The double burden on safety net providers: placing health disparities in the context of the privatization of health care in the US.

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.'