Redistributing the Poor
Jails, Hospitals, and the Crisis of Law and Fiscal Austerity
ARMANDO LARA- MILL Á N
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© Armando Lara-Millán 2021
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Library of Congress Cataloging-in-Publication Data
Names: Lara-Millán, Armando, author.
Title: Redistributing the poor : jails, hospitals, and the crisis of law and fiscal austerity / Armando Lara-Millán, PhD, Department of Sociology, UC Berkeley.
Description: New York : Oxford University Press, 2021. | Includes bibliographical references and index.
Identifiers: LCCN 2020044919 (print) | LCCN 2020044920 (ebook) | ISBN 9780197507896 (hardback) | 9780197507902 (paperback) | ISBN 9780197507926 (epub)
Subjects: LCSH: Jails—United States—Administration. | Prisoners—United States—Social conditions. | Public hospitals—United States—Finance. | Poor—United States—Social conditions—21st century. | Social control—United States. | Fiscal policy—United States. Classification: LCC HV9469.L267 2021 (print) | LCC HV9469 (ebook) | DDC 338.4/3362110973—dc23
LC record available at https://lccn.loc.gov/2020044919
LC ebook record available at https://lccn.loc.gov/2020044920
DOI: 10.1093/oso/9780197507902.001.0001
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Paperback printed by LSC Communications, United States of America
Hardback printed by Bridgeport National Bindery, Inc., United States of America
Preface
Introduction
PART I. THE EXPANSION OF MEDICINE IN LARGE URBAN JAILS
1. Summoning the Sick and Violent to
2. The Medicalization of the Los Angeles County Jail System, 1978–2015
PART II. THE RESTRICTION OF MEDICINE IN LARGE PUBLIC HOSPITALS
3. Opioids, Observation, and
4.
Preface
When I started research for this book in 2009, I came across an article in the Los Angeles Times about a yearly mass burial. Every year since 1896, Los Angeles County’s government has buried the ashes of around one thousand unclaimed bodies into an unmarked grave in East Los Angeles. In 2009, with the onset of the Great Recession, cities across the nation were seeing increased burials into such “pauper’s graves.”1
Fast-forward nearly a decade later, and I am writing this preface during the 2020 COVID crisis. Local governments in major cities are once again seeing an uptick in the premature death of mostly poor, mostly brown and Black people, necessitating their burial into unmarked graves. New York City has gone from burying 25 to 120 such people per week. It is difficult to know exactly who these people are but—given the contours of American poverty— it is easy to imagine they are the bodies of the under-housed found on park benches, the impoverished elderly living alone, or families unable to afford funeral costs.2
I will return to these deaths momentarily, but first a detour into the virus currently raging through America’s jails and public hospitals. At the start of the crisis, prison abolitionists and legal advocates were threatening to sue county jails for endangering inmates. Indeed, despite expansive efforts to conduct testing during jail intake, inmates have been falling ill at alarming rates. Less widely acknowledged, though, is that public agencies across the country actually responded to legal pressure by releasing thousands of inmates early, stopped booking many into jail, and moved to issue citations rather than arrest. Such policies have resulted in drastic drops in jail populations; Los Angeles County, for instance, decompressed its jail from 17,000 inmates to 11,000 in just one month.3
It will probably become a footnote in history, but early in the crisis, social distancing policies saw many hospitals significantly under capacity and, as a result, hemorrhaging revenue. People were avoiding normal healthcare, and patients are money-makers for hospitals. It was not until late June 2020 that hospitals in major urban areas finally began to hit disastrous capacity limits. In addition to the relaxing of social distancing adherence, officials
have quietly noted that prison and jail releases may have contributed to the recent uptick in hospitalizations. Indeed, early research in Chicago showed that jail releases accounted for 55% of the variance in case rates across zip codes. Persons released from incarceration and the people they have come into contact with are filling up the nation’s public hospitals.4
The standard story we have been given to make sense of this situation is to blame overinvestment in criminal justice and underinvestment in public health. The idea would be that because criminal justice budgets have risen exponentially in the United States, it is no wonder that during a pandemic the sick and poor have ended up behind bars and that our nation’s public hospital system would become overwhelmed. Such a theory is rooted in our understanding of the way mass imprisonment has shaped our county’s institutions.
