FILLING THE CRACKS: AN ETHNOGRAPHY OF HEALTH AND SOCIAL SERVICE
ADVOCACY AT A NEIGHBORHOOD-BASED MICHIGAN NGO
By
Heidi J. Connealy

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
Anthropology
2012

ABSTRACT

FILLING THE CRACKS: AN ETHNOGRAPHY OF HEALTH AND SOCIAL SERVICE
ADVOCACY AT A NEIGHBORHOOD-BASED MICHIGAN NGO

By
Heidi J. Connealy

In this dissertation I analyze the work of a Michigan based NGO (non-governmental
organization) that provides health and social service advocacy and assistance to low income
individuals. The NGO, which I call the Smith Street Center, or SSC, is a non-profit organization
funded by several agencies to promote public health and social services, administer programs
and provide assistance to low income neighborhood residents. This study explores the SSC’s
role in the neighborhood it serves and its relationships with its public funders and other NGOs.
I document the SSC’s work of providing health advocacy and assistance for the
neighborhood it serves in the wake of changes in public support for health and social services. I
situate the SSC’s work within a broader context of public health and social service distribution
and investigate the experiences of low income, sick and vulnerable people participating in its
services. Specifically, the project addresses how changes in funding policies have influenced the
role of non-profit organizations like the SSC and the availability and distribution of public health
and social services in Michigan in the last twenty years.

Using ethnography, I demonstrate that the current political-economic climate that
promotes privatization and decreased public services leaves many already marginalized people
without necessary healthcare, food and housing. The ethnographic examples provided challenge
neoliberal rhetoric about the merits of smaller government, increased choices and liberation
through work. Specifically, I expose fallacies of neoliberal rhetoric and policies that promote
self-sufficiency and personal responsibility for poor, sick and marginalized people. I use case
examples to argue that an increased reliance on NGOs does not replace a competent, easily
navigated public health and social service sector. Based on this analysis, I argue that many
people “fall through the cracks” in the current system of public health and social service
distribution.

Copyright by
HEIDI J. CONNEALY
2012

DEDICATION
To my dear husband, Christopher Farrow, thank you for believing in me and supporting me. To
my parents, Lucy O’Hanlon and Del Connealy, thank you for your financial and emotional
support and for always nurturing my curiosity. To my delightful daughters Lucy and Eleanor
Farrow, you bring so much joy and love to my life. In memory of my grandmother Marybelle
Connealy, who was always so supportive and encouraging. In memory of John Farrow, who
supported and guided us so well.

v

ACKNOWLEDGMENTS

First and foremost, I would like to thank everyone who participated in and assisted me
with this project. I am indebted to the people I interviewed and worked with during my research.
I was regularly overwhelmed by their gifts of time, enthusiasm, hospitality and honesty. I am
especially grateful to the director and staff at the Smith Street Center. I hope that the
organization’s unique spirit, tenacity and dedication to the neighborhood it serves is well
reflected in this dissertation.
I would like to thank Professor Linda Hunt of the Michigan State University Department
of Anthropology. Dr. Hunt’s dedication, guidance and support have been invaluable. I hope my
future work reflects well on all she has taught me. Thank you to Nancy Smith, Dr. Judy Pugh,
Dr. Margaret Holmes-Rovner and Dr. Heather Howard for all of your time and insight. Thank
you to Kate Patch, Sonia Johnson, Karin Rebnegger, Maria Raviele, Megan McCullen, Marita
Eibl, Michael Perez, Christine LaBond, Inez Adams and Lori Scheiss. I am so lucky to have
journeyed through graduate school with such bright, supportive colleague-friends.
I am extremely grateful for the Families and Communities Together Coalition at
Michigan State for their generous support of this project. I would also like to thank the faculty
and staff of the Center for Ethics and Humanities in the Life Sciences and the program in
Bioethics, Humanities and Society at Michigan State University for their financial and
intellectual support of my graduate education. I truly hope that my future professional
experiences are filled with such lovely, dedicated colleagues.

vi

I am thankful for the teachers and staff of People’s Church Preschool in East Lansing,
Michigan and the excellent care they provided to my daughter, Lucy. Their hard work made my
work possible.
Most importantly, I would like to give thanks and love to my family who has always
supported me. I am so blessed to have such wonderful parents, such a supportive husband and
such beautiful, delightful daughters.

vii

TABLE OF CONTENTS

LIST OF TABLES……………………………………………………….. ................................... ix
Chapter 1: Introduction…………………………………………………..1
Chapter 2: Political Economic Issues Impacting the Work of the SSC…...23
Chapter 3: Privatization and Partnerships in Michigan……………………50
Chapter 4: The Study: The Site, Methodology and Demographics………66
Chapter 5: The Smith Street Center………………………………………86
Chapter 6: Navigating “Choice” With Few Choices………………………121
Chapter 7: Patching up the Cracks or Creating New Holes? Increased Bureaucracy and PublicPrivate Partnerships…………………………….151
Chapter 8: Conclusion……………………………………………………................................. 179
Appendix A: Interview Schedule for Neighborhood Residents…………. ................................. 194
Appendix B: Interview Schedule for Smith Street Center Staff and
Volunteers…………………………………………………………………196
Appendix C: Interview Schedule for Public Health Professionals………. ................................ 197
Works Cited……………………………………………………………….198

viii

LIST OF TABLES
Table 1: Specific Characteristics of 15 Neighborhood Residents Who
Participate in SSC Programs………………………………………………76
Table 2: Specific Characteristics of 15 Smith Street Center Employees or Volunteers
Interviewed……………………………………………………79
Table 3: Specific Characteristics of 12 Public Health Professionals
Interviewed………………………………………………………………. .................................. 82

ix

Chapter 1: Introduction

1

In this project, I draw on research from fieldwork at a Michigan non-profit organization
to challenge the rhetoric that increased public-private partnerships, privatization and decreased
public services simplify government, promote work and increase self-sufficiency among the poor
and sick. Using interviews and ethnographic accounts, I argue that the role of small non-profit
organizations in community advocacy, health promotion and social service navigation frequently
leaves both the agencies and the people they serve in positions of sustained dependency on
publicly funded agencies and programs. I demonstrate that the current system of private-public
partnerships has, in many cases, lead to a dysfunctional system of dependence between nonprofit organizations and the public funding agencies overseeing grants and projects for services
and programs for the poor and sick.
This dissertation is based on fieldwork I conducted at a small, neighborhood based nonprofit organization that I call the Smith Street Center, or SSC, from October 2005 until October
2007. I initially chose the SSC as a site for the study because I was interested in its health
programs and wanted to conduct research at a small non-profit organization that was engaged in
grass-roots level health advocacy and outreach for the poor in the United States. While
designing this research project, I sought to examine the role of non-profit organizations in
assisting some of the 45 million Americans without health insurance. I wanted to understand the
lived experiences of those without health insurance or access to care, as well as the perspectives
of those working to improve access to care and compare these experiences to the rhetoric
promoting privatization and fewer services for the poor and sick. While collecting data at the
SSC, I observed a complicated, nearly symbiotic relationship between the SSC and its funding
agencies. What I observed at the SSC often contrasted with popular and political notions about
2

public health and social services, the role of public and private agencies in their distribution and
the experiences and expectations of the individuals receiving services.
In this dissertation, I draw on research at the SSC to demonstrate that privatization and
decreases in directly provided government services to the poor have created more complex,
dependent relationships between public and private entities and the people they serve. I
challenge the rhetoric about the merits of “smaller government” and argue that the privatization
of public health and social services in the United States has, in many cases, actually increased
bureaucracy. Using interviews and observations from fieldwork at the SSC and the public
agencies it worked with, I expose the flaws in popular rhetoric and state and federal policies that
claim to promote health and reduce poverty by privatizing services.
I demonstrate that the Smith Street Center’s role in community advocacy, health
promotion and social service navigation leaves both the agency and the people it serves in a
position of sustained dependency on public agencies and programs. Using ethnography, I show
how the SSC assists those it serves with navigating public health and social service safety-nets
and I ask how its role and its relationships with government agencies impact the quality and
availability of services for the poor and sick. Throughout the dissertation, I ask how the rhetoric
promoting privatization and the downsizing of state services fits with my observations and
interviews at the SSC.
In the 1990s, political and popular rhetoric increasingly promoted the notion that “smaller
government” and fewer public support services for the poor and sick bolster self-sufficiency,
personal responsibility and moral liberation through increased choice and participation in the
workforce. Conservative politicians and proponents of privatization and decreased public
3

assistance espoused anti-“big government” rhetoric and promoted policies that framed poor
recipients of public assistance as dysfunctional, unwilling to work and morally lacking. The
rhetoric promoting privatization and decreased public services continues to influence social
services and public health policies and approaches poverty, poor health and the assumed
behaviors of the poor as problems that can be easily fixed with fewer government services and
“handouts”. The focus of the rhetoric places the onus of eliminating poverty on the poor
themselves, rather than on capitalism and social and economic inequality. This rhetoric has
contributed to a push for privatization and limited government throughout the United States by
dismantling publicly provided programs and bolstering funding to non-profit and faith-based
organizations.
Popular rhetoric and policies supporting privatization, “smaller government” and
decreases in public services for the poor remain strong today despite the current recession and
record high unemployment rates. This is especially critical in Michigan, the state where I
conducted this research. Because of the state’s close ties to the declining domestic automotive
and manufacturing industries, Michigan has a depressed economy and an unemployment rate
higher than the national average.
Politicians like former Michigan Governor John Engler, who served from 1991-2003,
changed the landscape of public health and social services in the state. He promoted rhetoric that
denounced “big government” and the poor’s “dependency on government.” Engler lauded the
merits of increased personal responsibility and liberation through work and implemented policies
that cut state government and services. Engler, a conservative Republican, began the work of
dismantling and privatizing state services, promoting public-private partnerships and shrinking
4

Michigan’s state government and its public safety-net for the poor. Michigan’s Governor
Jennifer Granholm, a Democrat who served from 2003-2011, largely maintained Engler’s
trajectory with her continued promotion of early retirement, privatization and decreased social
and health services for the poor. Republican Governor Rick Snyder was elected in 2011 and has
enacted even more stringent guidelines for welfare recipients and state employees than instated
by Engler or Granholm. Both Granholm and Snyder have enacted legislation resulting in more
stringent requirements and limitations for welfare recipients (Brush 2011).
Under the banner of public-private partnerships, non-profit organizations are frequently
called on and funded by public agencies and citizens to fill in the duties and services no longer
provided directly by the state. Rather than providing these services to citizens directly, public
agencies are now providing private non-profit organizations and religious institutions with
funding to carry out social service and health programs once under their jurisdiction (Isaac
2003). The privatization and downsizing of public agencies and social and health services for
the poor have been praised by many conservatives as a panacea wherein government
responsibilities were deflected to the private sector and free market. In this dissertation, I
challenge the rhetoric that privatization and fewer directly provided public services simplify
government, promote work and increase self-sufficiency among the poor. I draw on research
with SSC program participants, staff and public health and social service employees to situate the
work and role of the SSC among those it serves. These observations document the realities of
low income and sick people who rely on public health and social service safety-net services
offered at the SSC and other agencies.
By drawing on ethnographic examples from people I met at the SSC and related agencies,
5

I ask how the popular and political rhetoric promoted by Engler and so many others holds up to
the everyday lives of the people I met and worked with at the SSC. I begin my introduction to
the work of the Smith Street Center with Debra’s story, which illustrates the SSC’s role in the
lives of poor and sick people in the neighborhood it serves. Debra’s story, like that of so many
others I met and interviewed, illustrates the complicated, bureaucratic relationships among
private agencies like the SSC, state agencies and the people who depend on them.

Debra

1

In 2006, Debra moved back to the Michigan city where she grew up to take care of her
elderly father. She returned to Michigan after ending her marriage and leaving her job as a legal
secretary in a Western state. She was 55 years old, recently divorced, unemployed and
uninsured. She was living in her father’s house in a working class neighborhood and relied on
his income to cover her living expenses. I met Debra about a month after she moved back to
Michigan when I knocked on her door during a neighborhood “canvass” for the Smith Street
Center, where I was conducting fieldwork for a doctorate degree in anthropology. I was working
as a volunteer health outreach intern on a team with two other women at the SSC. One of the
many duties I had as a health outreach intern was to “canvass” the neighborhood to meet
residents and let them know about the SSC and the services and programs it offered.
Canvassing the neighborhood was a huge undertaking and involved knocking on the
doors of the more than 2,000 homes in the SSC’s neighborhood service area, promoting the SSC
1

All names are pseudonyms. Identifying details have also been changed to protect subjects’
anonymity.
6

and enrolling uninsured neighborhood residents who met income and residency requirements for
a publicly funded health plan. The SSC relied on volunteer interns, most of whom were students
at local colleges and universities, to conduct its annual neighborhood canvass. Along with the
agency’s monthly newsletter, canvassing was integral to the promotion of the SSC and its
programs and services. The SSC’s programs and its role in the neighborhood were presented to
neighbors during conversations on people’s front porches. The agency’s work centered on
neighborhood improvement and increasing neighborhood residents’ access to the goods and
services necessary for their health and social well-being. In conversations that took place during
canvassing, people often asked why we were canvassing and if we were employees of the health
department. We would answer by explaining that the County Health Department (CHD) and
other public agencies contract with the SSC to promote and administer its programs. The SSC is
located in the neighborhood and the CHD is located several miles away from the SSC.
Representatives of the SSC’s health outreach team canvassed in pairs or groups of three.
I met Debra while I was canvassing with Anita, the director of health outreach at the SSC, and
with a volunteer intern who was an undergraduate student at a local college. When we met
Debra we introduced ourselves, told her that we were from the SSC and gave her a brief
description of the agency and its programs. We asked whether everyone in her house had health
coverage and learned that she was uninsured and unemployed. She told us that she needed to see
a physician because she had high blood pressure. She was concerned about being able to pay for
the visit and necessary prescriptions. Anita told Debra about the Free Health Plan (referred to
here as the FHP), a set of benefits covering some basic healthcare services and prescription
coverage for the uninsured of the county. She explained that the FHP was provided through the
7

County Health Department (or CHD) for people with low and middle incomes who didn’t
qualify for Medicaid, but didn’t have health insurance.
Anita told Debra that the Free Health Plan “wasn’t insurance” and described what it
covered and what it didn't. She explained that the plan's scope of coverage was limited and that
it paid for primary care, some outpatient procedures, and certain prescription drugs, but did not
include visits to the emergency room or hospitalizations. Once enrolled in the FHP, Debra would
pay a $5 or $10 co-pay per covered appointment and for many commonly prescribed
prescriptions. Anita explained that we would submit Debra’s application and she would be
contacted with the name of a primary care physician who participated in the plan in the next
couple weeks. To complete the application for the FHP, Anita had Debra sign a form indicating
that she had no source of income and that she relied on her father’s income to cover her living
expenses.
During the next few months, Debra started coming to the SSC regularly. She came to the
farmer’s market, for free bread or just to talk. She regularly talked about how “serendipitous” it
was that we canvassed her house and signed her up for the FHP. About two months after our
initial meeting, Anita received a phone call from Debra telling her that she had recently been
admitted to the hospital because of a heart attack. Her condition was stable but she was very
concerned about paying the hospital for her care, which was not covered under the FHP's limited
system of benefits. Debra wanted to know whether Anita had any experience helping uninsured
people with their hospital bills. During her stay in the hospital Debra accumulated thousands of
dollars of bills and had no way of paying them. Anita did have experience helping uninsured
neighborhood residents like Debra negotiate with hospitals to set up payment plans. She helped
8

Debra navigate the hospital bureaucracy and apply to a foundation at the hospital to have some
of her fees waived based on her lack of income and health insurance. Debra was able to
negotiate with the hospital to forgive much of her bill. Unfortunately, the small amount that she
was left owing the hospital presented a significant hardship to her already perilous financial
situation. She set up a payment plan with the hospital and plans on making monthly payments to
them for the foreseeable future.
Debra’s situation is, in many ways, quite typical of many uninsured people in the United
States. She worked and paid taxes for most of her life but, after a series of hardships related to
various circumstances in her life, she found herself unemployed and unable to pay for private
insurance. She got sick and faced thousands of dollars of hospital bills that she had no way of
paying. Faced with a health crisis that soon evolved into a financial crisis, Debra, like many
Americans, found no recourse in the government sector and turned to the SSC, a non-profit
organization, for assistance. Debra’s case illustrates the role such agencies have come to play in
addressing many of the current problems the poor in this country face when trying to navigate
the health care systems.

Why the SSC?

The Smith Street Center’s role in Debra’s life reflects a trend whereby government
services and programs are increasingly contracted to private agencies. Debra found out about the
publicly funded Free Health Plan through the SSC staff. She was able to sign up for the program
with representatives from the SSC on her front porch. After a major health event that exceeded
9

the scope of the FHP’s coverage, an employee from the SSC once again helped her negotiate and
navigate the public health system. Later, staff at the SSC encouraged Debra to sign up for food
stamps and assisted her with its complicated application process.
Many of Debra’s experiences were similar to other neighborhood residents I met during
fieldwork at the SSC. When faced with a major health crisis, Debra, like so many others,
contacted Anita and the employees at the SSC for assistance with the daunting task of navigating
the complicated web of health care and social service providers. The experiences of
neighborhood residents I met provided the foundation for my questions about the work of the
SSC in health advocacy and assistance for low income residents of its neighborhood service area.
Specifically, I wanted to know why a small, poorly-funded non-profit organization like the SSC
is so often the first place that vulnerable people go to get the services and goods they need.
Debra’s situation and the SSC’s role in it also served as a contrast with much of the rhetoric
justifying cuts to directly provided state services. When Debra was faced with a health crisis,
she was completely overwhelmed by hospital bills not covered by the Free Health Plan. She was
unable to appeal to public agencies for assistance with her bills and called on Anita to help her
navigate hospital and health plan bureaucracy. Debra’s situation also didn’t fit with the
assumption that the poor are lazy and don’t value work. Up until her recent move, Debra had
always worked full time and paid taxes. She was not lazy; she was interested in “giving back”
and even volunteered regularly at the SSC and another local non-profit organization in between
caring for her elderly father.
The rhetoric promoting public-private partnerships and fewer services for the poor and
sick frequently falls short when contrasted with examples from people like Debra. Questions
10

about the realities of this rhetoric are central to this dissertation. Other questions about the SSC
and its relationship to the people it serves and the agencies that fund it inform this project. These
questions include: Why is the SSC promoting public programs and services without being a
public agency? What historic and contemporary political-economic factors have contributed to
the phenomenon whereby poor, sick and vulnerable individuals like Debra must rely on the
assistance of non-profit organizations like the SSC? If the rhetoric promoting neoliberalism, a
weakened public sector and increased public-private partnerships does not reflect the experiences
of the people I worked with at the SSC, why is it so pervasive?

Focus of the Dissertation

In this project, I demonstrate how the work of the SSC and the experiences and
perspectives of the individuals I met there challenges the rhetoric used by politicians and others
to support increased public-private partnerships and government contracts with non-profit
organizations. Specifically, I explore the role of non-profit organizations like the SSC in the
promotion of public services and health coverage. I seek to situate the SSC and its work in a
broader context by considering political and economic forces related to how and to whom health
and social services are distributed.

I contacted Sandra, the director of the Smith Street Center, about the possibility of
serving as a volunteer intern and about eventually conducting dissertation research at the agency.
11

Sandra put me in contact with Anita, the director of the SSC’s health outreach team. After my
initial interview with Anita, I quickly became aware that the organization did much more than
direct people to needed goods and services. The SSC worked closely with the County Health
Department and several consortiums composed of professionals from public and private
organizations that focused on helping low income and vulnerable populations access services and
addressing structural inequalities and the social determinants of health. In approaching the social
determinants of health, the consortiums were concerned with identifying macro-level factors like
education, teen pregnancy, violence and racial justice, which they identified as key contributions
to social inequities and poor health. Anita explained that there was a team of employees at the
County Health Department (or CHD) dedicated to addressing the “upstream issues” responsible
for health inequalities among minority and low-income residents and that this group relied on
places like the SSC to do on-the-ground work to inform policy and create programs.

Having conversations with SSC staff and neighborhood residents, conducting participant
observation of the agency’s programs and attending meetings with representatives from public
health and social service agencies shaped the questions that I asked throughout this dissertation.
While attending meetings with Anita and other SSC staff, I learned of a number of other local
non-profit organizations in the area providing services in ways that were similar to the SSC. I
also met people in state and local government who were committed to addressing inequality and
structural barriers through their policies and programs. I became increasingly aware of the SSC's
close relationships with city, county, state and federal agencies while I was working at the SSC
as a volunteer intern. I observed that these relationships were largely collaborative and involved
mutual financial and programmatic benefits.
12

The Smith Street Center

The SSC was initially formed in 1999 following collaborations among the local hospital,
neighborhood groups and the County Health Department. The SSC holds official 501(c)3 nonprofit status and is governed by a board of directors. Although the SSC is a 501(c)3, the bulk of
the agency’s operating budget comes from public sources. In addition to informing the County
Health Department of pressing issues and health concerns in the neighborhood, the SSC
implemented a number of programs funded by other public agencies like the Michigan
Department of Community Health, Medicaid and the USDA. SSC staff signed neighborhood
residents up for the Free Health Plan, hosted smoking-cessation groups, offered nutrition
education and gardening assistance, encouraged families with asthmatic children to participate in
an allergen abatement program and assisted people with the paperwork required to receive food,
housing, health and cash assistance.
The SSC contracts with public agencies like the County Health Department, the state of
Michigan and Medicaid to promote programs and assist low-income and uninsured people like
Debra with managing their health and addressing their social service needs. The SSC does not
directly provide health care services. Rather, it promotes and enrolls people for several publicly
funded health plans and social services, assisted neighborhood residents with barriers to
healthcare and promoted “empowerment” through education and programs that increased access
to healthy foods and lifestyle improvement like smoking cessation and exercise groups.

13

The Fieldwork

This research explores the SSC’s role in health advocacy and situates its work and the
experiences of those it serves in a broader political-economic context. It also seeks to
demonstrate the many instances where the current public-private model of providing and
navigating public health and social services falls short. Non-profit organizations like the SSC
often act as stop-gaps in the current health and social service system by cobbling together
services for the poor, sick and marginalized. Throughout this study, I examine the work of the
SSC, its relationship with its publicly supported funding agencies and the experiences of those
relying on its services. I situate the work of the SSC in a historical context by providing details
of Michigan’s twenty year experiment with privatization which resulted in shrinking state
services, pushing early retirement for state workers and increasing state contracts with private
agencies for public health and social services.

I document how the SSC assists with the procurement and advocacy of healthcare and
other necessary services for low-income people. I demonstrate that much of the work of the SSC
is centered on strengthening and empowering the community it serves. I argue that the push for
community is in many ways a response to the increased bureaucracy that has resulted in greater
public-private partnerships and the privatization of public services. During field work, I was
fortunate to be treated as a colleague by the director and staff of the SSC. As a “staff member,” I
was also allowed to assist in the agency’s daily operations, attend weekly staff meetings and
attend staff retreats and parties. Being privy to the work of the agency provided me with a
wealth of information about the work of the SSC, its history, its position in the neighborhood and
14

its relationships with other public and private agencies engaged in procuring, distributing and
advocating for safety-net services. I am extremely grateful to the staff and directors of the SSC
for affording me the opportunity to conduct this research.

Throughout this dissertation, I show how the Smith Street Center helps low-income
neighborhood residents navigate the complex web of state and private sector public health and
social services. Using ethnography, I demonstrate some of the ways in which recent trends
towards the privatization of government services have created a blurry line between public and
private providers of safety net services. I argue that health disparities and inequalities have been
amplified in the wake of neoliberalism and privatization and the onus for addressing these
disparities is increasingly falling on underfunded, understaffed non-profit organizations like the
SSC. Throughout this project, I demonstrate that many individuals must rely on increasingly
ineffective safety- net health services like those provided to marginalized people like Debra by
the SSC and its affiliated clinics and organizations. I argue that this ineffectual system of
distribution leaves many already disadvantaged people with few healthcare and social service
options and largely absolves government agencies of accountability for the care of the poor.
Ethnographic examples included throughout this dissertation refute some of the central tenants of
the rhetoric supporting neoliberalism; specifically, that privatization and increased choice and
participation in the market, personal responsibility and liberation through paid work create a
more empowered populace and smoother more efficient government.

15

Theory Guiding the Analysis

The Smith Street Center’s role in navigating healthcare and social services illustrates
many of the complexities of balancing neighborhood needs with neoliberal political agendas and
the privatization of public health and social services. In the course of exploring why the SSC is
often the first agency contacted by neighborhood residents like Debra during a health and
financial crisis, a number of theoretical questions have arisen during the course of this research.
When designing questions for this project I was struck by how the experiences of neighborhood
residents like Debra were impacted by political and economic trends influencing public health
and social service policy. I sought a holistic approach to my research, and attempted to consider
the many forces and factors that influenced the experiences of the people I met during my
fieldwork at the SSC.
In this analysis, I draw on Critical Interpretive Medical Anthropology, or CIMA, to guide
my questions (Comaroff 1985, Scheper Hughes and Lock 1986, Taussig 1980, Young 1983).
CIMA considers the ways in which individuals' experiences and encounters with health, illness
and medical systems reflect larger political economic trends. Specifically, the CIMA approach
situates the work and position of the SSC in a political-economic context. With it, I consider
trends of federal, state and local governments increasingly relying on the private sector to
provide services to the poor and sick. CIMA approaches health disparities and the distribution
and management of chronic diseases from both, micro-level and macro-level perspectives.
CIMA bridges the strengths of Interpretive Medical Anthropology and Critical Medical
Anthropology by stressing the importance of individuals' experiences and understandings and of
16

political, economic and ecological forces. This approach shows that there is salience in linking
political and economic processes with ethnography and local experiences (Scheper-Hughes and
Lock 1986). I consider policies and economic factors related to the project as well as
ethnographic data throughout the dissertation. In combining the discussions, I attempt to create a
picture of both local phenomenon and individuals’ experiences with large-scale political
economic factors impacting these realities.
In addition to relying on CIMA to better understand how political-economic processes
impacted and contributed to what I was observing, I draw on the work of contemporary medical
anthropologists and social scientists to situate my findings in a broader context. In particular,
this project is strongly influenced by the work of Gay Becker. Becker contributed a great deal to
the medical anthropological scholarship of health disparities in the United States. Her work
about the US’s “two-tier hierarchy of healthcare,” (2007: 299) is especially significant in the
construction of the questions and subsequent analysis of data for this dissertation. Becker sought
to understand the effects of unequal access to healthcare among poor and minority populations
and argued that, “Emphasis is placed on managing and normalizing healthcare differentially for
those with health insurance and those without it, even if the ultimate cost to the state may be
greater by doing so, in terms of both human life and economics." (2007: 301). Becker’s
argument that the cost of sub-par healthcare for the poor supersedes its expense is supported with
the ethnographic data I present throughout this analysis. My analysis of data from interviews,
participant observation, and news and scholarly articles support Becker’s contention, showing
that the current system of shrinking government responsibilities for health care services and an

17

increasing role of small, poorly-funded non-profit organizations frequently fails to meet the
needs of those it serves.
This project aims to contribute to the medical anthropological literature both topically and
theoretically. Scant anthropological analyses address the role of non-profit organizations in
health advocacy in the United States. My analysis makes a dual contribution to the
anthropological literature by presenting an ethnographic account of low income, sick individuals
seeking services from a non-profit organization, and situating that organization within a broader
historical and political context. In it I expose the implications for political decisions and popular
rhetoric that favor “smaller government,” individual choice and responsibility and public-private
partnerships. I build on the work of Becker and others by providing a holistic account of the
SSC, the people it serves and the perspectives of some of those with whom it contracts.

Summary of Dissertation Chapters

This dissertation provides descriptions and ethnographic accounts of the SSC, the people
it serves and its staff. My analysis offers a critique to neoliberal rhetoric supporting privatization
and government downsizing as a means to bolster self-sufficiency and individual responsibility
among the poor and sick. This critique seeks to situate work of the agency and lives and
experiences of the people it serves in a larger context through an analysis of historical, political
and economic factors related to how safety-net services are distributed in Michigan and
throughout the United States. In addition to situating the SSC within a macro-level context, I
18

seek to understand the relationship between the SSC and the governmental organizations that
fund it and other similar non-profit organizations.
Chapter Two provides background information and a review of salient literature
influencing the role of non-profit organizations like the Smith Street Center. In this chapter I
address the political- economic factors influencing the work of the SSC. I explore the status of
public health and social service safety-net services in the United States and the lives and
experiences of those individuals relying on them. I situate policies influencing the work of the
SSC in contemporary and historic contexts. I address how political and popular shifts towards
“smaller government,” personal responsibility and decreased health and social services for the
poor have contributed to the role places like the SSC play in low income and sick people’s lives.
The literature review includes discussions of the roots of neoliberal policies in the United States,
health disparities in the United States, the privatization of Medicaid, welfare reform,
compassionate conservatism and Faith Based Initiatives.
In Chapter Three, I offer an overview of Michigan’s political history since Governor John
Engler’s administration began in 1992. I provide an in-depth discussion of Engler’s policies and
changes in Michigan’s public sector since his administration. I discuss how the legacy of
privatization was continued in the administration of Governor Jennifer Granholm, which began
in 2003 and ended in 2011. Throughout this chapter, particular attention is given to changes to
social services and public health and the rise of public-private partnerships in Michigan.
Throughout Chapter Three, I draw on the work of political scientists and economists to evaluate
how cuts to public services and departments impacted Michigan’s budget. I also discuss the
state’s tax structure and budget and its effects on low and middle income people.

19

In Chapter Four, I present the research methods guiding the project and offer an overview
of demographic information pertinent to the project. In this chapter I include a description of the
SSC’s setting and a description and demographic overview of the neighborhood it serves. I
offer detailed descriptions of the research participants’ demographics.
In Chapter Five, I provide an overview of the history, programs and work of the Smith
Street Center. In this chapter I ask how neoliberalism and privatization in Michigan play out at
the SSC. I describe the SSC’s history and its role in the neighborhood it serves. I describe the
work of the SSC as well as its relationship with its funders and collaborative public and private
agencies. Specifically, I focus on the SSC’s partnerships with public agencies and how these
influences the programs and services available to neighborhood residents.
In Chapter Six, I ask how policies supporting privatization and decreases in the
availability of public health and social services in Michigan impact the health and wellness of
vulnerable residents of the SSC’s service area. I draw on ethnographic accounts from
neighborhood residents to challenge the political and popular rhetoric supporting privatization
and decreases in government services that frames individuals as healthcare and social service
consumers who are empowered through work, choices and responsibility. I do this by drawing
on the experiences of individuals who, despite receiving public assistance from the state for
disability and income, cannot make ends meet without the assistance of agencies like the SSC.
In this chapter, I draw attention to the limitations of framing healthcare recipients as “citizen
consumers” who are empowered by supposed choices that arise with increased privatization.
Finally, I discuss how my findings support the anthropological literature about the United States
having a “two tiered” healthcare system.

20

In Chapter Seven, I build on Chapter Six by including the perspectives and experiences
of employees of the SSC and public health organizations to ask how neoliberalism and
privatization in Michigan have influenced the work of employees serving the poor and sick. This
question is explored using interviewees’ perspectives and centers on the notion that changes in
the distribution of public health and social services have increased bureaucracy and created a
more complicated, difficult to navigate system at all levels. I draw on interviews with public
health professionals and ask whether decreasing the scope of public services aided those relying
on services and working in government. I present discussions from interviews about the
consequences of Michigan’s early retirement buy-outs and subsequent restructuring of state
government to argue that the neoliberal rhetoric about simplifying government by decreasing
services and personnel falls short.
I draw on interviews and observations to question whether moving towards smaller state
government with increased privatization of government services and more public-private
partnerships actually increased dependency between public agencies and the non-profit
organizations they fund. I use data from field work and interviews at the SSC to argue that the
privatization of public health and social services has contributed to a culture of constant flux and
uncertainty for non-profit organizations like the SSC and the individuals they serve. Lastly, I
present observations and data from interviews with neighborhood residents who use services at
the SSC to argue that constantly changing policies and funding streams lead to bureaucratic
constraints that create complications and barriers to health and healthcare for many poor, sick
and vulnerable people.
Chapter Eight serves as a conclusion to the project. In it, I argue that the SSC’s
21

programs and its ability to successfully advocate for residents of its neighborhood service area
leave many people without the important health and social services they require. I argue that the
government’s decreasing role in the direct provision of public health and social services and its
increasing reliance on non-profit organizations like the SSC to carry out the distribution of health
and social services to the poor has much room for improvement. I draw on observations from
fieldwork to argue that neighborhood based organizations like the SSC largely operate as a
response to increased bureaucracy and changes in safety-net services. I suggest that small,
community-based non-profit organizations like the SSC cannot replace a functional state and an
easily navigated healthcare system.
I reiterate my argument that popular and political rhetoric regarding the merits of
“smaller government” and the importance of work and increased responsibility among recipients
of safety-net care reflect cultural assumptions about how and to whom resources are to be
distributed and are not supported by evidence of efficacy. I challenge the notion that the
recipients of safety-net services are problematic and call for a shift towards greater
acknowledgment of the political and economic systems in which inequalities thrive and
community based non-profit organizations operate.

