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This paper uses an institutional perspective (Scott, 1994; 2001; DiMaggio and Powell, 1991) to analyze the history and current state of the American health care field in terms of the alignment of its normative, cognitive, and regulatory elements. I depict the relation between institutional elements in each of three historical eras of the health care field (Scott et al 2000): the era of professional dominance (1945-1965), the era of federal involvement (1966-1982), and the era of managerial control and market mechanisms (after 1983 to the present). I argue that a weakening of alignment between these elements, beginning in the 1970s and increasing in the 1980s, led to consumer and provider dissatisfaction with managed care, and that the state of the field in the beginning of the 21st century suggests that a new era is emerging with renewed alignment between normative beliefs and values, cognitive models, and regulation. Implications for the future of health care and institutional theory are discussed. [ABSTRACT FROM AUTHOR]

The United States is the only western industrialized nation that fails to provide universal coverage and the only nation where health care for the majority of the population is financed by for-profit, minimally regulated private insurance companies. These arrangements leave one-sixth of the population uninsured at any given time, and they leave others at risk of losing insurance as a result of normal lVe course events. Political theorists of the welfare state usually attribute the failure of national health insurance in the United States to broader forces of American political development, but they ignore the distinctive character of the health care financing arrangements that do exist Medical sociologists emphasize the way that physicians parlayed their professional expertise into legal, institutional, and economic power but not the way this power was asserted in the political arena. This paper proposes a theory of stakeholder mobilization as the primary obstacle to national health insurance. The evidence supports the argument that powerful stakeholder groups, first the American Medical Association, then organizations of insurance companies and employer groups, have been able to defeat every effort to enact national health insurance across an entire century because they had superior resources and an organizational structure that closely mirrored the federated arrangements of the American state. The exception occurred when the AFL-CIO, with its national leadership, state federations and union locals, mobilized on behalf of Medicare. [ABSTRACT FROM AUTHOR]

This paper examines the psychological impact of receiving welfare. The prospective longitudinal data are from a cohort of African American mothers (N = 833). Four explanations structured the analyses: social selection; chronic burdens; a failure hypothesis; and earlier life conditions of welfare recipients. Psychological distress was assessed by women's reports of depressed and anxious moods. Women were categorized into one of four welfare conditions by receipt of welfare when their children were first-graders and 10 years later. Concurrent and longitudinal relationships existed between the women's welfare status and reports of psychological distress. Welfare recipients had more chronic burdens--including perceived ill health--which helped to explain these relationships. Measures of failure did not "explain" the greater psychological distress. Women who grew up receiving welfare were more likely to report psychological distress and lower self-esteem later in life. The women's education influenced welfare and physical and psychological well-being. [ABSTRACT FROM AUTHOR]

This paper is a revision of the address given upon receipt of the Leo G. Reeder Award for Distinguished Scholarship in Medical Sociology. It was presented on September 1, 1986 to the Medical Sociology Section of the American Sociological Association during its annual meetings, held in New York City. [ABSTRACT FROM AUTHOR]

A selective systematic overview is provided of the literature on the utilization of health and welfare services that appeared in the United States and Europe, mainly within the last two decades. Methodological questions that appear to characterize much of the work to date, are discussed and analytically distinct approaches or research strategies in the study of utilization behavior are presented. The paper traces the emergence of work in this area, questions the wisdom of investigators proceeding along traditional research lines, and highlights a number of promising new possibilities for research. [ABSTRACT FROM AUTHOR]

This paper presents findings which test some of the relationships among disability, public assistance, and rehabilitation. The central question is whether the availability of public assistance constitutes a form of secondary gains for the disabled and a negative influence upon their motivation toward work and self reliance; or whether the disabled resort to that source of income primarily because of the absence of other alternatives. Findings support the latter position. Recipients of public assistance were not less disabled, nor did they demonstrate less response to rehabilitation than non-recipients. [ABSTRACT FROM AUTHOR]

When biomedical knowledge and technology create the capacity for humans to avoid disease and circumvent early death, sociological factors become more, not less important for population health. The transformation of disease causation from cruel fate, accident, and bad luck to circumstances that are under some degree of human control facilitates a powerful social shaping of disease and death. When humans have control, it is their policies, their knowledge, and their behaviors that shape the consequences of biomedical accomplishments, and thereby extant patterns of disease and death. I propose a "social shaping approach" that can frame our understanding of these processes and allow us to take action to optimize population health. Support for this approach is garnered from evidence of dramatic improvements in population health and in the uneven distribution of those improvements across persons, places, and times. Health improvements suggest that humans have gained control of disease whereas the uneven and very slow spread of such improvements underscores the critical importance of social factors. But the evidence presented represents a stick figure at best, one that needs to be filled in by a well-supported "epidemiological sociology" that uses a wide range of sociological concepts and theories to elucidate the social shaping of disease and death. Absent a robust societal investment in epidemiological sociology, population health will reside below its optimal level and the maldistribution of health-enhancing innovations will continue to create health disparities. [ABSTRACT FROM AUTHOR]

