Research Brief November 2017 PUBLIC Public Health & Wealth in FINANCE RESEARCH Post-Bankruptcy Detroit SERIES by Suparna Bhaskaran HAASINSTITUTE.BERKELEY.EDU This report is published by the Haas Institute for a Fair and Inclusive Society at UC Berkeley About the Author Acknowledgments Suparna Bhaskaran is a Senior The author is grateful to and Researcher at the Haas Insti- would like to thank the follow- tute for a Fair and Inclusive So- ing people for conversations, ciety in the Just Public Finance resources, and permission to program. Her work explores reprint: Dennis Archambault, the interconnections between Chris Allen, Gadah Sharif, Es- debt and credit systems, the peranza Cantu, Sarah Lewis financialization of households & David Goldbaum (Authority in health, education and care Health, Detroit); Sister Mary work, and public health. She Ellen Howard (Cabrini Clinic, is a member of Closing the Detroit); Jan Hudson (Michi- Women’s Wealth Gap, part of gan League for Public Policy, a national initiative to advance Lansing); Shea Howell (James policies that build wealth for & Grace Lee Boggs Center); low wealth women. She is the Regan Patterson (UCB); Moni- author of the report “Pinklining: ca Lewis-Patrick and Emily Kutil How Wall Street’s Predatory (We The People of Detroit); Products Pillage Women’s and Paula Ginsborg (California Wealth, Opportunities ad Fu- Health Care Foundation). tures. Suparna was involved in the research and implementa- Report Citation tion of the Affordable Care Act, Suparna Bhaskaran. “Pub- Medicaid Expansion and Medi- lic Health and Well-Being in care education. She has been Post-Bankruptcy Detroit.” Haas a professor at Antioch College, Institute for a Fair and Inclusive Ohio Wesleyan University, and Society, University of Califor- Agnes Scott College. nia, Berkeley: Berkeley, CA. November 2017. haasinstitute. berkeley.edu/justpublicfinance Editors Wendy Ake Contact 460 Stephens Hall Infographs & Maps Berkeley, CA 94720-2330 Samir Gambhir Tel 510-642-3326 haasinstitute.berkeley.edu Layout / Design Rachelle Galloway-Popotas haasinstitute.berkeley.edu Public Health & Well-Being in Post-Bankruptcy Detroit 2 Contents Introduction 5 Water and Well-Being 8 Housing and Health 13 Conclusion 19 Endnotes 21 “Health” is a bold expansive aspiration. Let’s make sure that what we call “healthcare” is broad enough to get the job done.1 haasinstitute.berkeley.edu A Pivotal Moment for the US Refugee Resettlement Program 4 Introduction THIS REPORT EXPLORES THE paradox and poten- ernment and industry. tial of Medicaid Expansion (or the Healthy Michi- Borrowing from and building upon the works of gan Plan) in the aftermath of Detroit’s bankruptcy. several scholars, I use the term structural violence In particular, it examines efforts at leveraging to describe political, economic, social and psy- health equity, such as Medicaid Expansion, within chological processes that severely compromises the backdrop of toxic policies of water and hous- individual and community health and opportunity.2 ing insecurity experienced by Detroit residents. The social and physiological traumas experienced Michigan’s Medicaid Expansion, particularly in by residents of Detroit due to the water and hous- Detroit, can be viewed in at least three critical ing crisis is an example of structural violence. ways. First, Medicaid Expansion has been a way Medicaid expansion in Michigan has been one for the federal (and state) government to increase avenue through which governments have sought access to medical care to vulnerable communi- to interrupt glaring health inequities generated by ties in Detroit who have recently (and historically) structural violence. experienced economic crisis (in housing, social In this report, structural violence refers to system- services, water, education and work). atic ways in which multiple structures of injustice Second, Medicaid Expansion was a way for the can come together to harm, restrict, contain, and Obama administration to infuse federal funds into disadvantage individuals and communities. Mul- states and distressed municipalities. tiple systems of inequity co-exist, intersect, and Third, Medicaid Expansion has been a way for the simultaneously disadvantage individual/communi- Michigan Legislature to access federal dollars by ty material, psychological, and biological well-be- pursuing decades long economic policies and ing (structured by race, gender, class, sexuality, thinking about who is deserving in US society. age, and citizenship). This experience, both on- This economic and social philosophy has meant going as well as historical, of structural violence the expansion of a hyper-deregulated safety-net promotes a continuous transfer and removal of program like Medicaid, the profound