22

Chapter 2: Political Economic Issues Impacting the Work of the SSC

23

In order to examine the work of the Smith Street Center (or SSC) and address why poor,
sick and vulnerable neighborhood residents like Debra have come to rely on it, it is essential to
consider some of the major political-economic forces influencing the role the SSC and other nonprofit organizations in the United States. In this chapter, I provide background discussions of
salient macro-level factors, policies and cultural phenomena influencing why non-profit
organizations like the SSC are so often called on by poor and sick individuals in need of
healthcare and social services. I situate the state of health care and social service availability in
political and historic contexts and ask why the staff of a small, poorly funded neighborhood
based non-profit organization is so often met with requests for assistance from people who have
“fallen through the cracks” of the public health and social service safety-nets.
This review addresses how neoliberalism impacts the provision of health and social
services in the United States. It begins with a discussion of neoliberalism, and extends to indepth analyses about the effects that privatization, health disparities, a for-profit healthcare
system, welfare reform and compassionate conservatism have had on the distribution of health
and safety-net services in the United States. Chapter Three elaborates on this chapter by
addressing the role and roots of neoliberal policies in Michigan and asking how they’ve impacted
and influenced the work of the SSC and other non-profit organizations serving the poor, sick and
vulnerable.

24

Neoliberalism

Since the late 1970's and early 1980's, there has been an increase in the privatization of
governmental social services in the United States and throughout the world. Neoliberalism has
emerged as a “guiding principle of economic thought and management” (Harvey 2005:3). David
Harvey defines neoliberalism as, “a theory of political economic practices that proposes that
human well-being can best be advanced by liberating individual entrepreneurial freedoms and
skills within an institutional framework characterized by strong private property rights, free
markets, and free trade” (2005: 2). He states that since the 1970s, there “has been an emphatic
turn towards neoliberalism in political economic practices and thinking” (ibid). In the United
States, the political and popular ideals supporting neoliberalism are intertwined with the political
economic hierarchies that determine how and to whom goods and services are distributed.

Neoliberalism is a product of capitalism and conservatism and was largely created and
promoted by the Reagan and Thatcher administrations. It operates on the notion that states
should create markets then allow them to grow without intervention. Neoliberalism largely
emerged in the shadow of the cold war and gained momentum from perceived threats of
communism and socialism. Harvey argues that neoliberalism, “seeks to bring all human action
into the domain of the market” (2005: 3). Neoliberal policies and privatization have largely
weakened the state's role in the distribution and oversight of safety- net services for vulnerable
populations and have contributed to the work of private industry and non-profit organizations in
the provision of care for the poor and undeserved. Throughout this dissertation, I address how
25

neoliberalism and the rhetoric surrounding it has influenced policies, laws and practices that have
shaped the work of the Smith Street Center and the experiences of the people depending on the
agency’s services.
Becker (2004) contends that neoliberal, American ideals of “deserving and undeserving
groups” stem from ideas about individualism, responsibility and moral worth. She argues that
neoliberalism "downplayed racialization and social class in health care" (Becker 2004:260).
There are major disparities related to race, gender and class which impact access to all resources,
including health; these disparities stem from and perpetuate historical and contemporary political
and economic hierarchies (Krieger 2005, Lopez 2004, Smedley 2003). Throughout this
dissertation, I explore the influences of neoliberalism and how they have impacted the state of
the current health and social service safety-nets and the work of non-profit organizations like the
SSC. Specifically, I explore the conundrum of how public spending on health and social services
has risen greatly while oversight and administration of public services by public agencies have
decreased.

Roots and Influences of Neoliberal Policies

Neoliberalism has far-reaching influences on the provision and distribution of health and
social services in the United States. Analyses of popular and political support for personal
responsibility and “deservingness” for social services and health care have mostly relied on
philosophical and moral arguments to assign blame and responsibility for individual’s poor

26

health (Conrad 1994, Donahue and McGuire 1995, Minkler 1999). Policies that decrease the
scope of government and provide public funding to faith-based and community-level social
service providers eliminate government oversight and regulation of social services. These
policies encourage state agencies to undertake contracts and partnerships with the private sector
to adequately provide for vulnerable citizens. Political calls for “smaller government” by pundits
and politicians frequently support the notion that government services foster dependency and
contribute to social ills.
Many ideals determining modern political economy, specifically, ideas about work and
deservingness, and the distribution of health care and social services in the United States, were
strongly influenced by European Protestantism. Newman (1999) identifies the culture of public
health and social service distribution in the US as meritocratic individualism. She describes
meritocratic individualism as a cruel, blaming, devastating culture for those who are not
economically successful. Meritocratic individualism is rooted in Calvinism, a form of
Protestantism, and closely ties individuals’ moral worth to their wealth and financial success. In
it, individuals are viewed as completely responsible for their spiritual and economic success,
with no regard for or consideration of the root causes of inequalities or the hierarchies that
maintain unequal distribution of goods and services.
Weber (1946) identified the role of Calvinism and other forms of Protestantism in the
historical rise of market based economies and the development of capitalism. Weber introduced
the idea of the Puritan Ethic (also referred to as Protestant Ethic), which tied dedication to work
and profit making to moral worth. The Puritan Ethic, which spread throughout the world with
colonial expansions and missionaries, largely shunned displays of wealth, thus encouraging
27

followers to give large sums of money to the church. The ideology also provided a moral
rational for Protestant capitalists to open markets and profit from colonial expansion. Weber
observed a trend in Protestantism that equated economic success with salvation. The equation of
economic wealth with moral worth and salvation has been an ideological rallying point of
neoliberalism in the United States and throughout the world.
Much political and public support for privatization and decreased government
involvement in the distribution of public health and social services for the poor and vulnerable is
rooted in individualism and Puritan notions of deservingness and moral worth. This is illustrated
in the political and popular rhetoric surrounding programs like Welfare to Work and Medicaid
Managed Care which seek to limit services to the poor and emancipate them from government
dependency through work, increased market participation and consumerism. Both Welfare to
Work and Medicaid Managed Care are federal and state programs that gained momentum in the
1990s; each was promoted by politicians and policy makers as means by which to increase
personal responsibility amongst the poor and involve them in the receipt of government benefits.
Both are described in greater detail in later parts of this chapter.
There is a long history of the promotion of individualism and resistance to government
involvement regarding the provision and distribution of healthcare and social services in the
United States. In 1920, the American Medical Association (AMA) adopted its first resolution
opposing government paid health care. Little has been written about the AMA's staunch history
of opposition to healthcare reform with the exception of Max Skidmore's 1999 book, Social
Security and its Enemies: The Case for America's Most Efficient Insurance Company. In it, he
shows that in 1939, a Journal of the American Medical Association editorial made the following
28

claim, "Indeed all forms of security, compulsory security, even against old age and
unemployment, represent a beginning invasion by the state into the personal life of the
individual, represent a taking away of individual responsibility, a weakening of national caliber, a
definite step toward either communism or totalitarianism" (Skidmore, 1999: 86.)
These ideas have been promoted and revisited in current and historic advertising
campaigns and political speeches. Calls for limited government have remained a rallying point
among conservatives and the rhetoric remains largely unchanged since that used by the AMA in
1939. Anti-government fear and rhetoric were promoted by the AMA in its “Operation Coffee
Cup” campaign against Medicare in the late 1950s and early 1960s. In 1961, Ronald Reagan
was hired by the AMA to expand on “The Speech” and record an LP entitled, “Ronald Reagan
Speaks Out Against Socialized Medicine” (Skidmore 1999). “The Speech” was used to drum up
popular opposition to Medicare and largely fed off of growing national fears about the global
threat of Communism. While Medicare ultimately passed, calls for limited government and
decreased public support of health and social services have remained strong among some
conservatives and those with financial interests in the healthcare system.
Those with major financial interests in the healthcare system have long been wary of a
strong, publicly dominated health and social service safety-net in the United States. Tensions
have existed between public and private interests regarding how, by and to whom safety-net
services are made available. Neoliberalism has shifted the way health care and social services
are delivered in the United States. Nelson (2005) contends that neoliberalism re-framed the
approach to public health in the United States. She argues that public health is now considered
to be an “individual commodity” rather than a “public good” (Nelson 2005:107). This approach

29

is reflected by the government's involvement with the increasingly privatized, profit driven
private health sector.

Privatization of Services in the United States

In the United States, a trend of public agencies downsizing their staff and services and
partnering with private organizations has transformed the landscape and distribution of public
health and safety- net services both for the providers and recipients of services. I refer to this
phenomenon as “privatization” throughout this dissertation. The term “privatization” has
complex and varied meanings depending on the contexts to which it’s considered and applied.
Gollust and Jacobson (2006) define privatization as, “the transfer of decision making authority,
delivery, or financing from a public to a private entity” (1734). Alkhafaji (1993) defines
privatization as, “the act of reducing the role of government, or increasing the role of the private
sector, in an activity or in the ownership of assets” (24). Starr (1988) describes privatization as a
phenomenon with various applications and definitions related to political economic processes
and policies. He states,

Yet however varied and at times unclear in its meaning, privatization has unambiguous
political origins and objectives. It emerges from the countermovement against the growth
of government in the West and represents the most serious conservative effort of our time
to formulate a positive alternative. Privatization proposals do not aim merely to return
services to their original location in the private sphere. (6).
30

Throughout this dissertation, I use the term “privatization” to indicate the transfer of
programming, funding, responsibilities, administrative duties and program recruitment from
publicly funded and administered agencies to private for-profit agencies and non-profit
organizations. Specifically, I use the term to refer to the transfer of programs and responsibilities
between state and county government agencies and programs to non-profit organizations like the
SSC.

Public-Private Partnerships in Public Health

A wide array of public health and social services are regularly contracted to private
agencies and providers by county, state and federal health agencies. In a 2001 survey of 380
public health departments in the United States, Keane et al. found that 73% contracted some
services to private agencies or providers. In their review article based on surveys of agency
directors in all 50 state governments regarding privatization in state government, Chi, Arnold
and Perkins (2003) contend that states increased public-private partnerships from 1997-2002.
The authors were interested in why privatization has increased and whether it is an effective
(cost saving and work reducing) means of governance. They argue that public-private
partnerships and outsourcing increased due to a need for staff expertise, and that it was based on
an assumption that money is saved from such endeavors. Chi et al. argue that little empirical
evidence exists to support the claims to efficiency through privatization. They show that the
31

scant existing evidence does not support privatization or outsourcing as effective means of
saving money (2003).

Privatizing Public Insurance: The Case of Medicaid Managed Care

Government agencies increasingly contract with private companies to oversee and
carryout public health and social services for the poor. An example of this is Medicaid Managed
Care (or MMC). Medicaid, the health insurance plan for low-income and disabled Americans, is
funded by federal and state funds and has largely been privatized under neoliberal influences.
Much of the rationale for privatizing Medicaid is related to policies intended to decrease the role
of government in favor of an expanded private sector (Medicaid is discussed in more detail later
in this chapter). In many states, including Michigan, Medicaid has been privatized into Managed
Care HMO's. Health Management Organizations, or HMO's, emerged in the early 1980's as
mostly local, not-for-profit means of paying for and providing healthcare services; as
privatization, neoliberalism and the corporatization of health care increased, HMO's became
more popular and more centered on profit (Rylko-Bauer and Farmer 2005). Medicaid, which is
technically a federal program and paid for by both the federal government and the states, has
relinquished much control and oversight to private insurance companies and state and local
health departments.
Although there are federal guidelines regarding factors such as income, age and
citizenship to determine who is eligible for Medicaid, its availability and scope of coverage vary
32

widely by state and political will. In the case of Medicaid Managed Care, Medicaid is largely
privatized and its provision and management have been overtaken by private insurance
companies. Federal, state and local health agencies, like other governmental entities,
increasingly call on the private sector to complete their work and provide necessary services.
This trend towards privatization has had a major impact on the delivery and distribution of public
health across the United States. Boehm (2005) considers the effects of the privatization of
Medicaid on already burdened federally qualified health centers in New Mexico. Medicaid
historically provided funding to federally qualified health centers that act as safety nets to
uninsured and low income individuals. Neoliberalism and privatization have created a climate of
decreased funding which has had a detrimental impact on health center staff's ability to care for
patients. Nelson considers physicians' frustration over the scope of Medicaid Managed Care
(MMC) in New Mexico. She shows that MMC does not allow for adequate preventative care.
Under neoliberal inspired privatization, the poor are being framed as "consumers" rather than
"recipients" of care.
Medicaid Managed Care "requires the reconfiguration of the poor from passive recipients
of welfare-state services into self-empowered and self-governing health care consumers"
(Morgen and Maskovsky 2003:322). Approaching the poor as consumers of health care requires
that they actively enroll with a Medicaid Managed Care company and make decisions about
which plans they partake in and which providers they use. Under current enrollment guidelines,
children and parents of children are given enrollment priority. Many poor, single adults who
meet financial requirements for Medicaid are denied coverage. Those left without coverage
usually have few health care options and usually rely on the healthcare safety-net.
33

Medicaid and other forms of publicly funded health coverage are, unfortunately, not a
panacea for health access. Willging et al. (2006) observe the effects of privatization and
Medicaid Managed Care on psychiatric clinics in New Mexico. They contend, "While the
reform was intended to improve mental health practice, the new system led to administrative
burdens, payment problems, and stress among clinicians. It diminished incentives to care for the
poor and exacerbated access problems for Medicaid recipients" (Willging et al. 2006:254). They
report that administrative work at safety-net mental health providers increased with MMC.
Reimbursements became more difficult than under federal Medicaid, doctors were expected to
make up the cost by increasing patient loads and decreasing the amount of time spent with each
patient. Many physicians quit accepting patients with Medicaid because they felt that they were
unable to meet patients' needs in the short amount of time allotted. "Medicaid managed care
changed the environment for safety-net institutions sufficiently that their capacity to provide
services to Medicaid recipients was jeopardized" (Williging et al. 2006:252).
The examples of MMC in New Mexico demonstrate that neoliberalism and privatization
and the subsequent shift in responsibility for much of the provision and administration of care
and programming from the public to private entities has decreased the availability of publicly
funded health and social services for the most vulnerable citizens. These trends exist everywhere
in the United States and are not unique to New Mexico (Williging et al. 2006). Services are not
universally available to all residents of the United States because healthcare is approached as a
commodity, rather than a right.

34

Healthcare as a Commodity

Healthcare in the United States is a complicated system consisting of varying quality of
care and experiences for citizens. Healthcare is experienced very differently by upper and
middle class Americans with private, employer-based health insurance than for poor Americans
with no health insurance, limited private insurance, or public health insurance. Public health
experts and social scientists have repeatedly shown that racial and class inequalities influence
access to and quality of care in the United States (Krieger 2005, Matthews et al. 1999, Navarro
and Shi 2001, Smedley 2003). Healthcare access and availability is also closely related to the
commoditization of care, procedures and pharmaceuticals. Although healthcare and medicine
have long been purchased commodities, Budettie (2008) argues that commoditization of
healthcare has recently undergone a transition, “marked by deregulation of capital expenditures,
conversion of not-for-profits to for-profit corporations, consolidations in the insurance industry,
and a highly profitable pharmaceutical industry” (93). Caplan (1989) claims that
commoditization of care has been transformed in recent years by the capitalization of healthcare.
That is, physicians and other practitioners have recently shifted from owning the means of their
production to laboring for insurance corporations and other capitalist interests.
Health inequalities are largely a function of a healthcare system that approaches the
distribution of care as a commodity rather than a right. Having access to healthcare is an integral
part of maintaining health, but other factors, such as quality of housing, education, food,
transportation and occupation play a major role in who gets sick and why. Rylko-Bauer and
Farmer (2005) argue that getting sick and having access to quality care are direct functions of the
35

market. "There is evidence that market forces and managed care are affecting the health care
system in ways that do not merely favor persistence of inequalities but may, in fact, worsen
them" (Rylko-Bauer and Farmer 2005:490). They identify US health policy as “medicine-ascommerce” (ibid). Inadequate access to healthcare is popularly approached in news media and
political rhetoric as a consequence of individual irresponsibility and poor choices, rather than a
function of capitalism which relies on an inequality and an unequal system of resource
distribution (ibid). Waitzkin (1986) contends that biomedicine reproduces aspects of capitalism,
especially the notion that health is defined by the ability to work. Being able to work is closely
tied with ideas about the merits of responsibility and self-sufficiently, ideals that have influenced
political rhetoric and policies impacting the provision and distribution of health and social
safety-net services. Health insurance is directly linked to employment for the majority of
Americans under the age of 65.

Health Disparities in the United States

Like Debra, whose experience was described in Chapter One, millions of Americans
struggle to get the care, medicine, and services they need to stay healthy. More than 50.7 million
Americans were uninsured in 2009 (DeNavas-Walt et al. 2010). This section examines the ways
in which inequalities based on racial, class and gender hierarchies affect individuals' access to
health resources, healthy environments and overall well-being. Institutional factors related to the
36

distribution of goods and services as well as environmental factors, like pollution and safety,
have major implications on health and well-being. Because these factors are closely related to
racial, class and gender hierarchies, there are major health inequities among socially constructed
groups. There is a tendency in biomedicine for practitioners to approach individuals, rather than
institutions, as problematic and responsible for poor health (Braun 2002). This tendency to focus
on individuals rather than institutions has resulted in major health inequities for many
Americans. Differential access to the goods and services impacting health has been exacerbated
by a health care system focused on individual consumers rather than the political economic
factors affecting health.
Poverty is closely related to poor health measures for all people in the United States (Good
et al. 2003). Racial minorities represent a larger percentage of people in poverty in the United
States and have worse health outcomes than white Americans. The factors influencing racial and
economic health disparities are complex and not easily identified as single variables; rather,
disparities result from a host of variables related to poverty and discrimination (Dressler 1993).
Brian Smedley et al. demonstrate that even when poor minority patients have access to health
care and private insurance, standards of care and quality of treatment they receive are lower than
for whites (2003). Disparities in income and access have real implications for the health and
well- being of all Americans. Coburn (2004) argues that inequality is unhealthy and contributes
to poor health outcomes for poor and sick individuals. He states, “income inequality is itself the
consequence of fundamental changes in class structure which have produced not only income
inequality but also numerous other forms of health-relevant social inequalities" (43). Krieger
(2005) argues that poverty causes poor health and that the racial health inequities are caused by
37

poverty, not race. Lopez (2004) supports the notion that poverty and inequality, rather than racial
differences, are responsible for health inequities, arguing that poverty is in itself a risk factor for
several chronic diseases.
Becker (2001) compared the health of insured and uninsured individuals with chronic
diseases and found that people without insurance were in worse health and were less able to
control their diseases than those with insurance. Having health insurance improves people’s
access to health care and necessary pharmaceuticals. It does not alleviate all disparities and
barriers to care. Health disparities in the United States span far beyond whether someone has
health insurance or is uninsured. Millions of Americans are “underinsured.” Underinsured
people have health insurance but are not able to afford or access all of their healthcare costs.
Many of America's uninsured and underinsured must rely on an increasingly under- funded and
ineffective privately procured health care and social service safety- net to meet their health
needs. Who has access to quality care is largely related to social status and hierarchies built on
race and class. How health and social services are distributed is increasingly related to neoliberal
policies.

Health Insurance Coverage

Health coverage is not universally available to all Americans. All types of healthcare
coverage are not created equally. Much of the work of the SSC consisted of advocating and
promoting health coverage for neighborhood residents. In this section, I provide a brief
38

discussion about health insurance in the United States to situate the work of the SSC and the
experiences of the people it assists.
Healthcare costs have grown at a higher rate than inflation since the 1960s in the United
States. In 1970, healthcare spending was 7.2% of the GDP and healthcare costs averaged $356
per person in the United States (Kaiser Family Foundation 2009). In 2009, spending on
healthcare was 19% of the GDP ($2.5 trillion) and healthcare costs averaged $8,160 per person
(ibid). Healthcare costs have risen for a number of reasons, including but not limited to new and
expensive technologies, the high cost of prescription drugs, increases in procedures and the
increased costs of basic care. The costs of health insurance premiums have also grown faster
than inflation. The Kaiser Family Foundation (2009) states, “Between 1999 and 2008, the
cumulative growth in health insurance premiums was 119%, compared with cumulative inflation
of 29% and cumulative wage growth of 34%” (2).
While not having insurance is an issue of great importance, most Americans have some
kind of health insurance. In 2009, 63.9% of Americans had private insurance. 87.3% of those
with private insurance had coverage offered through their (or their spouses or partners’)
employer (DeNavas-Walt et al. 2010). In 2009 15.7% of Americans were covered by Medicaid,
14.3% by Medicare and 16.7% were uninsured (ibid). It is important to note that there is overlap
in coverage, especially between Medicaid and Medicare, and between Medicare and private
insurance. The publicly supported health insurance programs Medicaid and Medicare vary in
many ways and are explained in further detail in the following sections.

39

Medicaid

Medicaid, which began in 1965, is a health insurance program paid for by the federal
government and the states. It is intended to provide health coverage to low income people who
meet certain criterion; in addition to providing health coverage, it also pays for nursing home
services and provides funding to hospitals and clinics providing services to the poor and
uninsured (Kaiser Family Foundation 2010). Certain groups like low-income pregnant women,
children, and children’s caregivers are typically favored in Medicaid insurance enrollment.
Single adults without children or disabilities are often denied coverage. According to the Kaiser
Family Foundation, in 2007 58.8 million Americans had insurance coverage through Medicaid.
Children are the largest group covered by Medicaid; in 2007 29 million, (1 of every 4) American
children were insured by the program. 15 million adults (mostly parents), 6 million senior
citizens and 8.8 million people with disabilities had health insurance covered by Medicaid in
2007 (ibid).
Although poverty is a necessary requirement for Medicaid, it is not the only requirement
(http://www.cms.gov/MedicaidGenInfo/). Currently in most US states, the majority of poor
adults without dependent children are not covered by Medicaid (Focus on Health Reform, KFF,
February 2010). The commonly held belief that all poor people are covered by Medicaid is
simply not true. States put caps on the number of people who can receive Medicaid because of
budget constraints. Despite state and federal limits on the program, spending on Medicaid has
risen exponentially in recent years. In 2008, Medicaid spending totaled $339 billion (Kaiser
Family Foundation 2010). These costs were shared by states and the federal government with
40

the federal government paying at least 50% of every state’s costs (ibid).

Medicare

Medicare is a federal entitlement program for all Americans over 65 and people with
certain disabilities and end stage renal failure. Like Medicaid, it began in 1965. It currently
covers more than 47 million Americans (Kaiser Family Foundation 2010). In 2010, Medicaid
spending was $519 billion. Medicare is comprised of four “parts” with various benefits; all parts
require most participants to pay a percentage of their care through co-pays and direct billing
(ibid). Most Medicare recipients have supplemental coverage; in 2008 90% of beneficiaries had
some kind of supplemental coverage to offset care that wasn’t covered. Those 10% without
supplemental coverage were disproportionately poor, disabled or African American.
Like Medicaid, Medicare often leaves recipients responsible for paying for a portion of
healthcare costs. As described previously, Medicaid Managed Care is structured to allow
recipients choices in providers and care. Recipients of Medicare also choose the type of
coverage they receive. The programs are also not universally accepted by healthcare providers.
Providers often receive incentives to care for individuals covered by public insurance programs
but reimbursements for public insurance plans remain significantly lower than private plans.
Both Medicaid and Medicare have been influenced by privatization and neoliberalism,
specifically in regards to increased choices and responsibilities of recipients.

41

Welfare Reform

In the previous sections I drew on literature that demonstrates that health is influenced by
both access to healthcare and social determinants related to poverty and wellbeing. In the
upcoming chapters, I demonstrate that in United States, publicly funded assistance programs
frequently require a great deal of bureaucratic navigation. I show that recent changes to public
assistance, along with increases in privatization, have led to a complicated system of publicprivate partnerships whereby many low income individuals require assistance in the complicated
task of accessing services and enrolling in programs. Helping people navigate programs like
welfare (cash assistance), food assistance and housing subsidies is a major part of the work of the
SSC and has a huge impact on the lives of the individuals it serves.
In order to situate the work of the SSC and the lives of the people it serves in a larger
political-economic context, it is important to first consider some of the changes to welfare and
public assistance with an overview of welfare reform. In 1996, federal legislation was enacted in
the United States to pass the Personal Responsibility and Work Opportunity Reconciliation Act
(PRWORA). Michigan Governor John Engler and several other conservative state governors
were instrumental in the introduction and implementation of welfare reform at both federal and
state levels (Chin et al. 2003). Welfare funding and other assistance programs were drastically
cut by federal and state governments during Welfare Reform as means of saving money, breaking
the cycle of poverty and ending the poor’s dependency on public agencies. These changes have
dramatically shifted the distribution of social services in the United States.
42

While it is certainly true that poverty has always been an issue in the United States,
strides towards eliminating poverty through government programs and assistance to the poor
began after the Great Depression and grew in the 1960’s during President Johnson’s War on
Poverty (Goode 2002 and Morgen and Maskovsky 2003). These efforts were largely stymied
with the passage of Welfare Reform legislation. Goode argues that PRWORA, “abrogated the
sixty-one year social contract between the state and poor women that had been put in place as
part of the Keynesian New Deal" (2002:65). PRWORA, which is commonly referred to as
welfare reform, put limits on the amount of time individuals are allowed to receive assistance. It
also mandated that most recipients of assistance work outside of the home even when they were
caring for young children (Sommerfeld and Reisch 2003). This is referred to as “welfare to
work” or “workfare”. These policies were lauded by conservatives like Engler as steps towards
increasing self-sufficiency and ending cycles of poverty.
Sommerfeld and Reisch claim that the work of non-governmental organizations involved
in providing services for the poor before Welfare Reform was not considered during the passage
of PRWORA (2003; 301). They argue that, “The reduction in state welfare caseloads appears to
represent a deliberate transfer of social costs from the public to the NGO sector” (301). Newly
implemented mandates for receiving welfare assistance were largely unfunded. For instance, the
county in which the SSC was located had an extremely limited number of daycare vouchers
available for mothers participating in the Workfare program, thereby leaving a number of
participants responsible for financing their own childcare. Welfare authority has long been
punitive and unfriendly; it has become increasingly more so since Welfare Reform. Morgen and
Maskovsky (2003) contend, "Welfare reform claims to empower the poor by bringing them into
43

the mainstream of society, i.e., the workforce. But many of those affected by Welfare ‘Reform’
experience quite the opposite: intensified surveillance, punishment, and ultimately the abrogation
of their citizenship rights" (329). They argue that Welfare Reform made applying for and
receiving aid more dehumanizing; privacy was invaded, benefits were easily evoked for myriad
reasons, and welfare “fraud” was criminalized (ibid).

Surveillance, Blame and Dependency: The Case of Welfare Mothers

Social scientists have repeatedly demonstrated that since changes in industry and the
availability of high paying blue-collar jobs, workers lacking formal education simply cannot
escape poverty or become self-sufficient in the current American workforce (Morgen and
Maskovsky 2003). Despite the paucity of well-paying jobs since the implementation of
neoliberal policies like NAFTA (North American Free Trade Agreement), public support for
welfare reform and other neoliberal policies that focus on individual responsibility, decreased
dependency and the promotion of work remains strong.
Morgen and Maskovsky (2003) contend that, "public debate was framed in terms set by
neo-conservatives in the 1980s around the need to eliminate the socially unproductive
‘dependency’ of welfare mothers” (316). They argue that welfare reform follows neoliberal logic
and assumes that personal responsibility is a direct function of a free market and demonstrate
that rhetoric supporting welfare reform maintains that the poor are unable to conform to middle
class American values and ideals because of their dependency on the state. Morgan and
44

Maskovsky argue that the urban poor, once the labor backbone of the nation, have been
economically abandoned in the wake of neoliberalism and privatization (ibid). The authors hold
that in this political climate, poverty has been framed in racialized and feminized contexts rather
than as the function of a capitalist political economy focused on profit above all else.
Goode (2002) argues that welfare reform and decreased funding of public health and
social services was made possible by a history in the US and other neoliberal states of ignoring
and suppressing the consideration of political economy as a cause of poverty. Rather than
observing the macro-level structural causes of poverty, public attention and policy focus on the
assumed behavior and morality of the poor. She points out that policies remain focused on
micro-level services rather than macro-level causes of suffering and inequality (Goode 2002).
The political will for PRWORA and other neoliberal policies largely emerged from the
"racialized constructions of poor women" during the 1960's War on Poverty (Goode 2002:65).
Racist rhetoric depicting some groups as “undeserving” contribute to the political will behind
privatization, “smaller government,” an unregulated market, and ultimately to the impossible
task small non-profits like the Smith Street Center have in navigating healthcare and social
services for poor and marginalized neighborhood residents.
Susser (1987) argues that, “the recipient of welfare assistance is enmeshed in an
extraordinarily complex web of constraints" (Susser 1987:62). Much of the application and
reception of public assistance seeks involves surveillance, control and constraints for those
individuals relying on services. Surveillance of populations has long been a tool of governments
seeking to influence citizens’ behavior and actions. In Governmentality, Foucault (1982)
demonstrated the ways in which government public health and social service programs
45

encouraged and motivated individuals to discipline and monitor their bodies in accordance with
standards, norms and values expected of populations. Current trends towards privatization have
expanded discipline and monitoring of populations to the private sector, which views citizens as
consumers of health and social services. Increased surveillance and monitoring under US
welfare reform illustrate neoliberal and conservative expectations of marginalized populations
and assumptions about their behavior and choices.

Compassionate Conservatism and Faith-Based Initiatives: Serving the Poor and
Maintaining the Status Quo

Conservative politicians and their supporters have long combined popular support for
individual responsibility and “small government” with policies that maintain capitalism and
corporate interests. During the second Bush administration, so much emphasis was put on the
role of non-profit organizations and faith-based institutions in providing health and social
services that a federal Center for Faith-Based and Community Initiatives was established in
2001. Bush campaigned to champion a new era of “Compassionate Conservatism” in the 2000
presidential election by increasing the government's funding to faith-based institutions and nonprofits to address the needs of the poor and sick. Under the banner of Faith-Based Initiatives and
private-public partnerships, non-profit organizations like the SSC are increasingly called by
public agencies and citizens to fill in the duties and services no longer provided directly by the
state. Rather than providing these services to citizens directly or changing policies to improve
46

access to publicly supported care, public agencies provide private non-profits and religious
institutions with funding to carry out social service and health programs once under their
jurisdiction (Isaac 2003). Funding was provided to private agencies to deliver services and care
to needy populations with few requirements or bureaucratic oversight. This was praised by many
conservative supporters as a panacea wherein government responsibilities were deflected to the
free market and private sector, which, they claimed, is better suited than “big government” to
deal with the problems of the poor (ibid).
Proponents of GW Bush’s Compassionate Conservatism lauded the private sector's
growing role in the provision of safety-net services claiming less government involvement and
bureaucracy and more private responsibility were crucial steps towards decreasing the poor's
dependency on government entities and increasing self-reliance and individual responsibility.
They cited the benefits of local responses to local problems. Proponents of funding faith-based
initiatives argued that tapping into faith based institutions' existing grassroots social service
networks encouraged greater community involvement and responsibility and cut government
bureaucracy and allowed needy people to be served more quickly and with less hassle. Critiques
of faith-based initiatives included concerns about the legality of the US government funding
religious institutions and maintaining the separation of church and state. There were criticisms
that over-reliance on local organizations assumes that such problems have local solutions.
Critics were concerned that relying on local private entities to provide care and services for the
poor fails to consider macro-level causes of poverty, like institutional racism, unequal
educational opportunities, and economic exploitation. In addition to this, there were concerns
about dismissing the important role government agencies have played in the provision of care
47

and services (Isaac 2003). Aside from concerns about separation of church and state, these
criticisms are salient to my research at the SSC.
Faith-based initiatives and an increasing reliance on private sector agencies to address the
social safety- net span party lines. Isaac (2003) argues that the road for Bush's faith-based
initiatives and “compassionate conservatism” was laid by Clinton, under the title Charitable
Choice, during the welfare reform years. He contends, “the Charitable Choice option first
codified in the 1996 welfare reform represents a significant departure, because it frees faithbased organizations from bureaucratic regulation (including employment and non-discrimination
laws) that previously constrained the terms under which they might receive funds for the delivery
of social services” (Isaac 2003: 4). In 2009 Obama's administration changed the office's name to
the Center for Faith-Based and Neighborhood Partnerships; however, the office's scope and reach
remain dedicated to increasing the responsibilities of faith- based and secular non-profit
organizations in the delivery of services for the poor and sick.

