Welfare State Replacements: Deinstitutionalization,Privatization and the Outsourcing to Immigrant Women Enterprise

Abstract

The U.S. government has a long tradition of providing direct care services to many of its most vulnerable citizens through market-based solutions and subsidized private entities. The privatized welfare state has led to the continued displacement of some of our most disenfranchised groups in need of long-term care. Situated after the U.S. deinstitutionalization era, this is the first study to examine how immigrant Filipino women emerged as owners of de facto mental health care facilities that cater to the displaced, impoverished, severely mentally ill population. These immigrant women–owned businesses serve as welfare state replacements, overseeing the health and illness of these individuals by providing housing, custodial care, and medical services after the massive closure of state mental hospitals that occurred between 1955 and 1980. This study explains the onset of these businesses and the challenges that one immigrant group faces as owners, the meanings of care associated with their de facto mental health care enterprises, and the conditions under which they have operated for more than 40 years.

Keywords

U.S. deinstitutionalization privatization welfare state replacements Filipino women long term care residential care facilities mental health care services labor force conditions immigrant entrepreneurship

Of the approximately 246 million adults in the United States, an estimated 9.8 million have been diagnosed with a severe mental health condition.¹ Since the deinstitutionalization era that occurred in the United States between 1955 and 1980, scholars have critiqued the state for failing to provide sufficient community mental health and health care centers and public long-term housing alternatives.^2–4 Such policy changes particularly affected low-income, underserved groups with little social support. After the closure of public state mental hospitals, these displaced individuals have become part of the growing U.S. aging population and have spent much of their lives on the streets, in and out of family homes and psychiatric hospital wards, locked up in prisons across the country, or contained in privately owned long-term care facilities, such as nursing homes and residential care facilities.^3,5–11 Currently, there are 51,367 licensed residential care facilities (1,233,690 beds) across the nation. (Residential care facilities provide room and board, meals, supervision, custodial care, and health-related services, such as medication management. This number includes facilities that care for individuals with chronic illnesses such as severe mental illness, dementia, and physical disabilities.)¹² A sector of these facilities (also known as assisted living and board and care homes), along with nursing homes and prisons, have replaced the function of the mental state hospital as de facto mental health facilities.^{3,5,6,8–10,13–16} A growing but overlooked number of the smaller-sized residential care facilities that oversee and care for both younger and older adults diagnosed with a severe mental health condition are owned and operated by racial minorities.^17–20

This is the first study to examine how immigrant Filipino women emerged as owners and operators of businesses that provide long-term care services to this aging population after the massive closure of state mental hospitals and the privatization of the welfare state. To explain this onset, this article highlights the formation of a stratified, increasingly two-tiered U.S. long-term care industry and the assemblage of Filipino-owned enterprises in the second-tiered market. Given the marginality of their businesses, this study also explains the challenges that immigrant Filipino women faced as owners, the meanings of care associated with their businesses, and the conditions under which they operate in order to provide long-term care services.

Previous Research

U.S. Welfare State and Social Contract

The term “welfare state” refers to a “collection of programs designed to assure economic security to all citizens by guaranteeing the fundamental necessities of life: food, shelter, medical care, protection in childhood, and support in old age.”²¹ Historians underscored that the U.S. welfare state includes an extensive range of private organizations that are government subsidized to provide direct services.^21,22 Katz argued that, instead of developing a robust welfare state in which the government takes on direct responsibility for its citizens’ social welfare, during the era after Nixon to the Reagan administration (mid-1970s to 1990s) the U.S. social contract with its citizens became heavily mediated by three conditions: the devolution of authority to the private sector and the promotion of smaller government, an enduring war on dependence and the “undeserving poor,” and the advancement of market-based models to social policy.²¹ Estes argued that three dominant perceptions of reality influenced social and public policies, particularly in relation to aging and disabled populations during this time, including the political declaration of a federal fiscal crisis that conjured up psychological uncertainty among the American public and stirred intense debates around the dismantling of major social programs.²³ The second perception related to powerful rhetoric around decentralization and getting the federal government “off the backs” of people stimulated the view that state and local government and the private sector can instead solve issues related to disadvantaged groups. The third perception included the popular view that old age is simply an individualistic and biological issue.²³