In this book we will see how this received wisdom is inadequate for understanding the current moment. While we largely assume that jail officials were pressured into releasing inmates during COVID, the theory offered in this book suggests that officials—for the moment—were likely privately ready and willing to cut costs. We might also assume that public hospitals were decrying the growth in caseloads, but in this book, we will see how these new caseloads are actually a way to earn revenue and renew interest in the funding of public hospitals.5
This book argues that we have drastically misunderstood not only this nation’s largest jails and public hospitals, but the way that states govern at the turn of the twenty-first century. In short, the idea of “redistributing the poor” draws attention to how state agencies circulate people between different institutional spaces in such a way that generates revenue for some agencies, cuts costs for others, and projects illusions that services have been legally rendered. The concept pushes us away from viewing governance as either a problem of officials being overly concerned with punishing poor people or not concerned enough about extending a helping hand. Instead, public agencies are in the business of redefining problems in whatever way possible with the aim of reconstituting dying public institutions and reproducing the status quo.
By using this new language to describe state activity, we can better understand the premature deaths I encountered at the beginning and end of my research. Redistributing the poor shows how these deaths—what Ruth Gilmore (2007) calls “disposable” Black and brown life—are not simply the result of society’s failure to act. Instead, as we shall see, they are the inevitable outcome of the state agencies’ successful resolution of a particular kind
of crisis. When state agencies encounter a crisis generated by a fundamental tension between fiscal austerity and legal demand the social suffering associated with that crisis evolves into some new, legally visible, and more affordable kind of suffering. The fiscal and legal crises generated by COVID are just the latest examples in which the social suffering of huge swaths of people are simply written off on paper.
Armando Lara-Millán, PhD
June 30, 2020 Oakland, CA
Acknowledgments
This book is not perfect. And it is through a lot of love and support that I have come to understand that it is okay for books to not be perfect; that I did the best I could. I had always envisioned writing extensive acknowledgments to thank the people who offered that kind of support and guidance. Some of that made it into the methods appendix, but alas, at the end of this journey, I feel the need to keep things short.
I feel deep in my heart there is no way that I could have researched this project and written this book alongside everything else that occurred in my life without the love of many people surrounding me. First and foremost, to the many who have since passed. You know who you are, but for whatever reason I feel the need to name my grandmother Nellie, who it feels as though if not for the critical thinking skills, intuition, and articulation of all that wisdom, I would not have been able to overcome many obstacles. To the living: there are so many of you that made a difference, both people who are still in my life, who will always be in my life, and those that have since moved on. To my best friend Evan, there is no way that I could have written this book without your confidence in me. To my mother, even though we have had our troubles I love you and thank you for everything you did to help me make this possible. The same goes to sister and brother. I am sorry that this book and everything that occurred alongside it took me away from you at times. I hope that can change. To my step-parents, you have shown me a different way that I can love and while it is difficult to explain, it made finishing this book possible. To John and Cindy, to my many cousins in all of my families, my friends Zack, Daniel, Joe, Manuel, thank you for bearing with me and still being there. To those who have since moved on, you know who you are and your impact on my life, your support and love through it all is still with me. Thank you. To my partner Babi, you have filled me with joy and taught me to kill the self-criticism; to my surprise you made being a happy person possible through the finish line.
There were people, for reasons I do not understand, who were willing to read drafts of these chapters and help me sort through all the mess. To Michael Burawoy, you have taught me what it takes to be good at this job
and you challenged me to get this story straight. I am in your debt. To Mary Pattillo, you pushed me to find my voice (and get to the point!). To Lynne Haney, Ann Orloff, Valerie Jenness, Neil Fligstein, Calvin Morrill, Claude Fischer, Josh Pacewicz, Neil Smelser, thank you. Elizabeth Onasch, you were always there to make sure something I had written wasn’t crazy. Thank you to my editor James Cook, who believed in my vision from the beginning, as well as the anonymous reviewers for their meticulous feedback.
