Social Inequalities, Health and Health Care Delivery: Volume 20

In this study we used community health survey data to test an adapted version of Lin's (2001a, b) theoretical model for explaining health differences in terms of the differential generation of social capital. There was considerable support for the model's explanatory components with regard to differences in physical health. Variation in physical health was related to resources generated by education and avoidance of cost barriers in paying for care, embeddedness in the form of household composition, and accessibility of interpersonal health resources. However, life satisfaction differences were more related to employment experience and to being female than to health resources generation or utilization. Cost barriers had a considerable positive effect upon stress levels, as did being female. Overall, findings show that life orientations were largely independent of health-related resources, and that differences in stress reflected problems in paying for health care and gender-related experiences. The importance of gender in our results suggested the need for considering gender-specific models of the generation of health resources. The reciprocal relationship found between households' mobilization of provider services and their involvement in community health activities suggested the collateral generation of resources at the individual and community levels stressed by network theorists such as Burt (1992), Granovetter (1985), and Wellman (1983). Implications of our results for policy issues regarding inequalities in health and for the future study of health-related social capital are discussed.

This paper uses a historical analysis of medical writing to argue that use of categories of age, sex, and race in bio-medical research creates and perpetuates inequalities. I consider these categories from a view of philosophy of science for control and attribution of causal significance. Age, sex, and race are social constructions that reflect elements of biological reductionism. The role of biological reductionism in marginalization has been severely criticized in areas of social life such as work, education, class, family, and crime. Biology can be criticized for the same problem and the way it perpetuates inequalities within bio-medical research and treatment. I trace this to a problem of unit, the attribution of social processes of age, sex, and race to a body. Medicine by its mandate and everyday practices is in the business of bodies. Skin becomes a functional boundary. Problems arise when this functional boundary is used without consideration of the social landscape that goes into making choices about which body goes into which category. Recent work on the concept of racialization provides a theoretical framework to think about age, sex, and race as verbs.

Medicaid, Medicare, and managed care reimbursement changes since the early 1980s have put added financial pressure on hospitals, increasing fears that private hospitals will decrease support for indigent care and that those hospitals that serve a disproportionately large indigent population may be forced to close. Wilson and Kizer (1997) use the term “safety net” to convey the notion that public health facilities, such as Veterans Affairs Medical Centers (VA), municipal hospitals, community health centers, and local public health departments, are providing uncompensated care for an increasing number of uninsured due to increasing cost pressures on private health facilities. Other research efforts also give evidence of increasing patient demand pressures on public health facilities in recent years (Lipson & Naierman, 1996). However, these efforts are often cross-sectional in design or limited to information from only one or a few health facilities in a metropolitan area (Baxter & Mechanic, 1997). As such, it is very difficult to measure fully the extent to which new legislation and private market changes have an effect on the public health “safety net” over time.This research considers the longitudinal relationship between the effect of Illinois implementation of the ICARE Medicaid reimbursement program, private hospital closings and the demand for VA inpatient services in a large metropolitan market in Chicago in the 1980s. Analysis is conducted with a combination of VA hospital discharge data, zip code level sociodemographic data from the U.S. Census, and data on hospital closures in the Chicago area between 1980 and 1990. The combined data allow for a longitudinal analysis of the tradeoffs between new state policy and hospitals over the provision of care for the indigent, including the effects of changes in reimbursement for Medicaid patients.

Considerable research has linked lower socioeconomic status (SES) and non-majority racial-ethnic status with poorer health, but much research in this area has been cross-sectional and has not examined whether psychological well-being factors help mediate the influence of SES and race-ethnicity on physical health over time. The aims of this study were to examine the degree to which education, household income, and race-ethnicity were independently associated with changes in physical health (global health, functional limitations, and mortality) over five years and to examine whether psychological well-being factors (depressive symptoms, global happiness, self-esteem, and self-efficacy) helped account for these associations. Results from models estimated using data from 7,414 midlife and older adults (4,513 women, 2,883 men) aged 35–98 who participated in the U.S. National Survey of Families and Households 1987–1993 suggested that lower education helped predict a greater decline in global health and a greater increase in functional limitations over time for both men and women; lower income helped predict a greater decrease in global health for men and a greater increase in functional limitations over time for both men and women; being African-American (vs. non-Hispanic white) helped predict a greater increase in functional limitations for women; and lower income and being African-American each independently helped predict mortality over time for men. Psychological factors only very minimally accounted for social inequalities in health; however, a positive profile on each psychological factor (net of Time 1 health and numerous sociodemographic factors) helped predict more positive health over time.

The purpose of this paper is to examine whether health lifestyles differ significantly between social classes within the Deep South. Relatively little is known about the health lifestyles practiced within this region. Results from this study show significant class differences in health lifestyles within the South (especially drinking alcohol, smoking, dietary practices, and exercise as well as self-reported health variables). The cultural and social features of this area have not facilitated dispersion of health promoting lifestyles. Therefore, “life chances” and especially “place” appear to be more important than “life choices” for positive health lifestyles.