However, scholars argue that welfare spending does not impede economic growth, but instead divestment has led to the rapid rise in health care costs, lower educational attainments, and the increase in economic inequalities in the United States.²⁴ Depending on the time in history and U.S. administration, the welfare state has been described as “reluctant” because of the underlying contradictions around the social welfare system as both generous and punitive, which have led to the repressive treatment of marginalized groups.²⁵ After the U.S. deinstitutionalization era, social scientists argued that the driving forces that characterized the mental health system included the fiscal “crisis” of the state that led to the transfer of fiscal responsibility to the federal government and restrictions on government and insurance reimbursements to predominantly private entities.^3,15,16,26 Other scholars emphasized the influence of certain industries (i.e., nursing home, residential care, drug companies), the overwhelming power of the profit motive, and professional vested interests in maintaining the medical model that disguised the underlying root causes of sickness, such as poverty and social inequalities.^{3,4,15,26–28}

Filipino Women Labor in U.S. Health Care and Long-Term Care Industries

Historically, immigrant Filipino women nurses were heavily recruited to the United States and often assigned less desirable work shifts and paid lower wages than their white American nurse counterparts.^29–32 One major consequence of this globalized heavy recruitment of a “cheaper” nursing labor force was the funneling of jobs, information, and the health industry as an “ethnic niche” for Filipino immigrants in general.³³ The concentration of immigrant Filipino laborers grew in both health care and long-term care related fields in the United States. In addition to working as nurses in hospitals, they can be found laboring in nursing homes, residential care facilities, and private households as therapists, medical technicians, and formal caregivers.^19,31–36

A growing body of research has focused on the increasing role that immigrants (particularly women) play in providing long-term care services to the rising U.S. aging and disabled populations in need of formal support.^19,36–43 Additionally, the National Survey of Minority Business Enterprises show that business ownership for Filipinos grew 51% (128,223 to 193,336) from 2002 to 2012.⁴⁴ Of the 193,336 Filipino-owned enterprises in 2012, more than half of them (98,849) were operated by women.⁴⁴ The majority of these enterprises are found in the health care and social services sector, which accounts for approximately one-third (33.4%) of Filipino-owned business revenue. A study published in 2007 found that Filipino immigrant women operated 97% of the 563 licensed residential care homes for older adults in Honolulu, Hawaii.¹⁹

More recently, scholars have made the case for examining ethnic entrepreneurship from an intersectionality perspective.⁴⁵ This approach (made prevalent in the social sciences by Patricia Hill Collins) provides a more complex understanding of the simultaneity of privileges and oppressions shaped by various historical processes and policies (e.g., social policies, immigration policies) intersected with social locations, including gender, race/ethnicity, class, and citizenship. These complex dynamics influence access to different forms of capital and the types of businesses that immigrants establish. Stemming from previous works on the U.S. welfare state and the enactment of government-funded policies that subsidized the private sector intersected with the globalized market demand for “cheaper” immigrant labor forces; this article aims to examine how the culmination and intersection of various social forces shaped the emergence of immigrant Filipino women owners and operators of de facto mental health care facilities that serve as welfare state replacements after the U.S. deinstitutionalization era.

Methods

This study draws from a more extensive qualitative research study conducted in Southern California of 25 Filipino women owners, 25 co-ethnic employees, and 18 supplemental interviews with other long-term care industry stakeholders and ancillary providers. For the purposes of this paper, I will only discuss findings related to the 25 Filipino women owners and their interactions with other industry stakeholders and ancillary providers. Among the 1,844,000 Filipino immigrants in the United States, 44.8% live in California and the largest concentration (606,657) of Filipinos in general (immigrants and native born) is found in Southern California counties (e.g., Los Angeles, Long Beach, Riverside, San Diego).^46,47 California has the largest and fastest growing formal care workforce in the country, the majority of whom are foreign-born women of color.⁴⁸

