At 11:45 a.m. on a Friday, the medical assistants have left for an early lunch. The waiting room of my clinic on Mission and Van Ness smells faintly of disinfectant.
It is empty except for a DoorDash driver in a high-visibility yellow vest clutching a red insulated delivery bag to his chest like a shield. He is 34 years old, originally from Kathmandu, and currently experiencing crushing substernal chest pain that radiates to his left jaw.
He has been sitting rigidly in a plastic chair for 40 minutes. He has not described his symptoms to the front desk or to the assistant who took his vital signs, because he is calculating the exact geometry of his ruin.
My Patient in the Gig Economy
According to Gridwise, which tracked 115,771 Dashers in 2025, the median total trip pay for a DoorDash driver is $11.26 per hour before expenses. After the cost of the electric bicycle, the phone mount, the insulated bag, the data plan and the self-employment tax, the number is something far less.
The driver does not receive health insurance through DoorDash, because DoorDash does not employ him. He is an independent contractor — a term that, in the context of U.S. labor law, functions less as a job description than as a legal mechanism to remove obligations.
The electric bicycle he rides belongs to a company called HMP Bikes, which operates out of a warehouse on Sixth Street in SoMa, a few blocks from the Metreon. An HMP assistant named Mike Sherpa — who speaks multiple Himalayan languages — communicates with what the company describes as its largely Nepalese clientele. For the price of $79 a week, Sherpa rents Dashers a bike, a phone stand, and a delivery bag rack, plus one free repair per month.
When asked about the business model by the San Francisco Chronicle, the founder of HMP likened it to selling shovels during a gold rush.
This never-ending dependence on one’s employer is not a new arrangement.
Veena Dubal, a law professor at the University of California, Irvine who studies gig labor, offered a different comparison. She called it profiting off the desperation of and compared HMP to the car-leasing operations that rent vehicles to ride-hail drivers — businesses that entrench, in her words, a system of frenetic, underpaid work.
By the Chronicle’s reporting, the Dasher in my waiting room pays $330 a month for his equipment and earns between $100 and $150 on a 12-hour day. Rent for the bike is due whether or not he works. It is due whether or not he is sick. It is due whether or not he is sitting in a clinic with substernal chest pain radiating to his left jaw.
The arithmetic is not complicated: roughly three full working days each month go to paying for the tool that allows him to work.
This never-ending dependence on one’s employer is not a new arrangement. In the coal towns of Appalachia in the late 19th and early 20th centuries, the company store sold miners their own equipment on credit, at markups that ensured the debt was never fully retired.
In the sharecropping South after the Civil War, the tenant farmer put up his future harvest as collateral for the seed and the plow.
Millions of workers were written out of the New Deal’s protections at the moment of the laws’ creation. The gig economy did not invent this exclusion. It inherited it, refined it, and gave it a sleek interface.
The vocabulary has changed. The structure has not.
A 2019 analysis in the American Journal of Preventive Medicine found that independent contractors had 4.92 times the odds of being uninsured compared to standard employees — the widest gap of any work arrangement the study examined.
A 2021 study in Health Services Research found that one in four self-employed workers lacked health insurance altogether, and that the act of transitioning into self-employment increased the probability of being uninsured by 18 percentage points.
These are not marginal effects. They are the difference between a man who walks into a clinic and tells someone about his chest pain and a man who sits in a plastic chair for 40 minutes doing arithmetic.
His phone, propped on the armrest of the plastic chair, shows three pending orders. The app does not know he is in a clinic. It knows only that he has stopped moving.
Legal Frameworks Exclude Contractors
The distinction between an employee and an independent contractor descends from the common law master-servant doctrine — a framework built not to protect workers but to define the scope of a master’s liability for the acts of those who served him.
When Congress passed the Fair Labor Standards Act in 1938, establishing the federal minimum wage and the 40-hour workweek, it excluded agricultural workers and domestic servants from its protections. At the time, as a 2010 article in the Social Security Bulletin documented, those two categories of labor employed roughly 60% of the Black workforce.
Whether the exclusion was a concession to Southern Democrats who wished to preserve the racial order of the Jim Crow South, or whether it reflected the genuine administrative difficulty of collecting payroll taxes from scattered farms and private households, is a question that historians continue to debate.
Whatever the cause, the effect was not ambiguous. Millions of workers — disproportionately Black, disproportionately poor — were written out of the New Deal’s protections at the moment of the laws’ creation.
The government has a longer history with this kind of extractive arrangement than most people remember.
In other words, the gig economy did not invent this exclusion. It inherited it, refined it, and gave it a sleek interface.
