The effort to put family caregiving and direct care workers at the top of the nation’s healthcare agenda has been a long time coming. As with all things of a policy nature, the prospect of funding has raised the tone and volume of this conversation. The Biden administration’s pledge to commit billions of dollars to improve care to disabled and aging adults promises to create a new approach to caring for our most vulnerable and neglected populations. It also addresses the terrible economic toll that caregiving takes on women, whether interrupting and shortening their careers, or through suffering terrible pay and working conditions as employees in direct care, one of society’s most invisible and least understood industries.
A silver lining to the otherwise horrific COVID-19 epidemic has been the big reveal that our public health system is in shambles, and must be almost completely rebuilt. But the new public health structure cannot be allowed to incorporate the same structural inequities and disparities found throughout the present system, disparities that have been part of the system from the very beginning. The new initiative, funded by a massive public expenditure, must get to the very core of what makes disparities so endemic and ineradicable: healthcare in this country is commerce. Everything is grounded in economics, which is to say, business ownership. The marginalization of Black and Brown people as healthcare recipients mirrors their historic marginalization in the American economy.
While it is righteous to demand a living wage for Black and Brown direct care workers who endure untold suffering because of the family pressures, stress, and physical risks that come with their poorly paid jobs, increasing hourly wages is itself little more than a marginal improvement economically speaking. The United States is estimated to have spent more than $4 trillion on healthcare in 2020. In this vast and lucrative industry, the real advance, the real equity, is to increase Black and Brown business ownership in the healthcare industry. The massive injection of public funding about to take place provides a perfect opportunity to do this. There must be in the overall spending scheme, a plan to capitalize Black and Brown enterprises, especially in basic healthcare support services, which will increase exponentially in the emerging home-based healthcare system.
Research repeatedly shows that one of the worst cultural features of our healthcare system is the lack of cultural diversity among providers. That’s because providers are business owners. Discrimination has prevented Black and Brown people, especially women, from becoming business owners. They are bracketed within the subordinate ranks of employment, regardless of pay. An innovation that will reduce both discriminatory behavior and disparity is increasing the number of Black and Brown owners in the provider ranks. That is where norms are fashioned and decisions are made that perpetuate race discrimination and disparity. It is all well and good to talk about equity in healthcare. Practically everyone is for that. But equity is not achieved at the margins. It requires restructuring the core. The core of American healthcare is business. There is no equity without ownership.