To the many colleagues and friends that through many presentations, conversations, and feedback, I am also in your debt. Brian Sargent, Robert Vargas, Nicole Gonzalez Van Cleve, John Eason, Amada Armenta, your friendship was just as important as your feedback. Same goes to the members of the Race, Crime, and Democracy Network. I could not have finished without all your support. Thank you to Patrick Lopez-Aguidado, Anjuli Verma, Chris Muller, Issa Kohler-Hausmann, Benjamin FleurySteiner, Joshua Page, Reuben Miller, Kimberly Hoang, John Hagan, Ann Swidler, David Harding, Melissa Guzman-Garcia, Phil Goodman, Tony Platt, Jonathan Simon, Julia Adams, Tianna Paschel, Raka Ray, Heather Haveman, Cristina Mora, Monica Prasad, Colin Jerolmack, Christopher Wildeman, Marcus Hunter, Sarah Brayne, Megan Comfort, Stephen Sweet, Margaret Andersen, Elijah Anderson, Karen Barkey, Gary Alan Fine, Victor Rios, Cybelle Fox, Kimberly Morgan, James Mahoney, Forrest Stuart, Corey Fields, Elisabeth Clemens, Annette Lareau, Iddo Tavory, Erin Kerrison, and Anthony Peguero. Finally, thank you to the men and women who opened their places of work to me. It was not easy, but I tried to study your constraints and I hope you will see some of that represented in this work. Forgive me if I have forgotten anyone.
Introduction
On January 10, 1998, the Los Angeles County Sheriff’s Department— operator of the largest jail system in North America—moved “all” of the incarcerated persons suffering from mental illness into its newly opened flagship Twin Towers jail. Deputies offered ice cream, cookies, and even cigarettes to entice the “mentally fragile” into leaving their cells and making the trek to the new facility. Throughout the day, 1,500 mentally ill inmates were transferred into the one- and two-man cells of the Twin Towers jail. The moves were accompanied by the doubling of the Department of Mental Health staffing in the jail and the hiring of 100 custody staff to properly monitor sick inmates whenever they left their cells. Concerning the unprecedented jail healthcare expansion, the Sheriff said at the time, “It is an issue that must be resolved. . . . There are no other options, except get it done.”1
A few months earlier, just down the road, in front of a raucous crowd, another move was being finalized. The Los Angeles County Board of Supervisors—the county’s five-member political leadership—voted to rebuild its flagship public hospital with no more than 600 hospital beds. Most concerning for the hundreds of community activists who packed the county’s Hall of Administration was that every commissioned study on the issue had shown that a bare minimum of 750 beds were needed to serve the community. An emergency room (ER) physician warned the supervisors about their downsizing plan, “they are going to be dying in the hallways,” he said “dying waiting to get into the operating room.”2
At first glance, these two scenes fit a single idea that comes to mind whenever the topics of urban jails and public hospitals are raised. It is widely believed that because we as a society disinvested in public health, particularly mental health institutions, during the 1960s, the sick and poor are now finding themselves within the purview of criminal justice institutions. Actors on both sides of the political aisle, journalists, and academics generally agree that we have funneled resources into local criminal justice institutions— making it possible for them to take on new duties such as healthcare and other kinds of social services—at the expense of health and welfare institutions.
Redistributing the Poor. Armando Lara-Millán, Oxford University Press (2021). © Armando Lara-Millán. DOI: 10.1093/oso/9780197507902.003.0001
Making matters worse, places meant to protect the nation’s poorest—places like public hospitals, welfare offices, and even public schools—have become more difficult to access. And in some cases, we have even securitized these supposedly helping institutions with police and criminal suspicion to deter people from abusing their goodwill.
While seemingly straightforward, the puzzle of why medicine has expanded in America’s largest jails and has been restricted in its largest public hospitals is more complicated. Consider Los Angeles County in the preceding examples. The decision to rebuild the hospital represented a significant investment, using over a billion dollars of public revenue sourced from local, state, and federal funding. Conversely, the expansion of healthcare in the jail took place during significant capacity retrenchment of the jail system—the jail system had been shedding thousands of inmates due to severe fiscal shortfall. Together they seem to contradict the idea that jails are taking on medicine because we have divested in our public health system and overinvested in jails.
It may be surprising to hear that these cases are not anomalous, but actually fit wider national trends in our largest cities. It is a little acknowledged fact that, since the early 1990s, the nation’s largest jails have seen declines in capacity, released thousands of inmates, and suffered severe shocks of austerity. It may be equally surprising to know that spending on public healthcare, including the money we have committed to large safety-net hospitals, has grown tremendously during the past 30 years. This holds true even when we control for rising medical prices.
