Health care systems in the United States are experimenting with a form of surveillance and intervention known as "hot spotting," which targets high-cost patients-the so-called "super-utilizers" of emergency departments-with intensive health and social services. Through a calculative deployment of resources to the costliest patients, health care hot spotting promises to simultaneously improve population health and decrease financial expenditures on health care for impoverished people. Through an ethnographic investigation of hot spotting's modes of distribution and its workings in the lives of patients and providers, we find that it targets the same individuals and neighborhoods as the police, who maintain longer-standing practices of hot spotting in zones of racialized urban poverty. This has led to a convergence of caring and punitive strategies of governance. The boundaries between them are shifting as a financialized logic of governance has come to dominate both health and criminal justice. [health care, chronic illness, governance, policing, poverty, United States].

Our paper explores how legal status stratification shapes the health and health care of low-income patients with chronic illnesses in the U.S. healthcare safety net. Drawing on data from over two years of ethnographic fieldwork at urban safety-net clinics, we examine efforts by Complex Care Management (CCM) teams to stabilize patients with uncontrolled chronic illnesses through primary care-integrated support. We show that stratified citizenship and geographic variability correspond to different possibilities for health care. We suggest an approach to immigration as a structural determinant of health that accounts for the complex, stratified, and changing nature of citizenship status. We also highlight how geographical differences and interactions among local, state, and federal policies support the notion that citizenship is stratified across multiple tiers with distinctive possibilities and constraints for health. While county-based health plans at each of the study sites include residents with varying legal status, lack of formal legal status remains a substantial obstacle to care. Many immigrants are unable to take full advantage of primary and specialty care, resulting in unnecessary morbidity and mortality. In some cases, patients have returned to their country of origin to die. While CCM teams provide an impressive level of support to assist immigrant patients in navigating healthcare and immigration bureaucracies, legal and geographic stratification limit their ability to address broader aspects of these patients' social context.

As medicine integrates social and structural determinants into health care, some health workers redefine housing as medical treatment. This article discusses how health workers in two U.S. urban safety-net hospitals worked with patients without stable housing. We observed ethnographically how health workers helped patients seek housing in a sharply stratified housing economy. Analyzing in-depth interviews and observations, we show how health workers: (1) understood housing as health care and navigated limits of individual care in a structurally produced housing crisis; and (2) developed and enacted practices of biomedical and sociopolitical stabilization, including eligibilizing and data-tracking work. We discuss how health workers bridged individually focused techniques of clinical care with structural critiques of stratified housing economies despite contradictions in this approach. Finally, we analyze the implications of providers' extension of medical stabilization into social, economic, and political realms, even as they remained caught in the structural dynamics they sought to address.