From home to hospital and back again: economic restructuring, end of life, and the gendered problems of place-switching health services

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Abstract

Economic restructuring in the health services industry in the USA exemplifies general patterns of economic change propelled by neoliberalism, especially industry privatization, diminished social services, and dependence on “flexible” labor and management regimes. Combined with the widespread entry of women into the labor force, an aging population, and minimal assistance for high quality long-term care at the end of life, these economic and social conditions raise a set of difficult policy questions for health services planning. Set in these broad contexts, this paper situates access to and experience of health services in the home, the hospital, and nursing facility, to demonstrate how economic changes have relocated and redefined health services in ways that distinctively impact how people experience the places where they receive care. This place switching of health services externalizes costs of subacute and “daily life care” (the so-called custodial care) to the sphere of the individual, their family, and communities. The theoretical analysis uses current geographical and philosophical approaches to place and space, and considers the tensions between institutionally managed health care space, and the patient's experience of receiving health services in place. The place/space dilemma of health services provision is examined through several interrelated subjects: long-term care at the end of life, gendered characteristics of care giving, the limitations of Medicare and Medicaid, historical changes in hospital length of stay, the restructuring of nursing practices, and the “no-care zone”. The analysis is based on examples of stroke and incontinence care to demonstrate the importance of considering place and space issues in health care planning.

Introduction

Economic restructuring in health care services combined with the widespread entry of women into the workforce and demographic shifts in the US population have resulted in new health care needs and reorganization of health services provision. As the baby boomer generation looks ahead to retirement and end of life, more people will need long-term care, and the traditional care providers within families—women—will not be readily available to step into care-giving roles. By and large, the response from the health services policy sphere has yet to address these demographic changes and instead has continued to treat end of life care according to the medical model, which insures medical procedures but limits benefits for nursing care or so-called custodial care, what I call in this paper “daily life care”. Medicare, the federal insurance for the elderly, generally limits nursing care to “skilled” nursing facilities and benefits to about 3 months. Medicaid, federal health benefits for those without resources for daily life care, generally requires people to enter designated nursing facilities. The cost of individually funded long-term daily life care often results in personal bankruptcy, which Medicaid benefits effectively require. Perceptions and realities about varying quality of nursing home care contribute to these concerns.

This analysis makes a contribution to the complex set of issues about end of life care by making the case that the places of health care provision matter, for individuals in need of care, their families, friends, care givers, and also for health care professionals. It urges that economic models of health policy formulation have been decontextualized from place, and that instead the provision of care must encompass questions about the location of care and the quality of care-giving environments. This is in part an ethical argument to increase the comfortability of health services provision and the outlook for patients—to improve patients’ “sense of place”. It is also a pragmatic response to spatial differentiation and fragmentation of health services provision generated by economic restructuring in the post-Second World War period. At the heart of the spatial problematic in end of life care is the spatial separation of “medical services” care from “non-medical” or “custodial care”, in which non-medical services have been removed from hospitals and relocated in spatially segregated facilities, especially nursing homes. The spatial segregation of nursing services from hospitals is a cost-saving strategy for hospitals, but does not eliminate costs; instead it externalizes them to the sphere of patient, the family, and society. Moreover, frequent relocation of the fragile elderly often has negative health consequences. In order to shed some light on these conditions, I situate this analysis in the spatial continuum from the home to the hospital, nursing facility, and back again—what health care professionals refer to as the “revolving door” of health care provision for patients whose deteriorating conditions defy continuity of care in any one location under the current system. Along the circuit between home and hospital, problems of securing access to the health care system emerge in place-based tensions about quality of care, gaps in care, and confidence in the health care system in general.

Section snippets

Concept and method

The conceptual approach of the analysis uses contemporary theory on place and space from geography and philosophy to define these subjects and give some shape to their importance. I also draw on the literature of economic restructuring from geography and related fields to explain how economic policy changes in the health services industry are characteristic of larger scale patterns of change in the US economy. Restructuring in the health care industry demonstrates cost savings strategies

Conclusions

From its origins, the US system of federal health insurance for the elderly has been characterized by policy gaps that neglected to fund long-term daily life care. Effects of the subsequent neoliberal transformations in the US economy, including the minimization of labor costs through discriminatory gender policies (i.e. employing more women while paying them at lower rates than men) and associated flexible management systems, have certainly characterized the health care system in its increased

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  • Cited by (0)

    This paper was originally drafted while I was a fellow in the “Health and Place” seminar at the University of California Humanities Research Institute. I am grateful to Ruth Malone for bringing me in to the seminar, and to Michael Dear for first suggesting the opportunity. I am also grateful to Ruth Malone and to the other members of the seminar, Sharon Kaufman, Sara Shostak, and Nancy Stoller, for unstinting encouragement of the ideas at the foundation of this work. Sharon Kaufman offered especially brilliant interventions in the process of thinking through stages of the paper's development. The extraordinary week-long discussion with Ed Casey and Jeff Malpas led me to enlarge my geographical understandings about concepts of place and space in ways I did not initially think I would be inclined to accept. Two critical referees challenged the remaining weak links in the paper and I am grateful for their efforts. The paper's remaining limitations are mine alone.

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