Conclusion

The literature reviewed in this chapter provides insight into the policies, laws and rhetoric
impacting the state of social and health services in the United States. It also provides a context
to the role of the Smith Street Center and other non-profit organizations assisting the poor with
health care and social service seeking and advocacy. Neoliberalism, privatization, health
disparities, class inequities, poverty, racism, Welfare Reform and Compassionate Conservatism
48

have influenced the public health and social service landscape and, consequently, the work of
places like the SSC. The analysis of the macro-level historic, economic and political factors
influencing privatization, increased public-private partnerships, and decreases in the scope and
availability of social and health services provide insight into the work of the SSC and its
relationship to its public funders and the people it serves.
Chapter Three elaborates on the role, roots and influences of neoliberal policies by asking
how they’ve played out in Michigan. In it, I provide an overview of the policies and laws in
Michigan that have impacted and influenced the work of the SSC and other non-profit
organizations serving the poor, sick and vulnerable. The overview involves a discussion of
Michigan’s budget and its spending on health and social services in recent years. Considering
the specific case of Michigan and its policies and budget provides necessary context to
understand the ethnographic examples from my fieldwork and interviews at the Smith Street
Center and related public health and social service agencies.

49

Chapter 3: Privatization and Partnerships in Michigan

50

In this chapter, I provide an overview of the policies and political rhetoric in Michigan
that have impacted and influenced the work of the Smith Street Center (or SSC) and other nonprofit organizations serving the poor, sick and vulnerable. Specifically, I focus on changes in
public support since John Engler’s governorship which began in 1991 and ended in 2003. I also
review changes implemented during Jennifer Granholm’s governorship, which lasted from 2003
to 2011. During Engler’s administration, there were major changes to the way that state and
federal governments were run as well as how and to whom public assistance was made available.
Early retirement, government restructuring and hiring freezes were enacted during Engler’s
administration and have drastically changed the landscape of state government and available
public services in Michigan. The changes implemented by the administration were maintained
and, in the case of early retirement buy-outs, re-instated during Jennifer Granholm’s
governorship. Public-private partnerships and decreases in state workforce remain a major part
of Michigan’s health and human service landscape and influence the funding and work of nonprofit organizations like the Smith Street Center.
In this chapter I identify specific changes to social services and public health in
Michigan, review political rhetoric supporting these changes and provide an overview of the
state’s health and human service budget before and since changes were implemented. By
identifying changes in public support and shifts in available services over the last twenty years, I
demonstrate how these changes have influenced social service and public health distribution in
Michigan. Identifying and situating these changes provides insight into the work of non-profit
organizations like the SSC and the lives of the people they serve. Considering the specific case
of Michigan and its policies contextualizes the role of the Smith Street Center in the
51

neighborhood it serves and situates the ethnographic examples and interviews presented
throughout the dissertation in a historical, political and economic context. In addition to
providing a review of policy, this overview involves a discussion of the state of Michigan’s
budget and its spending on health and social services. Here I ask whether the policies
implemented saved the state money and how these changes impacted the work of non-profit
organizations like the Smith Street Center that rely on public funding to operate. By providing a
history of state social service distribution and public employment in Michigan, I create a more
in-depth analysis of the work of the SSC, the circumstances surrounding the lives of the people it
serves and the agency’s relationship to other public and private agencies.

Changes to Public Health and Social Services in Michigan

Privatization and decreases in the direct provision of public services has become
increasingly common throughout the United States since the 1990s. Under the leadership of
Governor John Engler, the state of Michigan embraced privatization and “smaller government”
as means of saving tax dollars and increasing the poor’s participation in the workforce. During
the last 20 years, Michigan decreased its state workforce and privatized much of its public health
and social services through increased public-private partnerships, Welfare Reform and Medicaid
Managed Care (Willging et al. 2006 and Chi et al. 2003). Since 1991, the state of Michigan has
decreased its scope by eliminating programs, cutting employees and combining state
departments. Despite cuts in state employees and increased public-private partnerships, the
52

state’s budget has grown above the rate of inflation each year since 1991.
In 1991, the state of Michigan eliminated the General Assistance (GA) program, which
provided cash assistance to low income state residents (Danziger and Kossoujdi 1994). General
Assistance was a cash benefit primarily for very low income adults living in households without
dependent children. In 1991, when General Assistance was ended, it provided a maximum
benefit of $160/month to 80,000 Michigan residents (ibid). Upon termination of the program,
most former GA recipients were labeled “able bodied” by the state, and therefore, deemed
ineligible to receive cash assistance.
Danziger and Kossoujdi (1994) conducted a survey with former GA recipients and found
that the majority of those deemed “able bodied” were unable to replace the income they lost
when the program was eliminated. The authors found that the majority of former GA recipients
resided in urban areas with high unemployment rates. They reported that most of the people they
surveyed were unemployed and reported not having health insurance. No evidence was found
that eliminating GA increased former recipients’ participation in the workforce. The authors
conclude that eliminating the General Assistance program did not eliminate poverty or improve
the lives of those deemed “dependent” on the program.
In addition to ending General Assistance, Governor John Engler’s administration
implemented more stringent guidelines for welfare recipients by implementing Welfare Reform
in the state of Michigan. Welfare Reform, or the Personal Responsibility and Work Opportunity
Reconciliation Act (PRWORA), which was discussed in in Chapter Two, was implemented
federally in 1996 with the intention of overhauling government programs providing support to
low income Americans. Welfare Reform and the elimination of GA were largely promoted by
53

Engler and his supporters as means of saving tax money and promoting independence and selfsufficiency among former recipients. The rhetoric used by Engler and his supporters to promote
the elimination of benefits to the poor reflects a number of assumptions about recipients of
assistance.

Rhetoric and Public Support for the Elimination and Privatization of Services

In Michigan and throughout the United States, a great deal of popular support existed for
the changes in state government and public health and social service distribution that began in
the 1990s and continue presently. Much political and popular rhetoric promoted the notion that
smaller government and fewer government support services for the poor and sick would lead to
decreased dependency among the poor, and ultimately to increased self-sufficiency through
participation in the work force and increased personal responsibility. In 1992 Governor Engler
implemented a more stringent state welfare program called, “To Strengthen Michigan Families”
(or TSMF). The TSMF program implemented a “Social Contract” with all Michigan welfare
recipients. Recipients of assistance signed forms agreeing to take part in job training, education
or paid employment. TSMF also eased restrictions on two parent families receiving benefits and
allowed teen children to collect their own incomes through paid employment. In a letter to the
state’s department of Human Services on October 30, 1995, Engler praised the successes of To
Strengthen Michigan Families and lauded the federal government’s proposed Welfare Reform
program. He wrote, “Our challenge is to ensure that all Michigan families and children can look
54

forward to a system that rewards work, encourages personal responsibility, and achieves family
self-sufficiency.” (Engler, 1995).
Engler and other politicians involved in transforming policies regarding welfare and
public health service distribution contributed to major changes in the way goods and services to
the poor are distributed. They claimed that creating more stringent guidelines about welfare and
health services would create a more responsible, self-sufficient citizenry that valued work
(Danziger and Kossoujdi 1994). Much political and popular rhetoric surrounded the notion that
smaller government and fewer government support services for the poor and sick would lead to
decreased dependency and ultimately, to increased self-sufficiency through hard work and
personal responsibility. This rhetoric relied on the assumption that the behaviors and morality of
poor people were dysfunctional and that the key to alleviating poverty was addressing the
perceived beliefs and actions of the poor, rather than the social systems in which poverty and
inequality persist.
Throughout the United States, popular rhetoric supporting privatization and “smaller
government” remain strong today despite the current recession and record high unemployment
rates. This is especially critical in Michigan, where unemployment is currently double the rate of
the United States. Conservative politicians like Engler denounced “dependency on government”
and lauded the merits of increased personal responsibility and liberation through work. Antigovernment rhetoric and policies have remained strong since Engler was governor; in 2010,
Michigan elected Governor Rick Snyder, a conservative who promised to decrease government
dependency, cut welfare benefits for poor families, cut benefits for state employees and decrease
government spending. The rhetoric and policies implemented by politicians like Engler and
55

Synder rarely consider how the lives of vulnerable people are influenced when services and
programs are cut or shifted.
State government changed dramatically in Michigan after Welfare Reform, early
retirement buyouts and decreases in the scope of services of public health and social safety-net
services. Engler and several other conservative state governors were instrumental in the
introduction and implementation of Welfare Reform at both federal and state levels (Chi et al.
2003). The political and popular will for Welfare Reform and “workfare” failed to consider the
often binding constraints of capitalism and the reality that most poor people do work. They also
relied on the often false assumption that well-paying jobs were available to those willing to work
and that the desire to work and participate in the market was lacking among recipients of aid and
services. Ethnographic examples from the lives of people I met during fieldwork at the SSC are
presented in later chapters to challenge these assumptions and the rhetoric promoting them. In
further chapters, I show the implications that cuts in services have had on an institutional level.
Decisions made to decrease the state of Michigan’s government’s size and scope had far-reaching
implications for those working in public health and social services as well as those depending on
safety-net services.

Government Downsizing

In Michigan, several early retirement options have been offered to state employees in the
past two decades. In 2002, 12% of Michigan’s state employees took the Early Out option offered
56

by Governor John Engler (Chesney 2002). The number of state employees in Michigan dropped
by a total of 11,000 employees (whose jobs were not replaced) from 2001 to 2008; this drop
reflects an 18.1% decrease in the number of state employees after newly hired employees are
considered (Ballard and Funari 2009). Michigan did not replace the vast majority of state
employee positions lost to early retirement offers. A January 2011 buyout cut another 10% of the
Michigan state workforce (Maki 2010).
While the impact of a significantly reduced state workforce has far-reaching implications
for those remaining employees still working for the state as well as civilians dependent on state
services and programs, the consequences of fewer state employees and “smaller” state
government varied significantly by department. A Michigan television news station’s web article
reported an interview with an official from the state’s Department of Human Services who
claimed that case loads for social workers had more than doubled (from around 320 to 710 per
employee) since Governor Engler’s Early Out (retirement) program began in 2002 (Maki 2010).
The exact implications of decreases in the number of state employees are not known, but it is
clear from my work at the SSC and my interviews with former and current public health
employees that fewer competent and experienced state workers lead to fewer services offered,
shifting responsibilities and increased reliance on outside agencies. Despite a complicated web
of social service and public health providers, increased bureaucracy and decreases in available
services, rhetoric supporting claims for “smaller government” remains strong among politicians
and the citizens who elect them.

57

Privatization in Michigan

The trend of public agencies downsizing their staff and services and partnering with private
organizations has transformed the landscape and distribution of public health and safety net
services for the poor and sick both for the providers and recipients of services. A wide array of
public health and social services are regularly contracted to private agencies and providers by
county, state and federal health agencies. In a (2001) survey of 380 public health departments in
the United States, Keane et al. found that 73% contracted some services to private agencies or
providers. They reported that larger health departments were more likely to contract more
services than small departments. The results of Keane et al.’s survey were consistent with data
from Michigan and my observations in the city and county in which the SSC was located. The
County Health Department relied on the SSC and other neighborhood based agencies to do much
of its participant recruitment and health education. The majority of the SSC’s operational funds
came from contracts and grants from federal, state and county agencies. More on the SSC’s
budget can be found in Chapter Five.
In their review article about privatization in state government, Chi, Arnold and Perkins
contend that states increased public-private partnerships from 1997-2002 (2003). The article is
based on surveys of agency directors in all 50 state governments. Chi et al. were interested in
why privatization has increased and whether it has been effective at saving costs and reducing
labor. In their piece, they argue that public-private partnerships and outsourcing increased for
reasons related to lack of expertise among personnel and because of the assumption that money
is saved from such endeavors. The phenomenon of needing to seek outside, private contracts due
58

to lack of expertise within a state agency is often a result of early retirement offers. I explore
how this directly impacted the SSC and agencies related to its work in greater detail in Chapter
Seven. Chi et al. argue that little empirical evidence exists to support the claims that
privatization is efficient; they demonstrate that the existing evidence does not support
privatization or outsourcing as effective means of saving money (2003).
Non-profit organizations like the SSC regularly partner with state and county government
agencies to promote and execute programs and services. Decreases in the size and scope of
Michigan’s government and the state’s direct provision of health and wellness services have
increased since Engler’s governorship (Chi et al. 2003). Agencies like the SSC receive contracts
from government agencies to carry out services and programs targeted at low income and sick
populations. Despite a lack of clear evidence of benefit, decreases in the size and scope of
Michigan’s government and the state’s direct provision of health and wellness services have
persisted. Non-profit organizations like the SSC continued to receive contracts from government
agencies to carry out services and programs targeted at various low income and sick populations.
The increase in public-private partnerships and privatization has created a complex
network of public health and social service agencies and providers. Jacobsen et al. (2005)
analyze the role of safety-net organizations in Michigan and argue that many non-profit
organizations are not equipped to meet the demands of the population they serve. They state,
Policymakers cannot rely on health care safety net organizations to meet the burgeoning
needs of the uninsured population. Nor are public–private partnerships likely to be a
panacea because private sector partners have not been fully committed to the
arrangements. Increased federal funding or, ideally, a national health insurance
program, may be the only viable option for alleviating the burgeoning community need
for health care safety net services. (938)

59

The network of providers and agencies is varied; some work closely together to limit
bureaucracy and increase usability. The operating budgets and missions of these agencies vary
widely. Some of these agencies have religious affiliations. Others are small, secular
organizations like the Smith Street Center. Others, such as insurance companies providing
Medicaid Managed Care plans are large non-profit organizations that existed and thrived before
taking on contracts with the state. One agency, the Michigan Public Health Institute, was created
as a bridge between public and private agencies as a means to eliminate bureaucracy and
increase partnership between agencies and universities engaged in public health work throughout
the state of Michigan.

The Michigan Public Health Institute

The Michigan Public Health Institute (or MPHI) was created in 1990 by employees of the
Michigan Department of Public Health. Jeffrey Taylor, a former Michigan Department of Public
Health employee, was appointed as the agency’s Executive Director in 1990 and remains in that
position currently. The MPHI was initially an off-shoot of the Michigan Department of Public
Health. It shared its headquarters with the Michigan Department of Public Health from 1990
until 1993 when it moved to an independent location. The Michigan Department of Public
Health was later incorporated into an agency called the Michigan Department of Community
Health (or MDCH), despite these changes, the MPHI has retained a close relationship with the
state’s public health community (Piggott 2009).
60

The Michigan Public Health Institute is a non-profit organization and holds official
501(c)3 status. Its initial board of directors consisted of representatives appointed by the
Michigan Department of Public Health and Michigan’s three research universities: Wayne State,
University of Michigan and Michigan State University. The agency seeks to be an “in between”
agency committed to public health. Its goal is to eliminate bureaucracy and encourage research
collaborations among universities, government agencies, communities and private corporations
(Piggott 2009). The agency claims to represent the “fourth sector” as an intermediary among
government, academia and community spheres. The Michigan Public Health Institute is one of
among 32 Public Health Institutes in the United States. The scope of each public health agency
in the United States differs but all collaborate with public and private agencies (ibid).
In article describing the Michigan Public Health Institute, Jeffrey Taylor, its Executive
Director, draws on research by Fairweather & Tornatzky (1977) to promote the work of MPHI
and its position as an “in between agency”. Taylor states,
Such an organization offers a number of advantages, including the ability to bring
researchers, policymakers, and community members together to work on neutral ground
with a focus on cooperation and problem solving. Research is divided into contracted
research, performed at the request of participating governmental agencies, and
innovative research (1998:18).

The MPHI engages in public health research including research related to social sciences,
biological, chemical and physical sciences, nursing, medicine and epidemiology. According to
Taylor, advantages of the MPHI’s position as an “in between agency” include its ability to:
receive funding from a wide array of agencies, patent vaccines and other biologicals, contract
temporary employees specifically for certain projects, generate fee-for-service income, and
61

terminate projects quickly (ibid). Taylor presents the MPHI’s advantages in contrast to its
collaborating agencies by pointing out funding and contract limitations of state agencies and
universities. He also lauds the agency as a place where students from partnering universities can
conduct internships and possible job placements. The issue of contracting workers and being
able to easily end projects is in contrast to employment through the Michigan Department of
Community Health where workers maintain long-term job security and are protected by a labor
union.
The Michigan Public Health Institute’s funding comes from public and private sources,
including grants from the state of Michigan, the federal government, counties, local townships
and municipalities. MPHI’s impact on the state’s budget and on the operations of the MDCH
and partnering universities is not clear. Taylor (1998) and Piggott (2009) claim that the agency
eliminates bureaucracy and promotes more efficient research. Claims that public-private
partnerships save money are difficult to measure, but most likely have some merit based on the
ease of private agencies’ temporary employment contracts. The impact of privatization and
changes to public health and the role of places like the MPHI on Michigan’s budget are difficult
to measure because of the quickly growing expenditures on health and social services. The
rising costs of Medicaid and Medicare make assessing cost savings difficult. The following
section provides an overview of Michigan’s budget since Engler’s governorship.

62

Michigan’s Budget

Michigan’s economic outlook, as well as that of the rest of the United States, initially
improved during Engler’s governorship. From 1995 to 2000, the state’s income grew both in
terms of state revenue and personal income and individual employment (Olson and Mangla
2005:1). From 2000 until 2005, the state’s economy declined both in terms of personal income
and state revenue. Much of this decline is related to a downturn in the national economy and a
decrease in Michigan’s manufacturing base (ibid). Changes to Michigan’s tax structure also
slowed the amount of revenue gained by the state (Olson and Kleidon 2007). The most
significant of these changes was a sharp decrease in Michigan’s income tax, which was
implemented in 1999 (ibid).
Despite economic downturns and a massive restructuring of state agencies and early
retirement, Michigan’s budget appropriations have grown steadily since 1994. During the 199495 Fiscal Year, Michigan appropriated $9,433,321,500 to its departments of Community Health,
Social Services, Public Health, Mental Health and Family Independence Agency. During the
2003-04 Fiscal Year, $14,123,518,541 was appropriated to the same departments (Olson and
Mangla 2005:8). It is important to note that a large part of the increased costs represent growing
costs of medical care.
During Governor Jennifer Granholm’s administration (from 2003-2011) Michigan
continued to experience an economic downturn. The Granholm administration implemented
several cuts to Medicaid and increased the amount tobacco and casinos were taxed in an attempt
to address budget shortcomings. Funding to higher education was also cut during Granholm’s
63

administration. The state workforce did not grow during the Granholm administration; hiring
freezes and early retirement offers were implemented as a means of saving money (Olson and
Kleidon 2007). During Granholm’s administration, several concessions to state employers were
implemented, including unpaid furlough days and banked leave time programs (ibid).
Despite efforts by the Engler and Granholm administrations to decrease the cost of state
workers on Michigan’s budget, costs have continued to grow. Olson and Kleidon (2007)
reported that during the 2005-06 Fiscal Year, the State Employees Retirement System comprised
of 25.4% of all of Michigan’s employee costs. The large number of relatively young retirees in
Michigan due to large early retirement offers in 2000-01 and 2002-03 is an important factor in
the high costs of the State Employees Retirement System. Increases in the costs of fringe
benefits have also created a strain for the state (ibid).

The economic benefits of early retirement and the push for the privatization of health and
human services in Michigan are difficult to analyze. The state saved money with early
retirement offers. It also shifted much of its work to the private sector and increased the
workload and expectations of its existing employees. Shifts in public health and social services
from public agencies to private organizations have transformed the landscape of safety net
services in Michigan and the county where my research was conducted.

Conclusion

In this chapter, I asked how the downsizing of Michigan’s state government agencies
64

since the 1990’s led to decreases in services provided directly by the state. I described how these
decreases contributed to the growing role of non-profit organizations in the distribution and
administration of safety-net services. I described how privatization and government downsizing
were touted by politicians as ways of increasing personal responsibility and eliminating the
poor’s dependency on governmental programs and assistance. I drew on the work of scholars in
Michigan to argue that cutting programs and services and decreasing the state’s workforce has
not alleviated poverty for Michigan residents (Danziger and Kossoujdi 1994, Olson and Kleidon
2007). I provided an overview of Michigan’s budget and its social service and healthcare
spending and asked whether privatization and government downsizing have been effective means
of saving the state money. I have shown that despite privatization and early retirement,
Michigan’s budget appropriations have grown steadily since the 1990s; this growth is complex
and difficult to measure because of restructuring and the elimination of services.
In this chapter I presented a historical and political economic account of privatization and
downsizing in the state of Michigan since the 1990’s. I draw on this throughout the dissertation
to contextualize the work of the Smith Street Center and the services and programs available to
the neighborhood residents it serves. In Chapter Four, I describe the Smith Street Center and
provide an account of the methodology I used to conduct this project. Following Chapter Four, I
examine how the policies and rhetoric discussed here and in Chapter Two play out for the people
I met at the SSC.

65

Chapter 4: The Study: The Site, Methodology and Demographics

66

In this chapter, I provide an account of the setting of my field site. This includes
descriptions of the neighborhood it serves, demographics of the people I interviewed and an
overview of my methodology and data analysis processes. I collected data for this project from
October 2005 until October 2007 at a small non-profit organization in a Michigan city.
Throughout this dissertation, I refer to the non-profit organization where my research was
2

conducted as the Smith Street Center (or SSC). I provide an overview of the agency’s work of
assisting low income neighbors with accessing health and social services. These descriptions
show how the political and economic forces described in the previous chapters impact the work
of non-profit organizations like the SSC.

The Setting

The Smith Street Center is a non-profit organization that seeks to improve the health and
wellbeing of residents of the low-income neighborhood it serves. It serves as a space for
neighborhood improvement, advocacy and community building and assists neighborhood
residents in meeting their health needs by advocating and enrolling individuals for several
publicly and privately funded health, wellness and social service programs. The agency hosts
several programs designed to improve residents’ health and quality of life. During the course of
my field work, the programs and work of the SSC varied based on the availability and mandates
of external funding sources and the interest and participation of neighborhood residents. The
2

All names of places and people are pseudonyms to protect subjects’ anonymity.
67

SSC was created by a combination of neighborhood need, political will and private foundation
funding.

The Smith Street Center was established in 1999 after neighborhood and local leaders
identified several health and social service disparities impacting neighborhood residents. The
neighborhood served by the SSC has been hard hit by decades of economic downturns and
decreases in Michigan’s manufacturing base. As discussed in more detail in Chapter Three, the
effects of Michigan’s shrinking manufacturing sector have had far-reaching consequences on all
aspects of its economy (Hill and Negrey 1987). Michigan’s economic downturn coupled with
increased privatization and downsizing of public services created a climate of fewer jobs and less
government support for health and social services. Economic devolution and fewer available
public services affected the lives of many residents of the SSC’s service area and neighborhood
residents often presented to the SSC with major economic and health crises. Much of the work
of the SSC’s staff centered on helping residents navigate “the system” and increasing
neighborhood residents’ access to healthcare, food and housing. The SSC began when
community leaders and neighborhood residents identified a need for a centralized, neighborhoodbased agency to assist people with health and social service needs.
The SSC’s work largely consists of advocating for healthier neighborhoods by mobilizing
neighborhood groups, advocating for improvements to policies impacting neighbors and
assisting residents in need of health coverage, food, housing needs and community support. At
the time I conducted my research, the SSC had between 4 and 6 full-time employees and
between 6 and 10 part-time employees and volunteer interns; positions were rather fluid and
68

employees came and went depending on the agency’s resources and funded programs. Like the
programming, the number of employees varied greatly depending on grants and funding sources.
The agency relied mostly on financial support from public granting agencies to operate. While
the SSC shifted its programs to fit available funding and neighborhood support, its mission of
improving the health and wellness of neighborhood residents has remained since the agency’s
inception.

The Space and Neighborhood

The Smith Street Center is housed in a two-story storefront building on a city street. The
first floor of the SSC mostly serves as a space for neighborhood residents and the second floor
houses offices where most of the administrative and bureaucratic work is done. Like its work
and mission, the physical space occupied by the SSC is bifurcated to balance the needs of those it
is intended to serve with those of the agencies that fund its programs.
The SSC’s service area is comprised of more than 2,000 mostly single family homes that
were built during the late 19th and early 20th centuries and are in various states of repair. While
most of the people living in the neighborhood served by the SSC are low income, some upwardly
mobile residents choose to live in the neighborhood because of its central location and historic
homes. The service area is home to many students, young professionals, and gays and lesbians
who choose to live there because of its inexpensive housing, tolerant urban atmosphere, close69

knit neighborhoods and its proximity to a university, a community college, two hospitals and
several professional schools. The neighborhoods served by the SSC host a business district with
shops, restaurants and bars, a library and community center, several places of worship and 5 city
parks.
While there is some income and class diversity in the SSC’s service area, the majority of
residents are poor. Many neighborhood residents lack sufficient means to secure necessary
goods and services. In 2003, the SSC conducted a survey of neighborhood residents that focused
on food and health access. I draw on this survey, along with data collected from the 2000 US
Census, to present demographic information about the neighborhood residents living in the
SSC’s service area. The SSC’s survey showed that nearly 1/3 of households in the service area
had problems accessing enough food. The 2000 US Census shows that 59% of households in the
SSC's service area were below or at 50% of the federal poverty line. Census data showed that
many neighborhood residents are underinsured or uninsured and that more than 50% of births in
the neighborhood were covered by Medicaid. This is a significantly higher percentage of
Medicaid births than the United States (41%) and Michigan (35%) (Kaiser Family Foundation
2003).
The majority of the SSC’s service area residents are white; however, the area was more
diverse than the state of Michigan and the United States. The neighborhood hosts some ethnic
diversity; according to the 2000 US Census, 65.48% of residents identify as Caucasian, 16.49%
as African American, 15.26% as Hispanic, 1.69% as Asian, .85% as Native American, and .22%
as “Other”. The ethnic diversity of the area has grown since 2000 with a recent influx of
African, Middle Eastern, and Caribbean immigrants and refugees.
70

Methodology

My fieldwork at the Smith Street Center consisted of a combination of participant
observation and semi-structured, open-ended interviews with people related to the work of the
SSC. Following daily fieldwork, I wrote field notes, which were stored electronically. Field
notes captured the daily occurrences and interactions at the SSC and related public health
agencies and specifically highlighted the experiences of neighborhood residents seeking
assistance with healthcare and social services. The majority of observations took place at the
SSC or in the neighborhood it served; however, some observations occurred during meetings
with public health officials, employees from other non-profit organizations and community
members at the county health department, area churches and community centers.

The Study

Participant Observation

Between October 2005 and October 2007, I conducted participant observation as a
voluntary intern at the Smith Street Center. I spent most of my time at the SSC working with its
health outreach team. While the majority of my work occurred in the SSC’s offices, it also took
71

place at houses, parks, schools and businesses throughout the neighborhood and at various
meetings and conferences with public health workers at locations throughout the city. During
participant observation I was allowed full access to the agency and worked closely with many of
the SSC's staff and neighborhood residents.
As a member of the SSC's health outreach team, my daily work consisted of promoting
the SSC and its programs, providing direct services to neighborhood residents with specific
needs, and assisting residents with navigating health and social service bureaucracy. Along with
other SSC employees, I regularly canvassed neighborhood residents' homes and local businesses
to let people know about the SSC and its programs and to sign-up uninsured people for the FHP.
During the course of my field work, I helped distribute free bread and other donated food items
to residents on weekly “free bread days”. Once a month, I went with staff to the Red Cross
where we picked up enough over the counter medicine and other personal health items to fill a
mini-van. I helped distribute these items at the monthly over the counter medicine giveaway
days.
My work at the SSC also included submitting residents’ applications for health plans and
public assistance, entering information into databases for grant deliverables, answering the
agency’s phones and assisting people from the neighborhood with applications for the FHP and
other publicly-funded programs like Medicaid, Section 8 housing, food stamps, and cash
assistance. While assisting neighborhood residents in need, I frequently identified and provided
referrals to state agencies and other non-profit agencies and religious organizations. The SSC
worked closely with other non-profit organizations and public agencies that provided help related
to health, food, and housing for people in need.
72

During participant observation, I recruited volunteers for interviews through the
relationships I made at the SSC. I got to know the staff during daily work and weekly staff
meetings. I met a number of regular program participants from the neighborhood who
participated in SSC programs and events during the course of my fieldwork. I met public health
officials during various collaborative meetings and “task forces” with county and state officials
as well during my daily work at the SSC.

Interviews

After nearly a year of conducting participant observation, I began interviewing people
with whom I regularly interacted at the SSC and its affiliated public health and social service
agencies. I conducted 40 interviews with people who participated in the SSC’s programs and
services, worked with the SSC and were employed in public health or social service agencies
related to the work of the SSC. Interview subjects were chosen because of their participation in
SSC services and programs or because of professional affiliations. I recruited all interviewees
directly, either by telephone or by e-mail. Interviewees chose the location of interviews. This
was a purposive, convenience sample; interviewees were chosen for their role at the SSC and
their availability. They do not necessarily reflect the demographic make-up of the organizations
or groups they represent.
Interviews followed three specific open-ended interview schedules, which are included as
Appendices A, B and C. Questions for all interviewees’ asked about demographic characteristics

73

and their relationships to the SSC. The interview for neighborhood residents asked about
individuals’ health histories and their experiences with the healthcare system as well. I asked
SSC staff about their work responsibilities and their understandings of the role of the SSC in
health promotion, in the neighborhood and among other agencies. I asked public health
professionals questions about their work responsibilities and the relationships between their
agencies and non-profit organizations like the SSC. All research procedures were approved by
Michigan State University’s Internal Review Board (IRB). The interview schedules used with
SSC employees and program participants were also approved by the SSC’s board of directors. I
read the IRB approved consent forms to all interviewees prior to interviews; interviewees signed
the forms and indicated that they understood the information presented to them. All interviews
were conducted in English and all but one was taped and transcribed. There was one tape
recorder malfunction that resulted in an interview not being completely taped. In addition to
taping the interviews, I took extensive notes during each interview.