Of California’s approximately 36.8 million residents, the National Alliance on Mental Illness (NAMI) asserts that close to 1,175,000 adults (3.9%) live with a severe mental health condition.⁴⁹ According to the California Health Care Foundation, nearly 1 in 20 California adults have a serious mental health condition.⁵⁰ Availability of affordable housing and supportive services is considered one of the biggest challenges that this population faces.⁵¹ I identified Filipino owned and operated long-term care businesses in various cities around Southern California using a snowball sampling method. Since no established databases identify the racial/ethnic make-up of health and long-term care business owners, the snowball sampling technique is most appropriate in locating such operators. This method entails locating and collecting data on a few members of the target population and attaining references for other potential study participants. I was referred to business owners through mental health social workers and hospital discharge planners, attending administrator licensing courses and continuing education unit seminars for long-term care operators, and through friends and relatives. All interviews were conducted using open-ended and semi-structured questionnaires. The participant was made aware that all interviews were confidential and all information obtained will not be used in a way that risks identification. Upon consent, interviews took place and were recorded at the participants’ choice of location. Interviews were conducted in English and Tagalog. The interview time was ranged from one to two hours in length. All audiotapes were transcribed and immediately erased and discarded at the end of project to ensure participants’ confidentiality.

Filipino women owner respondents were asked about their migration process to the United States, educational and work background, social class background, and various forms of capital that assisted them in becoming entrepreneurial. Respondents were also asked about their exposure to entrepreneurial opportunities, formal and informal networks, daily business operations, as well as opportunities and challenges they experienced as operators of their respective long-term care businesses. The transcribed interviews were read line by line and coded for the following themes: how structural forces and agentic processes created an entrepreneurial pathway, the types of long-term care business that respondents owned, resident/patient populations served, and the opportunities and challenges of being an owner. Other themes also referred to the different types of meanings that respondents attributed to their respective businesses and the care they provided as well as the conditions under which they provided such services to various younger and older adult and disabled populations.

Findings

Prior to business ownership, 21 out of 25 of the immigrant Filipino women entrepreneurs in my sample were nurses or had a health-related occupational or educational background (e.g., pharmacist, social worker, dentist, medical and pharmacist technician), while four of them were teachers, administrative assistants, or real estate agents. All participants were heterosexually married and had children. The majority of Filipino women entrepreneurs stated that they went into the business with their respective husbands. However, the women participants reported that since they had a health care–related occupational background, they became the officially designated licensed administrator instead of their spouses.

Of the 25 immigrant Filipino women entrepreneur respondents, I found that 19 of them were owners and operators of government-subsidized (e.g., Supplemental Security Income (SSI), Medicare, Medi-Cal) long-term care businesses, including 14 residential care facilities for both younger and older adults, 3 home health care agencies, and 2 adult day care centers who oversaw the health and long-term care of an impoverished aging and disabled population. Six of the immigrant Filipino women in the study owned residential care facilities and home care agencies that catered to the more affluent, private-pay clientele. They provided care to older adults who could afford services without assistance from government subsidies. I found that these immigrant Filipino women businesses served as a less expensive alternative to the corporate businesses that predominantly served wealthier populations as well.

Owners of government-subsidized residential care facilities and adult day care centers reported that the primary diagnosis of their clientele was a severe mental health condition, particularly schizophrenia, bipolar disorder, or depression. Home health care agency owners reported that a substantial part of their business revenues came from contracting with co-ethnic-owned residential care facilities and providing medical related services to their residents with severe mental health condition. Among the spectrum of long-term care businesses that respondents have owned and operated, the earliest business was a residential care facility for younger adults (ages 18–59), purchased in 1974. Overall, the number of years in operation for the businesses in the study ranged from 13 to 42 years; some of the earliest businesses purchased by the study respondents from white/Caucasian previous owners were government-subsidized businesses that catered to individuals with severe mental health conditions. The businesses in the study were specifically located in mostly low-income sectors of certain counties and cities in Southern California, including San Bernardino, Riverside, Redlands, Loma Linda, Hesperia, Perris, Garden Grove, Westminster, Torrance, East Los Angeles, Lomita, Valencia, Newhall, Rosemead, and San Diego.

