Until about 35 years ago the health care system in the United States was made up largely of relatively small, fee-for-service providers, non-profit community hospitals and modestly sized private insurance companies, including the non-profit Blue Cross Blue Shield companies. Beginning in the late 1970s, however, the health care system gradually underwent a qualitative change in its fundamental economic characteristics. This change is often referred to as the corporatization of US health care, as predicted by Paul Starr in his 1982 book The Social Transformation of American Medicine (Starr, 1982).
The focus of this chapter is the spread of corporatization to publicly funded health care programmes, mainly Medicare and Medicaid, after 2000, and the emergence of neoliberal health and long-term care (LTC) in the US. One of the major characteristics of neoliberalism is the privatization – or what David Harvey (2007) calls ‘accumulation through dispossession’ – of the public sector, by corporate acquisition of their assets and services. Privatization of the public side of the American health care system began slowly after 2000, but accelerated rapidly after the passage of the Affordable Care Act (ACA), or what became known as Obamacare, in 2010. Corporate health interests now control most public health care services in the US through proprietary health maintenance organizations’ (HMOs) domination of the Medicaid and the Medicare Advantage programmes (Henry J. Kaiser Family Foundation, 2019).
The implications of these trends are discussed for the growing number of workers who are precariously employed and retirees (current and future), for whom neoliberal health care threatens to undermine their economic and emotional security in their later years. The chapter uses the concept of the precariat to refer to the growing percentage of the labour force receiving relatively low wages, few if any retirement and health benefits, and who have no guarantees regarding continuing employment (Standing, 2011). Precariously employed workers are located disproportionately in the services sector, especially in the food services, cleaning and maintenance, caregiving, and retail sales industries. Many contract workers in the gig economy of Uber and Lyft drivers and other workers with unstable jobs and limited benefits are also members of the precariat work force.