The Interview Subjects: Neighborhood Residents

In choosing subjects, I attempted to recruit participants that represented the diverse
population served by the SSC. However, this was a convenience sample of residents served by
the SSC’s programs. During selection, I paid attention to individuals’ race, age and gender in an
attempt to choose participants that reflected the neighborhood's makeup. Ultimately, because
more women participate in the SSC’s programs and services, I interviewed more women than

74

men. Having more women in the sample doesn’t reflect the demographics of the neighborhood,
but it is consistent with the neighbors who participate in the SSC’s programs and services.
I interviewed 15 neighborhood residents who participated in the Smith Street Center’s
programs. Around 50% of the neighborhood residents I approached who participated in the
SSC’s programs agreed to be interviewed. The other 50% either declined to participate when I
initially asked them or they did not return my calls and messages about being interviewed. All
neighborhood residents who participated in the study received a $10 gift card to a nearby grocery
store for compensation for their time and participation in the project. Interviewees chose the
location of their interviews. 7 were interviewed at the Smith Street Center, 1 was interviewed on
the telephone (after signing consent formers prior to the interview) and 7 were interviewed in
their homes. The interview schedule for neighborhood residents who participated in SSC
programs addressed interviewees’ health histories, insurance status and their opinions and
experiences with the SSC, its programs and its role the neighborhood. All neighborhood
program participants who I interviewed were recruited at the SSC.
During the early stages of the research project, I attempted to interview neighborhood
residents who were low-income and lived in the SSC’s service area but did not utilize the
agency’s services. I approached several neighborhood residents who didn’t use the services of
the SSC during neighborhood canvass and asked them whether they were interested in being
interviewed about their health and perspectives about the neighborhood and social service
agencies. All of my attempts at recruiting “non-participants” were unsuccessful. Due to this
lack of interest, I chose to only interview those individuals participating in the programs or
utilizing the services of the SSC.
75

Table 1: Specific Characteristics of 15 Neighborhood Residents Who Participate in SSC
Programs
Characteristic
Number
Percentage
Gender
Male
3
20%
Female
12
80%
Race*
White or Caucasian
9
60%
Black or African
4
27%
American
Native American and
2
13%
English
Type of Health Coverage
Medicaid
7
46%
Private
4
27%
Free Health Plan
4
27%
(Uninsured)
Annual Income
Less than $10,000
2
13%
$10,000-15,000
6
40%
$15,000-20,000
5
33%
$20,000-30,000
1
7%
$30,000-40,000
0
0
$40,000-60,000
1
7%
Primary Source of Income
Employed
4
27%
Supported by a family
5
33%
Member
Government Assistance
4
27%
Retired
2
13%
Housing Status
Owns
4
27%
Rents
8
53%
Lives with Family
1
7%
Homeless
2
13%
Highest Level of
Education
Some High School
2
13%
High School
8
53%
Associate’s Degree
1
7%
Bachelor’s Degree
3
20%
Master’s Degree
1
7%
*Racial category names are based on interviewees’ self-report
76

Most of my interviews with SSC program participants lasted between 30 and 90 minutes.
I asked all participants every question on the interview schedule. The majority of questions that I
asked were answered, but some interviewees chose to omit questions and stated that they didn’t
know enough about what I was asking to respond. During interviews I asked for demographic
information including interviewees’ age, income, race, housing status and health coverage status.
I also asked about interviewees’ personal health histories as well as those of their family
members. I asked respondents several questions about their experiences with the SSC’s
programs and staff. I encouraged people to comment about what they liked and didn't like about
the organization and the programs they participated in and whether they had ideas about how to
improve access and programs. The full interview schedule is available in Appendix A.
Table 1 presents characteristics of program participants who I interviewed. There were
12 females and 3 males. When asked to report their race or ethnicity, nine identified as white, 4
as African American or black and 2 as Native American and English. Interviewees were between
29 and 69 years, with an average age of 52. The highest level of education attained ranged from
some high school (N=2) to a Master’s Degree (N=1). Five interviewees had college degrees (or
more), 8 had high school diplomas and 2 did not complete high school. According to the 2000
US Census, less than 25% of the zip code served by the SSC had a bachelor’s degree or higher.
Work histories, income and housing status varied widely as well. Despite the educational
diversity among the SSC neighborhood residents interviewed, the vast majority (12/15) had
incomes well below the federal poverty line, which was $22,350 for a family of four in 2011
77

(United States Department of Health and Human Services 2011). Thirteen of fifteen
neighborhood residents whom I interviewed for the project had total household annual incomes
below $20,000. Although 4 of the interviewees were employed outside of their homes, none held
full-time jobs. The low incomes of interviewees can also be explained by various life
circumstances of the interviewees. Two of the interviewees were students, one had been recently
fired from their job and seven were either taking care of a disabled family member, were
disabled, or had been injured while working physically demanding jobs.
Neighborhood residents' housing statuses varied greatly; 2 were homeless, 4 owned their
homes, 1 lived with a parent and 8 rented their homes. Marital statuses varied as well; 5 were
married and 10 were either divorced or had never been married. There were differences in
residents’ health insurance status; 4 of the 15 had private health insurance, 7 of 15 had Medicaid
and 4 were uninsured and had coverage through the Free Health Plan. Three neighborhood
residents had coverage through both Medicaid and Medicare because of age or disability.

The Interview Subjects: SSC Staff and Volunteers

I interviewed 15 people who worked or volunteered at the Smith Street Center for this
project. All of the SSC staff that I approached agreed to be interviewed. I interviewed 13 of the
15 SSC employees at the SSC, 1 at a local cafe and 1 at a library. The interviews conducted at
the SSC took place in private offices with closed doors. Interviews lasted between 30 and 150
minutes. All but one of these interviews was tape recorded. There was a tape recorder
malfunction during one of the interviews during which I took extensive notes to record the
78

interviewees’ answers. Every SSC staff and volunteer I interviewed answered all of the
questions I asked.

Table 2: Specific Characteristics of 15 Smith Street Center Employees or Volunteers Interviewed
Characteristic
Gender
Male
Female
Race*
White or Caucasian
Black or African
American
Asian
Chicana
Length of Time at SSC
Less than 1 year
1-2 years
3-5 years
6 or more years
Primary Job
Responsibilities
Director
Health Outreach
Food/Gardening/Farmers
Market
Economic Development
Housing/Neighborhood
Safety
Youth and Senior
Outreach
Family Support
Newsletter/
Communication
Employment Status
Full-Time
Part-Time
VISTA (Full Time)
Highest Level of
Education
High School

Number

Percentage

1
14

7%
93%

11
2

73%
13%

1
1

7%
7%

1
8
4
2

7%
53%
27%
13%

1
3
4

7%
20%
27%

1
2

7%
13%

1

7%

1
1

7%
7%

4
5
6

27%
33%
40%

2

13%
79

Table 2 Cont’d
Bachelor’s Degree
9
Master’s Degree
3
Doctor of Philosophy
1
*Racial categories are based on interviewees’ self-report

60%
20%
7%

My interviews with SSC staff and volunteers addressed interviewees’ job responsibilities
and work, the SSC's programs, the agency’s role in the neighborhood and its relationship to its
funders and other safety-net agencies. The schedule for these interviews can be found in
Appendix B. During interviews with SSC staff and volunteers, I asked them basic demographic
questions about age, gender, race, job responsibilities and length of employment at the SSC. An
overview of demographic information from these interviews is presented in Table 2.
Fourteen of the fifteen SSC employees I interviewed were paid staff; one was a volunteer
intern from a local college. The majority (93%) of SSC staff and volunteers that I interviewed
were women. Four were full-time paid staff, four were part-time paid staff and six were fulltime AmeriCorps VISTAs (Volunteers in Service to America). The 15 staff and volunteers did
not all work at the same time during my fieldwork at the SSC. Staff and volunteers came and
went depending on programming and available funding. I did not interview some SSC
employees because their work wasn’t closely related to health outreach or information and
referral. Many of the employees I didn’t interview were men. Since I stopped doing fieldwork,
several men have been hired as AmeriCorps VISTAs and permanent outreach employees at the
agency. Therefore, the agency has more gender diversity than is represented by my data. The
impact of the lack of interviewees’ gender diversity on my findings is unclear; however, it does
80

point to the largely female dominated fields of social service and health advocacy work.
The average length of time the 15 SSC staff had been working for the organization was
2.8 years. The range was 7 years (N=2) to 6 months (N=1). The high turnover at the agency is
largely related to the number of VISTAs working at the SSC because their contracts only last one
year. It is also related to the number of project-based positions at the SSC which are funded on
“soft money”. Many of the agency’s staff positions are directly tied to specific grants and when
these grants end, the positions end. The SSC’s limited budget and the fact that its salaries and
benefits are not competitive with many for-profit and public organizations is a likely contributor
to the agency’s high turnover rates as well. Four of the staff members who were working at the
SSC during the course of my fieldwork have since left the agency for higher paying jobs with
public agencies or larger non-profit organizations.
The majority of the Smith Street Center’s employees I interviewed were college
educated. All but two of the SSC staff members I interviewed had at least Bachelor's degrees.
One had a PhD and three had Master's Degrees. The educational achievements of the staff
interviewed are generally higher than the neighborhood it serves. The average age of the
interviewed SSC staff and volunteers was 35. The ages of staff and interns ranged from 22-64.
Among my interviewees, full time, non-VISTA staff were notably older than the VISTA
volunteers. All four of the VISTA workers I interviewed were 25 years old or younger. Unlike
the highest level of education reached, the racial makeup of the SSC's staff was more reflective
of the neighborhood. The majority (73%) of the staff interviewed at the SSC identified as white;
2 identified as black or African American, 1 as Chicana and 1 as Asian.

81

Interview Subjects: Public Health and Social Service Professionals

During field work, I regularly attended workshops and meetings with county and state
public health officials and members of other publicly and privately funded health and social
service agencies throughout the area. After developing a more in-depth understanding of the
SSC’s relationship with state and county agencies, I approached several of these professionals to
be interviewed. I interviewed 12 public health professionals for the project. Public health
professionals were recruited by a combination of snowball sampling and direct interactions. The
majority (8/12) of these professionals were recruited for participation directly because of their
close work with the SSC. Four were suggested for participation by other public health
professionals during interviews or other interactions. All of the public health professionals who
I approached about participating in the study accepted and were interviewed for the project.

Table 3: Specific Characteristics of 12 Public Health Professionals Interviewed
Characteristic
Gender
Male
Female
Race*
White or Caucasian
Black or African
American
Employer
County
Private Agency
State of Michigan
Split Private/Public
Length of Time at Job

Number

Percentage

3
9

25%
75%

10
2

83%
17%

6
3
2
1

50%
25%
17%
8%
82

Table 3 (cont’d)
Less than 1 year
3
25%
1-3 years
4
33%
4-7 years
2
17%
8-10 years
3
25%
Highest Level of
Education
Bachelor’s Degree
2
17%
Master’s Degree**
7
58%
Doctor of Philosophy*** 3
25%
*Racial categories are based on interviewees’ self report
**4 Masters in Social Work, 1 Master of Public Administration, 1 Master of Public Health, and 1
Master of Arts in Counseling
***PhDs were in Anthropology, Sociology and Urban Planning

The interview schedule (found in Appendix C) for public health professionals presented a
number of questions with the intention of gathering data about the current state of policy and
public health delivery. Questions were asked about privatization and public-private partnerships
in Michigan and how agencies and individuals working in various agencies have adapted to these
changes. I also asked public health professionals about their work and job responsibilities and
how their agencies interacted with non-profit organizations like the SSC. Questions for public
health professionals centered on the role that these individuals and their employers played in the
provision of healthcare and social services for low income, uninsured and under-insured people.
I also asked a number of demographic questions regarding interviewees' age, gender, race, place
of employment, professional position and length of current employment.
An overview of demographic characteristics is presented in Table 3. All 12 of the
interviewees had at least Bachelor's degrees; 10 of these interviewees held graduate degrees.
83

Three had PhDs (the degrees were in anthropology, sociology and urban planning) and 7 had
Master's Degrees (1 Masters in Public Health, 1 Masters in Public Administration, 1 Masters in
Counseling and 4 Masters in Social Work). Interviewees were employed in various capacities.
Seven worked for the County Health Department, two worked for the Michigan Department of
Community Health and three did contractual work for publicly (state, county or federal) funded
health agencies. One interviewee who was employed as a contractor worked for a non-profit
public health agency that contracts with the Michigan Department of Community Health.
Another retired from the state and owned a business where she contracted with public and
private organizations related to public health. The other interviewee worked for a non-profit
organization that contracted with the County Health Department.
The majority (10) of public health professionals identified their race or ethnicity as white;
2 identified as African American. Their ages ranged from 29 to 66 with an average age of 48.
One person declined to provide certain identifying regarding work responsibilities and specific
details of employment because of concerns about remaining anonymous. Most (9/12) of the
interviewees were women. All had been at their current jobs for ten years or less. The average
time the public health professionals I interviewed had been in their current jobs was four years.

Data Analysis

Upon completing fieldwork, I conducted content analysis of data collected through
interviews and observations. Thirty nine interviews were tape recorded and transcribed by me;
84

one interview was not recorded due to a failure in the recorder. Analysis of field notes and
interview transcripts involved summarizing transcripts and field notes and identifying key
content and themes. This was followed by open-coding of data and identifying relationships and
patterns using the qualitative data analysis software ATLAS t.i. Using ATLAS t.i., I created
codes and identified variables and themes based on interview questions and observations from
fieldwork. I then created data bases for all three sets of data using findings that emerged from
content analysis. The data-sets consisted of demographic data, answers to questions asked
during interviews and other salient variables coded in ATLAS t.i. I identified patterns and trends
in data sets which were used to make comparisons between variables. In addition to formal data
collection, some of the data presented in the dissertation was gathered through informal means
specific to relationships I formed with neighborhood residents and SSC staff.

Conclusion

In this chapter, I provided descriptions of the field site, demographics of the people I
interviewed and an overview of research methodology and data analysis techniques. In the next
chapter, I provide a more in-depth discussion about the SSC’s history and its staff’s perspectives
about its role in the neighborhood. I compare popular and political rhetoric about public health
and social services with what I observed at the SSC. I then ask how the agency and the
experiences of those who rely on it fit with Michigan’s public health and social service landscape
since increases in downsizing and public-private partnerships.
85

Chapter 5: The Smith Street Center

86

In this chapter, I provide an overview of the history and programs at the Smith Street
Center to ask how policies impacted by neoliberalism and privatization have shaped its work. I
describe the SSC’s relationships with the people it serves and the organizations that provide its
funding to situate its work in the broader context of health and social service advocacy and
assistance in Michigan. In order to examine how neoliberal influenced policies and privatization
have impacted the agency, I focus on its role in the neighborhood and its relationships with
public health and social service departments.

I collected much of the information presented here during fieldwork and interviews with
SSC employees and public health employees from October 2005 until October 2007. The latter
sections of this chapter are based on SSC staffs’ perspectives about the agency’s history, its
programs and its relationship with public safety-net providers. I present perspectives from the
SSC’s director and staff about the SSC’s history, programs and funding to illustrate how
neoliberalism and privatization have impacted the landscape of public health and social services
at the SSC and surrounding communities. Finally, I provide an overview of the county’s Free
Health Plan (or FHP) and the SSC’s role in the promotion of the plan. I demonstrate that the
FHP was made possible due to the creativity of the County Health Department staff and a series
of collaborations between public and private agencies. Like the SSC, the FHP has been created
and maintained by private agencies and public funds and is a creative on-the-ground solution to
addressing the needs of vulnerable populations.

87

The History of the Smith Street Center

The Smith Street Center first opened its doors in 1999. The SSC opened after a
community summit in 1996 involving leaders from local and state government, public health
workers and neighborhood representatives. During this summit, attendees identified several
barriers to health and social service access in the neighborhood now served by the SSC. From
the very beginning, the SSC has been a product of public-private partnerships. It was created by
community activists with funding and support from officials at the County Health Department
(or CHD). The CHD’s work was supported in part by a grant from a private philanthropic
organization.
The SSC’s complicated beginning as a public-private endeavor is reflective of the
complex web of public-private relationships influencing safety-net services. The SSC was
formed largely because its founders believed that establishing a legal non-profit (501(c)3)
organization was essential to carry out their work of community organizing and neighborhood
activism. Receiving non-profit organization status allowed the founders of the agency to receive
funds from public and private organizations, pay staff and administer programs. The SSC was
one of four neighborhood outreach centers in the city that was formed in the years following the
1996 summit.

In 2000, community members and leaders met to follow-up on the 1996 summit and
make plans for the neighborhood outreach agencies that had been created to address health
88

access and advocacy and community improvement in the city. According to the Executive
3

Summary that reported on both summits, the summits were organized by an organization
representing several neighborhood groups and a hospital located in what is now the SSC’s
service area. The Executive Summary is a report that provided an overview of the summits’
progress; it also contained suggestions and descriptions of further plans for the neighborhood
served by the SSC. It explained that both the 1996 and 2000 summits focused on improving
health, housing, population stability and economic opportunities for residents of the
neighborhood. The summary stated that the people attending these summits sought to implement
several projects and initiatives by engaging neighborhood residents with local institutional
partners like hospitals, schools and businesses. It reported that the idea was to draw on the
neighborhood’s strengths and use existing agencies and organizations to improve the health and
overall status of the neighborhood. The Executive Summary reported that the 1996 summit led
to the city’s decision to fund the SSC and three other agencies engaged in neighborhood outreach
and advocacy in other low income areas of the city.

According to the Executive Summary, the 1996 summit was followed by several
meetings and other summits with interested neighborhood and institutional representatives. The
County Health Department (or CHD) received funding from a major national philanthropic
foundation. This funding supported several other summits and a project documenting the
experience of uninsured people. Ultimately, the philanthropic grant funded part of the Free
Health Plan (FHP) for uninsured county residents. In 2000, 250 “stakeholders” from the
neighborhood and its institutional partners met to celebrate the creation and success of the SSC,
3

Identifying details about the summit are intentionally vague to protect subjects’ anonymity.
89

assess the state of the neighborhood and create a plan for further action. The Executive
Summary reported that further actions involve the following: increasing neighborhood residents’
participation in exiting neighborhood organizations and increasing the leadership capacity in
these organizations, creating a more desirable community for businesses and vibrant residents,
increasing communication between the SSC and neighborhood residents and partners, creating
and maintaining a desirable physical environment in the neighborhood, improving housing stock
in the neighborhood, creating programs that focus on families, creating strong neighborhood
schools, improving residents’ health through awareness and education and increased access to
health resources and improving the safety of the neighborhood.

Staff Perspectives on the SSC’s History and Mission

According to Sandra, the director of the SSC, the impetus for establishing the SSC
emerged from decades of neighborhood organizing and mobilizing by residents, activists and
politicians. During our interview Sandra described herself as a long-time community activist,
neighborhood resident and the current director of the SSC. She told me about the summits that
were described in the Executive Summary. She said that in 1996 she was hired by a local
hospital to lead the neighborhood summit that eventually resulted in the creation of the SSC.
According to the Executive Summary, the hospital became involved in the summit because of its
desire to improve the neighborhood and engage stakeholders. The summary also cited the
hospital’s concerns about health access and health disparities among the residents of the
90

neighborhood. Sandra said that she was hired because she had been involved with poverty
reduction, health advocacy and neighborhood improvement in various capacities throughout the
city for decades. She told me that she first began working in the neighborhood now served by
the SSC in 1968 when she graduated from college and accepted a position as a community
organizer for a program funded by Lyndon B. Johnson's “War on Poverty”. Since then she has
held similar leadership positions organizing for the improvement of the health and safety of the
city in various capacities.

According to Sandra, she was asked by a local hospital foundation to mobilize other
community leaders to improve the overall health of the city and area now served by the SSC.
During our interview, she described the initiative that launched the neighborhood summit as
community based, stakeholder driven and unique from more paternalistic endeavors and agencies
that serve the poor in a hierarchical, top-down manner. Sandra contends that the SSC’s
stakeholder driven programs, along with the neighborhood organizing approach taken by its
leaders, contribute to the organization’s success and excellent reputation among public agencies
and community leaders.

Sandra told me that the initiatives behind the neighborhood summit and eventual
inception of the SSC included the opinions, experiences and perspectives of stakeholders in the
community. She defined stakeholders as neighbors, neighborhood organizations, police, clergy
and school officials. In its early years, the SSC sought to build on the relationships that began
with partnerships between neighborhood residents, an elementary school and community police
officers. According to Sandra, the school served as a centralizing locus for parents and children
91

enrolled in or involved with various state agencies. Representatives of multiple social service
agencies would come to the school; parents were able to interact with representatives from
different public agencies in a nearby and familiar environment. This model also resulted in
parents being closer contact with their children's teachers and school officials. Community
police officers assigned to the neighborhoods were involved as well. Sandra explained that this
centralized, community based program was very popular among neighbors and the participating
agencies.

Sandra told me that the popularity of the school-based model that helped launch the
Smith Street Center was largely due to the economic hardships felt by many of the neighborhood
participants. Recent shifts in the city's economy due to decreases in its manufacturing base,
declines in the auto industry and changes in the distribution of public health and social services
led to an increase in the number of neighborhood residents seeking assistance. During our
interview, Sandra stated that as the economy grew worse in the city and more manufacturing jobs
were lost, neighborhood residents' demands for services quickly grew. She said that the space
offered by the school was outgrown and the program needed a bigger space dedicated solely to
assisting residents. County officials temporarily relocated the school program to a larger space
in the neighborhood. Sandra said that the political will behind these local, grassroots social
service agencies eventually led to the mayor's decision to encourage the county commissioners to
fund four neighborhood based organizations, including the Smith Street Center, in low income
areas throughout the city.
Funding from the county has never been the sole source of the SSC’s support. Besides
92

Sandra, the SSC’s first employee was paid through the AmeriCorps VISTA (Volunteers in
Service to America) program. The VISTA program has remained an integral source of
employees for the Smith Street Center and the other neighborhood based organizations created
by the city. The VISTA program is a federal service program intended to fight poverty in the
United States (Corporation for National and Community Service 2011). The program was
created by President Kennedy in 1965 and is popularly referred to as “the domestic Peace
Corps”. It pays its volunteers a small cash stipend to work full time for one year with
organizations serving low income populations. In addition to their stipend and benefits like
health insurance and food stamps, VISTA volunteers receive $1200 cash or $4725 towards
college or college loans when they complete their service.

The Smith Street Center relies on the work of AmeriCorps VISTAs to operate its
programs. Four of the fifteen SSC staff and volunteers I interviewed for this project were
4

VISTAs . All of the VISTAs I interviewed were recent college graduates. It was common for
the VISTAs serving the SSC to renew their contracts and return to work at the SSC after their
initial year of service. The VISTAs that I interviewed for the project worked at the SSC from 1-4
years with an average of 1.9 years. VISTAs were usually appointed to a program or initiative
within the SSC. Usually these appointments involved working closely with neighborhood
residents and program participants on projects intended to improve the neighborhood or better
the health of neighborhood residents.

4

Four VISTAs were not employed at the SSC simultaneously; each was in service for one year.
Terms were sometimes renewed when service ended.
93

Promoting Community Change

According to its staff and directors, the SSC was created to be a space for community
improvement and advocacy, not as an extension of a social service agency. VISTA appointments
usually nominally reflected these goals, but often in practice, the work of the VISTAs and other
staff resembled that of social service agencies. Despite the discrepancies between the agency’s
goals and practice, the SSC sought to improve the neighborhood and the quality of life of its
residents. During interviews, I asked SSC staff about the SSC’s work and its role in the
neighborhood. I repeatedly heard that the SSC was important because it built community and its
programs were based on the needs and wants of neighborhood residents. Lisa, an AmeriCorps
VISTA and recent college graduate told me,
It’s important that we build these communities. To help get them on the right track and
besides just being a resource at the subsistence level, I think that we also provide a forum
for people if they wanna talk about various problems or to help them build their
neighborhoods or start something.

The Smith Street Center was intended to be a space for community improvement that was
steered by the needs of neighborhood residents. One staff member, who I call Carol, said that the
SSC was meant to serve neighborhood residents in need and inform the policies of the agencies
that funded its programs. The County Health Department frequently asked the SSC and the other
94

neighborhood based agencies it funded for feedback about how to better serve and improve the
health of members of the community. During my interview with Carol, she said,

I see us as a catalyst for change and getting things in place that we don't necessarily run.
We just get them in place so that they can be run by the community or whoever. You
know, but informed by, informed by people who live here and people who work here and
have businesses here, and I think that's another role. I see the SSC as a place where we
collect information to inform policy makers, institutions, schools, and maybe the
neighbors themselves. So they have the information they need to take action or form
groups or whatever- Carol, SSC staff person

Carol’s understanding of the SSC as a “catalyst for change” is similar to Lisa’s
perspective about the importance of the SSC not just being another social service agency. Both
Carol and Lisa stated that the SSC’s role in the neighborhood involved fostering communitylevel responses to challenges. During fieldwork, I observed that community leaders and
representatives from the County Health Department went to great lengths to hear from residents
and better understand the source of health disparities and community needs. The 1996 and 2000
summits helped launch a number of collaborative organizations and task forces with
representatives from the SSC and several other public and private agencies to better understand
and address social and health disparities in the area.

Sandra told me about several summits that occurred throughout the city following those
in 1996 and 2000. She said that many of these summits were intended to address health
inequities and the needs of specific, under-represented groups. According to Sandra, separate
summits were held to address inequalities for African Americans, Latinos and Native Americans
in the city and its surrounding areas. She said that these summits were sponsored by a
95

consortium representing public (Michigan and County Health Department, the city and the
county commissioners) and private (neighborhood organizations, churches, free clinics and
several churches) agencies. They were held in public locations like high school or community
center gymnasiums and were attended by people from all over the area. The summits featured
guest speakers and advocates from the sponsoring agencies. Audience members were
encouraged to ask questions and share their experiences and opinions about how to make the
community healthier and stronger.

During my field work I attended a summit in 2005 that focused on community responses
to health inequities and racism. The summit was sponsored by the County Health Department.
It was held in a large gymnasium at a city community center and was so well attended there was
standing room only. The majority of people who attended were community residents; however,
health activists, representatives from the SSC and the other outreach agencies in the city,
employees of the County Health Department, politicians, university professors and healthcare
professionals also attended.

Task forces and consortiums were created following these summits to attempt to improve
the needs of the city and its communities. Representatives from stakeholder groups such as nonprofit organizations, health insurance companies, health department officials, churches and
school districts regularly met to share ideas, represent the needs of the populations they serve and
inform the trajectory of the County Health Department. During fieldwork, I attended dozens of
meetings focusing on issues of concern such as early education, infant mortality, safe infant sleep
and teen pregnancy reduction. At these meetings and summits, representatives of diverse groups
96

addressing the same problems designed several task forces and consortiums to address barriers to
health in the city. Consortium meetings included representatives from neighborhood-based
organizations with the SSC with the intention that the perspectives of neighborhood residents
and staff would create “stakeholder driven” programs and better inform policy and the work of
public health and social service providers.

The SSC’s Programs

The programs of the SSC were intended to be “stakeholder driven;” in practice, they were
based on the needs of the community, the mandates of the agency’s funders and the availability
and willingness of its staff. Sandra, the SSC board of directors and the SSC staff regularly had to
balance their wants, the community’s needs and their funders’ demands. Surveys were regularly
taken during neighborhood canvass to better understand the needs of community members.
Results of surveys were presented to the County Health Department and were described in grant
applications and reports to existing funding agencies.
Anita, the director of the SSC’s health outreach team, Sandra and other leaders of
successful agencies frequently acted as mentors to smaller non-profit and religious organizations
looking to write successful grants, “build capacity” and become more organized in their work.
97

During my interviews, the SSC was touted by county officials as successful in its service to
neighbors and its ability to procure and maintain funding. I regularly heard that the SSC was
considered the exemplary neighborhood-based non-profit organization in the city by the public
health community and the county commissioners. These comments were usually followed with
praise of Sandra's excellent leadership skills, her competent and caring staff and the organization
and participation of neighborhood residents. I asked Sandra about the SSC’s excellent
reputation. She humbly explained that the SSC’s success should be attributed to the work of its
past leaders. She claimed that she and others involved in the success of the organization were
fortunate to “stand on the shoulders of giants”.

Because neighborhoods in the SSC's service area have been well organized for decades,
the SSC has been able to draw on these existing relationships in its work of serving neighbors
and addressing their needs. Sandra attributed the agency’s success largely to its community
organizing approach:

Knocking on doors, talking with people, is a central component of not only the work that
we would do around health, but around everything. It was a community organizing
approach to health education and health access. And that, I think is the most significant
contribution that we've made to the city. It's that we established a community organizing
approach- modeled it, piloted it and then spread it.

The SSC’s community organizing approach allowed staff to reach neighborhood residents and
promote the agency’s programs.

98

Description of Programs at the SSC

According to its website, the Smith Street Center’s mission centers on community
building and neighborhood support. Its programs involve its staff working with community
members and stakeholders to build programs that improve health, housing, food access,
economic development and community relationships in the neighborhood it serves. During my
fieldwork, there were a variety of programs at the SSC. Some of the programs were designed to
address specific neighborhood concerns or needs; others, like Healthy Breasts and Stop
Smoking, were funded and informed by outside organizations such as the County Health
Department or national non-profit organizations. Both of these programs were tailored to meet
certain neighborhood demographics and preferences, but their existence and funding was closely
tied to the will of outside agencies. At the SSC, programs often changed based on funding,
staffing and neighborhood participation. Several of the programs that existed during my
fieldwork are no longer operational. There are also some new programs related to the urban
gardening and food security programs that began after my fieldwork ended.

During the course of my fieldwork, several SSC programs addressed specific
neighborhood needs and issues. These included the Teen Group, Senior Group, Housing Help,
Walk with Me, Be Prepared, the Farmers Market, Free Bread, Free Medicine, and Grandparent
Support. These programs were mostly funded with general SSC funds and were largely staffed
99

with AmeriCorps VISTAs. More information about the AmeriCorps VISTA program can be
found in Chapter Four. The Teen Group was a free, drop-in afterschool program for teens and
preteens in the neighborhood. The leader of Teen Group was an AmeriCorps VISTA who
frequently solicited donations from local businesses to supplement the program’s costs. During
my fieldwork, the members of Teen Group engaged in community service activities like raking
and mowing elderly and handicapped neighbors’ yards, cleaning up trash and delivering SSC
newsletters. The teens received small incentives like gift cards to local businesses for their work.
The Teen Group also went on several cross-country trips and attended leadership conferences.

Teen Group changed since my fieldwork ended. It is now mostly centered on gardening
and job training. The change was related to funding; the SSC received a major grant from the
United States Department of Agriculture to promote gardening and increase the availability of
fresh produce through the construction of a year-round indoor garden house that was built at a
neighborhood park. Funding for Teen Group was written into the grant, so the group shifted and
is now largely a gardening group that raises money by selling produce at the Farmers Market.

The Farmers Market began in response to community need and the identification of the
neighborhood served by the SSC as a “food desert.” Surveys conducted of neighborhood
residents by the SSC identified that fresh produce and healthy foods were not easily available to
everyone in the service area. The Farmers Market was created by the SSC as a direct response to
the lack of fresh foods in the neighborhood. Farmers and other vendors sell a variety of locally
grown produce weekly from May to October. The SSC’s Farmers Market was one of the first in
the state of Michigan to accept SNAP (Supplemental Nutrition Assistance Program, or food
100

stamp) benefits. The market also participates in the Project Fresh program, which gives low
income families and senior citizens vouchers for free produce at area farmers markets.

The market is well attended and has been financially successful for the SSC and its
vendors, but there were concerns among SSC staff that too many of the shoppers come from
outside of the neighborhood and that the diversity of the neighborhood isn’t reflected among
market patrons. Shoppers are regularly surveyed at the market and the results are usually that
about half of the market patrons drive in from other (more affluent) areas to shop. Some staff
were also concerned that the prices of the organic and sustainably grown produce are prohibitive
for many low-income neighborhood residents. The SSC’s staff and directors have tried to
address this issue by promoting Project Fresh and advertising that the market accepts SNAP
benefits. In 2011, the SSC’s market was awarded a grant that allows people with SNAP benefits
to receive double the amount of “market money” as they detract from their accounts each week.
Sandra was very hopeful that this program would be an incentive for more neighborhood
residents to shop at the market.

In addition to the Farmers Market, which attracts people from inside and outside of the
neighborhood service area, the SSC has several groups designed specifically for neighborhood
residents. A popular weekly program among neighborhood residents is Senior Group. The
Senior Group meets weekly at the SSC. The attendees are mostly retired neighborhood
residents. Coffee and baked goods are served. Each meeting features a speaker from the
community and is followed by a discussion. The Grandparent Support group is a monthly
support group for grandparents or other non-parents who are raising children. The group’s leader
101

is a volunteer community member who raised her granddaughter while her son served in the
military. The group offers emotional and practical support and resources for grandparents who
have custody of, or provide much of the care for, their grandchildren. The group’s leader is
closely affiliated with social workers and helps families navigate social and health services and
emergency custody placements. The group often features guest speakers to talk to the
grandparents about various social issues and challenges which children and teens may encounter.
For instance, they have had police officers talk to the grandparents about internet safety, truancy
and drug awareness.