Welfare State Replacements

I define welfare state replacements as government-subsidized, small and medium sized enterprises that have replaced the state as direct service providers by stepping in to meet the needs of some of the nation’s most underserved populations resulting from austere welfare state policies. The phenomenon of ethnic enterprises playing a role as welfare state replacements in the long-term care industry is rooted in and characterized by three factors: (1) The lack of a universal provision of long-term care, the outsourcing of direct care services, and privatization of formal long-term care services in the United States signified the advancement of a privatized social order and a scaled-down welfare state. (2) Increased bifurcation within the privatized long-term care industry has occurred. Even though private enterprises were government subsidized to provide long-term care services, many of the corporate-owned businesses preferred to cater to the wealthier sectors of society and accepted more profitable private-pay individuals. (3) Immigrant entrepreneurs, particularly immigrant Filipino women, have stepped in to meet the long-term care needs of the less profitable, government-subsidized individuals that resulted not only from a retracted, austere welfare state but also from corporations preferring to provide long-term care services to a higher payer mix that optimized their reimbursements. According to my findings, recruited immigrant Filipino women nurses who served as a cheaper labor force in the 1960s were some of the earliest long-term care business owners in Southern California.

This distinct kind of immigrant entrepreneurship emerged after the deinstitutionalization era and the enactment of Medicare, Medicaid, and Social Security government-funded policies in the 1960s and 1970s. Previous scholars have critiqued these policies because individual states did not allocate these federal dollars to build more public hospitals, community mental health centers, and public housing settings.^3,16,52,53 Instead, these dollars were used to attract for-profit enterprises to encroach into the public sector. Hence, the U.S. long-term care political economy characterized by the privatization of public sector programs and the outsourcing of direct care services began. As a result, control of tax-funded programs shifted from the public to the free, unregulated market and the private sector, where they were used to generate profits in the name of “increased choice” and “efficiency.”^54–56

However, researchers assert that a stratified, increasingly bifurcated, two-tiered hierarchical model of U.S. health care and long-term care industries have since formed.^57–60 In other words, the top tier caters to more affluent, upper- and middle-income sectors of society and the lowest tier is reserved for the poor with very limited resources and relies on government subsidies. For example, Mor and colleagues found that the U.S. nursing home industry has become a two-tiered system consisting of upper-tiered facilities with high proportions of “dual eligibles” (i.e., Medicare and Medicaid beneficiaries) and private-pay residents, whereas the lowest tier facilities mostly consisted of providing care to those who only qualify for Medicaid benefits. They found that private-pay individuals are far less likely to choose to live in facilities where the majority of residents are labeled as having severe mental health conditions, which limits those facilities to lower-income residents receiving government support and further contributes to patterns of segregation.⁵⁸

Many residential care facilities are owned and operated by corporations and cater to more affluent, private-pay clientele.^12,61,62 Some of the largest corporate and chain-owned residential care businesses include Sunrise Senior Living, Emeritus, and Atria Senior Living. For example, Sunrise Senior Living is a conglomerate of 300 facilities that can be found in three countries, including the United States, the United Kingdom, and Canada.⁶³ These corporate-owned businesses mostly do not accept government-subsidized assistance as a form of payment. In California, the median annual base rate to reside in these types of facilities is $44,520.⁶⁴ This rate can fluctuate based on the kind of accommodations and the custodial care services needed. Many of these corporate-owned assisted living facilities tend to cater to and accept more profitable private-pay individuals.

Therefore, immigrant Filipino women-owned, long-term care businesses have become welfare state replacements by directly overseeing the long-term health and illness of impoverished individuals diagnosed with severe mental health conditions and/or chronic physical disabilities and by providing custodial care, medical care, day care, and housing. The sustainability of these welfare state replacement businesses is based on providing cheaper care services; accepting fixed, lower government-subsidized reimbursements; and attaining overall decreased profit margins. Such circumstances posed various challenges for these immigrant women entrepreneurs.

Challenges of Care: Compulsory Compliance despite Racist Interactions with State Agents

The owner respondents were asked, “What are some of your biggest challenges in running your business?” The data indicated that some of the most significant challenges that the majority of government-subsidized immigrant Filipino women entrepreneurs experienced were dealing with the stress and anxiety concerning the scrutiny and pressures from state and federal agents around attaining and maintaining their operating licenses as well as sustaining their businesses on limited, fixed, state or federal government reimbursement rates.