In California, the refinement took the form of Proposition 22, a 2020 ballot initiative funded by Uber, Lyft, DoorDash, and Instacart — $200 million in campaign spending, the most expensive ballot measure in the state’s history — to exempt app-based drivers and delivery workers from a state law that would have reclassified them as employees.
The initiative promised a guaranteed minimum wage pegged to 120% of the local minimum and a healthcare stipend for drivers who worked more than 15 hours per week.
A 2024 study by the UC Berkeley Labor Center found that the median employee-equivalent wage for California delivery workers, after accounting for unpaid wait time, vehicle expenses and the absence of employer-provided benefits, was $4.98 per hour without tips. For passenger drivers, the figure was $5.97.
The California Supreme Court upheld Proposition 22 unanimously in July 2024. As CalMatters reported two months later, no state agency has been assigned to enforce its provisions.
Gig work itself constitutes a social determinant of health — that the conditions of the labor produce disease.
The government has a longer history with this kind of extractive arrangement than most people remember. Between 1942 and 1964, the Bracero Program brought 4.5 million Mexican guest workers to the U.S. to harvest crops in the fields of California, Texas, and the Southwest. At the border processing centers, the men were stripped, lined up, and fumigated with DDT and lindane — pesticides sprayed directly onto their skin and hair to kill lice. DDT was later banned for causing cancer. Lindane was later banned for causing neurological damage. The photographs from the Hidalgo Processing Center, preserved by the National Library of Medicine, show men standing naked in rows, arms raised, while officials in uniforms point spray nozzles at their bodies.
The labor was needed. The people that performed it were treated as cattle.
In January 1917, at the Santa Fe International Bridge in El Paso, a 17-year-old domestic worker named Carmelita Torres refused to submit to the chemical baths and sparked what became known as the Bath Riots — one of the earliest recorded acts of collective resistance against the medicalized dehumanization of immigrant labor at the U.S. border.
Gig Work Is Hazardous to Health
The Nepali driver in my waiting room is not being fumigated. But a 2022 viewpoint in JAMA Cardiology made the case that gig work itself constitutes a social determinant of health — that the conditions of the labor produce disease. The authors cited a study of 130 San Francisco taxi drivers in which 35% had four or more cardiovascular risk factors.
Taxi driving is not identical to app-based delivery, but the occupational exposures overlap: sedentary posture or repetitive physical strain, high psychological demand, low autonomy, algorithmically imposed pace, no predictable schedule, no separation between labor and rest.
The 1960s and 1980s Whitehall studies of British civil servants found that a man’s employment grade was a stronger predictor of his risk of dying from coronary heart disease than any of the traditional risk factors his physician would screen for. Men in the lowest employment grade had 3.6 times the coronary heart disease mortality of men in the highest grade.
The gradient was not fully explained by smoking, cholesterol, or blood pressure. It was explained, in substantial part, by the degree of control a person had over his own labor.
The irony — if that is the right word — is that the DoorDash driver in the yellow vest is sitting in San Francisco, which operates Healthy San Francisco, a program established in 2006 that provides access to primary care, specialty care, mental health services, emergency care, hospital care and prescription drugs for uninsured residents with incomes up to 500% of the federal poverty level. It does not ask about immigration status.
The system around him — the legal classification, the algorithm, the bike rental, the insurance architecture, the political climate — was not failing. It was working. Just not for him.
It is not, technically, insurance — it is a health access program that covers only care delivered within its provider network and only within the city’s boundaries — but it is, by the standards of healthcare in the U.S., a remarkable thing.
It exists. It is available to him.
But enrollment requires an appointment with a certified application assistor. It requires documentation of residency and income. It requires the worker to stop working long enough to prove that he is poor enough to deserve care.
A January 2025 report by KFF found that 27% of likely undocumented adults had avoided applying for public assistance because of immigration-related fears, and that 75% of immigrant adults were uncertain whether using non-cash assistance programs would affect their immigration status.
What Happened to My Patient
The man in my waiting room is legally present. He has a visa. But the atmosphere of enforcement does not make fine distinctions. A clinic waiting room is a place where you give your name, your address, your date of birth, your insurance status.
For a man who is calculating the geometry of his ruin, each of these disclosures carries its own weight.
I do not know, as I write this, what happened to him. I know he sat in the waiting room with a presentation that, in a textbook, would be described as classic acute coronary syndrome until proven otherwise. I know we gave him aspirin, a statin, and tried to talk him into an EKG and an ambulance and to tell him the public hospital would never send him a bill.
But I know he had heard promises of free things before, and he was calculating. I know the system around him — the legal classification, the algorithm, the bike rental, the insurance architecture, the political climate — was not failing. It was working.
Just not for him.
He stood up. He adjusted the red insulated bag. He walked out of the clinic.
Even though his chest was still tight, he got back on his bicycle. It cost him $79 dollars a week.