The intersection of race and gender present challenges to the studies of aging and life course. The higher rates of African-American women experiencing functional limitation in old age is but one example of disparity between black and white women during the aging process. This paper is an exploration of the relationship among, race, gender, socioeconomic status (SES), and health. Functional limitation that leads to disablement is used as the marker of health among African-American women at midlife. The National Survey of Midlife Development in the United States (MIDUS) provides the data to identify partially the relationship among present health status, lifestyle, and patterns of successful aging. In fact, preliminary findings from a MIDUS data analysis indicate that when controlling for age, SES, and self-rated health, black women have more limitations than do white women. It is hypothesized that as a consequence of limited opportunity, differing social structure and history, African-American women at midlife are more likely than their white counterparts to demonstrate patterns of health behavior that adversely affect the aging experience.

One of the greatest challenges of our society is the provision of humane and affordable services in ways that empower, rather than disempower, its aging members (Minkler, 1985, 1996). The concept of “consumer direction, ” being the exercise of choice and control, is derived from the independent-living movement of the disability community (e.g. Gilleard & Higgs, 1998). Adults with disabilities have long articulated and acted upon a moral vision that maximizes the rights of disabled people to define their own destinies. The factors discussed as having contributed to a delay of consumer direction in the aging community are ageism, a narrow concept of autonomy, the biomedicalization of aging services, and fiscal and bureaucratic constraints (Minkler, 1987, 1990, 1997). Conceptual frameworks based upon the disability model that support the concept of consumer direction for the aging community, and its applicability to home and community-based (HCB) long-term care systems, are discussed. The central and interrelated themes of broadening the concept of autonomy, examining ageist assumptions in social policies and practices, articulating a vision statement, validating caregiving, providing a variety of services that are flexible and accessible, and implementing systems and policy changes are presented as elements of an integrative model of consumer direction for an aging population.

Despite a substantial body of research on physician incomes and hours, there has been surprisingly little study of part-time work in the professions or on the organizational structures that support or inhibit part-time arrangements. To assess the factors associated with the presence and prevalence of part-time work in radiology practices, we conducted structured interviews with 69 practice administrators and 13 self-employed or retired radiologists. Patterns of part-time work are heavily gendered; men use it as a transition to retirement while women seek it early in their careers to balance work and family needs. As hypothesized, larger practices, academic practices, and those affiliated with larger organizations were significantly more likely to have part-time radiologists. Controlling for level of competition between practices, those that had recently experienced increased competition were less likely to have part-time radiologists. Neither difficulty recruiting radiologists to the practice nor length of the average workweek for full-time radiologists were associated with having part-time radiologists in the practice. Practices that had a senior partner or administrator who supported the concept of part-time work were more likely to offer this option to physicians. We expected that radiology practices would have explicit policies regarding part-time work; however few of the practices had any formal policies on this career option. As a result, radiologists seeking part-time work early in their careers were at a distinct disadvantage in negotiations. Fear of the stigma and related career consequences may restrain male radiologists from seeking part-time work early in their careers. Despite acceptance in some practices and a growing presence of part-time radiologists in the specialty as a whole, there are significant and persistent barriers to part-time work arrangements other than as a transition to retirement.

Increasing attention has been given to racial inequities in health care quality. As part of the movement to assess inequities and uncover their source, researchers have used patient ratings of health care providers as an indicator of health care experiences. Despite growing interest in this area, an adequate theoretical framework for guiding this research has not been offered. Sociology can bring together the theoretical and methodological tools essential for insightful analysis of this problem. In this paper, I offer a theoretical approach to analyzing African American and white differences in evaluation of outpatient health care providers. In addition, I discuss some of the methodological implications of the approach and organize findings from the existing research.

Health care disparities exist in the United States. Social inequalities contributing to disparities in health care include poverty, socioeconomic status, being uninsured, one's life course, and being unemployed. Each social inequality has an effect on health status and produces a gradient of poor health and mortality that spans all socioeconomic strata. Selected policies implemented in the United States have resulted in perpetuating health care disparities and negative health outcomes for certain populations. Health care professionals are in a strategic position to implement pragmatic strategies for eliminating some health disparities. Strategies discussed include changes at the following levels: personal, worksite, professional association, community, and civic.

Access for the uninsured for medical care has been studied retrospectively via interviews with the uninsured and by surveys of physicians concerning acceptance of uninsured patients. In this study we simulate the experiences of uninsured persons by calling primary care physician offices seeking appointments to treat current illnesses. Callers were instructed not to volunteer uninsurance status unless requested by office staff. We find that patients can get timely appointments over half the time, insurance information is requested around half the time, and that office staff knowledge of uninsurance status did not affect the probability of obtaining an appointment. Our findings agree with physician survey rates for acceptance of uninsured patients. Our findings demonstrate that medical appointments are likely available for the uninsured, even though the out of pocket costs may be burdensome or unaffordable. Nevertheless, many uninsured persons have incomes above hospital emergency room, charity care guidelines and would be far better off financially and medically to have a medical home.