Housing Help was a program staffed by AmeriCorps VISTAs. The VISTAs acted as
counselors to neighborhood residents who had questions about becoming home owners or
keeping their existing homes out of foreclosure. During the time I conducted fieldwork, the
SSC’s service area had a number of housing foreclosures and homes at risk of being foreclosed.
The Housing Help staff counseled people with delinquent mortgages to help them avoid
foreclosure. They also worked to attract new residents and first time home buyers to the
neighborhood. The SSC also held home improvement workshops and, at one time, assisted the
city in the administration and distribution of grants for neighborhood residents with low incomes
and homes in need of improvement. The Housing Help program no longer exists at the SSC in
the capacity that it did during my research. Because the SSC was engaged in housing advocacy
and foreclosure prevention for several years before the nation-wide mortgage crisis in 2009, the
staff members doing this work at the SSC were recruited for high profile jobs with larger
agencies to address Michigan’s housing and foreclosure crises.

102

Be Prepared was a program that targeted a specific neighborhood in the SSC’s service
area that was prone to flooding. The program was funded by a grant from the County Health
Department and was part of a larger federal disaster preparedness program. It was designed to
increase neighbors’ awareness of flooding and other threats and increase general emergency
preparedness in the neighborhood. All staff, including myself, and several neighborhood
residents were trained by personnel from the city’s fire department to be designated community
responders in the case of natural disasters and other emergencies. This training was supported by
the CHD and was paid for by county and federal funds. Be Prepared no longer has dedicated
staff, but the SSC remains involved with emergency preparedness in the neighborhood.

The SSC also had programs where free goods were distributed to participants. Free
Bread and Free Medicine were popular distribution programs. Free Bread was a weekly program
where the SSC staff distributes bread and baked goods donated by local bakeries to
neighborhood residents. Free Bread is still operating and remains a very popular program.
During fall harvests, produce was frequently “gleaned” (picked from farms where it would
otherwise rot) and distributed for free at the SSC during the Free Bread program. It was not
uncommon to see a massive box of apples or cucumbers or hundreds of small bags of dried
beans at the SSC. Although bread was officially distributed every Wednesday, neighborhood
residents frequently dropped in throughout the week asking if any baked goods or produce was
available. There was usually surplus bread and unlike other food programs in the area, the SSC
required no identification or proof of poverty or hardship to receive free food. People simply
came in, signed a sheet and took food. The weekly program generally had about 50 regular
participants, most of whom were neighborhood residents.
103

Free Medicine took place once a month during the course of my fieldwork. The program
has been discontinued for reasons related mostly to staffing and space. Free Medicine was a
massive undertaking that involved SSC staff making monthly trips to the Red Cross’s
distribution warehouse to pick up several very large boxes of medicine. It involved sorting and
storing the medicine and organizing it for the monthly distribution at the Smith Street Center.
People from all over the city would come hours before the program started to receive the free
over the counter medicines and other items like condoms, bandages and bug spray. Free
Medicine days were very hectic for all SSC staff and required the labor of at least three staff
members or volunteers for the entire afternoon. Program participants often waited for an hour or
more for the allotted three free items. The program ended a few months after I finished my
fieldwork. The SSC had fewer staff because of budget constraints and the demands of the Free
Medicine program were too great.

During the first year of my fieldwork, the SSC received funding from the County Health
Department to promote smoking cessation through its Stop Smoking Club. Stop Smoking Club
served as a support group for neighborhood residents who were trying to quit using tobacco.
Residents received free nicotine replacement therapies (like patches or gum), counseling and
group support. The program was administered by a SSC staff person or social work graduate
student intern. Stop Smoking Club ended when funding for the staff and nicotine replacement
therapies ended.

The SSC had several programs that were supported by grants from outside agencies.
While the majority of these agencies were publicly funded, the SSC received funding from
104

private organizations as well. During my fieldwork, the SSC received grants from two private
organizations to do health outreach in the neighborhood. They received a small amount of
funding by a non-profit health insurance plan to do general health outreach in the neighborhood.
They received a larger amount of funding from a major breast cancer foundation to do outreach
related to breast cancer awareness and prevention. The SSC created the Healthy Breasts Club to
educate neighborhood women about breast cancer risks and prevention.

The SSC tried to promote its health programs in ways that were meaningful to all
neighborhood residents. In addition to specific programs like Stop Smoking and Healthy Breast
Clubs, the SSC’s health outreach programs put a lot of focus on wellness and preventative care.
Sandra, the agency’s director, has held and promoted neighborhood walking groups since the
SSC began. Walk with Me currently meets on Fridays at noon and consists of Sandra and a
group of neighborhood residents who get together at the local park and walk on its walking path.
The program is advertised in the SSC’s bi-monthly newsletter and is promoted by outreach
workers during neighborhood canvass. The Smith Street Center’s programs were flexible and
shifted depending on their success, funding and the availability of staff. Programs like Walk
With Me survived because they required no funding or oversight. For many of its programs, the
agency had to remain flexible and willing to shift its programming around in order to remain
relevant and retain funding.

105

The Space and Its Uses

The Smith Street Center’s central location is closely related to its success. The agency
operates in a building in the heart of the neighborhood it serves. It is located in a two story store
front building; the first floor of the SSC mostly serves as a space for neighborhood residents and
the second floor is where most of the administrative and bureaucratic work is done by the SSC
staff and professional partners. The SSC holds its weekly farmers market in the building’s
parking lot from May until October. The SSC’s storefront neighbors are a day labor business, an
African American barbershop, a Christian church and a small law office. The agency has an
excellent relationship with its neighbors and often collaborates with the church and barbershop
for events and programs. A number of the men who frequent the day labor agency also regularly
participate in the SSC’s programs.

The SSC's work with neighborhood residents is done mostly in its first floor storefront
office space. This space is about 1000 square feet and has a large common room where people
from the neighborhood are welcome to spend time. In this area there is a large conference table,
a couch, two comfortable chairs, a water cooler next to the entrance, two public computers, a
public telephone, a shelf with pamphlets for various social services and community agencies,
toys and books. A large wooden cabinet separates the common area from the staff’s workspace.
The workspace is comprised of four desks with computers and phones for staff and volunteers.
Behind the staff workspace is a small storage room, a kitchen area with a sink, microwave,
coffee maker and refrigerator and a bathroom.
106

Throughout the day, people from the neighborhood drop in on the SSC’s first floor space
to chat, sit down, use the restroom, have a snack, get water or coffee, or use the computers or the
phone. There is usually a plate of day old baked goods donated from a local bakery on the
conference table. People help themselves to goodies and coffee throughout the day. Depending
on the day, there may be a sign-up sheet on the conference table and free bread that was donated
by a local bakery for the SSC’s Free Bread program.

The SSC is a community oriented place where people socialize. Programs and services
are always conducted in a friendly, informal context. Neighborhood residents often chat with
SSC staff and volunteers while they are there. The SSC, like the neighborhood, is diverse and is
many things to many people. Its staff is trained to assist everyone who comes through the doors
the best they are able. Staff members frequently make phone calls to advocate for services and
goods for neighbors without phones. During fieldwork at the SSC, I made dozens of phone calls
to Medicaid, Department of Human Services and to other public agencies on behalf of
neighborhood residents.

It was not uncommon for SSC staff to call the Department of Human Services, Medicaid,
doctors’ offices or food banks on behalf of neighborhood residents. Neighborhood residents
were frequently unable to call these agencies themselves for various reasons. Some were too
overwhelmed and frustrated by their situations to deal with all of the bureaucracy involved;
others faced access issues, literacy barriers, language barriers or time constraints that made it
difficult for them to advocate for their health and social service needs. When people came into
the SSC for the first time to use the phone or go to the bathroom, they often end up receiving
107

information and referrals (called “I &R” by the SSC staff) about other programs and services that
they might qualify for because the SSC’s programs and services were so varied. People
frequently came into the SSC to use the computer or get bread only to learn after having a
conversation with the staff person on duty, that they qualified for food stamps or the Free Health
Plan. Neighborhood residents learned about the other programs and services offered at the SSC
when they came into the storefront office. Programs like Teen Group, Walk with Me, Senior
Group, Garden Club, Housing Help, Stop Smoking, Be Prepared, Healthy Breasts, Farmers
Market, Free Medicine and Grandparent Support were promoted during I&R sessions. They
were also written about in the SSC’s bi-monthly newsletter and promoted during neighborhood
canvass.

Because the SSC was dependent on obtaining and retaining external funding, much of the
staff’s work consisted of writing grants, maintaining data bases and reporting program progress
and “deliverables” to funders. The SSC had an annex area with several offices that was located
on the floor above the storefront space. This space, which is about three times the size of the
first floor storefront office, had six staff offices, a conference area, and a restroom. During the
course of my fieldwork, the offices were used by the director of the SSC, the director of the
health outreach team, the head of Healthy Breasts Club, the head of Economic Development, two
housing advocates and an employee working on an emergency preparedness project.

There were several small desks on the second floor for interns and volunteers from the
neighborhood and local colleges. Although there was a conference table on this floor for
meetings, neighborhood residents were less likely to use this space than the main storefront
108

office. Sometimes meetings were held upstairs when more privacy was warranted or when
someone had to concentrate on filling out a lot of paperwork and required a quiet space. For the
most part, the SSC's space was divided between direct service, which occurred mostly in the first
floor storefront space, and administration, which was usually carried out in the upstairs offices.
The Housing Help program operated in a private room in the back of the second floor office.
Housing was the only SSC outreach program held on the second floor office. This office was
chosen by the housing team because of the sensitive nature of its work.
Not all of the SSC’s programs operated from inside the SSC. The agency’s goal was to
be out in the community and many of the programs functioned in the neighborhood surrounding
the SSC. Sandra and the board of directors held the philosophy that health should be viewed
holistically and included exercise and access to healthy food as a component of the agency’s
health outreach work. In addition to its Farmers Market, the SSC operates a garden house in a
nearby park. The garden house program was funded by a grant from the USDA. The space
supports plots for urban gardening and has become a common space for food growing education.

During neighborhood outreach, the health outreach team signed women up for the
Healthy Breasts Club. When women signed up, they received monthly postcards encouraging
them to do a breast exam. The postcards had information about cancer prevention related to diet,
exercise and healthcare. Although there were more than 300 women from diverse backgrounds
enrolled in the club, the club specifically targeted minority and lesbian women because of higher
breast cancer mortality rates among these groups. Every year representatives from the Healthy
Breasts Club attended public events with information about breast cancer and screening for
109

uninsured individuals. Public events that I attended during fieldwork included the city’s annual
African American parade and celebration, the state’s gay pride festival and parade, the SSC’s
weekly farmers market and an annual Mexican American cultural celebration. During my
research, the SSC also sponsored annual informational dinners for members of the Healthy
Breasts Club featuring speakers such as an oncologist, a popular women’s health author and a
breast cancer survivor.
The SSC’s attention to breast health and, subsequently, women’s health issues highlights
the tensions that can surface with external funding sources. The Healthy Breasts Club was
funded by a major national anti-breast cancer foundation, which had a number of requests and
mandates of its funding recipients. The foundation paid a significant portion (around ¼) of the
SSC’s operating budget. The Healthy Breasts Club was a large part of the SSC’s program focus
and members of the health outreach team promoted the Healthy Breasts Club at many public
events and in every newsletter. During outreach events I was frequently asked by neighborhood
residents about whether the SSC had groups that focused on other types of cancer and diseases.
Men often mentioned that they had suffered from cancer and were concerned that programming
and outreach efforts weren’t being made to address their issues and needs. There was a clear
benefit of the SSC’s Healthy Breasts Club, but the SSC’s focus on breast health illustrates well
how difficult it is for the agency to maintain funding and fully consider and address everyone’s
needs and wants.

110

Staying on Course: Balancing Funding and Community Need

Unfortunately, the SSC was unable to procure grants to address other diseases and major
health issues impacting the health of its neighborhood residents. The example of the Healthy
Breasts Club shows how vulnerable small non-profits like the SSC are to being “steered” by their
funding agencies. Sandra and Anita made efforts to be inclusive and promote health generally by
promoting exercise, nutrition and the Free Health Plan. The SSC’s programming tried to address
general health, but it wasn't able to actively promote awareness and prevention of other illnesses
because it wasn't funded to do so. Funding was obtained from several sources and programs
were built with the intention of honoring neighbors’ needs and wants with the mandates of
funders. The staff and directors of the SSC often chose a flexible approach to the agency’s
programs.

The Smith Street Center was often placed in the difficult position of trying to balance the
needs of all of the residents in its service area. During fieldwork, I observed that tensions
sometimes arose about whether the perspectives of some neighborhood residents were valued
more than others. Staff and SSC “regulars” talked openly about whether everyone’s
perspectives, wants and needs were taken into consideration equally and represented in
programming decisions. The SSC was unable to meet the needs of all residents and sometimes
faced difficulties finding balance between being stakeholder driven and externally funded. The
issue about which stakeholders drove programs and received more services not resolved easily.
The director, board and staff were frequently faced with difficult decisions about which problems
111

to address, what neighbors to advocate for and how to structure the agency’s programs. Some of
these decisions, like working with police against crime, came fairly easily. Others, like putting
the mandates of funders above the wants of program participants, were more difficult.
During my fieldwork, the SSC operated on about $150,000 every year. Most of its
funding came from the County Health Department. The agency also received funding from other
public (USDA, Michigan Department of Community Health, Medicaid) and private (Komen
Foundation) agencies to provide specific programs and services to the neighborhood residents it
served. Although its funding situation left it with mandates that influenced the scope of its
programs, the agency was still able to do a great deal of work in assisting neighborhood residents
with procuring the goods and services necessary for their health. As demonstrated in this
chapter, much of the SSC staff's energy was spent trying to improve access to health for people
on the margins of society. As stated previously, the agency began because of disparities in access
to care identified by several community leaders, including representatives from the County
Health Department.

Because the Smith Street Center is a 501(c)3 non-profit organization, its funding stream
is complex and directly impacts the programs and work of the organization. 501(c)3 refers to the
Internal Revenue Code for tax-exempt organizations operated for exempt purposes (United
States IRS 2011). There was an inter-dependent relationship among the Smith Street Center,
publicly funded health and social service agencies and the low-income residents directly served
by these agencies. Public social service agencies such as the County Health Department and the
Department of Human Services (or DHS) depended on the SSC and the three other
neighborhood-based non-profit agencies in the city to provide on-the-ground, grass roots level
112

health and social service assistance, advocacy and program promotion to needy residents.
During interviews, I specifically asked SSC staff about the agency’s relationship with the county
and every response I received praised the County Health Department’s support. During our
interview, Anita, the director of Health Outreach described the SSC’s role in health promotion
and its relationship between the SSC and the state and County Health Departments. She said,

We have a county grant for services with them to provide our neighbors and residents
with access to our programming. Specifically, we try to hook them up with health
coverage, we try and get them- we try and assist them in their quit smoking efforts,
basically, any way that we can offer people assistance- the county supports that in theory
and financially. We also work with, I work with, some committees and coalitions and
boards that look a little more broadly at the systems of care that we have in place, we try
and come up with some ways that we can change the system- either in small ways or
larger ways. To make it more easily accessible for people- both the coverage itself and
then, you know, appointments or prescriptions. We do get some money from the health
department. We get some money from the Department of Community Health. The state
Department of Community Health funds the county who then funds us for their particular
initiative. Like the infant mortality initiative. We are contracted through the county, and
the county is contracted through the state.
The County Health Department promoted and enabled the SSC’s work. As described at
the beginning of this chapter, the CHD’s leaders and employees were dedicated to involving
community members and organizations like the SSC in its work. It supported a number of
summits, consortiums and meetings that involved neighborhood based organizations like the
SSC in discussions seeking to address health inequities. The CHD funded the four neighborhood
based organizations to do health outreach work out of the belief that established, neighborhood
based agencies were able to reach marginalized individuals best. Anita, described her work as
necessary because,

113

Our system of social services has a few flaws. It is not terribly user friendly. There's a lot
of bureaucracy involved- a lot of paper work, a lot of meetings and it's overall just a
difficult system to navigate if you have limited resources. We are in the middle of a
neighborhood that has limited resources. So I think that as long as we have a system that
ensures that we will have poor people and people who are marginalized for their basic
needs like food and housing and healthcare, that there will always be a need for
organizations like ours that try to get people access to the services that they're entitled to.

The SSC received funding from public agencies that provided services and care to the
poor to help the poor navigate these services. Rhonda, a recent college graduate employed as a
full-time health outreach worker commented that she believed health and social services were
unnecessarily bureaucratic. She told me that much of her job duties involved helping people
navigate complicated public services. She said,

I think there's a lot of people in this country who, unjustly, don't receive the privileges
that some of us do, and I think that, even a lot of the services that are available for people
who don't, for instance, have a lot of money. They're not designed for the people they are
meant to serve, they're really difficult to navigate, and, it's harder to, it's almost harder to
get the services than it's worth, for a lot of people.
Much of the SSC’s outreach workers’ duties involved assisting neighborhood residents
with the daunting task of navigating health and social service bureaucracy. Authors of literature
on non-profit providers and health argue that in the United States the primary role of non-profit
agencies like the SSC has become filling social service and health care gaps left by the state and
serving as bridges between shrinking public agencies and citizens (Austin 2003, Boehm 2005).
The Smith Street Center contracted with the County Health Department to recruit and
enroll uninsured neighborhood residents for the county’s Free Health Plan (FHP). The SSC’s
staff also assisted neighborhood residents with the complicated application for cash assistance,
114

food stamps, housing assistance and Medicaid. It received a significant percent of its operating
budget through these contracts. Grants for promoting the FHP and enrolling in the program
provided the SSC with most of its operating budget.

The Free Health Plan (FHP)

The Free Health Plan is a system of basic health benefits designed to increase uninsured
people’s access to basic healthcare in the county where I conducted my research. In 1998,
employees of the County Health Department designed a system of benefits for the uninsured
because they were concerned with the number of uninsured people in the county who did not
qualify for Medicaid but were unable to access primary care. Currently, there are plans in
several counties throughout Michigan that are similar to the FHP. Each plan is unique, but all are
funded through Medicaid and the county in which they operate. Most of these systems of
benefits, including the FHP have two plans. The FHP’s Plan A is also referred to as the Adult
Benefits Waiver (ABW) and is reserved for very low income (those with incomes less than 35%
of the Federal Poverty Level) enrollees. Plan B covers a wider range of recipients and has less
stringent income guidelines. Plan A offers more comprehensive coverage and regularly stops
enrollment based on funding restrictions and the number of enrollees. Both Plan A and Plan B
are health coverage products intended to increase access to healthcare for the uninsured.
During interviews with the current CEO of the Free Health Plan and several employees at
115

the CHD, I learned that the FHP was implemented after years of planning and many discussions
by leaders of the County Health Department, administrators from the area’s three main hospitals
and community organizers like Sandra. As Medicaid eligibility requirements shifted to favor
children and parents and hospitals received fewer Disproportionate Share Hospital (DSH)
payments for serving poor populations, healthcare services for low income, uninsured and
childless adults became increasingly scarce. The FHP was largely a response to an increased
need among residents in need of healthcare services.
In the late 1990s, the director of the CHD was awarded a grant from a national
philanthropic foundation to better assess and meet the health needs of the community. This grant
also supported the summits that led to the creation of the SSC as well as several other initiatives
intended to foster increased understandings of health disparities and their impact on the
community. The CHD used the data it collected about health inequalities and lack of access in
the county to write a second grant from a different major private foundation. The CHD was
awarded this foundation grant to support the work needed to assess the needs of the uninsured
and promote a system of health benefits for the uninsured in the county. Money from this grant
was used to heighten community awareness about issues facing uninsured populations and
advertise the newly created FHP.
Eventually, the CHD established the FHP as its own corporation and it was awarded nonprofit 501(c)3 status. When I asked public health officials knowledgeable about the plan and its
history why the CHD was not the main proprietor of the FHP, I repeatedly heard that it was
because of “funding purposes”. It was explained to me that it was easier for the county to fund
the plan if it remained its own entity and was separate from the other work of the health
116

department. The plan, like the SSC and other neighborhood based non-profit organizations, was
funded with a combination of federal money from Medicaid, local funds from the County
Commissioners, and a small amount of private money from the foundation to promote the
program. During an interview with an employee of the CHD, he relayed the following to me:
5

The FHP began in 1998. We've always had about 2 million dollars dedicated to health
care services, in the county. The idea that came around in the late nineties was that we
could leverage that money to leverage federal Medicaid dollars against that money and
what it involved is that our commisioners gave up that 2 million dollars, basically, to an
independent corporation, the Free Health Plan Corporation, that they helped us create.
And so that became sort of the manager of health care for all of these uninsured people
that we receive.- Mark, CHD employee

The FHP was first financed when the CHD leveraged its federal and county funding for
providing direct care to the poor to the 501(c)3 and paid itself back with money earned through
its health clinics. Although the CHD’s clinics for services like well-child visits, immunizations
and reproductive health were Federally Qualified Health Centers (FQHC), the CHD relied
heavily on family practice doctors in the area to serve the vast majority of patients with the FHP.
The doctors that accepted the FHP received reimbursements for accepting the plan that were
significantly lower than private insurance and similar to Medicaid reimbursement rates.
The Free Health Plan operates as a private non-profit corporation with a combination of
money from Medicaid and the CHD. Its board of directors, made up of representatives from the
County Health Department, other public health organizations and members of the community,
felt that neighborhood based organizations would be more successful than a centralized health
plan corporation in recruiting uninsured participants in the plan and helping these participants

5

The quoted name of the health plan has been changed for anonymity.
117

establish “medical homes”. A “medical home” refers to an individual having access to a
consistent, primary care provider. It is based on the notion that having access to and using
primary care services leads to better health outcomes and saves money. Neighborhood based
non-profit organizations were elicited and funded by the County Health Department to recruit
uninsured participants in the health plan. A large percent of the SSC's budget comes from the
county (through a combination of leveraged Medicaid and county funds) to do this work. The
SSC has been extremely successful as a local recruiting agent for the FHP.

Mark, an employee of the CHD, told me that he and his colleagues were faced with a
difficult decision when designing the FHP. They had to decide whether to design a plan that
made basic, primary care available to many or to design a system that provided comprehensive
care to few. Ultimately, they chose to focus on making basic care available to many. This
decision had mixed reviews among those I interviewed and met during field work. I met
hundreds of people at the SSC whose health coverage was provided through the FHP. Most of
them felt grateful to have some coverage but felt frustrated by the plan’s limited scope and the
few providers who accepted it. People were especially frustrated that the plan didn’t cover
hospitalizations and that it wasn’t accepted by many specialists.
Although it offered those individuals it covered with some healthcare options, the Free
Health Plan was far from a perfect solution for the uninsured people it covered. Its limited
coverage left a lot to be desired. The people I interviewed from the county were well aware of
the plan’s constraints. During interviews, several county health care workers lamented the state
of healthcare in the United States and talked at length about the effects of health disparities,
racism and inequality. They talked about the FHP being a step towards a solution in what they
118

saw as a flawed healthcare system.
The Free Health Plan, like the SSC, is very much a product of public-private partnerships
and privatization. The FHP was started by employees of the County Health Department largely
in response to decreases in public funding for Medicaid and hospitals serving uninsured and low
income populations. Since it began, it has been financed with mostly public funds and is closely
related to the work and decision making of the County Health Department. Despite this, the FHP
is a 501(c)3 non-profit organization and officially operates as its own entity. The Free Health
Plan’s non-profit status has allowed it to receive funding from major philanthropic organizations
that are also 501(c) non-profit organizations. Like the SSC, the FHP exists in a liminal stage and
operates in response to the current state of public health care and social services. Although
limited, the services provided by the SSC are very much needed by the people who use them.
Despite the plan’s utility, its existence does little to alleviate large-scale health inequalities or
address the systemic political and economic issues contributing to its operation.

Conclusion

In this chapter I examined the history and work of the Smith Street Center. By presenting
an overview of the SSC and its relationships with other agencies, I discussed the influence of
public-private partnerships on the agency’s work and the programs it promotes. I demonstrated
119

how the County Health Department has responded to inequalities and unequal access to health by
providing an overview of the many community summits designed by the CHD. I described the
consortiums and agencies that have become offshoots of these summits and presented a history
of the public-private partnerships related to the creation and maintenance of the Free Health
Plan. I argue that the Free Health Plan provides enrollees with necessary services but does little
to challenge the system in which health inequities persist.

In the next chapter, I examine how limited healthcare and social service systems play out
for the neighborhood residents who depend on safety-net healthcare and social services and
participate in the programs and services at the SSC. I use ethnographic examples to examine
how the neighborhood residents I met during fieldwork were coping with limited access to
healthcare. I then ask specifically how the neoliberal rhetoric promoting privatization, smaller
government and increased personal responsibility compares to the lives and experiences of the
neighborhood residents who I met at the SSC.

120

Chapter 6: Navigating “Choice” With Few Choices

121

In the United States, shifts in the structure and scope of public agencies have changed
how health and social service safety-net services are distributed to those in need. Specifically,
downsizing public agencies, increasing private contracting of government services, increases in
the cost of health care and creating new public-private partnerships have contributed to public
agencies’ increased reliance on non-profit organizations and businesses for the distribution and
provision of many health and safety-net services. In recent years, a number of non-profit
organizations like the Smith Street Center (or SSC) have emerged to advocate for people in need
by assisting with navigating the increasingly complicated web of health care and social services.
During fieldwork at the SSC, I observed that many of the recipients of safety-net care and
services frequently had difficulties fully navigating “the system” and gaining access to adequate
healthcare, food and housing. At the SSC, I regularly met neighborhood residents who received
assistance from government agencies and participated in programs and services at the SSC to
supplement their health and food needs. Often, the people I met who relied on these services
also had jobs outside the home. Despite working, receiving government and food assistance and
participating in other programs at the SSC, many struggled to maintain their health.
In this chapter, I draw on interviews with neighborhood residents and ethnographic
examples from fieldwork at the Smith Street Center to examine the complexities and difficulties
some neighborhood residents have in accessing needed health services. In addition, I explore the
role the SSC plays in helping them meet these needs. I ask how changes in public safety-net
services have impacted the lives of the neighborhood residents I met at the SSC. Throughout
this chapter, I draw on my findings from fieldwork and participant observation at the SSC to
challenge neoliberal rhetoric and the notion that privatization has served as a successful means of
122

empowering individuals through choices and involvement in self-care. I use ethnography to
demonstrate that in the era of public-private health and social service safety-nets, a number of
poor, sick and vulnerable people, “fall through the cracks”. Specifically, I use ethnography to
challenge the notion that the privatization and downsizing of government services have
transformed the poor and sick into more motivated, responsible, citizen-consumers.
In this chapter, I present the experiences of several neighborhood residents I met at the
SSC who regularly relied on government assistance and the programs and advocacy services at
the SSC. I draw on ethnography to argue that the current trends toward the distribution of public
health and social services by various private agencies leaves those with the fewest resources
vulnerable and dependent on agencies like the SSC. By drawing on interviews and observations
from neighborhood residents who participated in programs at the SSC, I will discuss the
phenomenon of “falling through the cracks” and the role of agencies like the SSC in assisting
poor, sick and vulnerable neighborhood residents since increases in privatization and changes in
the distribution of health and social services in Michigan and the United States.

Challenging the Rhetoric

The political rhetoric used to realign both how and by whom social services and
healthcare are distributed increasingly focuses on choice, responsibility and empowerment
through employment and participation in the free market economy. As discussed in more detail
in Chapter Three, the assumptions of the rhetoric by former Michigan Governor John Engler
123

center on the notion that poor people need encouragement to work and increase their
participation in the workforce. During his administration, Engler changed policies with rhetoric
purporting that dismantling “big government” and programs that allegedly foster dependency, a
more efficient and morally up-right means of distribution will emerge. There is an underlying
assumption here that the economic system works if and when the poor choose to participate in it.
In a letter to the state’s department of Human Services on October 30, 1995, Engler praised the
successes of Michigan’s Welfare Reform program “To Strengthen Michigan Families” and
lauded the federal government’s proposed Welfare Reform program. He wrote, “Our challenge
is to ensure that all Michigan families and children can look forward to a system that rewards
work, encourages personal responsibility, and achieves family self-sufficiency.” (Engler, 1995).
The focus that Engler and others supporters of neoliberalism have placed on work and
personal responsibility assumes that the recipients of public aid and services are irresponsible,
don’t work and don’t value work. Engler’s rhetoric puts the onus of poverty’s effects on the
poor themselves, rather than on the political and economic systems responsible for low paying
jobs, an unskilled workforce and high levels of unemployment. The attention to public aid
recipients seeking outside employment puts the poor in a position where they must negotiate
myriad factors associated with poverty and working outside the home like child care, job training
and transportation.
The experiences and perspectives of many of the individuals I interviewed who
participated in the SSC’s programs challenge many of the assumptions that are made about “the
poor” in much of the neoliberal rhetoric. Specifically, I observed that the idea that poor people
and people who receive assistance from the government and agencies like the SSC are simply
124

irresponsible and unwilling to work was not supported by the experiences and perspectives of
those I met during fieldwork. I found, as I will present in greater detail further in this chapter,
that most recipients of services at the SSC valued work and attempted to be responsible. Despite
this, most of them were faced with overwhelming life circumstances such as poor health,
disability, divorce and low paying jobs, which led them to seek assistance from outside agencies.
Many of the people I met were overwhelmed by the health and social service safety-nets and had
a difficult time navigating the system. I also observed that increased choices in care did little to
increase access and quality of the care received by the people I met at the SSC.
The effects of public-private health partnerships are complex both in their tendency
towards increased decentralization and increased reliance on individuals to manage and make
choices about where and from whom they receive care. Those in favor of increasing the private
sector’s role in public health and social services have touted privatization’s merits with the
notion that individuals take on increased responsibilities and a greater role in their healthcare
decision making when faced with more choices and responsibilities. In this approach, choices
are stressed as a means by which individuals can become active “consumers” of their healthcare
needs. Contracting services to the private sector has increased the scope of agencies like the
SSC that are involved with providing services to the poor and vulnerable.
Morgan and Maskovsky (2003) argue that in the current climate of public-private
partnerships, the poor have increasingly been framed as "consumers" rather than "recipients" of
health care and social services. They contend that the decreased participation of the state in the
direct provision of public safety- net services "requires the reconfiguration of the poor from
passive recipients of welfare-state services into self-empowered and self-governing health care
125

consumers" (ibid 322). Nelson (2005) builds on the idea that decreases in state services and
increases in partnerships with private agencies have contributed to a “consumer culture”
approach to the distribution of public health and social services. She states, "Ideologically
neoliberalism reframed our concept of public health care. It is no longer thought of as a "public
good," but rather as an individual commodity" (Nelson 2005: 107).
Framing healthcare and social services as individual commodities and approaching
individuals as responsible for their care and well-being places sick, disabled or otherwise
vulnerable citizens at great risk. Partnerships between public agencies and private organizations
like the SSC frequently fall short of creating a fully functioning health and social service safetynet that is able to provide for needy citizens. Despite political rhetoric espousing the contrary, my
observations at the SSC and related organizations repeatedly showed that existing public and
private health and social service systems are often ill-equipped to properly address the needs of
the sick and the poor. There is a current trend where government agencies call on the poor to act
as citizen consumers who are assumed to be empowered by work. The trend of looking towards
citizen consumers and non-profit agencies to fill gaps in health and social services leaves many
without all of the goods and services they need to maintain their health. During fieldwork at the
SSC, I met several people who, despite being hooked into “the system” of public and non-profit
assistance, were unable to get the care and goods they needed to maintain their health.

126

Observations from the SSC

During fieldwork at the Smith Street Center I met many neighborhood residents who
struggled to access adequate healthcare and social services. Changes in the approach and
delivery of public safety-net services, more stringent assistance requirements and an increased
reliance on non-profit and private organizations for the provision and distribution of healthcare
and social services created a complicated web of service providers. The staff at the SSC was
trained to assist low-income and sick neighborhood residents with the daunting task of
navigating public and private health and social services. Trends towards individualized,
consumer-driven healthcare and social services left many of the vulnerable, low-income
individuals I met through the SSC in a double-bind. Recipients of safety-net services were
expected to work and be responsible owners of their healthcare choices, but were often missing
the tools and resources to navigate the complicated healthcare delivery system on their own.
Many of the individuals I met at the SSC faced major barriers to care from factors related to
finances, clinicians’ refusals of public insurance, transportation, communication, health status
and housing. These barriers made it difficult for them to act as enlightened healthcare
consumers. Another pressing factor, which I will address at greater length in the following
section, is that the poor no longer qualify for publicly funded health and welfare benefits if they
earn too much money. This left some of the people I interviewed with a feeling of being
“punished” when they lost benefits after attempting better their situations by entering the
workforce.