In order to better explain the puzzle of medicine’s expansion in large urban jails and its restriction in public hospitals, this book proposes an alternate way of thinking about state action at the turn of the twenty-first century. It is not just “fiscal austerity” that shapes policy, but also the equally constraining force of what we can call “legal demand.” In short, contemporary urban governments in the West are in the unique position of having to continuously manage catastrophic budget cuts while also navigating a policy and legal environment that at least ostensibly holds them accountable to the laws of the land, procedural rules, court rulings, watchdog groups, and minimum service requirements. This is the central and least recognized problem of contemporary statecraft wherein officials must routinely solve a mismatch between available public funds and the public’s legally recognized right to those resources.
The central argument of this book is that in response to such crisis, state officials redistribute the poor. This concept describes how state agencies circulate people between different institutional spaces in such a way that generates revenue for some agencies, cuts costs for others, and projects illusions that services have been legally rendered.
The theory helps us to understand that the move to expand medicine in jails has not occurred simply because jails have more resources and are seeing more mentally ill arrestees, but because reorganizing jails along these lines has allowed public officials to renew dying institutions. Likewise, public hospitals dismantled inpatient capacity not simply because of budget retrenchment, but because doing so allowed local governments to receive huge infusions of revenue from the federal government. New forms of restricting access to hospital services occurred in the wake of these cash infusions. In total, the move to expand medicine in the United States’ largest jails and to restrict it in the largest US public hospitals is a part of the same crisis abatement effort.
Theorizing transformations in these institutions as crisis abatement is worth underscoring. Michelle Foucault (1975) and Pierre Bourdieu’s (2015) influential work serve as starting points for many accounts of what scholars call “poverty governance institutions,” places like jails and public hospitals that spend a bulk of their resources intervening in the daily lives of the poor. In different ways, they argued that what defined such institutions was their effort to acquire more information about the populace and fit people into neatly digestible categories for the purposes of social engineering. The account presented in this book is in fundamental agreement with the idea that state institutions work to socially control, but takes a step away by suggesting that transformations in such institutions are also the result of a series of temporary resolutions to state crisis. Poverty governance institutions may reclassify people, but this is a first and necessary step for redistribution in times of major constraints on the state.
As such, by the end of this book we should begin to think less about the dismantling of the state and more about the disappearing of crisis. A significant body of scholarship has tried to account for the persistence of social spending despite major political efforts to dismantle the welfare state (Pierson 1994; Thelen and Streeck 2005; Hacker 2004; Morgan and Campbell 2011). By focusing on the redistribution of the poor, we can be attentive to how it is increases in social spending (usually mandated by new laws) that
actually shroud structural retrenchment. When welfare states use redistribution to resolve crises a kind of social suffering associated with those crises are disappeared from the public record and transformed into some other, more affordable kind of social need.
It is my hope that by taking the idea of redistributing the poor and the disappearing of crises more seriously we can begin to make sense of other kinds of social problems. For example, in recent years, we have seen mass school closures in places like Philadelphia, where 30 schools were closed in one year, waves of violence in places like Chicago, and unaccompanied minors at the US-Mexico border. Officials usually respond with some kind of service expansion: shifting displaced students around in Philadelphia (Jack and Sludden 2013), funding violence prevention workers or providing community relations training to police officers in Chicago (Vargas 2016; Weichselbaum 2016), and sending hundreds of legal professionals to the border (Hennessy-Fiske et al. 2014). A short while later, these problems become considered publicly resolved in ways that indicate disappearing. After first appearing in 2012 under the Obama administration, the problem of unaccompanied children at the US-Mexico border was partially serviced by losing track of thousands of minors under the Trump administration (Nixon 2018). In Philadelphia, overcrowded classrooms became less of a public concern when many of the transferred children were simply suspended or began engaging in truancy (Steinberg and MacDonald 2019). After a short while, stakeholders stop debating solutions, call off emergency meetings, and produce policy metrics that represent these problems as resolved or at least stabilized; that is, an atmosphere of imminent crisis disappears.
It is the concept of redistributing the poor that can provide us with the language to understand these moments and how, despite the public resolution of crisis, people continue to suffer and underlying economic strife continues.