Since devolution, the four countries of the United Kingdom have pursued strikingly different National Health Service (NHS) reforms. While England created a supply-side market more radical than the previous internal market system, Wales moved to a softer version of the purchaser/provider split emphasizing localism. This article deploys institutional theory to analyze the forces shaping change, and describes the hybrid forms of economic organization emerging, including the economic regulation model implemented in England. The schism that has resulted in separate NHS subsystems warrants a different analysis from the more familiar phenomenon of infield divergence. We argue that schism was triggered by political-regulatory influences rather than economic or other social institutional forces, and predict that other decentralized public health care systems may follow a similar path. While political-regulatory, normative, and cognitive institutional influences push in the same direction in Wales, the misalignment of political-regulatory and normative elements in England looks set to result in a period of organizational turbulence. [ABSTRACT FROM AUTHOR]

In an attempt to understand the social forces and the economic and political conditions under which new social policies emerge in developing countries, this study outlines factors affecting the introduction of the health insurance system in South Korea. The emergence of the South Korean health insurance system was influenced by changing labor needs of the industrial sector, increasing social expectations, external and international pressures, increasing medical costs, and class conflict. These pressures compelled the South Korean government to respond to demands for the introduction of new social welfare policies in the 1970s. In the case of South Korea, the new health insurance system resulted from the government's attempts to cope with political, economic, and social pressures rather than from an ideological commitment to the well-being of the population. The resulting insurance system was a way to maintain the social order and legitimacy of the regime, and a means to promote the health of groups important to defense or production. [ABSTRACT FROM AUTHOR]

The emphasis of this analysis is on the social institutional history of medical sociology. This subfield is described as (1) closely connected with the patterns of development in its current discipline, (2) as containing a dual thrust between applied and basic science, and (3) as struggling with "insider-outsider" ambiguity involving the work of subgroups working either in medicine or from roles external to medicine but studying the sociology of medicine. Tracing a detailed historical fragment from the decade following World War II, it is predicted that the continuity of an accepted position for medical sociology is assured even though the style and quality of its professional life are full of uncertainty. [ABSTRACT FROM AUTHOR]

In this study, we examine public evaluations of government performance in the medical care sector. We develop five theoretical models (Consensus, Disillusionment of Target Groups, Resource Control, Reluctant Middle, and Conditional) based on different explanations of welfare state development and examine them across eight countries (the United States, Great Britain, est Germany, Austria, Switzerland, Finland, Italy, and the Netherlands). No single model adequately predicts which individuals most negatively evaluate government performance, but a number of patterns emerge. First, targeted groups (i.e., the "needy") rarely give poorer performance evaluations in any country. Second, those groups often identified as bearing a heavier tax burden (e.g., upper socioeconomic and middle-aged groups) are more likely to give negative evaluations in many countries we consider. Third, a nation's reputation as an innovator or laggard in guaranteeing health care influences which models operate and why individuals, similar in social position or attitudes, give different evaluations across countries. [ABSTRACT FROM AUTHOR]

Although initial research in the stress field has treated stress and support as independent entities, more recent efforts have emphasized their interrelatedness. It has been suggested: (a) that part of the influence of stress on psychological well-being is due to the adverse impact of stressful events and strains in reducing social support; and (b) that social support can have positive, indirect effects on health by reducing the subsequent occurrence of stress. To address these issues, a two-wave, two-variable panel model was used to examine longitudinal relationships between stress and support in a sample of 233 clinically depressed patients. The results showed that changes in levels of strain and in positive life events were significantly associated with changes in family support over the one year follow-up period. There was less evidence of an effect of social support on negative life change events, ongoing strains, or positive life change events. In addition, analyses are described which examined differences in the pattern of results as a function of: (a) the occurrence of exit or loss events; (b) the timing of events; and (c) the use of nonlinear models. [ABSTRACT FROM AUTHOR]

It was hypothesized that among subjects who perceive themselves to be in poor health those with fewer or less urgent symptoms, whose life situation makes it more difficult to seek care, and who lack faith in the medical care system would be most likely to fail to seek medical attention. The hypothesis was tested with a population of applicants for social security disability benefits. The hypothesis was only partially confirmed. Two life situational factors of income and welfare contact, and three measures of system orientation were found to be related to the seeking of medical care but urgency and number of symptoms were not. Subjects with low income, recent welfare contact, and negative system orientations were most likely to fail to seek medical attention. Moreover, negative system orientations proved to be associated with low income and welfare experience suggesting that negative orientations may be created by situational factors and serve as rationalizations for failure to seek care when situational factors make it difficult to do so. [ABSTRACT FROM AUTHOR]