127

Despite being employed and/or having access to public and private sources of assistance
and healthcare, many people who used services at the SSC had difficulties getting the things they
needed to stay healthy. Political and popular rhetoric often espouses the notion that the poor
don’t value work, and that participation in the workforce is a means of liberation from poverty.
Most of the people I met at the SSC worked outside the home or took care of disabled family
members. This is consistent with US Census data which shows that 53% of Americans at or
below 100% of the Federal Poverty Level are employed outside the home (Rosenbaum et al.
2001). The ethnographic examples presented in this chapter are in many ways rebuttals to
Governor Engler and other conservative proponents of privatization and neoliberal policies.
Specifically, they refute the claims that increased participation in the workforce and more
choices about healthcare are means of liberating the poor. With the examples presented in this
chapter, I show that despite policies espousing the contrary, poor and sick individuals often have
difficulties meeting their needs even with government assistance, outside employment and
assistance from public and private agencies like the SSC. I begin my examples with the story of
a man I met at the SSC who I call James.

James:

James’ story shows that despite working and receiving assistance from several public and
private sources, it’s possible for someone to “fall through the cracks” in the United States. I
present his account to refute the neoliberal notion that an individualistic healthcare and social
128

service safety-net that promotes choice is beneficial to the sick and poor. I use his example to
argue that work is not a panacea for ending poverty. James’ story exposes some of the flaws in a
safety-net system that claims to value work and self-reliance but rejects the poor and the sick
when they work too much. James’ account is used to demonstrate that having health insurance
does not guarantee that an individual will be able to access the healthcare. I use examples from
the SSC to argue that consumer driven healthcare and increased choices are essentially
meaningless when poor and sick individuals are unable to access them.
I first met James in 2005 while I was conducting fieldwork at the SSC. I saw him
regularly at the agency and in the neighborhood during this time. James was a “regular” who
came to the SSC for a host of reasons. I met several “regulars” during the time I spent at the
SSC. “Regulars” came into the agency frequently - some came primarily to socialize. Others
came to use the computer or phone, some regularly participated in programs and some came to
get free medicine or food and others came for support and assistance. James was often frustrated
by his life circumstances and shared his struggles and strife with staff, volunteers and other
neighborhood residents. During the years that I interacted with him, James shared with me that
he had been diagnosed with a number of health conditions, including high blood pressure and an
intestinal disorder called diverticulitis.
I formally interviewed James and had regular contact with him while I was conducting
fieldwork at the SSC. During our interview and interactions at the SSC, James shared much of
his life story with me. James was 47 years old, white, single and had never had children. He
served in the military after graduating from high school. James struggled to pay rent and was
frequently homeless. He was chronically ill and often hungry. Despite having ended my work at
129

the SSC, I continued to regularly see James walking in the SSC’s service area and at the SSC
when I visited or attend its seasonal farmers market. I had several conversations with James
since our interview. Unfortunately at the time this was written, little had changed to improve
James’ situation and his health, housing and food availability remained bleak.
During our 2006 interview, and in several conversations over a 5 year period, James
shared a great deal with me about his health, the dismal circumstances of his life and his
difficulties getting the things he needed despite working and receiving public assistance. He
struggled to access healthcare, housing and food and relied on the services and programs at the
SSC and other local non-profit organizations in addition to support from the government.
Despite receiving aid and assistance from the government and several non-profit organizations,
James’ life was full of uncertainty, violence and suffering.
When James was first diagnosed with diverticulitis in 2001, he was working part time for
a landscaping company and had health coverage through the Free Health Plan or FHP. The FHP,
which was discussed in greater detail in Chapter Five, is a system of health benefits for low and
middle income uninsured people that is administered through the county. At the time that James
was diagnosed, he could not find a specialist that accepted FHP; his diverticulitis progressed and
he became extremely ill. He was unable to work. His abdominal pain was so severe that he quit
eating. He went from weighing 239 to 139 pounds and was ultimately hospitalized for over a
month after his intestines burst. During this hospitalization, 16 inches of his intestines were
removed and he required a number of reconstructive abdominal surgeries. Following James’
release from the hospital, SSC staff and an attorney from the hospital where he was a patient
advocated for James to receive Medicaid and Medicare and Social Security Income (SSI, which
130

is commonly referred to as, disability) benefits. He was approved for these benefits but even
with this assistance, James struggled to maintain his health and pay for a home and food.
James’ income from disability was not nearly enough to cover his living expenses.
During our interview, he described being extremely frustrated with his position and the fact that
the assistance he received from the government was insufficient to help him maintain his health
and permanent housing. He said:
I am stuck working at a day labor company because when I would go in for a physical, to
get hired into a place, they take one look at the scars on my stomach and they tell me that
I'm not eligible to work because I'm damaged. I can't make enough money to live on my
own. I bounce from place to place, I'll keep it for a short while and then I'm homeless
again. This has gone on for three years. I'm supposedly 100% disabled. But I can't live
6
on that; it's $561 a month. I can't get any of the social service agencies like the VOA or
whatever to help me. Because I'm a single male, and even though I'm disabled, I work, so
I've got income. You know, I've tried to live, you know, but with day to day expenses, I
can never come up with the first month's rent. You show me anyone, an adult who can
live on 500 dollars a month and support themselves.

Despite receiving health benefits and $561 a month for disability, James struggled to
manage his health and support himself. He slept under bridges and in tents in the woods during
warmer weather when he was without a home; he stayed at homeless shelters or with friends
during the winter. James was hospitalized regularly for complications from diverticulitis and
high blood pressure that were exacerbated by his poor living conditions. James was unable to
live on the $561 a month he received from disability and, when he was well enough, worked
various physically demanding jobs through the day labor agency next to the SSC. During our
interview, he told me that including the $561 a month, his yearly income was about $12,000.
This means that when he was well enough to secure work, he earned around $400 a month as a
6

VOA stands for Volunteers of America. It is a national 501(c)3 non-profit organization that
runs a homeless shelter and housing outreach program near the SSC.
131

temporary day laborer. James said that earning this $400 a month disqualified him from
receiving full Medicaid benefits.
During our interview, James told me that he “fell through the cracks”. He told me that he
was angry and frustrated about his experiences with the healthcare system and what he believed
was the government’s failure to properly care for poor people. He was especially frustrated with
his Medicaid spend down. He explained that his spend down meant that every quarter he had to
first pay for several hundreds of dollars of his health expenses before Medicaid would begin
covering his healthcare costs. The spend-down was implemented because his income from
working exceeded the income requirements for a single childless man to receive “straight”
Medicaid. James told me that he felt that he was being punished by the government for working
and trying to improve his situation. James’ experience of having to pay a certain amount
towards his healthcare expenses before they were covered by Medicaid each month despite
receiving disability benefits from the government frustrated him. The co-pays and spend-down
contributed to him forgoing maintenance care, getting sick and staying homeless.
James said that he was grateful for the SSC’s programs and its supportive staff but felt
frustrated with his struggles to get the things he needed and stay healthy. He described being in
a cycle where he went without all maintenance care until some catastrophic illness landed him in
the hospital. When I interviewed him, James had recently suffered a heart attack and his third
lung infection of the year. He was also dealing with the chronic effects of diverticulitis and
having had 16 feet of his intestines removed. James had just spent two weeks in the hospital
recovering from his heart attack and the lung infection and had eight prescriptions he was
supposed to be taking. He couldn’t afford the co-pays to have them filled so he wasn’t taking

132

any of them.
James did not have a car or bicycle and lacked transportation to get to and from doctor
visits. Because he usually lacked a permanent address, he received his mail at a homeless
shelter. Depending on where he was living at the time, he didn’t receive his mail daily. He
frequently missed appointment cards and other important information from his care providers
and case workers. Not having a phone number caused similar problems. James had many
difficulties staying in contact with his healthcare providers. His communication and
transportation problems were compounded by difficulties paying for his healthcare before his
quarterly “spend down” was met. Because of these difficulties, he relied on the local hospital’s
emergency department for most of his healthcare needs.
James’ immune system was compromised and he was often ill; he had a constant deep
cough and frequently suffered from pneumonia and lung infections. His living conditions
contributed to a state of stress and scarcity, which made it difficult for him to eat well, get
enough sleep and stay in contact with his healthcare providers. All of these things exacerbated
his poor health. James was hospitalized four times during the two years I interacted with him.
Despite being covered by Medicaid and Medicare, James relied almost exclusively on the
emergency department at the local hospital for his healthcare. He told me that he had little
choice about his healthcare. He relied on care he could easily access in the Michigan weather
without reliable means of communication and transportation. His experiences with the
healthcare system were completely limited by whether services were close and affordable and
had little to do with choice. Despite working and receiving insurance and disability benefits
from the government, James’ health and living conditions continued to deteriorate. He was not

133

an empowered healthcare consumer nor was he empowered by his employment as a day laborer.
James’ ability to meet his healthcare needs was actually hindered by the income he brought in
from his work as a day laborer.
James’ suffering and ill health persisted despite receiving medical insurance and financial
assistance. In 2010, while talking to James during a visit to the SSC, he told me that he had just
been hospitalized after being severely beaten up and robbed while walking to a homeless shelter.
During this conversation, he told me that violence is part of his reality. He said that, “people out
here take advantage of each other” and, “that’s just how it is”. He knew the young man who
attacked and robbed him, but believed it would only complicate his life and make him a further
target if he pursued the crime with police. He had been attacked and robbed before and believed
that pursuing the perpetrators of crime would attract unnecessary attention and would ultimately
do nothing to change his situation positively.
Violence, suffering and little faith in police or public social service agencies contributed
to James’ stress and largely defined his everyday life. James’ experiences do not necessarily
reflect those of most of the neighborhood residents served by the SSC. The majority of the
people who rely on the SSC’s services were not medically fragile and homeless. Given how far
from typical James’ situation is, what do his experiences of sickness, violence and suffering tell
us about the current system of distribution and privatization of public services in the United
States?

134

Looking to the Margins

Much of James’ experience could be construed as extreme and might leave one
wondering how he got to such a dismal place in a country with so much wealth and so many
resources. James’ homelessness leaves him extremely vulnerable to violence and exacerbates his
poor health with constant stress and limited access to food, shelter and medicine. Homelessness
also results in numerous subsequent communication and transportation barriers which present
complications and obstacles that Americans with stronger familial and social support systems
may be able to avoid. What can James’ situation, though extreme, tell us about the state of
safety- net services for the poor and vulnerable in the United States? What does it tell us about
the rhetoric supporting the current state of public health and social safety-net services that largely
frame users as empowered consumers able to take control of their health through choices and
participation in market based systems?
James’ situation and experiences present a reality that isn’t often considered and shows
the vulnerabilities and insecurities of our current system of safety-net care. His experiences
challenge the rhetoric driving political decisions about how and to whom services should be
made available and reveals that they are not based on evidence and often run contrary to their
purported goals. James’ experience of losing benefits after increasing his income through his
work as a day laborer serves as a glaring contrast to the notion that the poor are empowered and
more “self-sufficient” when they work. James’ situation shows that empowerment through work
and choice is not possible for some of those at the margins.
James’ story illustrates that the current state of safety-net services in the United States is
135

not set up to function as a full source of support for the poor, sick and vulnerable. Anthropology
has a tradition of looking to the experiences of vulnerable people and groups existing in the
margins to examine the context and structure of the systems in which inequality and suffering
persist. James’ experiences provide a clear picture that his circumstances are abysmal and his
choices are few despite the fact that he’s tapped into both public and private safety-net providers.
His description of “slipping through the cracks” shows that the current system of privatization
and consumer “choice” may fail to fully provide for the most vulnerable. James’ situation
clearly illustrates that government assistance is woefully inadequate and leaves those who rely
on it at the mercy of non-profit agencies and other, private sources of income.
In many ways James’ situation was unique. Because he was a “regular” at the SSC and
frequently came in to use the phone, eat food and have a cup of coffee, I talked with James
frequently and got to know him better than the other neighborhood residents who I interviewed
for this project. James’ struggles with chronic illness and his difficulties accessing the most
basic life necessities clearly illustrate that health and social safety-nets are not equipped to care
for those at the very margins of society. I observed this phenomenon on a nearly daily basis
during my fieldwork at the SSC. Many SSC neighborhood residents who participated in the
agency’s programs and services, especially those living with chronic illnesses and disabilities
which left them unable to work, were also unable to make ends meet on government support. In
the following section I share the experiences of woman I call Mary and her daughter who I call
Theresa. I met Mary and Theresa through the SSC and chose to share their story because it is
very much out of line with the neoliberal rhetoric that hard work and responsibility end poverty.
Their experiences show the inaccuracies of neoliberal rhetoric about responsibility and
136

dependence, and the inadequacies of the healthcare system that is currently in place.

Mary and Theresa:

Mary is 52 years old, Native American and English and is the single mother of a severely
disabled adult daughter named Theresa. I first met Mary when she came into the SSC looking
for help finding a handicap accessible house or apartment in the neighborhood. When I first met
her I was in the downstairs office. She came in and asked about talking to the staff member in
charge of the housing program. I gave her his contact information and asked whether I could do
anything else to help her. She told me a little about herself and her daughter and said that before
she was divorced she and her husband had owned a home and a business in the SSC’s service
area and that she would like to move back to the neighborhood. She said that she and Theresa
were currently renting a place in a different part of the city. Their current house had been broken
into three times and they wanted out of the area. After our initial encounter, Mary and her
daughter Theresa found a house in the SSC’s neighborhood service area and moved in to it.
They started coming to the SSC on a regular basis to use the computer, get free bread and
medicine and attend the farmers market. I had several conversations with Mary and learned that
she could not work because Theresa required constant care and monitoring. Mary told me that
she was on an extremely limited budget that was completely determined by public social service
agencies. I learned a lot about Mary and Theresa’s lives during our informal conversations at the
SSC. Mary was very friendly and talkative and told me on more than one occasion how much
137

she appreciated being able to stop by the SSC and have “adult conversations”.
After several months of having informal conversations with Mary, I asked whether she
was interested in being interviewed for the project. She was enthusiastic about being a part of it
and invited me to come to her home. She lived in a small, two bedroom house on a quiet street
in the SSC’s neighborhood service area. Mary’s house was surrounded by a large yard which she
had almost entirely dug up and turned into at least a dozen garden plots. She had food growing
in the front, back and side yards. Her house was very cramped and full of antiques and books.
When I came in, she cleared a space for me on the couch and apologized for the state of her
home and explained that she had moved from a much larger home and struggled to find space for
all of her belongings. Theresa was in the living room during my interview and as soon as I
started asking questions, she contributed to the answers as well.
Theresa is 28 years old and, according to Mary, has the mental capacity of a 4 year old.
She is extremely friendly and talkative. Theresa uses a wheel chair and has 18 diagnoses
including hydrocephaly, a seizure disorder, diabetes, asthma and mental retardation. She is seen
by multiple specialists, and requires oxygen and a machine that constantly monitors her
breathing. Because of her complicated condition she requires 24 hour care; home health nurse’s
aides are assigned to help care for Theresa. During our interview, Mary said that these aides
frequently cancelled their care for Theresa, leaving her with little sleep due to Theresa’s need for
constant monitoring. The nurse’s aides cancelled when they were offered jobs caring for people
with private insurance, because these jobs paid nearly twice the amount allotted by Medicaid.
Mary was paid a small amount by the state to care for Theresa and also received Social
Security because Theresa is disabled. Their combined household income was about $12,000 a
138

year. They received some food stamps in addition to this, but had a very difficult time making
ends meet. Mary relied on the SSC and a food program at the church next to the SSC to
supplement her income and Theresa’s Social Security benefits. Like so many people I
encountered at the SSC, Mary had difficulties making ends meet with government assistance.
Even though Theresa received Social Security and Medicaid and Mary received money from the
government to care for her disabled daughter, they did not have enough money. Mary had few
choices regarding income sources and had to care for herself and her daughter. She expressed a
great deal of frustration with trying to make ends meet with the amount of money she received.
Mary’s husband left her when Theresa was a child and offered little in the way of assistance, so
her income from her daughter’s Social Security disability and her stipend for her care was her
only source of regular income. She talked at length about “living through” various state budget
cuts that resulted in fewer and less comprehensive services for her daughter.
When I interviewed Mary, she had just sold her van to pay their landlord money owed
from back rent. About a month before our interview, Mary’s wallet, which contained most of her
monthly income, was stolen from her purse while she and Theresa were grocery shopping. This
event was catastrophic; Mary had no savings and was unable to receive any emergency
assistance. Mary sold her handicap accessible van to pay her bills but told me she was unsure
about how they would do errands and get to and from doctor’s appointments without a vehicle.
During our interview, Mary told me that she existed in a constant state of stress and was
extremely anxious about her future and her ability to make ends meet and keep Theresa healthy.
She told me that she was grateful for the SSC’s bread and medicine programs because they
helped her afford things that she wouldn’t otherwise be able to purchase. Mary’s income, which

139

was completely determined by government agencies, was insufficient to meet their needs. She
struggled to pay for their electricity, rent, food, transportation and the co-pays for Theresa’s
medicine and medical supplies. Mary told me that she regularly went without proper meals so
Theresa got the nutrients she needed. The amount they got in SNAP (food stamps) benefits
wasn’t enough to cover all of their food needs. Mary struggled to pay for food and medicine and
was constantly worried about keeping Theresa healthy with few resources. Theresa took
between 24 and 40 pills a day and Medicare charged co-pays for each prescription. During my
interview with Mary, she talked about their financial troubles and praised the SSC’s programs.
She said:

Our budget is beyond shot. The bread and the fruits and even just getting the allergy
medicine, that helps our budget radically. We can't buy the cheap bread at the store
because of the diabetes and all of the different- her cholesterol, and with the swallowing
troubles, the soft gooey bread chokes her. So, I end up having to buy three-or-fourdollar-a-loaf bread- which is what's down there. So, that has been helping, I figured
that's been helping us at least 50 dollars a month on the budget. So that's one thing that
has really helped us.

Mary told me that she was frustrated that non-profit organizations were responsible for
much of the human service work in the area. She was bothered by the notion that medical nonprofit organizations and foundations were often funded to only address certain diseases and
disorders. Mary said that Theresa’s diagnosis was extremely rare- so much so that her “case”
was highlighted in a pediatric medical journal. Mary explained that Theresa’s rare diagnosis
meant that they couldn’t easily appeal to a focused health non-profit organization or foundation
for assistance. She said that she was grateful for the assistance they received from the SSC and
from their church community which had provided them with emergency assistance for a past-due
140

utility bill.
Like so many of the people I met during my fieldwork at the SSC, Mary stated that she
felt torn- she was grateful for the work of non-profit organizations like the SSC, but she was
frustrated by their limited scope and resources. In addition to having difficulties getting outside
assistance and struggling to pay for basic necessities, Mary and Theresa had a number of
difficulties using their health insurance. They struggled with finding specialists and dentists who
would accept Medicaid. On multiple occasions, Anita, the director of the SSC’s Health Outreach
Team, tried to help Mary find a physician who would treat the connective tissue disorder that
was affecting her gums. There were no oral surgeons in the area who would accept Mary’s
Medicaid. Because they didn’t have a car and Theresa’s health conditions made travel difficult,
they were unable to travel to another city to find a specialist who would accept Medicaid and
treat Mary.
Like James, Mary felt that she had “slipped through the cracks” in regards to her
healthcare and general needs. Mary’s experiences as healthcare consumer was extremely limited
and her choices were few. She saw doctors who would accept Medicaid and had few choices
about which practitioners she saw (or whether she saw one at all). Theresa was insured through
both Medicaid and Medicare and because of this dual coverage, she had an easier time finding
physicians than her mother.
Even though she was generally pleased with the Theresa’s doctors and the quality of care
she received, Mary stated that she believed that the government does not do enough to make sure
families dealing with major disability were well cared for. She talked at length about how she
felt that services for disabled families were viewed as expendable by politicians who had few
141

ideas about the realities of providing constant care to severely handicapped people. She also felt
frustrated that she frequently ignored taking care of her own needs to make sure Theresa was
cared for sufficiently.
Mary tried to alleviate financial stress and worry by bringing in extra income. She was
extremely resourceful and attempted to save money by gardening and stocking up on sale items.
As previously described, she dug up her entire yard and planted vegetables. Mary said she made
a very small amount of money selling various items on e-Bay. Despite her resourcefulness,
Mary and Theresa remained completely dependent on public services and the help of private
agencies.
Mary’s position as primary caregiver to her handicapped child put her in a dependent
position that clashed with the mythical “independent healthcare consumer” framed in the rhetoric
of those promoting privatization and a neoliberal agenda. Theresa’s need for constant care made
working outside of the home impossible for Mary and without consistent financial support from
family, she was totally reliant upon the ever changing public health and social service safety-net.
Mary considered the services at the SSC to be a boon to her finances, but largely felt insecure
and stressed about her future and her ability to care for her fragile daughter. During our
interview, she talked at length about her feelings of helplessness and vulnerability caused by her
dependence on the government and agencies like the SSC. She talked about the business that she
and her ex-husband owned before Theresa was born as well as her family’s history of
employment. Like many people I met at the SSC, Mary was proud and did not want to be
viewed as being lazy or taking advantage of tax-payers’ money.

142

“Beggars Can’t be Choosers”: Evaluating the Rhetoric of Responsibility and Deservingness

Becker (2004) contends that neoliberal, American ideals of 'deserving and undeserving'
groups impact whether or not individuals have access to quality health care. She holds that the
current market-based state of American health care and the idea that health and healthcare are
privileges emerged from American ideals about individuality and responsibility. Becker argues
that neoliberalism "downplayed racialization and social class in health care" by focusing on
individual responsibility and healthy behaviors (2004, 260). My interviews with neighborhood
residents who relied on the SSC to meet their health needs supported Becker’s claims and
provide a stark contrast to the rhetoric claiming that poverty and dependence are alleviated with
work, personal responsibility and increased choices in healthcare decision making. James and
Mary and Theresa’s stories demonstrate major shortcomings in the rhetoric about merit-based
health care and social services. Theresa’s disability required constant care and monitoring and
left Mary completely dependent on healthcare and social service safety-nets. Despite working
when he was able, receiving government assistance and relying on the assistance of a number of
non-profit organizations, James’ poor health and suffering persisted. James’ participation in the
workforce actually limited the type and scope of public benefits he was allowed.
James and Mary and Theresa’s suffering and struggles, like those of so many people who
rely on safety-net providers to meet their needs, were closely related to a political economic
system that failed to prioritize the health and well-being of the poor and vulnerable. Poor health,
homelessness and suffering are not unrelated to larger issues of how goods and services are
distributed. The current system of healthcare and social service distribution in the United States
143

is directly related to a political and economic system whereby the government largely omits
responsibility for the poor and vulnerable.
During fieldwork at the SSC, I often observed that neighborhood residents’ health
problems were closely related to and influenced by structural constraints such as access to
education, safe neighborhoods, healthy foods, housing and transportation. During interviews,
when I asked SSC program participants to share their experiences and opinions with the SSC and
other agencies they’ve relied on for assistance, I heard few complaints about the SSC and a
number of complements that praised the staff for their help. Regularly I heard similar comments
about the Free Health Plan and Medicaid. While some people, especially those who were
chronically ill like James or those with unmet health needs like Mary, did complain about their
coverage, many did not. A number of the people I met and interviewed at the SSC were
reluctant to criticize programs and agencies that provided free services. Often when people did
complain about the limited scope of the FHP or Medicaid, these complaints were prefaced by
comments like, “I’m lucky to have coverage, but. . .”
During interviews with neighborhood residents who relied on services at the SSC, many
people I talked to were reluctant to criticize the services that they received from the SSC and
from their healthcare providers because they felt “grateful” that they received services at all and
that people were working to help them. The systems in which care and goods are distributed are
closely linked to cultural notions about deservingness. The old adage that “beggars can’t be
choosers” ran deep and surfaced frequently during conversations with neighborhood residents
receiving publicly funded medical and social services and participating in programs at non-profit
organizations like the SSC.
144

Paul Farmer, a medical anthropologist and physician, has written a great deal about the
concept of “structural violence” and its impact on the health of the poor in the United States and
throughout the world. Farmer defines structural violence as “the nature and distribution of
extreme suffering” (2003: xiii). He contends,
Rights violations are, rather, symptoms of deeper pathologies of power and are linked
intimately to the social conditions that so often determine who will suffer abuse and who
will be shielded from harm –Farmer (2003: 7).

Farmer argues that health inequities are a form of structural violence. Gay Becker built
on the work of medical anthropologists like Paul Farmer and Nancy Scheper-Hughes (1993)
regarding the relationship between health inequalities and political economic structural
inequalities to bring attention to what she described as the United States’ two tiered medical
system (2007). She argued that the public health care system in the United States “fosters an
organized approach of containment toward the uninsured that not only marginalizes them but it
keeps the problem of the uninsured in check by discouraging people from using health care
services.” (2007: 299). In her discussion of the US healthcare system as a containment system,
she draws on Ong’s (1996) notion of cultural citizenship by arguing that having full access to
citizenship and health is largely dependent on race and economics in the United States.
James’ account of suffering, homelessness and violence speak to the notion that life,
liberty and the pursuit of happiness are not fully available to all Americans under the current
health and social service safety-net systems. The reluctance of the neighborhood residents to
complain about public healthcare and social services speaks to Becker’s notion of the US having
a containment system of care. Based on Mary and Theresa’s example, I propose that disability
benefits are very much part of the containment system of care. People who are disabled or are
145

caring for disabled family members without familial support are at the absolute mercy of safetynet services and cuts in public programs and support.

Public- Sector Health Care: Increased Needs and Shifting Terrains

Receiving Medicaid, Medicare and Social Security disability did not significantly
alleviate James’ poor health nor did they significantly increase his quality of life or access to
care. Despite receiving government assistance, James relied on non-profit organizations like the
SSC, the local homeless shelter, soup kitchens and various churches for food and shelter. Mary
and Theresa struggled to make ends meet on disability benefits as well. Their stories illustrate
that the public-sector health and support systems in the US are not sufficiently addressing the
needs of the disabled and chronically ill and that small non-profit organizations like the SSC are
not able to fill these gaps. The experiences of James and Mary and Theresa show that receiving
health insurance and disability benefits and participating in programs at agencies like the SSC
are not panaceas for having sufficient access to healthcare and necessary food and housing.
Mary and James frequently went without proper meals and other necessities. Their examples call
the efficacy of publicly funded health and social services and the increase in private agencies
contracting with public entities into question. James identified the government as responsible for
the failures of the current healthcare and public service systems and told me that he believed that
taking care of people should be a priority for governments and not left to places like the SSC.
When I asked about whether he believed the SSC was necessary, he said:
146

Yes, because the damn government isn't doing what it's supposed to do. Is that plain
enough? They need to concentrate more on social programs. The current leadership in
Washington and the past leadership here have been very anti-social programs. They
think it should be strictly done on local level, volunteer level sort of thing, and I don't
think that's correct. I believe it's just the opposite. The government should have more
responsibility for social programs. Both on a state and national level. I've fallen through
the cracks for years and years and years now. I'm so tired of it.

The trend for the governments to promote the merits of individual responsibility and to
look towards agencies like the SSC to serve poor and sick people like James and Mary and
Theresa has increased greatly in recent years with the onslaught of privatization and downsizing.
Shrinking government agencies regularly provide non-profit organizations like the SSC with
small amounts of funding to provide services and assistance to vulnerable people who have
slipped through the cracks. Even with government funds, small organizations like the SSC lack
the capacity to hold together the increasingly defunct social service and public health safety net.
The ethnographic examples provided here show that the needs of many of the SSC’s
neighborhood residents who participate in its programs greatly surpass the role of nongovernmental organizations like the SSC. Given the major cuts to Michigan’s state government
and several federal social service and health programs in the last two decades, the needs of the
poor and sick frequently surpass the scope of governmental agencies in the current political
climate as well.

147

Conclusion

Disabled, sick and poor residents of the Smith Street Center’s service area relied on the
SSC despite often receiving government assistance for disabilities and poverty. Like many of
the people it served, the SSC was, in many ways, caught in a cycle of dependence. It relied on
funding from public agencies but much of its work was complicated because of public
downsizing and privatization and the unmet needs of those it served. The vulnerable residents
who relied on the SSC as well as public agencies to meet their needs largely lost out on
opportunities to benefit from the choices conservative politicians lauded as liberating. SSC
participants’ financial and health circumstances frequently left them without the services and
resources they needed; this left them in the precarious position of cobbling together whatever
public and private services they could in order to meet their daily needs. Programs like the Free
Health Plan, Medicaid, social security disability, food stamps and free bread and over the counter
medicine provided poor neighborhood residents with some, but not all of what they needed to
stay healthy. Residents relied on the SSC to help sort out myriad details involved with managing
illnesses and staying healthy. Many called on the SSC and other non-profit organizations that
were largely funded by government agencies to supplement public medical and social service
assistance.
James and Mary and Theresa’s accounts show that an increasingly privatized, consumerdriven health and social service safety-net is not adequate to fully address the needs of
chronically ill and disabled citizens. Mary and Theresa’s situation demonstrates the fragility and
dependency of people dealing with severe handicaps while relying on public support. James’
148

Medicaid “spend down” and his inability to secure sufficient housing and food with the amount
of money provided by the government exposes that the rhetoric claiming to promote selfsufficiency and reward work doesn’t match the reality of public health and social service
policies. James could not secure his health, housing and food needs with the amount of money
the government provided him because of his illness and subsequent disability. When he sought
his own source of income to supplement the small amount provided to him, his Medicaid
benefits were reduced and he was unable to access care or necessary prescriptions to maintain his
health. James’ needs were very greatly compounded by several factors related to access,
communication and transportation. James’ situation overwhelmed the scope of services provided
by the Smith Street Center and he continued to “fall through the cracks”.
Government aid to disabled, poor and sick neighborhood residents frequently left gaps
that the staff at the SSC attempted to fill. Simple programs like the distribution of free bread,
produce and over the counter medicine made a huge impact in the lives of neighborhood
residents like Mary and Theresa who were dependent on limited government assistance for their
income. My interviews and observations at the SSC and its affiliated organizations lead me to
conclude that non-profit organizations like the SSC are not funded well enough to fill the ever
growing gaps in the social service safety net.
Privatization and government downsizing have done a major disservice to vulnerable
people like James and Mary and Theresa. They’ve also complicated the work of public health
officials in the name of “smaller government” while shifting public funds to private
organizations for the provision and distribution of health and social services. These examples,
and so many others that I observed at the SSC, lead me to conclude that a strong, well149

functioning, easily navigated public health and social service safety-net is needed.
In the next chapter I ask how neoliberal trends related to calls for “smaller government”
and privatization have impacted the employees at agencies providing public health and social
services. I draw on interviews with public health employees and ask how decreases in funding
and personnel have impacted their work experiences and their abilities to carry out their work.
Specifically, I address how privatization and early retirement have impacted their work. I then
move to how these changes have impacted the work of the SSC and its relationship with other
agencies. Finally, I demonstrate how the SSC’s relationship with outside agencies impacts its
work and its role in the neighborhood.