The Puzzle of Urban Jails and Public Hospitals
What does it mean to say that medicine is expanding in jails, but becoming more restricted in public hospitals? It is important to understand this point in all its nuances, because it is the puzzle we are trying to explain in this book.
Consider the following two scenes, taken from the fieldwork I conducted for a year in two such institutions. On one particularly crowded night in the jail, a sheriff’s deputy said something that stuck with me: “Thank god for the
nurses.” The young deputy I was shadowing made this offhand remark with a chuckle. After what had just occurred, it must have seemed like stating the obvious. The deputy had been called over to attend to an inmate who was huddled in the corner of the “fishbowl,” a room surrounded by Plexiglas where a dozen or so inmates await transfer into a bed in the sprawling jail. When the deputy attempted to jostle the inmate lightly on the shoulder, the inmate reacted violently, swinging his arms and screaming, “Just leave me alone!” The deputy immediately pinned him to the ground. Shortly after, a nurse responded to the situation. As I had seen her do before, she quickly administered an antipsychotic sedative. Eventually the inmate calmed down and was carried out of the room. As with hundreds of other inmates on a nightly basis, this inmate would be given a bed in the mental health unit of the jail—highly prized by inmates, extremely expensive from a budgetary standpoint, and very scarce from an organizational standpoint.
On a different night, I observed another provision of healthcare, but this time in the ER of a nearby public hospital. I watched a triage nurse administering another kind of pharmaceutical—opioid pain medication—to a waiting patient who had come to the ER complaining of general abdominal pain. The patient had been waiting for four hours and was among many in the observation room of the triage unit—a room packed with patients who were all qualified to receive a bed but had to wait because of overcrowding. An hour or so later, the patient was called by the nurse to receive a recheck of their vital signs. Indeed, the patient’s heart rate had slowed, and she reported feeling a bit better. The nurse looked up at me: “watch, they are going to leave.” I was not sure what the nurse meant, so when the patient indeed left another hour later, I asked the nurse how they knew: “a lot of people are in here when they shouldn’t be. Just looking to get drugs or whatever. Things are really crowded in here . . . so it’s fine.”
These were just two of many instances that characterized the fieldwork I conducted for a year in a large urban jail and a large public hospital: in the jail, the ubiquity of medicine as a form of knowledge and technology to understand inmates and run the jail smoothly; in the hospital, the ubiquity of criminal suspicion to understand patients and make the tough choices about who should receive very scarce public hospital beds. In the jail, nurses, doctors, therapists, psychotropic drugs, sedatives, mental health evaluation forms all sprang into action whenever there was a disruption to the normal routine of jailing. When the young deputy told me he was grateful for nurses, it was because he did not have to choose whether or not to use more severe
force on this inmate, which put him at legal and employment risk. In the hospital, the triage nurse described the situation as “fine” because, during the year I spent in this public ER, the ubiquity of criminal stigma was all around us. Not only were police, jailers, squad cars, and handcuffs a continuous presence in the ER, so was the suspicion that the patients who overcrowded the ER were not very sick, but instead were out to abuse the hospital as a source of drugs.
We can characterize the role of medicine in the large urban jail in following way: it is the potential of providing medicine to inmates that has come to define the way that jailers resolve their key organizational problems. We have to be careful with this characterization, as it is easy to slip into hyperbole. It is distinct from the claim that medicine is nowhere to be found in jails, or that jails do a great job of treating their inmates. Instead of such hyperbole, we can detail how medicine is able to resolve a fundamental tension in jails: the fact that there are too two few specialized beds (both medicalized space and high-security space) for far too many in-need inmates.
We can characterize the situation in the large public hospital with the inverse statement: it is the potential of restricting access to medicine that helps to resolve its key organizational problems. Through ethnographic observation we see the ubiquity of criminal suspicion among hospital staff; that patients are not particularly sick, but instead are drug-seeking criminals. This helps them make decisions about who can be delayed access to healthcare resources, which makes it more likely that waiting patients will stop seeking healthcare. Just as in the jail’s case, we have to be careful of hyperbole. It is not the case that the ER has become colonized by the criminal justice system, nor is it the case that medical professionals do their work without any contamination from law enforcement or bias against perceived criminals. Instead, we can detail how criminal suspicion helps to resolve the fundamental problem of public ER life: that there are far too many qualified patients in need of hospital beds than there are available beds.