On October 22, 2013, I attended a meeting sponsored by the one of the Southern California Departments of Mental Health and Social Services that hosted two state licensing agents. The purpose of the meeting was to provide an opportunity for those involved in overseeing and caring for long-term care populations in formal institutions to discuss their concerns and pose questions. Residential care owners and administrators, managers and supervisors of mental health related clinics, social workers, behavioral therapists, and psychiatrists who worked with long-term care populations in these state-licensed formal institutions attended. However, I observed that many of the immigrant owners rarely asked questions or shared concerns with the hosts regarding state licensing practices. Instead, the moderator (a state-employed behavioral specialist) asked the majority of the questions and led the conversation. State licensing agents provided an overview of their roles; discussed the growing need for more residential care facilities that provided care and supervision to the low-income, chronic mentally ill population; and stated the top three cited complaints and violations regarding residential care facilities. These three complaints included severe neglect of residents, financial disputes regarding refunds when a resident leaves a facility or passes away, and unlicensed facilities that take in residents who are in need of a higher level of care. Nevertheless, the majority of operators who were immigrant women (e.g., Filipino, Latino, Haitian/Creole) in attendance did not question these types of complaints or share any further opinions on such matters. My findings below may assist in elucidating why this may have occurred.

The majority of the participants in my study emphasized their compulsory compliance as well as rather contentious interactions they had with their state-licensing analysts and federal surveyors. For example, one of the nurse participants, Lita, 44, who owned a government-subsidized residential care facility for the elderly in Westminster, California, stated,

“Oh licensing … they are terrible! It’s just so stressful.” Plus, this is SSI. Nobody takes SSI anymore! She [licensing analyst] even says, “can I talk to your staff in private?” I never see that and so I asked. But she wanted to talk to them privately without me. I think they wanted to see if they have papers. I said that was fine, go ahead! I asked my staff afterwards and talked to them. Licensing really asked them when did they start, their ID, and stuff like that. She even went to the, umm, the grocery cabinet to see if it’s full. She borrowed the stool and looked at the top of all the shelves! All I could say, do what you have to do! They are checking the expiration date, and … and they also see if there’s enough food or are we just putting the food toward … like … the front, so, like nothing behind. She wants to see if we are just trying to make it look full but, but it’s not really … you know what I’m saying. Then I remember, she said, “Because we learned from you guys.” “What does that mean?! You can’t generalize … I sometimes want to kind of … like say something to them! But I just let it go …”

Another participant, Crespina, 62, who owned a government-subsidized residential care facility for the elderly in Riverside, California, stated,

Licensing can close you down, so we just follow the regulations … we follow and try to just get along. We just do the best we can and give them whatever they ask when they come … like the charts, also the medication records, paper works, everything … umm … they even go through all our personal files too … social security numbers, driver’s license … they are like that.

Alicia, 74, an owner of a government-subsidized home health agency in Los Angeles, recounted a contentious statement made by a Medicare surveyor during an unannounced federally mandated inspection,

I remember one of the surveyors was … was really really bad. He was saying that the Filipinos, they are second to the Armenians. He said something like … oh that the Armenians are #1 in Medicare fraud and Filipinos are #2! … I mean, we know it happens, we see it in the news you know, there is a Filipino on the news like I think almost two-three years ago … not sure, but she went to jail, but I think she’s already out now. Hmmm … well, what can you say, it happened. But not all of us are doing like that … it’s embarrassing for the Filipinos when you hear it …

Long-term care scholars have often argued for more policy regulations related to the increase of inspections and oversight for these types of businesses in order to ensure patient/resident health and safety.⁶⁵ Also, they have written extensively on the need for more staff members as well as better training and education for them to adequately care for the U.S. long-term care population.^66,67 Other social scientists have addressed the consequences of social control,⁶⁸ the political economy,^4,27 medicalization, and social stigmatization^3,15,26,28 of individuals labeled as “mentally ill.” All are important contributions to the literature. Much less research has examined the immigrant and racial/ethnic minority long-term care labor force and how the industry is embedded in larger structural processes that have shaped these contentious social interactions and the certain meanings attributed to immigrant Filipino-owned long-term care businesses.

