Complex Care: Health, Bureaucracy, and Neo-Welfarism in Los Angeles County

Abstract

Over the past 20 years, healthcare organizations in the United States have focused increasing attention on controlling costs by providing extra services and support to “the sickest and most marginalized” patients. While these patients have been informally acknowledged by clinicians for decades, a new category of the “high-need, high-cost patient” has recently emerged within academic and policy discourses, accompanied by an efflorescence of “complex care management” programs. In 2016, the Los Angeles County Department of Health Services debuted a billion-dollar, five-year initiative called Whole Person Care, which aspired to provide comprehensive, coordinated services to certain groups of these patients. In contrast to longstanding policy trends towards privatization and austerity, Whole Person Care represents a turn back towards the welfare state, albeit one primarily concerned with cost control. Drawing on 14 months of ethnographic research with Whole Person Care’s administrators, clinical staff, and patients, my dissertation analyzes the development and implementation of the program’s conceptual and material interventions. By focusing on the intersection of bureaucracy and care work with the effects of structural violence, I explore how the political economy of US healthcare contributes to the production of “high needs” and “high costs,” while simultaneously attempting to respond to the perceived crises they represent. To understand these processes, I propose a theory of “neo-welfarism,” an emerging regime of politics, policy, and practice that purports to integrate many of the traditional functions of the welfare state into the US healthcare system. I argue that this concept is useful for understanding the healthcare system’s role within capitalist political economy, the efforts of bureaucrats and care workers to address contradictions in that system, and, consequently, the nature of recent extensions of state resources to certain sub-populations of the poor.