These ethnographic findings make sense given broader trends in the largest urban jails and public hospitals. In 2010, roughly 65% of incarcerated adults in prisons or jails met the medical criteria for an alcohol or drug use disorder, seven times likelier than individuals in the community. One estimate puts the figure at 20% of those in jail who have a serious mental illness (defined as schizophrenia, psychosis, bipolar disease, and serious and persistent depression) compared with only 4% of the general population.3
The restriction of medicine in public hospitals also makes sense given their well-known capacity declines. There were 1,691 public hospitals open in 1983, but by 2003 fewer than 60% remained; 19% had closed, while 23% were converted to private or nonprofit organizations. The situation was a bit starker if we highlight urban public hospitals: more than half closed or were converted between 1983 and 2003. Such reductions are significant because urban public hospitals make up a huge share of the healthcare safety net. Private hospitals are often unwilling to pay for undercompensated care and transfer poor patients to public ERs. Moreover, health clinics are unevenly distributed and lack the specialty services offered by a public hospital. Consequently, public hospitals now provide 65% of uncompensated care within the largest metropolitan areas.4
The Limitations of Theories of Urban Poverty Governance
The growth of medicine in jails and its restriction in public hospitals is a rare topic in which the explanations we hold about them are widely shared. Consider the similarity between the following two statements. Longtime prison abolitionist Angela Davis— someone dedicated to ending our obsession with locking up poor people and people of color— wrote in 2014:
The three largest contemporary psychiatric facilities . . . are jails: Cook County Jail in Chicago, L.A. County Jail, and Rikers Island in New York.
A direct consequence of the closure of psychiatric institutions called for by progressive deinstitutionalization advocacy.5
Compare this to a statement in 2015 by the head of the Cook County Sheriff’s Department—someone dedicated to running the notorious Chicago Jails:
It’s a national disgrace how we deal with this . . . this person has a serious mental illness, he’s not being treated, his family and him [sic] have been disconnected for years, he obviously doesn’t have a job. . . . He will come in contact with law enforcement . . . if they’re going to make it so that I am going to be the largest mental health provider, we’re going to be the best ones. We’re going to treat ’em as a patient while they’re here.6
Whenever this topic is raised by social scientists, activists, journalists, civil rights lawyers, fiscal conservatives, and even law enforcement administrators, some version of the following idea is repeated: that because we as a society disinvested in public health, particularly mental health institutions during the 1960s, the sick and poor are now finding themselves within the purview of criminal justice institutions.
The idea actually rests on three related, but distinct theories about our largest public institutions: the thesis of “deinstitutionalization,” “retrenchmentcriminalization,” and “mass imprisonment.” In what follows, we consider each of these explanations and how they fail to fully account for important empirical trends.
Myth 1: Deinstitutionalization Leads to the Medicalization of Prisons
Scholars have identified the closure of state hospitals in the 1960s as a development that affected many different aspects of US society. Indeed, between 1950 and 2000, the number of people with serious mental illness living in psychiatric institutions dropped from half a million to 50,000. We can call this the “deinstitutionalization” thesis; that because of society’s failure to provide adequate traditional healthcare, housing, and social support outside of jail, persons who end up arrested are now sicker than they used to be. The idea is that the mentally ill engage in behaviors that make it likely they spend time in spaces that put them into contact with law enforcement and that new laws criminalize the behaviors that they tend to engage in (disturbing the peace, loitering, drug use, etc.).7
A key problem with the deinstitutionalization thesis is that it does not explain administrators’ willingness to provide healthcare resources in jail. The closure of mental health institutions in the 1960s does not explain why healthcare resources inside of jails in any form (whether they be therapeutic services, healthcare personnel, hospital bills, or psychiatric services) now make up large portions of jail budgets. For instance, D.C.’s jail system spent $33 million on medical services (a quarter of its budget in 2012), Chicago’s healthcare department spent $100 million for jail healthcare in 2016, which was in addition to the Department of Corrections’s own $327 million budget, and the New York City jail’s spending on healthcare per inmate grew by 175% from 2010 to 2020. While representative statistics on jail expenditures
on healthcare and mental healthcare are notoriously difficult to acquire, we can indirectly measure such spending through staffing levels. In the only two years that comparable statistics are available in the national jail census, healthcare workers in the largest jail systems grew from 2380 personnel in 1988 to 4214 in 1999.8
To think that such resources are related solely to the number of people who suffer mental illness in the jails would be naïve. Why not simply let the mentally ill languish untreated in jails? These numbers relate to the willingness of jail administrators to pay the salaries of medical professionals who work in their jails, to pay for mental health treatment areas that must be accredited, and to invest in continued diagnosis of individuals during their jail stays. For instance, as we shall see in Los Angeles County, we can quite easily trace a move from the denial of a medical problem in the county jails in the 1980s, to the acknowledgement of the problem by 1990, to major action taken on the problem in 1997, to major appeasement of courts on the issue in 2015.
