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Katherine Chen

Honors 230B Safety-net Hospitals in the US: Past, Present, Future

Dr. Maralyssa Bann

December 13, 2022

Part I: Self-Reflection:

What initially interested me in studying US safety-net hospitals was the desire to learn

more about the healthcare system in the US as a whole. I’ve been fortunate enough to have

access to private insurance through my parents’ employment my whole life, so I wanted to

understand government-provided insurance like Medicaid and Medicare more. I also did not

know what safety-net hospitals were before taking this course. I think learning about the US

healthcare system, like any system, is best studied by centering the most marginalized, because

not only then are we addressing the inequities baked into the system, but we are also moving

forward with the understanding that equity and care for everyone is improved if the most

vulnerable are centered in reform. Those are the reasons why I wanted to learn about safety-net

hospitals.

I was initially interested in studying the specific patient population I chose (incarcerated

patients, specifically in state prisons and county jails) because I am somewhat familiar with the

carceral system, but not from a healthcare perspective. I do not come from a pre-med or STEM

background; my major is Political Science and Sociology with a minor in Labor Studies. My

primary focus is the Social Sciences, so I wanted to see how systems like the carceral system

interact with healthcare institutions, because I normally don’t study healthcare related topics.

Some of the most pertinent lessons I’ve taken away from this course is how safety-net

hospitals fit into the healthcare industry, especially how for-profit hospitals benefit from being
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geographically close to safety-nets because they can send uninsured and Medicaid patients to the

local safety net. What I found very interesting was the history behind establishing

Medicare/Medicaid and how the formation of government-provided healthcare was tied up with

the Civil Rights Movements and efforts to desegregate hospitals. The history behind the

evolution of the healthcare system that illuminates the dysfunctional aspects of it. I also found it

very illuminating to learn about the history of the American Medical Association and how it

lobbied hard to prevent and limit government-provided and single payer healthcare. Because the

AMA has influenced the field of medicine so deeply, I found it very impactful to learn about the

history of the AMA and how it has perpetuated systemic inequalities.

What I found the most impactful was learning that safety-net hospitals receive less

federal funding than hospitals that have a higher percentage of privately insured patients, which

is exacerbated by COVID and the HHS distribution of CARES Act funding. One thing I also

found surprising was the politics behind EMTALA and the loopholes that are highlighted during

clinical vignettes that were provided in class. I found it surprising that the definition for

“emergency care” has a lot of gray areas attached to it, and that if people are not actively dying at

the very moment they are brought to the emergency center, their condition could potentially not

be classified as “emergency” even if it is a life threatening condition that could worsen and lead

to death.

What I remain curious about is what we do moving forward and how we can view

healthcare with an abolitionist lens. I have talked about abolition as an interpersonal practice and

discussed abolition of institutions like policing and the carceral system, so I would love to learn

more about the intersection of that with healthcare. How I see myself using the information I

learned in this course for the future is using course materials to actively think about how
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healthcare interacts with various institutions and systems. I also now have a better understanding

of how various marginalized patient populations access healthcare, particularly through Medicaid

and safety-net hospitals.

Part II: Op-Ed: Abolition and Healthcare

Healthcare is a complicated system to think about changing because, like many complex

systems, it interacts with other factors that can make accessing care much more difficult for

people with marginalized identities. For example, there are upstream barriers to healthcare, like

whether an individual has access to clean water, food, and safe housing. Barriers to healthy

living have downstream impacts that lead to lead poisoning, diabetes, and heart disease. The

healthcare system is so much larger than caring for a patient the moment they fall ill. When we

talk about equity and justice in accessing healthcare for better health outcomes for disadvantaged

groups of people, we need to situate healthcare within a larger context. The context I’m using

today is an abolitionist framework of examining how we can reimagine the healthcare system by

reimagining our society that surrounds healthcare, as well as looking at change within healthcare

institutions themselves.

Firstly, let’s briefly define abolition. Abolition is the understanding that the systems and

institutions we have in place today have been built out on the exploitation of the labor and bodies

of marginalized peoples, and that we must reimagine new systems entirely to truly have equity

and justice in society. An important concept in abolitionist literature is one of “organized

abandonment”, coined by Black Feminist Geographer and writer Ruth Wilson Gilmore.

Organized abandonment is the deliberate inaction and neglect from the state and federal

government in providing social services to make communities — usually poor, immigrant,

and/or BIPOC communities — liveable, which includes access to clean water, safe housing,
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employment, a non-toxic environment, etc (The Intercept Podcast, 2020). When targeted

communities fall into disarray due to organized abandonment, the government can then

naturalize these conditions and then pathologize the communities experiencing them, deeming

them as ungovernable places and therefore in need of increased surveillance and policing, instead

of social services. And because policing is an inherently racist institution that was created to

police the movement and bodies of enslaved Black people and the fact that experiencing racial

violence (including from the police) is a public health issue, from an abolitionist standpoint, the

only way to achieve equity in healthcare is to reimagine all of these institutions that are bound up

together.

So, what is abolitionist healthcare? The healthcare system also suffers from the impacts

of organized abandonment, such as accessible transportation, difficulty in taking time off of

work, “lack of adequate insurance, lack of affordability, and the presence of police and, often,

immigration and customs enforcement officials in urban emergency departments” (Khan et al,

2022). The difficulty in accessing healthcare is compounded if an individual is incarcerated, as

medical neglect is pervasive in prison healthcare. Imagining a new healthcare system means

addressing upstream barriers, exacerbated by organized abandonment, so that the downstream

health implications that disproportionately impact poor, immigrant, disabled, trans, queer, and/or

BIPOC communities can also be addressed. Abolition extends as far as the limits to our

imagination.

Reimagining the healthcare system and society at large can seem untethered to reality and

utopic. I believe that abolition is not ideologically opposed to incremental reform efforts, rather I

think that abolition-minded reform is extremely important. One such example within healthcare

reform are efforts to make insurance coverage more accessible to everyone and therefore access
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to regular and preventative care. One way that could be done is through implementing a single

payer system. The bureaucratic cost and slow down of having various payment plans and

provider networks in our current patchwork insurance system could be mitigated with an

incremental approach to a single payer system. One approach could be to first standardize all

health plans offered including by Medicaid to make the transition easier (APHA, 2021). All in

all, an abolitionist view on healthcare changes can encompass a reimagining of healthcare and

other systems in society as whole, and inform the way incremental change is advocated for.

Works Cited

Adopting a Single-Payer Health System. (n.d.). American Public Health Association. Retrieved

December 13, 2022, from

https://www.apha.org/Policies-and-Advocacy/Public-Health-Policy-Statements/Policy-Da

tabase/2022/01/07/Adopting-a-Single-Payer-Health-System

Intercepted Podcast: Ruth Wilson Gilmore on Abolition. (2020, June 10). The Intercept.

Retrieved December 13, 2022, from

https://theintercept.com/2020/06/10/ruth-wilson-gilmore-makes-the-case-for-abolition/

Shen, M. (n.d.). Abolitionist Reimaginings of Health | Journal of Ethics | American Medical

Association. AMA Journal of Ethics. Retrieved December 13, 2022, from

https://journalofethics.ama-assn.org/article/abolitionist-reimaginings-health/2022-03