Meanings of Care: “Armenians Are #1 in Medicare Fraud and Filipinos Are #2”

Individuals do not simply respond automatically to social situations but interpret, negotiate, and define each other’s actions through the use of shared symbols such as words, gestures, and language.⁶⁹ The symbolic interactionist perspective focuses on the ways in which individuals and groups generate, maintain, and transform subjective meanings and perceptions in our everyday social lives.⁶⁹ Hence, how the state and federal agents interacted with Filipino women owners emphasized the kinds of meanings they assigned to these ethnic-owned businesses and specifically how they viewed the individuals who operated them.

In extrapolating from the above-mentioned excerpts, federal and state agents viewed the respondents as not only potentially providing low-quality care, but providing care fraudulently as well as “illegally” through the suspected hiring of undocumented immigrant employees. Lita and Crespina’s statements elucidated how state-licensing officials unlawfully searched through legal documents and conducted private interviews with employees to confirm citizenship statuses. Lita and Alicia’s statements also provided a more in-depth example of the types of scrutiny that occurred and a confrontation that became overtly racialized via the statements, “we learned from you guys” and “Armenians are #1 in Medicare fraud and Filipinos are #2.”

However, the largest example of Medicare fraud in the United States occurred in 1996 and involved a huge transnational corporation made up of approximately 300 hospitals and surgery centers in the United States and the United Kingdom. Hospital Corporations of America (HCA) was found guilty of various fraudulent activities, such as providing monetary benefits and kickbacks to physicians for eliciting and referring new patients to HCA, performing false billing practices by fabricating procedures, and inflating diagnoses in order to attain larger Medicare reimbursements.⁷⁰ Unlike the immigrant Filipino women mentioned in Alicia’s statement, in the case of HCA, the corporation avoided criminal charges by paying close to $2 billion in settlement fees. Rick Scott, the CEO of the corporation, was forced to step down from his position but was never personally charged with any wrongdoing. Instead, he went on to become the governor of Florida and has been in this position since 2011. This example emphasizes the enormous inequity in power and influence of large corporations who find themselves above the law while specific ethnic businesses are marked as criminals. The meanings placed on specific ethnic groups emphasize the contradictory tensions surrounding immigrant labor in the United States.

Anti-immigrant rhetoric has long been rooted in an individualist, ahistorical argument that blames immigrants (both undocumented and documented) for certain social “ills” of this country. They are accused of taking away American, native jobs; depressing wages; abusing the health care, educational, and welfare systems; and not paying taxes. However, there is an inherent paradox within this type of conventional ideology that simultaneously supports both nativism and a privatized, free market agenda. It is important to emphasize that the majority of immigrant Filipino women-owned businesses in my study are situated within a peripheral, second-tiered market, and their major reliance on fixed government subsidies is particularly salient. This phenomenon illuminates not only that their mobility is limited but that they do not operate under the auspices of a supposed unfettered capitalist market. Also, the celebratory notions around privatization of social policies leading to “liberalization,” “choice,” “efficiency,” and “free markets” is in fact misleading because it masks the reality that markets are not “free” but rather dominated by powerful institutions whose main objectives are the pursuit of more profits, including through the exploitation of cheaper labor forces from less “developed” countries.^71–73 As these immigrant labor forces attempt to pursue upward socioeconomic mobility by becoming more entrepreneurial, they are faced with various stressors to sustain their long-term care businesses, and this is reflected in the conditions under which they provide care.

Conditions of Care: Operating on Below Poverty Level Government Budgets: $33 per Day

As mentioned earlier, private-pay individuals are much less likely to choose to live in facilities where the majority of residents are labeled as having a severe mental health condition and therefore this contributes to second-tier providers becoming increasingly dependent on government reimbursements.⁵⁸ These reimbursements served as a major challenge for immigrant Filipino women owners.

For example, one of the nurse participants, Crespina, 62, who owned an 82-bed government-subsidized residential care facility for older adults stated, “Well, we are only doing SSI. There been barely any increase in four years for the residents. We try to do the best we can, but we are limited too, and it sometimes can stress you out.”