150

Chapter 7: Patching up the Cracks or Creating New Holes? Increased Bureaucracy and
Public- Private Partnerships

151

Max Weber wrote, “Once it is fully established, bureaucracy is among those social
structures which are the hardest to destroy” (1946: 228). Despite popular and political rhetoric
espousing the importance of creating “smaller government” and privatizing public services, my
research at the Smith Street Center (or SSC) and related public agencies shows that privatization
and downsizing have actually contributed to a growing and complicated web of bureaucracy
stemming from public-private partnerships, government downsizing and the subsequent loss of
experienced government personnel. Michael Hertzfeld (1992) wrote about bureaucracy and
stated, "Rhetoric is not simply an epiphenomenon of other sources of power. It is the key to the
social production of indifference in nation-state bureaucracies" (81). Using ethnography, I
provide examples from my research that support Hertzfeld’s claim. The ethnographic accounts I
use illustrate some of the difficulties the current system of safety-net services presents to the poor
and sick as well as to those working in public health and human service agencies.
In this chapter, I explore the consequences of reducing government safety-net services
from the perspectives of SSC program participants, SSC staff and public health professionals. I
argue that public-private partnerships and the push towards “smaller government” have increased
bureaucracy, decentralized services and complicated the social service and public health safetynets in Michigan and throughout the United States. I ask how the privatization and the growing
role of organizations like the SSC in the provision of public health and safety-net services have
impacted and sometimes, overwhelmed, agencies and employees engaged in providing and
assisting with safety-net services for the poor and sick. Drawing on ethnography, I suggest that
the current system of privatization and public-private partnerships is essentially one of agencies
“passing the buck” of responsibility for assisting the poor and sick with vital services. In this
152

examination, I ask how the rhetoric of “smaller government,” the state of Michigan’s push for
workers’ early retirement and the promotion of increased public-private partnerships have
impacted the experiences of the individuals I interviewed for this project. I draw on interviews
and observations at the SSC to demonstrate that the privatization of government services and
increases in funding to non-profit organizations for the procurement and promotion of health and
social safety-net services have bolstered bureaucracy and resulted in a labyrinthine, inefficient
system both for those receiving and providing safety-net services.
Throughout this chapter I examine the effects and consequences of mandates from the
public agencies that fund the SSC and similar non-profit organizations. I draw on observations
and interviews to identify some of the effects of policies like early retirement and diminishing
state services on the programs and work of public and private agencies and the people they serve.
By drawing on interviews and fieldwork, I argue that Michigan’s push towards smaller state
government increased bureaucracy and created more dependency between public agencies and
the non-profit organizations they fund. Specifically, I draw on an ethnographic example from
Jane, a woman I met though the SSC, to show that fewer services and increased bureaucratic
constraints often leave the poor in difficult situations where they are reliant upon safety-net
organizations that largely lack the resources and power to alleviate the bureaucratic constraints
impacting their situations.

153

Background

The fluctuations in funding and mandates of public and private agencies have had farreaching consequences for low income and sick people receiving services; shifts in policies and
available services have also impacted the individuals working at public and private health and
social service organizations. In Chapter Six, I drew on neighborhood residents’ ethnographic
accounts to challenge popular and political rhetoric about the merits of privatization and smaller
government and the adequacy of publicly provided assistance programs to meet the needs of the
poor and sick. In this chapter, I expand this argument to show the complications of bureaucracy
and to demonstrate that shifts in funding and available programs and services caused a great deal
of stress and anxiety for SSC staff and program participants.
Interviews with public health professionals showed that many uncertainties were present
among people working in public health; constant changes in policies and personnel frequently
created difficulties for those involved with the provision and distribution of care for the poor and
sick. Changes to available services and programs had major implications for low income
residents in the SSC’s service area, including, but not limited to, inconsistent access to
healthcare. Constant changes to policies and available services created extra work for people at
the SSC and at public agencies. Staff and public health professionals had to learn about updates
and changes in public policies and programs and doing this frequently used time and energy that
could be used in direct service work. Publicly funded programs regularly changed enrollment
criterion and program details. Medicaid changed often depending on state and federal
requirements and budgetary restrictions, political administrations and managed care plans.
154

Changes to Medicaid were not always clear to enrollees and staff at the SSC was often called
upon by neighbors to explain why their coverage changed or why they were no longer eligible
for the program.
During interviews and observations, I came to understand that for many of the low
income and sick people I met doing fieldwork at the SSC, healthcare was a fluid commodity and
access to it was dependent on both governmental politics and various individual life
circumstances. Like those people relying on public and private safety-net services to make ends
meet, government agencies also came to rely on non-profit organizations like the SSC to
implement programs and services for the poor and sick. The inter-dependent relationship of state
agencies, non-profit organizations and individual seekers of safety-net services is complex;
exploring dependency and the power dynamics among those administrating, carrying-out and
receiving these policies provides insight into what works and what does not in health and social
service distribution. In the following sections, I explore the effects of political rhetoric, policy
changes and increased bureaucracy on the lives of people relying on and working with safety-net
services. I ask how increased bureaucratic constraints impact the work and mission of the SSC
and its ability to serve neighborhood residents. I also explore the consequences of Governor
Engler’s push for “smaller government” and increased personal responsibility on public health
and social service professionals.

155

Jane

In this section, I present an ethnographic account from a woman I call Jane. I share
Jane’s story to illustrate the constraints that bureaucracy can have on the poor. The SSC’s role in
her story also points to the relative powerlessness of some safety-net agencies in their attempts to
assist individuals facing bureaucratic constraints while in need of services. Jane’s example
supports Hertzfeld’s contention that rhetoric contributes to social indifference and demonstrates
the simplistic nature of the “smaller government” and “increased personal responsibility”
rhetoric. Like many of the people I met during my fieldwork at the SSC, Jane had great
difficulties navigating the stringent constraints of publicly funded human service agencies
despite her many visits to the Michigan Department of Human Services and the assistance and
best efforts of SSC staff.
Jane was an African American woman in her forties who lived in the SSC’s service area
in a small apartment that she shared with her adult son. I met Jane during neighborhood canvas
when Anita and I knocked on her door to tell her about the agency and its programs. When we
talked to Jane and asked her about her insurance status said told us that she was uninsured. She
invited us inside her home so she could comfortably fill out the paperwork required to enroll in
the Free Health Plan (or FHP). The inside of her apartment was sparse and had an old couch, a
small table and a small, old television. She told us that she slept on the couch so her son could
have the bedroom.
As she filled out the paperwork for the FHP, Jane started asking us questions about the
SSC and its programs. She told us about some of the problems that she was having getting
156

enough food and receiving other benefits. Jane explained that she had recently moved from
Chicago and was currently employed “under the table” by her landlord for doing odd jobs like
painting and cleaning some of the other properties that he owned. Her income was very low and
she was often hungry. She did not have a car or a phone. She told us that she had recently taken
two buses to the Department of Human Services (or DHS) to apply for the Supplemental
Nutrition Assistance Program (SNAP or food stamps) and other benefits. Jane told us that she
was assigned a case worker and was told by her case worker that she needed to have a Michigan
identification card in order to receive assistance. She said that she told the case worker how
hungry she was and the worker accepted her Illinois identification and processed her application
for SNAP benefits. Jane was told that she needed to get her Michigan identification in order to
receive the other benefits for which she might qualify. Jane told us that she did not know why
her Illinois identification was sufficient for food benefits but not cash assistance, Medicaid or
housing assistance.
Jane asked us to assist her in getting a Michigan identification card so she could start to
receive the other benefits. Before we met her, she had taken a bus to the Secretary of State office
to obtain a Michigan identification card and was rejected because she lacked sufficient proof of
identification. We told her we would try and help her get a Michigan identification card. When
we got back to the SSC’s office, Anita and I researched Michigan’s identification requirements
and found out that Jane’s Illinois identification alone was insufficient for her to qualify for
benefits and that her caseworker was not following state policies when she had processed her
food benefits. Anita researched what documents were necessary for a Michigan identification
card and later went back to Jane’s house to tell her what she needed to bring and how much it

157

would cost. Jane said that she did not have all of the necessary paperwork (which included
having at least four identifying documents including a social security card and birth certificate).
Anita made several calls on Jane’s behalf, but ultimately she was unable to help Jane get an
identification card. As far as I know, Jane did not return to the SSC for further assistance.
The lives of many people I met during fieldwork at the SSC were, like Jane’s, extremely
vulnerable to shifts in policies and changes in health and social safety-net services. The
magnitude of chaotic life circumstances and financial situations made accessing things like a
state identification card, which is a simple errand for many Americans, completely out of reach
for Jane and many of the other people I met at the SSC. The SSC’s employees did excellent
work and sought to effect change for those they served, but too often, poverty and bureaucracy
constrained their efforts.
On-the-ground effects of policies related to the current health and social service systems
in many cases leave a poorly functioning safety-net where people “fall through the cracks”
despite the best efforts and creativity of those working at safety-net providers and organizations
like the SSC. Privatization and downsizing have left many public agencies with fewer resources
and knowledgeable staff than necessary to meet needs. In Jane’s example, Anita and I made
several phone calls to advocate on Jane’s behalf to help her obtain a Michigan identification card.
Because she was not employed legally and did not have access to her birth certificate and social
security card, our attempts to advocate for Jane were unsuccessful.
Jane’s situation of being unable to access needed services because of bureaucratic
constraints was something I observed regularly during my fieldwork at the SSC. Frequently,
Anita and other SSC staff would attempt to contact various public agencies on behalf of
158

neighborhood residents like Jane only to receive rejections for reasons related to policies and
guidelines. Factors like residency requirements, immigration status, disability status,
identification, age, income and parental status determined who was eligible for what services.
Sometimes, the efforts of SSC staff made a difference and case workers and other public officials
granted services to residents to whom they had previously been denied. Jane’s case of being
granted SNAP benefits from a sympathetic case worker while being denied other benefits shows
that despite stringent bureaucratic constraints, public professionals’ adherence to policies and
procedures is sometimes arbitrary. The often successful advocacy by the staff of the SSC
demonstrates that the availability and applications of public services and procedures are
frequently inconsistent. Anita was often able to advocate services for neighborhood residents
that they had been unsuccessful in attaining for themselves. This shows that while important and
laudable, the efforts of SSC staff are necessary because public safety-net system is bureaucratic,
inefficient, complicated and inconsistently available. The SSC’s efforts cannot fully address and
properly serve the needs of sick and poor people without an easily navigated, better funded
public health and social services that offer real, tangible choices and options to the sick and poor.
In previous chapters, the examples from the SSC and related agencies demonstrated that
the trend towards the downsizing of government agencies and their increased reliance on nonprofit and private organizations to provide safety- net services frequently fail to fully address the
massive needs of the poor and sick. These accounts show that many of the choices lauded by
proponents of consumer-based healthcare are largely out of reach for those at the margins of
society who rely on multiple sources of assistance and places like the SSC to get by. My
interviews and participant observation at the SSC and affiliated public health agencies indicate
159

that the end result of privatization and decreased government services is not a smoother, more
efficient system. In the next section I consider whether the current system has improved
agencies’ abilities to serve the public efficiently.

Privatization’s Impact on Public Agencies

After conducting participant observation at the SSC, it became increasingly clear to me
that it was necessary to examine policy decisions related to funding and contracting social and
public health safety-net services in order to fully grasp the reliance of sick and poor
neighborhood residents on non-profit agencies like the SSC. Following fieldwork at the SSC
and several meetings attended by county and state public health employees, I decided that
interviewing public health and social service professionals was essential for this project.
Interviewing these professionals was necessary to situate the role of the SSC and related nonprofit organizations in a broader political-economic context.

Early Retirement and “Double Dipping”

I interviewed twelve public health and social service professionals employed at agencies
closely related to the work of the Smith Street Center. Several professionals I interviewed had
160

been employed by government agencies during different state and federal political
administrations. These interviewees shared a great deal of insight with me about their
experiences with changes made during John Engler’s terms as Michigan’s governor from 19912003. In Chapter Three, I discussed changes introduced to Michigan’s policies and
governmental structures by Governor Engler. Among many changes, Engler enacted Welfare
Reform in Michigan and ended its General Assistance program. He also offered public
employees several early retirement buy-out offers to decrease the size of government agencies.
Jennifer Granholm, Michigan’s governor from 2003-2011, offered more early retirement offers to
state workers, maintained the state’s relationships with private agencies and did not reinstate the
programs cut by her predecessor.
During interviews, I asked the former state workers I interviewed about the changes they
had seen or heard about since increases in privatization and downsizing during Engler’s terms as
Michigan’s governor. Interviewees told me about early retirement buy-outs, decreases in public
governance and increased government contracts with non-profit organizations like the SSC. I
interviewed one former state employee turned independent contractor who took an early
retirement offer from the state’s department of community health during the 1990’s. This
interviewee, who I call John, told me that he believed that the cuts in personnel from early
retirement offers too frequently resulted in the loss of experienced, senior employees and left
existing employees with more work and little guidance and expertise. He thought that the loss of
so many senior employees had far-reaching effects on both direct services offered to the public
and the ability for agencies to function well internally. It was John’s opinion that the loss of
qualified state employees from early retirement often shifted work previously done by state
161

agencies to non-profit organizations and independent contractors. He was in a unique position to
offer his perspective as a former state employee who was currently employed as a contractor to
state agencies and non-profit organizations.
As discussed in greater detail in Chapter Three, shrinking state government through
offers of early retirement was touted by many conservative politicians as an easy means of
balancing state budgets and as a solution in decreasing the scope of “big government.” John
refuted the notion that early retirement and “smaller government” contributed to a more cost
effective, more efficient, less bureaucratic system of governance. He said,

You take all of the most experienced, educated people in state government and you buy
them out because they're too expensive. So what are you left with? You're left with middle
management and newcomers who don't know how to do things. So you have lost your best
people . . . there is no historical context.

John stated that a number of former state employees who accepted early retirement went
on to work as contractors for private and non-profit organizations that contracted with various
state departments. He specifically spoke about former employees of the Michigan Department of
Community Health (MDCH) who accepted early retirement offers and then went to work in nonprofit public health agencies like the Michigan Public Health Institute, which conducts contract
work for the MDCH and other public agencies. John defended “double dipping,” a term
popularly used to describe the practice of pensioners working as contractors for the departments
from which they retired. It was his belief that the best, brightest and most senior state employees
were “pushed” out of their jobs by Engler and his administration. He told me that this was due to
frequently changing policies and what he deemed a hostile work environment prior to early
162

retirement offers. He claimed that many of the people who accepted early retirement and later
worked as contractors to the agencies they left were not ready to retire, loved their work and
were still needed by their former employers. In his view, “double dipping” was a consequence of
conservative governance and flawed policies, not greedy retirees. In John’s opinion, seeking
contracts with the agencies from which one was retired was not an act of greed; rather, it clearly
illustrated just how complicated matters become when public and private sectors meet.
John and the other two retired state employees I interviewed were “double dippers”.
After retiring from the state, John worked as an evaluator of human service programs. His
largest client was the state but he also contracted with a number of non-profit organizations.
John talked at length about the Michigan Public Health Institute, or MPHI, an organization that
mostly contracted with government agencies to do basic public health work once done by the
state’s department of public health. Because the mass exodus of tenured state employees left
many state agencies with few experienced employees, the state regularly contracted with its
newly retired former employees to do the work they did prior to retiring.
I repeatedly heard about retirees with state pensions who worked with non-profit public
health agencies and contracted with state, local and federal governments to do work that these
agencies no longer had the capacity to perform. According to the my interviewees, the bulk of
the funding for the state’s public health non-profit organizations came from the very public
sources they were created to replace. Like the SSC, the majority of large non-profit
organizations’ funding came from federal, state and county funds. Funding for these agencies
usually came from a combination of public agencies through competitive grants and contracts,
but the end result remained - many public agencies were contracting with private non-profit
163

organizations to fill personnel and expertise gaps created by downsizing and privatization.
According to my interviewees, many of the people who took early retirement from the state did
not actually retire. Rather, like those I interviewed, they continued their work in a capacity in
which publicly funded agencies relied on the work of private and non-profit organizations.
After my interview with John, I tried to conduct a literature review about “double
dipping” in Michigan to get other scholars’ perspectives about the phenomenon and to
investigate whether Engler and Granholm’s buyouts saved the state money. I was unable to find
any literature written on the subject aside from opinion pieces and news articles reporting on
specific buyouts. When I asked interviewees about the phenomenon, many were uncomfortable
and reluctant to talk about it. One person asked me to turn my tape recorder off during three
different parts of our interview and requested that I not record or write down any demographic
information or any identifying details out of a fear of compromising his or her employment. The
former state workers I interviewed were very guarded about the fact that they were contracting to
do similar work that they did before they retired. Some, like John, were defensive because they
felt like they were given very few options and believed that they were forced to retire during the
peeks of their careers. These interviewees were passionate about their work and believed they
had much to contribute even though they were no longer state employees.
During our interview, another former state employee, who I call Maxine, told me that she
felt she and many of her colleagues had been pushed out by Engler’s leadership. Maxine is a
former state employee who is currently employed by an organization that is a collaboration of
non-profits and state agencies intended to address social problems and bolster local services.
She spoke at length about her experiences working for state human service agencies and taking
164

early retirement. When I asked her about her work history and former position with the state, she
said,

Well, there was kind of a right wing point of view that the government is too big and that
the government is the problem . . . 5,000 of us went out within a 2 month period in 1997. .
That was the first and largest early retirement. But there have been several since then
too, but I don't think they've been that large. . . they suggested that there be a mechanism
that government, state government, would partner with these community collaboratives.

Together with other state retirees, Maxine helped establish and then worked for a public-private
community collaborative organization following her retirement from the state ten years prior to
our interview. The purpose and will for the collaborative organization stemmed from changes in
the distribution of public funds and increased community needs. Most of the collaborative’s
founders were retired state employees. The purpose of the collaborative was to increase the
efficiency of public and private human service agencies seeking to care for the poor and
vulnerable. A portion of Maxine’s salary was paid by a publicly funded agency and the rest by a
private foundation grant awarded to the collaboration. Maxine’s work centered on increasing the
health and well-being of the city by increasing the capacity of non-profit agencies to be awarded
grants and attract program participants. Part of her job entailed promoting public awareness
about health disparities and their causes and fostering the political will to fund public and private
agencies engaged in social service and public health work. Maxine’s daily work at the
community collaborative consisted of increasing the capacity of 501(c)3s to partner with state
agencies and enabling them to more efficiently provide safety net services to those in need.

165

Tracing the Funding Streams: Receiving Public Funds and the Smith Street Center

The collaborative organization where Maxine worked was a product of privatization and
downsizing whereby public agencies worked closely with private entities to increase their
capacity to serve needy and vulnerable populations. The work of the Smith Street Center (or
SSC) and its mix of public and private contracts is also very much representative of this wave of
public-private partnerships. The SSC, along with three other neighborhood based non-profit
organizations in the city, received funding from the county to promote the Free Health Plan
(FHP) among its uninsured neighborhood residents and program participants. This funding
made up the majority of the SSC’s operating budget. The remaining sources of its funding
varied, but were mostly comprised of grants and contracts with state and federal agencies. The
SSC’s contracts and programs positioned it as a navigator and distributer of social safety-net
services in the neighborhood it served. Many of the neighborhood residents that I interviewed
who relied on its services and participated in its programs told me that the people were “nicer”
and “easier to talk to” than the staff of the Department of Human Services.
Neighborhood residents were grateful for the SSC and its work, but during interviews and
field work I often heard ideas that people had for services and programs that they would like to
see incorporated at the agency. During interviews with professionals from the County Health
Department, I was repeatedly told about how wonderful agencies like the SSC were in assisting
public agencies with their work. Recipients of services and distributors of grants and funding
were enthusiastic about the programs, location and friendly staff at the SSC. Interviewees from
the County Health Department regularly stated that the SSC was better equipped to serve the
166

poor and sick people of its neighborhood because its employees were known and trusted, it was
located centrally and it was able to be flexible in its programs and outreach services. The SSC
was popular with many of the neighborhood residents it served and the public health officials
responsible for maintaining its funding.
Although the SSC was a busy organization and well-tuned to the community it served, its
directors and staff constantly juggled the needs of the community with the mandates of its
funders. The agency’s funders created a number of obligations for the SSC that had significant
impacts on the scope and limitations of its programs. The SSC’s role in the neighborhood was
simultaneously made possible and complicated by its funders. The SSC would fail to function
without its external funders and this reality influenced many of the decisions and programs
implemented by the agency. The SSC’s staff and directors had to negotiate balancing the needs
and wants of the community with the programs and services mandated by its funders. It was also
faced with the precarious position of balancing the needs and wants of an extremely diverse
community. Because the neighborhood was so diverse, the SSC was unable to meet the needs of
all residents.
When I asked them what the SSC did well, all 15 neighborhood residents I interviewed
answered the question with praise of the SSC, its staff, location and programs. Answers
included, “they treat me like a human being”, “they’re friendly”, “it’s easy to get to”, and
“they’re helpful”. The SSC program participants whom I interviewed were happy that the
agency was located in the neighborhood and found most staff members friendly and eager to
assist them.
Isabel, a single, 60 year old white woman in the neighborhood told me:
167

Everybody down here is so approachable. If there was something health-wise or even
something in the neighborhood - they will advocate for you, because if they don't know
they will find out. It's a good support system for anybody.

Camou (2005) argues that neighborhood based non-profit organizations frequently take
the place of the state by acting as “street level bureaucrats”. The ability to reach people who
would likely have a difficult time being reached by human service agencies is certainly a benefit
of small, local agencies being engaged in social safety-net work. As Debra, a neighborhood
resident put it, the SSC, “throws the net around things that aren't being covered today” and
creates community rather than, “a bunch of individuals just sitting in our households”. Agencies
like the SSC provide many excellent resources for community improvement and advocacy and
are frequently able to tailor their work to suit the needs and wants of the community being
served.
The SSC’s work was laudable and the efforts of its staff were excellent. The agency
served several hundred neighborhood residents each year. Unfortunately, the vast majority of
people I met who were served by the SSC were still in great need. Despite the SSC’s friendly,
willing staff and central location, its staff’s ability to help neighbors in crisis was completely
determined by funding and programming at other public and non-profit agencies. The current
trend of state agencies to downsize and fund private agencies to do public health work frequently
fails to meet the needs of vulnerable citizens who rely on assistance to survive.
Non-profit organizations like the SSC that are acting as “street level bureaucrats” lack the
resources to properly care for all of the people they are commissioned to serve; they’re
frequently forced to make difficult decisions to operate within their budgetary and staffing
limitations. These difficult decisions, which are largely products of policies that favor
168

privatization and decreases in services directly provided by the state, result in compromises to
the scope and quality of services offered to the poor and vulnerable people relying on them.
Unfortunately, the demands on non-profit agencies like the SSC by neighborhood residents are
increasing because of the inadequacies of government assistance to the poor.

Navigating Uncertainty and Staying on Track: Exploring the Implications of Sporadic
Funds for the SSC

Frequent changes in public health and social service policies and the funding of public
agencies left the SSC with the daunting task of regularly shifting its programs and necessary
services to residents of its service area. Changes to services and programs put the SSC in a
position of constantly evaluating and rationing programs, staff and services. This contributed to
near constant threats of uncertainty, changes and scarcity within the agency. Addressing changes
consumed a great deal of the SSC’s staff and directors’ time and energy. I regularly heard
frustrations from the staff and directors of the agency about their struggles to find balance
between maintaining funding, meeting the demands of the agency’s funders and honoring the
organization’s mission and the needs of the residents of its neighborhood service area.
During my interviews, a number of SSC employees expressed concerns about the
agency’s ability to serve the neighborhood, maintain autonomy and retain the necessary funding
to operate. One staff member described the SSC’s position of maintaining funding and balancing
autonomy as reflective of the very nature of non-profit organizations and what she called the
169

“non-profit industrial complex.” This interviewee, who I call Kara, was a recent college
graduate and employed at the SSC through the AmeriCorps VISTA program. During our
interview she explained what she identified as a contradiction between organizations having
official non-profit status and doing outreach work in a meaningful way. She was particularly
concerned with the SSC’s ability to achieve what she considered “radical changes” while
remaining accountable to its funders. She stated:

Usually you become a non-profit so you can get grants, and with grants come restrictions
on what you can do - you have to have deliverables. And as soon as you do that, you have
people from outside your organization telling you what you're going to do. . . you're part
of the establishment. . .To me, it seems like something we're doing because there's lots of
funding for it available. And that's another thing about being a non-profit. It's really
tempting to program around what there's money to program around.
The Smith Street Center’s operating budget, like the lives of so many it served, was
regularly in flux from changes in budgets and policies set forth by public agencies. The SSC
relied on public agencies for much of its funding and personnel; these came in the form of grants
and staff from the AmeriCorps VISTA program (for more details about the AmeriCorps VISTA
program, see Chapter Four). Cuts and changes in public funds to the SSC had far-reaching
implications which determined the amount of staff they were able to hire and the type and extent
of its programming. Staff and directors of the SSC frequently talked about how to keep the
agency from experiencing “mission creep.” “Mission creep” was used to describe centering
programming around available funding and eventually moving away from the mission of the
agency and the needs of those it served.

170

Despite the staff and directors’ awareness of the threat of “mission creep”, I observed
instances when funding, rather than the needs of individual neighborhood residents, steered the
direction of the agency’s funding. The youth group drastically changed during the course of my
fieldwork at the Smith Street Center. These changes (which are explained in detail in Chapter
Four) were largely due to the SSC receiving a large grant from a federal agency and shifting the
source of funding for the staff member in charge of the youth organization. In addition to
changing the types of programs offered, the very existence of programs and services is
threatened when funding agencies lose their sources of revenue or create impossible mandates.
During an interview with Kim, an employee of the SSC, she said,

I am perfectly comfortable with saying that I don't think all of our programs reflect the
needs of the neighborhood. I think that a lot of them are based on ideas that people have,
that they think would be beneficial, but they're really not in touch with the life situations
of a lot of people in the neighborhood.
Kim’s concerns about whether programs reflected the needs of the community represent a
major point of contention among SSC staff. “High capacity” or “key” neighbors were active in
the SSC and were engaged in its leadership, volunteer work, neighborhood watch groups and
other positions. Some of these neighbors sat on the board of directors and acted as
representatives of the neighborhood. The employees who spent most of their time engaged in
neighborhood outreach and information and referral worked closely with neighborhood residents
who often faced very different realities than the residents who sat on the board of directors.
Many of the neighborhood residents served by the “downstairs” staff presented in crisis. They
came to the SSC with serious unmet needs related to housing, food, medicine and other
necessities. The daily work of the “downstairs” staff of advocating for people in crisis often
171

contrasted sharply with the “upstairs” staff’s work of writing grants, attending meetings,
interacting with “high capacity” neighborhood residents and promoting the agency to policy
makers.
Much of the “upstairs” SSC’s staff’s time was spent maintaining funding and promoting
the agency, its work and programs. The “upstairs” staff was mostly older than the “downstairs”
staff. The “downstairs” staff’s work mostly consisted of direct service outreach in the storefront
office. During my fieldwork at the SSC, I observed some complaints from “downstairs” staff
about “upstairs” staff not being very in tune with the needs and realities of the program
participants from the neighborhood. I observed several discussions among the SSC staff about
this issue. It, like so much of the work at the SSC, came down to keeping the agency funded and
operating while remaining consistent with the neighborhood’s needs and the agency’s mission.
Sandra, the director of the SSC, was well aware of the issues that arose from balancing
the needs of the neighborhood and maintaining funding from outside agencies. She and other
SSC staff members regularly talked at staff meetings about the importance of staying true to the
agency’s mission and making sure that programs and services were stakeholder driven. Potential
grants and programs were always brought up during staff meetings and everyone was encouraged
to talk about whether they thought these would be a good fit for the agency. During a staff
retreat some of the VISTA employees brought up their concerns about “mission creep” and the
“upstairs” staff being out of touch with the needs of the most vulnerable residents of the
neighborhood. These concerns were talked about at length and it was decided that every
employee of the SSC would have to go on a neighborhood canvass at least once a month.
Sandra discussed avoiding “mission creep” and suggested that the agency would do more
172

internal fund raising by implementing a capital campaign in hopes of being able to support
programs proposed by neighborhood residents and staff. While these new initiatives did not
completely alleviate the problems, they did create some improvements. They also showed the
flexibility of the SSC’s staff and directors and their willingness to address staff’s concerns. By
remaining introspective and flexible, Sandra demonstrated that she was aware that the SSC will
always have to balance the needs of its funders with those of the neighborhood and staff in order
to continue its work and assist with and implement public programs.

Public-Private Partnerships

Like many public agencies, the County Health Department (CHD) relied on the work of
non-profit agencies like the SSC to fulfill its mission and deliver services to the public. The
CHD established a non-profit organization to oversee the Free Health Plan (FHP), which it
provided to uninsured residents. Staff of the CHD was in constant contact with the non-profit
agencies’ staff and relied on them to stay in touch with the needs of residents of the county.
Funding from the CHD provided the SSC and the other non-profit agencies with the majority of
their operating budget. During the course of my fieldwork, I regularly attended meetings with
Sandra, Anita and other members of the SSC’s Health Outreach Team at the CHD. During these
meetings, representatives from neighborhood organizations like the SSC reported on their work
and what they were seeing and dealing with in the neighborhoods.
173

During an interview with Michelle, who was a director of several programs at the County
Health Department, I asked why the FHP funded the non-profit neighborhood based outreach
centers so generously. She responded by praising these agencies’ abilities to better reach
vulnerable populations who were not able or likely to visit public human services departments.
Michelle explained the CHD’s decision to fund and rely on the SSC and other agencies by
saying:

What we're really about is looking at social determinants and creating social
capital, because when they're out doing their outreach work, they're really building
connections in the neighborhood. They're getting people connected to goods and
services and resources that they need and creating a sort of social safety-net.
Michelle told me that the County Health Department’s leaders believed that funding local
organizations like the SSC extended the CHD’s reach in the communities it served and gave its
staff a better idea about the issues impacting residents’ health. Leaders of the CHD approached
funding non-profit organizations to promote the FHP as a means of extending primary care
services to people who might otherwise go without. The CHD’s leadership regularly asked for
feedback from the neighborhood agencies it funded about what issues were impacting the
community and what the CHD could do to better serve residents. The CHD’s staff attempted to
tailor programs and outreach to better suit the needs of community residents based partially on
reports it received from small non-profit organizations like the SSC.
The CHD’s decision to fund agencies like the SSC had two main effects: it allowed
places like the SSC to operate and reach neighborhood residents and it fostered a relationship of
dependency between the local agencies. During an interview with Carol, an employee at the
SSC, she described the agency’s relationship with the health department as dependent. She said:
174

The relationship between the SSC and the county is a dependent relationship. Not
necessarily good to have that total dependency, but we do. Thank goodness there are some
progressive people in the health department.

The SSC maintained an excellent relationship with leaders of the CHD while struggling
to retain some control over its programming and mission. The SSC’s staff was divided about the
agency’s role in the neighborhood. Like the neighborhood residents I interviewed, many of the
VISTAs and staff members who worked in the storefront office of the SSC viewed the SSC as a
friendly, local extension of a social service agency. Not all SSC staff believed that the SSC
should be viewed and approached as an extension of government social service agencies. Two of
the individuals I interviewed who had worked at the SSC for several years and were integral in
the agency’s inception stated directly that the SSC was not a social service agency and that its
work centered on capacity building and neighborhood transformation rather than the distribution
and acquisition of public health and safety-net services.
Tensions often arose between what some employees and leaders of the SSC wanted the
agency to be and what much of its staff and neighborhood resident perceived it as. These
tensions illustrate the difficulties involved with creating and inspiring change while serving a
diverse population, relying on outside funding, navigating bureaucracy and adapting to shifting
policies. From what I observed, the SSC had multiple roles in the neighborhood. For some
neighbors it was a place where they could go in a crisis and sign up for government assistance
and receive free bread and medicine. For others, it was this and a place where they attended
neighborhood watch meetings and attended presentations. For many, it was a community space
where they met and connected with other neighborhood residents.
Despite the desires of some of the staff, the Smith Street Center was frequently viewed by
175

program participants as an extension of a public social service agency. In one instance, I assisted
two women with the paperwork for the application for Medicaid, SNAP (Supplemental Nutrition
Assistance Program), housing assistance and cash assistance. When I was helping them fill out
the lengthy applications for these benefits, I noticed that they both lived very far outside of the
SSC’s service area. I was curious about how they heard about the SSC and I asked them why
they came to the agency. One of the women told me that they had originally gone to the
Department of Human Services (DHS) to fill out the paperwork and that the room was incredibly
crowded. After they had waited for over an hour, one of the employees at DHS suggested that
they should leave and seek assistance at the SSC rather than continuing to wait. The women said
that they had never heard of the SSC, but figured driving across town would take them less time
than staying and waiting in the crowded room at DHS for an unknown amount of time.
While this was the only time that I heard about an overwhelmed public worker directly
suggesting that a person in need of assistance leave her office and go to the SSC, the implication
that state agencies were over-burdened was regularly made by neighborhood residents and public
health professionals. This and other examples like it show that even if the SSC’s directors and
board didn’t see the agency’s role as an extension of public social service agencies, public
employees and people who relied on its services sometimes did. The agency’s close work with
public agencies and its promotion and administration of public programs and services
complicated the SSC’s quest for autonomy. As explained in Chapter Four, the SSC was never a
fully independent agency and has always received funding and direction from the County Health
Department and other public agencies. Maintaining autonomy while dependent on frequently
changing government agencies for the majority of its funding put the SSC’s staff and directors in
176

a precarious position. Ultimately, the mandates of funding agencies almost always trumped the
needs and wants of staff and neighborhood residents.