capture of wealth, health, resources, and opportunity for government and public funds by corporate health- Detroit’s low-income communities, particularly care interests, and the insistence on personal communities of color. responsibility from the poor and marginalized. As systemic and daily phenomena, structural vi- Most significantly, Medicaid continues as an aus- olence is embedded within systems of injustice tere, stigmatized, and segregated program that and the bodies and lives of vulnerable communi- continues to separate the US population (into ties/individuals. Scholars have pointed out that low-income, seniors, those who are pregnant, or in addition to being exposed to and succumbing those with employer-linked benefits) and deny to more systemic stressors marginalized people universal healthcare to all in this country. Michigan are at greater risk for infection, slower recovery legislators managed to change federal Medicaid and unfavorable outcomes such as death. Trauma rules by including legislation that has vulnerable associated with daily social and economic op- populations demonstrate more “skin in the game” pression are marked upon bodies, psyches and and “personal responsibility.” Thus, low-income life chances. people and communities of color in the city, who Structural violence is also used in this report to continue to experience racial and class injustice, connect what is deliberately compartmentalized economic instability and compromised social ser- as clinical and non-clinical aspects of life. And, vices, are expected to be prudent price-conscious to propose, like many others, that the health consumers in order to bring down costs for gov- of individuals or communities suffer when sys- haasinstitute.berkeley.edu Public Health & Well-Being in Post-Bankruptcy Detroit 5 Figure 1 Health Spending Distribution by Category2 SOURCE: California Healthcare Foundation, 2016. tematic policies around work, housing, lending, north. On unpacking these reports scholars3 have redlining, reverse redlining, foreclosures, state shown that (1) while these healthcare expenses and private violence, unemployment, social ex- are indeed high, most of the funds go to hospitals, clusion, neighborhood safety and investments, physicians, clinics, and other biomedical invest- water and sanitation equity, and transportation ments; (2) health in healthcare is almost always deepen vulnerability to illness. Structural violence underscored by a clinical or biomedical worldview includes supremacist systems such as racism and at the expense of the political, economic and so- sexism that intensifies economic inequities, but cial dimensions of health; and (3) by not investing also economic policies of austerity imposed upon in social services (housing, water, economic se- Detroiters by governments and corporations that curity, education, transportation, and avenues to compound racism and sexism. challenge discrimination or segregation) to inter- Public health practitioners and scholars have rupt structural violence, health outcomes continue used the term “social determinants of health” and to be a troubling representation of toxic inequities "toxic stress" to describe how social conditions or and chronic suffering (see Figure 1). one’s environment influences exposure to disease, Structural violence also attempts to underscore chronic illness and health outcomes. The term how power and its multiple policies/practices of structural violence seeks to build upon the term social injustice can afflict individual and community “social determinants of health” to interrupt the well-being well before needing health care in a dominance of clinical, behavioral and biological clinical setting. “Health begins where we live, learn, frameworks used in public policy. For instance, work and play,”4 and, health should not be contin- many studies have shown that US has the high- ued to be compromised by the abuse of power est healthcare expenditures but unimpressive and social injustices where we live, learn, work and health outcomes amongst countries of the global play, or due to lack of access to clinical care. haasinstitute.berkeley.edu Public Health & Well-Being in Post-Bankruptcy Detroit 6 Detroit: Restructuring a Detroit’s loss of its tax revenue/base, people, Shrinking City communities, social services, opportunities and work that have been driven by factors including: The city of Detroit is an iconic example of how disinvestments from its monolithic auto-industry; the predispositions of the US economic and neoliberal government strategies; policies of ra- public health systems and welfare capitalism can cial injustice, including punitive policies of mass fail individuals, communities and cities. The city incarceration;7 white and middle-class flight