Interviewer: What can stress you out?

I mean, well you have to worry about so many expenses like the food, supplies, and the monthly bills and not just that, how about the … the property tax, the workers comp, and the different insurances for the building … and also the staff, make sure they are paid too. We also have to take care of the upkeep of the building, changing furnitures when they are not good anymore … also … oh and how about the vehicles we use to drive clients to doctors’ appointments … like that. You see … there’s really a lot, and you have to make sure you can make it every month.

Another respondent, Marytess, 45, who also owned a government-subsidized residential care facility for older adults stated,

Trying to fill up the facility and trying to break even because you’re only getting SSI … it took us five years to really feel comfortable. Hmm … you’re also always trying to be building good relationships with social workers, conservators, doctors, everyone who possibly having a connection to referring clients, and just balancing all aspects of the business I guess … like also the marketing, the accounting, the administration of it, and just doing all that and at the same time taking care of the clients and following all the regs. When licensing and ombudsman would come, I’m always thinking, why are they here?! Did I do something wrong? … you know it’s like a lot of second guessing thinkings, even though you’re trying to do all of this and so … umm … it’s … it can be very stressful too, the behind the scenes to running something like this.

The above-mentioned examples pointed to challenges related to operating on limited, fixed government-subsidized budgets. Their revenue and profit is completely based on “filling up the facility” and staying within a meager monthly budget, while feeling intimidated and antagonized by state officials and employees. The majority of their residents had a severe mental health diagnosis and received SSI and Medicaid benefits. These means-tested federal and state benefit programs attempted to provide modest monthly cash benefits and access to health care services for low-income individuals who could not afford to meet the basic needs of subsistence, such as food, housing, and medical care. However, similar to a study done on the inadequate Medicaid funding for nursing home care,⁷⁴ SSI rates may in fact also be lower than the actual costs of providing care in a residential care setting.

In the year 2012,the monthly benefit that residential care owners received per month was a fixed rate of $993 per resident to provide services in California.⁷⁵ On average, immigrant owners of residential care facilities reported that they operated on an annual budget of approximately $11,916 ($993 x 12 months) per individual resident to provide care and supervision, room and board. They received an average of $33 per day to provide a resident with a shared room, assistance with daily living tasks (e.g., grooming, bathing, toileting), housekeeping, three meals and two snacks per day, medication management, daily activities, medical appointment coordination, and daily transportation. In other words, they were operating on a fixed, fiscal budget that was well below the annual poverty threshold level ($15,103) set by the U.S. Census Bureau’s Supplemental Poverty Measure report for individuals without dependents.⁷⁶ According to the Glasmeier Living Wage Calculator, their budget per resident made up just a little over half (52%) of the overall estimated annual income necessary ($23,295) for an individual to afford basic living expenses in California. (Calculator created by Ann K. Glasmeier, an MIT professor of urban planning.)^77,78 Just for a crude comparison, a room at a Motel 6 in San Bernardino County (a lower-income county in California) costs $45–$59 per night. In the same county, it costs $39 to board your pet in a shared kennel and $49 for your pet to be in a private suite per night.

Given such constrained budgets, all 14 of the owners of government-subsidized residential care facilities reported that they took on extra care work shifts and often asked their employees if they could also work overtime. Six of these owners reported that they actually lived in the facility with their families and occupied one of the bedrooms, especially in the first few years of operating their respective businesses.

Regina, 43, discussed how she could not afford to initially hire any staff members. She shared some of the challenges she faced when she first opened her six-bed residential care facility:

When I first opened my board and care in 2006, I remember sleeping on the floor by the door for two weeks straight because one of my first residents would wake up in the middle of the night and keep saying “Help me, help me …” But she was confused, physically unstable, so I was afraid she might fall … I told her daughter that it was so difficult for me to care for her, but her daughter did not have anywhere else to take care of her because of her SSI. So I took care of her for almost a year. So I was the employer, caregiver, licensee, maid … you name it! Sometimes you know the kids are fighting too and you’re in the middle. They only pay $1500 but want best care. Some of them, some of the kids tell you, do your job, that that’s what we’re paying you for … and they don’t even know how hard it is to take care of mom.