Conclusion

Throughout this chapter I argued that the push for privatization and public-private
partnerships has resulted in an increase in bureaucratic constraints and more complicated public
health and social service safety-nets. I demonstrated that much of the SSC’s role in assisting
neighborhood residents stems from an increasingly bureaucratic and complicated web of safetynet services and the arbitrary adherence to policies and procedures by public case workers acting
as “gate keepers” to the poor’s access to services and programs. In this chapter, I argued that
policies related to privatization placed major constraints on the work of public health and social
service professionals. I drew on interviews with public employees working at agencies related to
the work of the SSC to argue that the rhetoric supporting privatization and “smaller government”
had serious implications for individuals working for public agencies. I shared the opinions of
several of these interviewees who felt alienated and overwhelmed by the state of Michigan’s
decreases in public services and workforce. I also drew on interviews with neighborhood
residents and SSC staff to show that the SSC and other non-profit organizations often lack the
resources and power to meet the needs of the people they serve. By providing the insights and
experiences of employees at public and private agencies, I showed that neoliberal pushes towards
privatization and public-private partnerships have resulted in a sort of mutual dependency
177

between public and private agencies.
Mutual dependency between public and private agencies was illustrated with an overview
of the SSC’s staffs’ concerns with staying true to the agency’s mission and the needs of those it
serves while procuring and maintaining outside funding. I demonstrated how the SSC’s staff and
directors regularly balanced their needs and wants with those of the residents of the
neighborhood service area. I showed that the agency’s employees and directors were often in a
precarious position whereby they invited both criticism and praise with almost every major and
minor decision they made.
Throughout this chapter, I argued that privatization and the push for “smaller
government” and more public-private partnerships increase bureaucracy and promote mutual
dependence between government agencies and private organizations like the SSC. I argued that
both private and public currently agencies lack the capacity, workforce and power to meet the
needs of the poor and sick individuals who rely on their services. I showed that rather than
simplifying safety-net services, public-private partnerships, early retirement and the elimination
of public programs and services increased bureaucracy. My observations and interviews lead me
to conclude that this system contributes to a great deal of uncertainty and frequent changes in the
ability of public agencies and non-profit organizations like the SSC to meet the needs of the
community they serve. Most importantly, it leaves an already vulnerable population with fewer
necessary goods and services and an extremely difficult to navigate safety-net.

178

Chapter 8: Conclusion

179

Throughout this dissertation, I have drawn on my research from fieldwork at the Smith
Street Center, or SSC, and related agencies to provide an account of the role of health and social
service advocacy by a non-profit organization. The research I presented challenges the rhetoric
that increased public-private partnerships, privatization and decreased public services simplify
government, promote work and increase self-sufficiency among the poor and sick. I have drawn
on interviews and ethnographic accounts to argue that the role of small non-profit organizations
like the Smith Street Center in community advocacy, health promotion and social service
navigation frequently leaves both the agencies and the people they serve in positions of sustained
dependency on publicly funded agencies and programs. I have demonstrated that the current
system of private-public partnerships, in many cases, leads to a dysfunctional system of
dependency between non-profit organizations and the public funding agencies overseeing grants
and projects for services and programs for the poor and sick. Using ethnography, I have shown
that already marginalized poor and sick people frequently suffer when faced with the oftenchanging, increasingly bureaucratic web of public-private services. Throughout this dissertation,
I have drawn on ethnographic examples from my fieldwork to argue that public-private
partnerships and decreases in public services have contributed to a complex, difficult to navigate
web of bureaucracy. I use ethnographic examples from fieldwork and interviews to argue that
these changes have resulted in people like James, Mary and Theresa “falling through the cracks”
despite their frequent participation at the SSC and their being enrolled in public healthcare and
social service programs.

180

Overview:

In the previous chapters, I asked several questions in order to situate the Smith Street
Center’s role in health management and promotion in the lives of the residents of the low income
neighborhood it serves. One of the questions that most significantly informed the project was
why the SSC was in the practice of promoting public programs and services without being a
public agency. Investigating this led me to ask several related questions and examine historical
and contemporary phenomena that contributed to the SSC’s role in navigating and promoting
public programs. Specifically, I examined the influences of neoliberalism and the historic and
contemporary political-economic factors that have contributed to the phenomenon whereby poor,
sick and vulnerable individuals rely on the assistance of non-profit organizations like the SSC
rather than directly on public agencies and publicly funded health and social service programs.
In addition to examining the influences of neoliberalism on non-profit organizations and
healthcare availability, I also sought to understand the relationship between the SSC and its
public funding agencies and the role these funders played in public health in the age of public
downsizing and public-private partnerships. All of these questions were asked with attention to
how neoliberal policies impacted the quality and scope of care and services available to the poor,
sick and vulnerable people participating in programs offered by the SSC.

My findings were framed in terms of literature from social scientists whose work
centered on the political-economic and historic factors impacting the availability of healthcare
and social services in the United States and the role of non-profit organizations in social service
181

and public health delivery. This project contributed to the literature on public health and social
service management by demonstrating how neoliberal policies influenced the lives and work of
people associated with a neighborhood based non-profit organization. Using Harvey’s definition
of neoliberalism as, “a theory of political economic practices that proposes that human wellbeing can best be advanced by liberating individual entrepreneurial freedoms and skills within an
institutional framework characterized by strong private property rights, free markets, and free
trade” (2005: 3), I investigated the impact of neoliberal policies and thinking on the work of the
SSC and the lives of the individuals depending on it and other non-profit organizations. I
showed that many of the sick and poor people I met at the SSC had serious difficulties managing
their health and social service needs in the environment created by these policies.

With this research, I have shown that people who are already marginalized and vulnerable
frequently have an even more difficult time getting the things they need under the new system of
neoliberal influenced public service distribution. The experiences of the people I met and
interviewed at the SSC demonstrated that the notion of individuals as empowered citizen
consumers often falls short when people are faced with crippling issues like chronic illness,
disability and homelessness. I observed that bureaucratic systems of distribution, economic
restraints and poverty stifled and overwhelmed many of the people I met at the SSC. In the
previous chapters, I used ethnography to demonstrate that the system of public-private
partnerships in which the SSC operates left the agency without sufficient resources to meet the
needs of those it served.
By examining the impact of neoliberalism on the availability of public services in the
United States, I generated a unique record of the role of a non-profit organization and its
182

complicated, often dependent relationship with its funders. I also produced an account of health
and social service seeking among the vulnerable people the SSC served. Drawing on
observations and interviews from my work at the SSC, I expanded on Newman’s (1999) claims
that the culture of public health and social services in the United States cruelly blames
individuals who are not financially successful.
Throughout this dissertation, I have used examples from fieldwork and interviews to
argue that the poor people I met value work and responsibility. I showed that many of the people
I interviewed worked but were not liberated from their poverty by their participation in the
workforce. I provided examples of people I met at the SSC who were unable to make ends meet
despite working for income and receiving public benefits and assistance from agencies like the
SSC. I showed that in some cases, like that of James, participation in the workforce was actually
a barrier to qualifying for necessary services. I reported that James felt “punished” when his
income from working disqualified him from receiving some public medical benefits and
hindered his ability to meet his healthcare needs. The ethnographic examples I provide refute
rhetoric about the liberation of participation in the workforce and the benefits of a more
consumer-oriented public healthcare system.

183

Findings:

I have demonstrated that neoliberal policies fail to acknowledge and account for the
larger political and economic structures in which inequalities persist. In analyzing privatization
and downsizing in Michigan and the United States, I argued that neoliberal policies and rhetoric
approached individuals as responsible for their health, well-being and financial status. I argued
that this attention to individuals, rather than economic and social policies, has resulted in a
system of distribution that bolsters profit and casts individuals into the role of empowered
citizen- consumers who are responsible for their health and financial statuses.

With the evidence gathered from field work and interviews at the SSC, I demonstrated
that rather than challenging corporations that pay their workers minimally and move well-paying
jobs overseas while creating record-profits for their stock holders, neoliberal rhetoric and
policies frame the poor as dysfunctional, unmotivated and responsible for their poverty. I
showed that framing individuals as totally responsible for their economic circumstances and poor
health largely absolves the corporate and political structures in which economic injustices persist
of culpability. This dissertation demonstrates that the implementation of neoliberal policies and
rhetoric that frame individuals as in control of their health and well-being allows the root causes
of poverty and economic exploitation to flourish unhindered.

My work at the SSC exposed the consequences of neoliberal policies and their influences
on the complicated, bureaucratic nature of public health and social service distribution in
184

Michigan. My research built on the work of anthropologists like Morgen and Maskovsky (2003)
and Becker (2001, 2004, and 2007) who used ethnography to link individuals’ suffering and
access to social services and healthcare in the United States with larger systems of economic,
political and racial inequality. The ethnographic accounts that I presented expose the limits of
neoliberal rhetoric and policies by demonstrating that non-profit organizations are frequently illequipped to meet the needs of the people they serve.

I used ethnographic examples from field work at the SSC and related agencies to
demonstrate that decreases in Michigan’s state services, departments and personnel and its
increases in public-private partnerships changed the way safety-net services were distributed to
the state’s poor, sick and vulnerable populations. I showed that many of these changes served to
further complicate the already bureaucratic social service and public health care systems serving
the poor and sick in Michigan. My analyses critique the neoliberal-influenced polices and
rhetoric that support privatization and government downsizing as a means to bolster selfsufficiency and individual responsibility among the poor and sick. I focused on the lives and
experiences of the people I met during my work at the SSC to expose some of the inadequacies
of the current system of public health and social service distribution. By observing at the SSC
and interviewing people who were employed there, as well as those who relied on the agency’s
services, I showed that the current system of public health and social service distribution has
become more complicated as non-profit organizations like the SSC have emerged to address
health and social inequalities with public funding.

185

Throughout this dissertation, I challenged the rhetoric of conservative politicians and their
supporters that favored “smaller government” and increased privatization with accounts of a
difficult to navigate, often ineffectual system of public-private partnerships. By drawing on
interviews and observations with neighborhood residents relying on the services and advocacy at
the SSC, individuals working at the SSC and public health professionals employed at agencies
related to the SSC, I provided insight into what works and what does not in the current state of
public health and social service distribution. By demonstrating some of the inadequacies with
the current system of public-private partnerships for health and social services, I argued that
accessing health and healthcare is much more complicated than simply having health coverage or
receiving government assistance.
Throughout this work, I have presented an account of the Smith Street Center’s role in social
service and public health outreach and navigation. I have used this account to counter claims in
the neoliberal rhetoric and policies that “smaller government,” downsizing and privatization
bolster responsibility and self-sufficiency among the poor and serve as efficient means of health
and social service distribution. I refuted the notion that privatization and increased choice and
participation in the market create a more empowered populace and smoother, more efficient
governmental services and agencies. I showed that privatization creates a more complicated web
of services that is even more difficult for very poor and sick people to navigate. In Chapter Two,
I presented an overview of pro-privatization policies and rhetoric from Michigan Governors
Engler and Granholm. I then documented how these policies impacted the availability of social
support and public health services, the experiences of individuals relying on these services and
the existence and work of public service agencies.
186

In Chapter Three, I described the rhetoric and policies that have shaped the current layout
of public services in Michigan. I outlined policies in Michigan like Workfare, the elimination of
General Assistance, a shifted tax structure, the privatization of Medicaid and decreases in state
spending on public assistance to situate the work of the SSC, its relationship with its funders and
the experiences of the people it served. The work and experiences of the people I met at the
Smith Street Center largely countered popular and political claims about the merits of “smaller
government,” specifically, that public-private partnerships and downsizing increase efficiency
and save public money.
I have shown that national and state policies resulting from pushes for “smaller
government,” privatization and public-private partnerships have resulted in a more complicated,
bureaucratic web of public health and social services. I provided ethnographic examples from
fieldwork and showed that ultimately, the people who are already at the margins have suffered
the most from neoliberal policies and programming changes. With the data presented in this
dissertation, I demonstrated that the efforts and work of the employees at the Smith Street Center
were laudable, but largely ineffectual when compared to stringent guidelines and bureaucratic
constraints impacting the distribution of public health and social services in Michigan. I have
drawn on observations and interviews with people related to the work of the SSC to document
instances where the rhetoric supporting the current model of privatized public services and
increased public-private partnerships falls short. Throughout this dissertation, I provided
evidence to argue that the current system of distribution leaves many already disadvantaged
people with few meaningful healthcare and social service options while simultaneously

187

absolving government agencies of accountability for directly providing care and services to the
poor and sick.
I demonstrated that calls for “smaller government” and subsequent downsizing of public
agencies contributed to a more complicated web of services. My work at the SSC showed me
that many of the public agencies that funded the SSC relied heavily on it and other non-profit
organizations to fill in gaps left by downsizing. In turn, non-profit organizations like the SSC
relied on funding from public agencies and designed much of their programs and services around
available public funding. The dependency among the agencies was mutual. I showed that
despite rhetoric that policies implementing privatization, decreased bureaucracy and increased
reliance on non-profit organizations saved money and bolstered self-sufficiency, these policies
created a more difficult to navigate safety-net. I demonstrated that because of increases in
bureaucracy and public-private partnerships, much of SSC employees’ time is spent helping
neighborhood residents navigate “the system.”
My research showed that a major consequence of Michigan’s push for “smaller government”
and increased public-private partnerships was the very emergence of non-profit organizations
like the Smith Street Center. In Chapter Four, I provided an account of the SSC’s history and
showed that it, along with several other neighborhood-based organizations, was created in order
to serve specific health and social service disparities in the city it serves. During my fieldwork, I
observed that the majority of the SSC’s operating budget came from public funders. I provided
several examples of staff being concerned that funding, rather than neighborhood need, steered
the agency’s programs and decisions. Throughout this work, I have argued that the push for
188

public-private partnerships has led to sustained, mutual dependency between non-profit
organizations like the SSC and the public agencies that fund them.

In Chapter Five, I demonstrated that frequent changes in public health and social service
funding presented the staff at the SSC with the daunting task of negotiating and adapting to
regular changes in programming staff because of policy mandates and shifts in funding. The
SSC’s directors and board tried to weather these shifts while attempting to meet increased
requests for assistance by low income neighborhood residents. I observed that neighborhood
residents frequently called on the SSC when faced with decreases in available social services and
subsequently, intermittent healthcare and safety-net services.
In Chapter Six, I drew on my research to show that some of the sick and low income
recipients of care and services felt reluctant to complain or challenge the services and treatment
they received from safety-net agencies. I observed that intermittent sources of funding and
decreases in state services led to a system of stop-gap services in government and non-profit
organizations. I used examples from interviews with Mary and James to illustrate that these
changes have had catastrophic impacts on poor, sick and vulnerable people who are at the mercy
of shrinking and shifting public health and social service safety-nets. I demonstrated that despite
most heavily impacting the lives of the poor and sick, shifting responsibilities and public-private
endeavors have far-reaching implications for everyone involved in the distribution and reception
of safety-net services.

In Chapter Seven, I presented data from interviews with public health officials to argue
that early retirement offers and downsizing of state government led to an exodus of highly
189

competent professionals into the private sector. After retiring, many of these professionals
continued to perform the work they did for the state while employed at various non-profit
organizations funded through public entities. Through interviews with public health
professionals, I have shown that a major consequence of political downsizing and a push for
public-private partnerships was the trend of “double-dipping” among young retirees. The
“double-dippers” who I interviewed told me that they felt pushed out of their public positions
and justified in their more recent careers at private and non-profit organizations. Several
mentioned that they would have continued to work for public agencies under better
circumstances but took early retirement offers because of “hostile” leadership and work
situations. Public health and social service professionals believed that government downsizing
made navigating and attaining services more difficult for many of the people who relied on them.
This sentiment was echoed by the neighborhood residents I met who participated in programs
and services at the SSC.

Conclusion:

This dissertation provides an account of the role of a small, neighborhood-based nonprofit organization in Michigan that works closely with public agencies to address the health and
social service of the low income people it serves. With it, I showed the complicated
190

relationships between the SSC and its funders since the state of Michigan’s push for government
downsizing and increased public-private partnerships. The examples I provide from the SSC and
other Michigan non-profit organizations show that while some public-private partnerships can
work well, they cannot replace an easily navigated, well-funded health and social safety-net. My
research demonstrates that non-profit organizations like the Smith Street Center can and do serve
as alternatives to over-bureaucratic, difficult to navigate public services.

I argued that public and private sources of support to the most vulnerable often fall short
and that people frequently “fall through the cracks” and go without necessary goods and
services. I demonstrated that increased bureaucratic constraints have contributed to arbitrary
applications of policies and decisions about recipients’ deservingness. Using ethnography, I
have shown that gatekeepers’ adherence to official policies and bureaucratic constraints are
frequently inconsistent, sometimes being determined by personalities and notions of
deservingness. My research demonstrates that the struggling individuals who depend on nonprofit agencies like the SSC for safety-net services and care are hardest hit by frequently
changing services and funding requirements.
My interviews and observations show that the SSC’s role as a neighborhood-based,
community driven agencies is central for community-building, organization and advocacy in the
low-income neighborhood it serves. The SSC’s work has moved far beyond community
organization and towards de facto social service and public health advocacy. The history of the
beginnings of the SSC reveals that its very existence and many of its successes emerged because
of failures in the safety-net. The organization’s programs and services are largely necessary
191

because of rising economic inequality and because government agencies are unable to directly
provide programs and services. I have shown that no matter how efficient and well-run, nonprofit organizations like the Smith Street Center are unable to pick up all of the pieces left from
persistent poverty and an increasingly dismantled government.

With this dissertation, I have contributed to the anthropological literature on the impact of
neoliberal policies on social service and health care distribution in the United States. I have
built on the literature on healthcare and disparities in the United States by showing that private
non-profit organizations like the SSC are largely funded and controlled by large governmental
granting agencies. During my research, I observed stark contrasts between the actual
experiences and beliefs of the poor and sick people I met and interviewed during fieldwork and
the rhetoric supporting neoliberalism, privatization and decreased public health and social
services. These contrasts led me to question the basis of this rhetoric and examine how it
became so pervasive when it so often does not reflect the experiences of the majority of the
people I worked with at the SSC. By presenting a record of neoliberalism’s influences on the
role of non-profit organizations like the Smith Street Center, I highlighted the political and
economic forces that have benefited from a weakened public sector and increasingly
individualized health and social services.

192

Appendices

193

Appendix A: Interview Schedule for Neighborhood Residents

1. General demographic questions: age, ethnicity, household income (will be
asked on a scale), household composition, etc.
2. General health assessment questions: kinds of illnesses respondent and/or family has had
to deal with in the past year, 5 years, and health seeking strategies for each.
3. Do you ever have problems getting everything you need to stay healthy?
4. How does your health affect your everyday life?
5. Do you have health insurance? What kind? Does it cover what you need it to? What
would make it better coverage for you?
6. Knowledge of SSC programs: What programs have heard of, and why/why not have
chosen to use them?
7. Use of SSC programs: Have you used any SSC programs? Why/Why not? have you
found them helpful, why/why not?
8. Do you think programs like those at SSC are necessary? Why?
9. Why do you think some people in the neighborhood might not participate in SSC
programs?
10. What SSC services help you or your family the most? Which do you find the least helpful
and why?
11. How did you hear about SSC and its programs?
12. Have you heard of SSC programs that you’ve decided not to use? Why not?
13. Do you use any support service programs somewhere other than at SSC? Where? Why do
you use those programs? What do you think of them?
14. How do you understand the relationship between non-profit places like SSC and the
“state” providers of health and social services?
15. Do you have any ideas about what SSC could do to get more people from the
neighborhood to participate in its programs?
194

16. What other services/ programs would you like to see offered?
17. Is there anything else that you think I should know?

195

Appendix B: Interview Schedule for Smith Street Center Staff and Volunteers

1. General Demographics: age, ethnicity, education, etc.
2. What are your primary responsibilities at SSC?
3. How long have you worked at SSC? Do you like it? Why did you choose to work at
SSC?
4. What do you see as SSC's role in the neighborhood?
5. Are neighborhood centers like SSC necessary? Why?
6. How do the SSC programs help people manage their health? Do you think they work
well? Why/Why not? What might make them more effective?
7. How do you see the relationship between non-profits like SSC and the “state” (public
health and social service providers)
8. What are the main benefits of the health and wellness programs? What are the main
problems?
9. What does SSC do to help people with chronic diseases? What works best and what
could be done better?
10. How do program participants find out about SSC's programs? What do you think makes
them decide to participate?
11. Why do you think some neighborhood residents don’t come and participate in SSC?
12. What could SSC do to get more residents to participate in its programs?
13. Is there anything else that you think I should know about SSC, the neighborhood, the
programs offered, or the participants?

196

Appendix C: Interview Schedule for Public Health Professionals

1. General Demographics: age, ethnicity, education, place of residence, etc.
2. Where do you work and what are your primary work responsibilities?
3. How long have you worked at your current job? Do you like it? Why did you choose to
work there?
4. What do you see as your agency/ employer’s primary responsibility?
5. How does this agency fit in with other governmental organizations?
6. Can you explain the relationship between your agency and non-profit organizations like
the SSC?
7. What is your agency's role in public health management?
8. Have privatization or downsizing impacted your work?
9. Who has benefited from downsizing and privatization?
10. How do you see the relationship between state and county social service and health
agencies and non-profits like the SSC?
11. Are neighborhood based agencies like SSC necessary? Why?
12. Do you think the neighborhood based agencies work well?
13. How do you understand health disparities?
14. Is there anything else that you think I should know about your work or the relationship
between the state and non-profits or just health inequities in general?

197

WORKS CITED

198

WORKS CITED

Alkhafaji, A. F. (1993). Privatization: An overview. Journal of Organizational Change
Management, 6, 24-43.
Austin, M. J. (2003). The Changing Relationship Between Nonprofit Organizations and
Public Social Service Agencies in the Era of Welfare Reform. Nonprofit and Voluntary Sector
Quarterly, 32, 97-114.
Ballard, C. & Funari, N. (2009). Executive Summary. The Retrenchment of the State
Employee Workforce in Michigan.
(http://www.miafscme.org/PDF%20Files/stateemployeesstudy.pdf)
Becker, G. (2001). Effects of Being Uninsured on Ethnic Minorities' Management of
Chronic Illness. Western Journal of Medicine, 175, 19-23.
Becker, G. (2004). Deadly Inequality in the Health Care "Safety Net": Uninsured Ethnic
Minorities' Struggle to Live with Life-Threatening Illnesses. Medical Anthropology Quarterly,
18, 258-275.
Becker, G. (2007). The Uninsured and the Politics of Containment in U.S. Health Care.
Medical Anthropology, 26, 299-321.
Boehm, D. A. (2005). The Safety Net of the Safety Net: How Federally Qualified Health
Centers "Subsidize" Medicaid Managed Care. Medical Anthropology Quarterly, 19, 47-63.
Braun, L. (2002). Race, Ethnicity, and Health: can genetics explain disparities.
Perspectives in Biology and Medicine, 45, 159-174.
Brush, Mark (2011, September 7). Reaction to stronger limits on Michigan welfare
benefits. Michigan Radio.
Buddeti, P. (2008). Market Justice and Healthcare. The Journal of the American Medical
Association, 299, 92-94.
Caplan, R. L. (1989). The commodification of American health care. Social Science and
Medicine, 28, 1139-1148.
Centers for Medicare and Medicaid Services (2011). Medicaid Program - General
Information.
Chesney, K. (2002). Nearly 8,000 Take Early Retirement; 2,000 New Jobs. State of
Michigan Agency of Technology, Management and Budget.
Chi, K., Arnold, K., & Perkins, H. (2003). Privatization in state government: trends and
199

issues. Spectrum: the Journal of State Government, 76(4).
Coburn, D. (2003). Beyond the income inequality hypothesis: class, neo-liberalism, and
health inequalities. Social Science & Medicine, 58, 41-56.
Conrad, P. (1994). Wellness As Virtue: Morality and the Pursuit of Health. Culture,
Medicine and Psychiatry, 18, 385-401.
Danziger, S. K. & Kossoudji, S. A. (1994). What happened to General Assistance
recipients in Michigan? Focus, 16.
DeNavas- Walt, C., Proctor, B. D., & Smith, J. C. (2010). Income, Poverty, and Health
Insurance Coverage in the United States: 2009 US Census Bureau.
Donahue, J. M. & McGuire, M. B. (1995). The Political Economy of Responsibility in
Health and Illness. Social Science & Medicine, 40, 47-53.
Dressler, W. W. (1993). Health in the African American Community: Accounting for
Health Inequalities. Medical Anthropology Quarterly, 7, 325-345.
Engler, J. (10-30-1995). Letter to the Michigan Department of Human Services .
Ref Type: Generic
Fairweather, G. & Tornatzky, L. (1977). Experimental methods for social policy research.
New York: Pergamon Press.
Farmer, P. (2003). Pathologies of Power: Health, Human Rights, and the New War on the
Poor. Berkeley: University of California Press.
Foucault, M. (1991). Governmentality. In G.Burchell, C. Gordon, & P. Miller (Eds.), The
Foucault Effect: Studies in Governmentality. Chicago: University of Chicago Press.
Gollust, S. E. & Jacobson, P. D. (2006). Privatization of Public Services: Organizational
Reform Efforts in Public Education and Public Health. American Journal of Public Health, 96,
1733.
Good, M.-J. D., James, C., Good, B., & Becker, A. E. (2003). The Culture of Medicine
and Racial, Ethnic, and Class Disparities in Healthcare. In B.D.Smedley, A. Y. Stith, & A. R.
Nelson (Eds.), Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care
(pp. 594-626). Washington, D.C.: The National Academies Press.
Harvey, D. (2005). A Brief History of Neoliberalism. Oxford: Oxford University Press.
Herzfeld, M. (1992). The Social Production of Indifference: Exploring the Symbolic
Roots of Western Bureaucracy. Chicago: The University of Chicago Press.
200

Hill, R. C. & Negray, C. (1987). Deindustrialization in the Great Lakes. Urban Affiars
Review, 22, 580-597.
Isaac, J. C. (2003). Faith-Based Initiatives: A Civil Society Approach. The Good Society,
12, 1-10.
Jacobson, P. D., Dalton, V. K., Berson-Grand, J., & Weisman, C. S. (2005). Survival
strategies for Michigan's health care safety net providers. Health Services Research, 40, 923-940.
Kaiser Family Foundation (2003). Michigan: Births Financed by Medicaid as a Percent
of Total Births, 2003.
Kaiser Family Foundation (2009). Trends in Healthcare Costs and Spending.
Kaiser Family Foundation (2010). Kaiser Commission on Medicaid Facts: Medicaid and
the Uninsured: The Medicaid Program at a Glance.
Kaiser Family Foundation (2010). Expanding Medicaid: Coverage for Low-Income
Adults under Health Reform.
Keane, C., Marx, J., & Ricci, E. (2001). Privatization and the Scope of Public Health: A
National Survey of Local Health Department Directors. American Journal of Public Health, 91,
611-617.
Krieger, N., Chen, J. T., Waterman, P. D., & Rehkopf, D. H. S. S. V. (2005). Painting a
Truer Picture of US Socioeconomic and Racial/Ethnic Inequalities: The Public Health Disparities
Geocoding Project. American Journal of Public Health, 95, 312-323.
Lopez, R. (2004). Income inequality and self-rated health in US metropolitan areas: A
multi-level analysis. Social Science & Medicine, 59, 2409-2419.
Maki, J. (2010). DHS To Lose 1,300 Workers. WLNS News [On-line]. Available:
http://www.wlns.com/Global/story.asp?S=13493994
Matthews, S., Manor, O., & Power, C. (1999). Social inequalities in health: are there
gender differences? Social Science and Medicine, 48, 49-60.
Minkler, M. (1999). Personal Responsibility for Health? A Review of the Arguments and
the Evidence at Century's End. Health Education and Behavior, 26, 121-140.
Morgen, S. & Maskovsky, J. (2003). The Anthropology of Welfare "Reform": New
Perspectives on U.S. Poverty in the Post-Welfare Era. Annual Review of Anthropology, 32, 315338.
Navarro, V. & Shi, L. (2001). The political context of social inequalities and health.
201

Social Science & Medicine, 52, 481-491.
Nelson, N. (2005). Ideologies of Aid, Practices of Power: Lessons for Medicaid Managed
Care. Medical Anthropology Quarterly, 19, 103-122.
Newman, K. (1999). Falling From Grace: The Experience of Downward Mobility in the
American Middle Class. New York: Free Press.
Olson, G. & Mangla, T. (2005). The Michigan Economy and State Budget FY 1994-95 to
FY 2003-4: Ten Years of Significant Changes. Lansing, MI: Senate Fiscal Agency.
Ong, A. (1995). Making the Biopolitical Subject: Cambodian Immigrants, Refugee
Medicine and Cultural Citizenship in California. Social Science & Medicine, 40, 1243-1257.
Piggott, K. (2009). Public Health Institutes: The Michigan Experience. Michigan Public
Health Institute
Rosenbaum, M. D., Altman, D., & Blendon, R. J. (2001). Poverty in America:
NPR/Kaiser/Kennedy School Poll.
Rylko-Bauer, B. & Farmer, P. (2005). Managed Care or Managed Inequality? A Call for
Critiques of Market-Based Medicine. Medical Anthropology Quarterly, 16, 476-502.
Scheper-Hughes, N. (1993). Death Without Weeping: The Violence of Everyday Life in
Brazil. Berkeley: University of California Press.
Skidmore, M. J. (1999). Social Security and its Enemies: The Case for America's Most
Efficient Insurance Program. Boulder, CO: Westview Press.
Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2003). Assessing Potential Sources of
Racial and Ethnic Disparities in Care: Patient- and System- Level Factors. In B.D.Smedley, A. Y.
Stith, & A. R. Nelson (Eds.), Unequal Treatment: Confronting Racial and Ethnic Disparities in
Health Care (pp. 160-179). Washington, D.C.: The National Academies Press.
Sommerfeld, D. & Reisch, M. (2003). Unintended Consequences: The Impact of Welfare
Reform in the United States on NGOs. Voluntas, 14, 299-320.
Starr, P. (1988). The Meaning of Privatization. Yale Law and Policy Review 6 (1988): 6-4,
6, 6-41.
Susser, I. & Kreniske, J. (1987). The Welfare Trap: A Public Policy for Deprivation. In
L.Mullings (Ed.), Cities of the United States: Studies in Urban Anthropology. New York:
Columbia University Press.
Taylor, J. R., Beane, G. E., & Genee, C. L. (1998). The Michigan public health institute:
202

A model for university, government and community research and practice partnerships. SRA
Journal/ Case Studies (30): 17-24.
United States Department of Health and Human Services (2011). The 2011 HHS Poverty
Guidelines.
United States Internal Revenue Service (2011). Exemption Requirements - Section
501(c)(3) Organizations. http://www.irs.gov/charities/charitable/article/0,,id=96099,00.html [Online].
US Census Bureau (2000). 2000 United States Census.
Waitzkin, H. (1991). The Politics of Medical Encounters: How Patients and Doctors
Deal with Social Problems. New Haven: Yale University Press.
Weber, M. (1946). Bureaucracy. In H.Gerth & C. W. Mills (Eds.), From Max Weber:
Essays in Sociology ( New York: Oxford University Press.
Willging, C., Waitzkin, H., & Wagner, W. (2006). The Death and Resurrection of
Medicaid Managed Care for Mental Health Services in New Mexico. In A.Castro & M. Singer
(Eds.), Unhealthy Health Policy: A Critical Anthropological Examination (pp. 247-256). Walnut
Creek: Altamira Press.

203