Myth 2: Declining Public Health Expenditure
The deinstitutionalization thesis is usually linked to what we can call the continued “retrenchment-criminalization” of social welfare institutions. Rather than simply emphasize the closure of state hospitals in the 1960s, this thesis would explain the decline of medicine in public hospitals with the attempt of politicians since the 1970s to curb social expenditures. This has meant the retraction of social protections, especially the widespread closure, downsizing, and privatization of public institutions that serve the poor. Scholars point to two developments: the application of market rationality to public institutions and the racialization of public spending. Concerning the former, a major political movement transformed what we think of as good governance, that legitimacy is gained when public authorities make prudent choices that lead to “returns on investment,” rather than investment to alleviate human suffering (Schram 2015; Brown 2015). Concerning the latter, the idea is that both national political parties took advantage of popular fears concerning the civil rights movement, urban riots, and social spending during the 1960s that was perceived as favoritism toward the urban poor and people of color. “Irresponsible” spending on welfare was racialized through media images of “welfare queens” and “deadbeat dads” and other images of black and brown persons abusing taxpayer money (Crafton 2014; O’Connor 1998; Block et al.
1987). More or less, both movements are thought to have led to the dismantling of the welfare state.
Scholars have also linked continued retrenchment to the use of crime control techniques or “criminalization” to restrict access to what remains of public institutions. The best-known examples are the use of policing techniques in urban public schools and welfare offices, which have been well documented to use new methods of surveillance, supervision, and deterrence that have led to an increase in the number of expulsions and arrests from both schools and welfare roles. These are instances of what law scholar
Jonathan Simon describes as the emergence of crime control as a dominant frame in public policy: in many cases this has meant interpreting the behaviors of the poor as related to criminal activity—especially drug abuse— testing for it, and using it to disqualify them from services.9
While it might be tempting to apply the “retrenchment-criminalization” argument to public hospitals, the empirical story of spending on public healthcare is actually quite the opposite. From 1992 to 2008, national and state expenditures on Medicaid nearly tripled, rising from $116 billion to $339 billion, a 90% increase in inflation-adjusted dollars. The growth holds true even if we adjust for increasing healthcare prices (but diminishes to 53%). Spending on healthcare also grew as a proportion of all federal spending from 5% in 1992 to 7% in 2008 and of all state spending from 17% to 22%. Beneficiaries of Medicaid grew from 36 million to 59 million or 66% from 1992 to 2008 (Figure I.1). These increases even square with rising need: Medicaid spending per poor person in 2008 constant dollars nearly doubled, from $4,700 to $8,500.10
Astonishingly, exactly during the period of public hospital capacity declines, mechanisms were created to help funnel public money into urban safety-net hospitals. The Omnibus Budget Reconciliation Act of 1981 under Ronald Reagan allowed Medicaid funding to take into account the heavy share that safety-net hospitals took in providing uncompensated care. Through various mechanisms, such as Disproportionate Share Hospital funding and the 1115 waiver programs, states creatively used such programs to funnel dollars to their largest public hospitals, even when those hospitals were not in the most fiscal need. Over time, the 115 hospitals represented by the National Association of Public Hospitals, the nation’s largest urban public hospitals, became highly dependent on federal funds to keep their hospitals afloat. This is a story of resilience in public hospital funding in spite of major efforts to dismantle them.11
19921993199419951996199719981999200020012002200320042005200620072008
Figure I.1 Trends in Medicaid expenditures and enrollees per poor person, 1992–2008 (no enrollment data).
