An Ethnography of Bureaucratic Practice in a New York State Federally Qualified Community Health Center David James Breslich Erickson Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy under the Executive Committee of the Graduate School of Arts and Sciences COLUMBIA UNIVERSITY 2020 © 2020 David James Breslich Erickson All Rights Reserved ABSTRACT An Ethnography of Bureaucratic Practice in a New York State Federally Qualified Community Health Center David James Breslich Erickson Federally Qualified Community Health Centers - aka FQHCs, Community Health Centers (CHCs), Neighborhood Health Centers, or simply Health Centers - are public and private non-profit healthcare organizations funded under Section 330 of the Public Health Service Act, directed by a consumer board of directors, and complying with Federal requirements to serve medically underserved populations. In 2017 FQHCs saw more than 27 million individual patients in the United States, of whom approximately two million were seen by health centers in New York State (Bureau of Primary Health Care 2017). Despite these staggering figures, relatively little academic work has investigated how these health centers operate at an administrative and bureaucratic level. To study the bureaucratic practice of FQHCs, this research utilizes an ethnographic approach, conducted over a period of three-plus years at a FQHC in New York State (pseudonymously called Care Center). It incorporates structured interviews, informal interviews, the collection of fieldnotes, and participant observation, as well as qualitative data analysis. Collectively this research approach produces a complex portrait of how bureaucratic activity at the specific FQHC field site was organized, conducted, and structured within the context of substantial growth in the FQHC program. The setting of the study offers a unique opportunity to explore the implications of this bureaucratic activity on FQHCs and, by extension, other safety- net healthcare institutions in the United States. This research also delivers a substantial historical account of the emergence of the FQHC program in order to connect that account to the broader arc of healthcare history in the United States during the 20th and 21st centuries. This connection demonstrates the linkages between specific aspects of FQHC bureaucratic practice and larger trends in health care more generally. The emphasis on “need” as a discursive object that is frequently referenced and utilized as an organizing mechanism by FQHC bureaucracy allows us to better understand and problematize the use of need as a criterion for organizational growth. Table of Contents List of Figures ............................................................................................................................... ii Acknowledgements ..................................................................................................................... iii Dedication ......................................................................................................................................v Introduction: Welcome to Care Center ......................................................................................1 Methodology ................................................................................................................................27 Chapter 1: History and the FQHC World in Context .............................................................55 Chapter 2: FQHC Organization Structure and Bureaucracy at Care Center ...................159 Chapter 3: When Grassroots Grow ........................................................................................218 Chapter 4: Need ........................................................................................................................257 Conclusion .................................................................................................................................302 References Cited ........................................................................................................................317 Appendix A: Care Center Interviews .....................................................................................349 Appendix B: Key Legislative Moments in FQHC History ....................................................350 Appendix C: Catalogue of “Wet” and “Dry” Terminology ..................................................354 i List of Figures Methodology ii.0. Coding Example ...............................................................................................................40 Chapter 1 1.0. Jack Geiger at his Home in Brooklyn, NY, August 8, 2017 ............................................73 Chapter 2 2.0. Nickerson .......................................................................................................................164 2.1. Wilthook .........................................................................................................................168 2.2. Analysis of “Wet” and “Dry” .........................................................................................183 Chapter 3 3.0. Care Center’s Growth .....................................................................................................229 3.1. Care Center’s Shrinking “Rebel Core” ..........................................................................237 3.2. Radiation Producing Equipment ....................................................................................247 3.3. The Sports Medicine Privileging list I wrote for Care Center with handwritten updates ............................................................................................................................252 Chapter 4 4.0. CON Schedule 17 ...........................................................................................................269 4.1. The Service Area Needs Assessment Methodology (SANAM) ....................................295 ii Acknowledgements Several fortuitous circumstances, failures, and chance encounters produced this dissertation. I am deeply indebted to the numerous friends, family members, colleagues, and mentors who helped me along the way. First and foremost, I benefited from financial support as a research assistant for Dr. Jennifer Hirsch at Columbia University’s Sociomedical Sciences Program (SMS) during my coursework. Her subsequent mentorship in navigating IRB processes and departmental requirements has been fundamental to the success of this project. Thank you! The opportunity to work as a teaching assistant for the Sociomedical Sciences Program with Dr. Ana Abraido- Lanza opened my eyes to a breadth of perspectives on healthcare institutions that I likely could not have gained through coursework alone. Thank you also to Edgar Rivera-Colon for the time I spent as his teaching assistant in SMS’s qualitative research methods course. Academic bureaucracy is as intricate as that of healthcare institutions and sifting through its twists and turns requires expert guidance. Andrea Constancio at SMS never ceases to astonish me with her familiarity of process, her willingness to tirelessly pursue solutions on behalf of students in the department, and her capacity to comfort those of us in distress. I would have been lost without her. I am deeply grateful to my committee members: Kim Hopper, Helen-Maria Lekas, Peter Messeri, Virginia Ashby Sharpe, and David Alfandre. For taking me on as an advisee amidst his considerable teaching obligations I remain especially indebted to Kim Hopper. Marilena Lekas has aided me in more ways that I can count and given me emotional encouragement balanced in equal parts with her tremendous intellectual and practical insights. iii To my colleagues, supervisors, and direct reports at Care Center, I am so grateful for your willingness to support my project. I benefitted greatly from my experience as an employee but am forever changed by my interactions with you all. It is my sincerest hope that you see parts of the Care Center world in this dissertation, and I hope that I have done justice to the words you were willing to share with me. I could never have made it to the finish line without you. My parents, John and Helen Erickson, and brother, Paul Erickson, have given me a lifetime of encouragement and always persuaded me to value intellectual endeavors, be it in canon law, landscape architecture, music, or history. It is because of them that I was in any way prepared to pursue academic study. I love them very much. There is one person whom I met while doing this project who has suffered its ups and downs more than anyone, Lana Klemeyer. I am endlessly grateful for her understanding, her proofreading and editorial talents, and her love. iv Dedication For hardworking bureaucrats everywhere. v Introduction: Welcome to Care Center1 On a frigid, crystal-clear day in December 2016, I joined a procession of cars as they inched along a narrow road running parallel to Long Island Sound. We were all en route to the same place, Care Center’s annual staff party. The event, heralded by an email invitation decorated with silver and teal orbs surrounding the health center’s logo, had been held annually by the health center since its inception, according to the accounts of the health center’s most senior employees, including the CEO. I pulled out of the stop-and-go traffic, parked, and began to walk alongside the cars still pushing onward toward a wrap-around driveway and a crew of listless valets.