Unequally Uninsured: Safety-Net Healthcare Delivery and the Reproduction of Inequality

Abstract

This dissertation explores how low-income and uninsured adults’ everyday experiences of inequality shape both the healthcare they have access to and the ways in which they navigate safety-net healthcare organizations in the years following the passage of the Affordable Care Act (ACA). Low-income and uninsured adults in the U.S. are the leading edge in the rising incidence of preventable chronic illness and are in need of high-quality preventive healthcare. However, social scientists have made little progress in understanding the role of healthcare safety-net organizations in the lives of low-income and uninsured adults as they traverse these settings amid everyday experiences of economic insecurity, pressing health needs, and interlocking systems of oppression in an era characterized by significant health and welfare policy changes, neoliberal privatization, and safety net resource fragmentation. The three studies in this dissertation advance this area of research by systematically analyzing multiple data sources centered on the perceptions and experiences of safety net healthcare workers and low-income and uninsured patients as they navigate a private primary care clinic in a mid-sized city in the southeastern U.S. which has become a New Immigrant Destination. In these studies, I explore the ways low-income and uninsured adults navigate a private nonprofit primary care safety net clinic and manage chronic health conditions amid everyday experiences of poverty and uncertainty. The first study explores how organizational features structuring patient eligibility and intake processes may exacerbate or lessen inequality among new patients as they enter primary care treatment in a private clinic in the healthcare safety net. The second study explores worker agency and offers a conceptual model to understand linkages between worker rule-breaking behaviors oriented to provide more equitable patient treatment or possibly harm patients, when and how organizational change occurs, patient background characteristics, and long-term patient health outcomes. The third study explores how individuals in one disadvantaged group, unauthorized Latina mothers, undertake strategies to combat cumulative health disadvantage as they access health-promoting safety net resources and traverse everyday social and economic hardships, uncertainty, and deportation threat.