As one facing administrativecensure explained, ‘‘We have to show the adminis-tration we’re working and those who miss appoint-ments interfere with that.’’ The emphasis on‘‘productivity’’ has thus led some clinicians toemphasize the documentable aspects of their‘‘work,’’ redefining as ‘‘undeserving’’ of care thosepatients who impede administrative goals of pro-ductivity. Thus the Hospital’s emphasis on ‘‘pro-ductivity’’ has indeed led to ‘‘drift towardscompatibility with the ways the organization isevaluated’’ (Lipsky, 1983, p. 51).

Yet, not surprisingly, perfunctory attendance is agoal more suitable to middle class patients than aworking-class immigrant patient base. For a patientbase that is primarily undocumented, the demandsof employers must trump those of clinicians. Asfront-desk staff explained, immigrant patients whoworked on an on-call basis would often have tocancel appointments at the last minute or face theprospect of losing their jobs. Others squeezed clinicappointments in between two jobs and wereoccasionally asked to work overtime. Thus whilefrom a clinical perspective, the practice of ‘‘firing’’no-shows may seem reasonable, it jeopardizes carefor a low-income immigrant population that mustmake work a priority.

As Lipsky argues, ‘‘performance measurementand monitoring can signal workers powerfullyconcerning which aspects of performance are mostsalient’’ (Lipsky, 1983, p. 170). The administrativeemphasis on ‘‘productivity’’ encourages providers toemphasize their role as workers producing docu-mentable outputs as opposed to their role ascultural brokers and patient advocates. In short,the practice of ‘‘firing’’ repeated no-shows singlesout immigrant patients whose contextual issuesmake regular attendance difficult, in turn contribut-ing to disparities in care.

Conclusion

I will conclude with three points relevant to boththe analysis of health disparities and of mentalhealth care for the poor in a context of tighteningfinances. First, analyses of disparities in mentalhealth treatment for minority patients must not onlyexamine clinician attitudes and bias, but also theinstitutional and systemic policies that discourageequal care. Minority clinicians’ unacknowledgeddouble burden is in part the result of a hospital

system that implicitly devalues advocacy work incontrast to ‘‘productivity.’’ Yet this hospital systemitself merely reflects broader societal trends ofprivatization and marketization that have buffetedsafety net providers for over a decade. Reducedpublic financing to safety net sites serving the poorand underserved are clearly a major cause ofdisparities in the availability and access of mentalhealth services, particularly in a mental healthsystem already riven by access problems (USDHHS,2001). This point is relevant for health care for thepoor in all countries considering restructuring theirhealth care systems along managerial principles toincrease system ‘‘efficiencies’’ and reduce govern-ment ‘‘bloat.’’

Secondly, clinicians—in this case predominantlyminority women—who serve an underserved im-migrant population frequently assume the respon-sibility not only of therapists but also of advocatesfor newcomers navigating a foreign social servicebureaucracy. Yet the productivity requirements ofhospitals facing decreased public financing do nottake clinicians’ double burden into account. Clin-icians who choose to continue to perform advocacywork are in effect subsidizing the hospital’s missionof providing charity care. In short, the health caresystem may not provide clinicians the support theyneed—in terms of relaxed productivity requirementsas well as Spanish-speaking services for theirpatients—in order to provide optimal care. As thecare-giving workforce is predominantly minorityand female, both minority women caregivers andtheir minority patients ironically absorb the bruntof private-sector reforms.

Finally, this data points to the transformation ofthe work of safety net providers, with implicationsfor their historic ethic of care. Clinicians increas-ingly perform ‘‘gatekeeping’’ functions such asdenying care to the uninsured and ‘‘firing’’ no-shows. Such practices single out groups of patientsdeemed to obstruct ‘‘productivity.’’ As clinicianscontinue to enjoy relative autonomy from bureau-cratic edicts, however, these practices are not yetaccompanied by the ideologies of blame commonamong welfare workers (Kingfisher, 1996). Suchideologies of blame, and a concomitant decline ofcaregivers’ ethic of care, may increase with morestringent administrative control of clinicians (see,for example, Willging, 2005, pp. 96–98). Analystsmust continue to monitor where clinicians fall onthe continuum between ‘‘advocacy’’ and ‘‘effi-ciency’’ as the treatment of patients as mass

ARTICLE IN PRESSS. Horton / Social Science & Medicine 63 (2006) 2702–27142712

categories rather than as individuals with particularneeds may be particularly detrimental to minoritypopulations (Balsa & McGuire, 2001; Good et al.,2003; Spitzer, 2004). Future research must considerthe price of productivity in the health care work-force, as the erosion of discretionary care mayadversely affect minorities with greater contextualneeds.

Acknowledgments

I am grateful to Louise Lamphere, Catie Willgingand Mary-Jo DelVecchio Good for their commentson this paper, and to the three anonymousreviewers. This research, carried out as part of alarger project directed by Mary-Jo Good, issupported by an NIMH post doctoral fellowshipon Anthropology and Mental Health Services, inthe Department of Social Medicine, HarvardMedical School (NIMH Grant # T32 MH18006),with additional funding from a Russell SageFoundation grant to Mary-Jo Good on ‘‘Culture,Race and Ethnicity and Disparities in MedicalCare.’’

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