Source: Thompson (2012).
Myth 3: The Ever-Expanding Penal System
The deinstitutionalization and retrenchment-criminalization theses have been paired with what can be described as the thesis of “mass imprisonment.” The idea is that because governments have funneled so much public revenue into criminal justice organizations (e.g., police, criminal courts, jails, and prisons) they are increasingly becoming the site where the urban poor access social services. Megan Comfort calls this “carceralized aid,” or social support given to the urban poor on the condition that they enter into contact and surveillance of criminal justice institutions. There is a good reason to believe this as the number of people under correctional supervision grew from 1.8 million in 1980 to 7.1 million in 2005—when combined with those released but still bearing the stigma of felony records the number jumps to approximately 16 million. Many have characterized this growth as “mass imprisonment” insofar as the incarceration rate is now high enough and concentrated enough to affect an entire demographic group: poor men of color from large urban areas.12
However, it may be surprising to hear that the jail systems in America’s largest cities stopped expanding in the early 1990s and have been suffering from retrenchment ever since. The proposition that retrenchment has affected carceral systems is a surprising claim given that the vast majority of scholarship conceptualizes the criminal justice system as an ever-expanding institution with nearly limitless capacity to incarcerate.13
In reality, since the early 1990s, the nation’s largest jail systems stopped expanding, and jurisdictions developed inmate decompression methods to grapple with retrenchment. The situation is most poignant in the municipalities that inform the public imagination of jails: Los Angeles, New York City, and Chicago (Figure I.2). After jail populations exploded during the 1980s, inmate populations flattened in the early 1990s, and have been oscillating ever since; adding or subtracting 1,000 inmates annually, depending on the annual budget. This oscillation belies long-term declines: since the early 1990s, the number of inmates in Los Angeles fell from 24,000 to its presentday number of 14,000; in New York City, from 20,000 to 9,000; and in Cook County, where Chicago is located, from 10,000 to 6,000. While this situation is most significant in these three cities, it also characterizes the largest counties in the country’s top 50 metropolitan statistical areas (MSAs), which collectively represent 30% of the nation’s total jail population.14
County Los Angeles County New York County
Figure I.2 Jail populations in Cook County, Los Angeles County, and New York County, 1978–2015.
Source: Vera Institute of Justice.
Jail Population
This decline was no mere happenstance. The stagnation represents organizational decision-making amid deep fiscal uncertainty. Large urban jurisdictions innovated with new kinds of early release and “alternative to incarceration” mechanisms, including own recognizance release, home supervision, electronic monitoring, halfway houses, and emergency early release, among many other programs. Scholars of penal state have had difficulty incorporating these developments into their analysis of mass imprisonment.15
In total, while these three related, but distinct theses create important backdrops to the expansion of medicine in jails and its restriction in public hospitals, they cannot fully account for important countervailing trends. On the one hand, while jails began spending more money on healthcare, they did so at exactly the time they began suffering from unprecedented—and little acknowledged—retrenchment. This makes it difficult to square the idea that jailers had the wherewithal to take on the new modalities of medicine. On the other hand, in large public hospitals, the provision of medicine is becoming more restricted, but public spending on large urban hospitals has expanded. Thus, we have a much more complicated puzzle, worthy of explanation.
The New Evidence: Historically Embedded Ethnography
As we saw, our three existing theories fail to fully explain the transverse trends of large urban jails and large public hospitals. It is often the case that in place of actual histories of field sites, ethnographers of poverty governance institutions make use of broad theories—theories like deinstitutionalization, welfare retrenchment/criminalization, and mass imprisonment—to explain the origins of what they have found, even if those theories do not fully fit their cases.
The alternative this book proposes is to tie our ethnographic puzzles to archival history. We can call this method of theory building “historically embedded ethnography.” While I discuss my methods in greater detail in the Appendix to this book, this is exactly what I did. I spent a year in a jail intake room observing the workers collaborate to process inmates into and out of the jail. I watched from areas closed off from inmates, watching and interacting with clerical staff, medical professionals, deputies, and risk-assessment officers behind Plexiglas as they carted files, conducted interviews, and collaborated to decide where inmates should be housed in the jail. I observed the
