Unhealthy states

So important is the profit motive to the US health system that the role social care staff play has become increasingly marginalised as they too become victims of the bottom line, says Paul Johnson.

The free market has taken over much of health care in the US. The economic foundation of health care in which social care is embedded is vanishing. In its place is a rapidly changing non-system typified by chaotic conflict between different organisational elements, mergers to form larger organisations and the formation of national entrepreneurial hospital chains.

These changes are reflected in the new language being spoken, such as “marketisation” and “managerialism”. Patients are “customers” as well as elements in “profit centres”, and woe betide the customers who lack the means of payment or whose payments are too low to generate profits.

The US spends about 14 per cent of its gross domestic product on health care. Yet the number of uninsured people has increased each year since 1987. It is estimated that 42 million Americans,

one-sixth of the population, lack health insurance and are limited in their ability to use market-based health care.

African-Americans and Hispanics are less likely to be covered than white Americans, and Mexican Americans more than three times as likely to lack coverage as white people. Despite the Medicaid programme (see background panel, right), nearly one-third of the poor have no health insurance.

Lack of insurance also varies by state. In 1999, Arizona, California, Louisiana, Nevada, New Mexico and Texas all had uninsured rates of more than 20 per cent. Even more shameful in a country of such wealth is the estimate that 14 per cent of all children have no health insurance.

The US has had two markets in health care for some time. The public market’s vision is that of the health of all members of society. The private market’s outlook is the provision of health services to all those who pay the cost of these services at a level that generates profit for the health enterprise. The two markets intermesh in the US in publicly financed programmes such as Medicaid and Medicare. The outcome of the political conflicts between these two markets, coupled with inadequate regulation, has resulted in private sector domination of publicly financed programmes.

The dominance of the profit motive in health care is occupying a key position in political debate. The dominant values reflected in recently enacted welfare reform measures are similar. Poor people are seen as lazy and shiftless, needing “tough love” to overcome their idleness. Together with the poor, immigrants are seen as draining the country of its wealth.

The effects of these attacks have a direct impact on the social work profession. Health care is the second largest setting in social work practice, and one in which social workers play many roles. But the structures which have permitted social workers in hospitals to work together to support one another, to avoid duplication and to co-ordinate the education of social work students, are being dismembered.

Instead, social workers are working in bureaucratic units, isolated from one another, often supervised by non-social work health care professionals or administrators. Time for supervision has become minimal and is focused on procedures. Job security is undermined and is now based mainly on profit and loss statements.

Paul Johnson is assistant professor, school of social work, University of Southern Maine.


  • Medicare is the federal health insurance programme for people aged 65 and over, some younger disabled people and people with end-stage renal disease (permanent kidney failure with dialysis or a transplant).
  • Medicaid is a joint federal and state programme that helps with medical costs for some people with low incomes and limited resources. Medicaid programmes vary by state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

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