(This is an example of a family privately subsidizing the SSI rate. Combined with the government subsidy, this particular resident and her family paid $1,500 for care services per month. However, the vast majority of respondents in the study stated that they did not receive additional funding from their care recipient’s relatives.)

Aside from living in their facility or taking extra care work shifts, many of the respondents stated that they managed their budgets and made a profit by buying various items in bulk, such as different foods and supplies at various discount stores (e.g., Food for Less, Costco, Marshalls, and 99 cent stores). They bought secondhand furnishings at Goodwill or negotiated deals with discount furniture stores often owned by other immigrant groups. Overall, many of the respondents practiced self-exploitation, particularly in the first few years of starting their businesses. In other words, they would labor as the “employer, caregiver, licensee, maid … you name it!,” sleep and live at their respective businesses, and accept below poverty level reimbursements that other privately owned entities were adverse to taking. Taken together, these findings emphasize the challenges, meanings, and conditions that immigrant Filipino women experienced to own and operate their businesses in the second-tier market of the U.S. long-term care industry.

Conclusions

The immigrant Filipino women in the study have strategically extracted and agentically benefited from their health care professional backgrounds as well as their group’s social class, particularly resources from their middle class and professional backgrounds, to pursue entrepreneurship. Historical and structural forces, such as the Americanized nursing training and education programs during U.S.–Philippine colonial rule and the 1965 U.S. Immigration Act, have also considerably impacted the development of this form of immigrant enterprise around health and long-term care services. Particularly, they played a significant role in selecting certain classes of Filipino women to migrate at certain times in history, since 1965 immigration policies favored those with professional skills, high levels of education, and vocational training.^31,79 Thus, the combination of these intersectional forms of resources and capital has significantly contributed to the agency and emergence of immigrant Filipino women entrepreneurs in the U.S. long-term care industry for more than 40 years.

At the same time, many of the Filipino immigrant women in my study became entrepreneurs by becoming private owners and operators of government-subsidized businesses located in the peripheral market sector, which highlights their constraints as business owners and underscores salient structural inequalities in general. Namely, their path to entrepreneurship was based on stepping in to serve as direct providers and deliver care to some of the most vulnerable populations in the United States after the deinstitutionalization era and the government failure to provide sufficient long-term housing and community mental health and health care services. My findings reveal that the state has not only shifted the responsibility but simultaneously displaced the blame that has kept the focus off the failures of the state to sufficiently fund and directly provide social welfare and social protections for some of its most marginalized citizens, made even more vulnerable due to the consequences of today’s social policies.

Furthermore, I found that the experiences of immigrant Filipino women reflected the challenges and limits of their social, political, and economic mobility as immigrant entrepreneurs and their role as welfare state replacements. These immigrant Filipino women business owners are held primarily responsible and perennially cited in violation by state and federal workers for not being able to provide “good,” “quality” care on below poverty level budgets. These perceptions are influenced by various dominant sociocultural paradigms around immigration, gendered care work and labor, social class, and entrepreneurship. Such social processes have directly impacted the human (inter)actions among care providers, care recipients, and those around them (e.g., state and federal agents, social workers, and family members) that occur within and around the U.S. long-term care industry. Yet, the meanings and the conditions of care attached to the vulnerable, disenfranchised populations and their displacement into immigrant-owned long-term care businesses are not due to a series of random outcomes but rather are the result of intersecting and recurrent patterns of inequalities in the United States. The on-the-ground tensions that mirror these disparities perpetuate certain meanings and perceptions that supersede and shroud the necessary, more difficult, complex critiques around how the historical and structural processes of the U.S. long-term care industry have created such consequences.

Footnotes

Declaration of Conflicting Interests

The author declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: During the time of research study, the author's mother had owned and operated a residential care facility since the year 1985. The author declared no other potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Jennifer Nazareno, PhD, is a Presidential Diversity Postdoctoral Fellow at Brown University and formally affiliated with the School of Public Health and the Jonathan M. Nelson Center for Entrepreneurship. She received her PhD in Medical Sociology from the University of California, San Francisco, in the Department of Social and Behavioral Sciences.

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