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Over the last 25 years, national Health Maintenance Organization (HMO) and hospital firms attempted to enter local markets, either by acquiring formerly independent, locally based HMOs and hospitals or by directly entering local markets. While national HMOs have been relatively successful, national hospital firms have had much less success. This paper explores the reasons for this difference. It reviews changes in presence of national HMO and hospital firms in markets, discusses common conceptual lenses through which national entry into local markets typically has been viewed, and shows how social network theory can be used to develop a better understanding of why the entry experience of national HMO and hospital firms varies across markets. The paper concludes with a research agenda that addresses issues raised by social network theory and its application to national firm entry into local markets. [ABSTRACT FROM AUTHOR]

Schizophrenia is diagnosed more frequently among African Americans while mood disorders are identified more often among whites. Such findings have raised serious questions about the accuracy of clinical judgment. This article analyzes data on 665 African American and white psychiatric inpatients using a semi-structured diagnostic instrument. The paper explores the relationship of patient race to schizophrenia, schizoaffective disorder, major depression, and bipolar disorder. The paper also explores the extent to which patient race is related to the manner in which clinicians link individual symptoms to diagnoses. Results indicate some significant race differences in diagnosis remain even when a semi-structured instrument and DSM criteria are used. whites, were more likely than African Americans to receive a diagnosis of bipolar disorder and less likely to be diagnosed with schizophrenia. There were no race differences in major depression. Some patterns of symptom attribution differed by race. The results are consistent with previous sociological research showing that patient race is related to diagnosis even when standardized diagnostic criteria are used. These findings underscore the importance of clinical judgment within the context of cross-race and cross-ethnic diagnosis. Clinical training programs must reduce ethnocentric bias by teaching the appropriate use of the socio-cultural information necessary to employ DSM-IV's Cultural Formulation. [ABSTRACT FROM AUTHOR]

This paper proposes a theoretical framework and an empirical example of the relationship between the civic stratification of immigrants in the United States, and their access to healthcare. We use the 2007 Pew Hispanic Center/Robert Wood Johnson Foundation Hispanic Healthcare Survey, a nationally representative survey of U.S. Latinos (N = 2,783 foreign-born respondents) and find that immigrants who are not citizens or legal permanent residents are significantly more likely to be excluded from care in both the United States and across borders. Legal-status differences in cross-border care utilization persisted after controlling for health status, insurance coverage, and other potential demographic and socioeconomic predictors of care. Exclusion from care on both sides of the border was associated with reduced rates of receiving timely preventive services. Civic stratification, and political determinants broadly speaking, should be considered alongside social determinants of population health and health care. [ABSTRACT FROM AUTHOR]

Education has a large and increasing impact on health in America. This paper examines one reason why. Education gives individuals the ability to override the default American lifestyle. The default lifestyle has three elements: displacing human energy with mechanical energy, displacing household food production with industrial food production, and displacing health maintenance with medical dependency. Too little physical activity and too much food produce imperceptibly accumulating pathologies. The medical industry looks for products and services that promise to soften the consequences but do not eliminate the underlying pathologies. This “secondary prevention” creates pharmacologic accumulation: prolonging the use of medications, layering them, and accruing their side effects and interactions. Staying healthy depends on recognizing the risks of the default lifestyle. Overriding it requires insight, knowledge, critical analysis, long-range strategic thinking, personal agency, and self-direction. Education develops that ability directly and indirectly, by way of creative work and a sense of controlling one’s own life. [ABSTRACT FROM AUTHOR]

Building on a detailed study of the Woburn, Massachusetts, childhood leukemia cluster, this paper examines lay and professional ways of knowing about environmental health risks. Of particular interest are differences between lay and professional groups' definitions of data quality, methods of analysis, traditionally accepted levels of measurement and statistical significance, and relations between scientific method and public policy. This paper conceptualizes the hazard-detection and solution-seeking activities of Love Canal, Woburn, and other communities as popular epidemiology: the process by which lay persons gather data and direct and marshal the knowledge and resources of experts in order to understand the epidemiology of disease, treat existing and prevent future disease, and remove the responsible environmental contaminants. Based on different needs, goals, and methods, laypeople and professionals have conflicting perspectives on how to investigate and interpret environmental health data. [ABSTRACT FROM AUTHOR]

This paper reports a study of the premedical student culture at a major university, based on fieldwork and interviews with 30 premedical students. The paper examines the role of stereotypes in the premedical culture; specifically, the common belief in "cut-throats" among premedical students. Cut-throats are described as excessively competitive, selfish, gradehungry students who cheat, steal books and lab reports, and sabotage lab experiments. Despite the widespread belief, our findings suggest cut-throats are a myth. We found more evidence for cooperative than cut-throat behavior. The myth emerges from the competitive and pressured situation of premedical students and the uncertainty of the medical school admission process, and is in part a manifestation of students' collective anxiety. More significantly, it provides cultural explanations for failure and success for premedical students. We discuss its connection to the general premedical stereotype and its relation to pre-medical education. [ABSTRACT FROM AUTHOR]

This paper takes a comparative approach to the topic of work time and health, asking whether weekly work hours matter for mental health. We hypothesize that these relationships differ within the United States and Germany, given the more regulated work time environments within Germany and the greater incentives to work long hours in the United States. We further hypothesize that German women will experience greatest penalties to long hours. We use data from the German Socioeconomic Panel and the National Longitudinal Survey of Youth to examine hours effects on mental health score at midlife. The results support our initial hypothesis. In Germany, longer work time is associated with worse mental health, while in the United States, as seen in previous research, the associations are more complex. Our results do not show greater mental health penalties for German women and suggest instead a selection effect into work hours operating by gender. [ABSTRACT FROM PUBLISHER]

Given the rapid aging of the U.S. population and reductions in federal funding, elder care has become a major issue for many families. This paper focuses on a long-term consequence of elder care by asking how caring for elderly parents affects women's subsequent risks of living in poverty. Using longitudinal data from the Health and Retirement Study, we examine whether and how caregiving for parents in 1991 increases women's risks of living in households with incomes less than the poverty threshold, receiving public assistance, and receiving Medicaid in 1999. Our findings illustrate that caregiving in earlier life raises women's poverty risks in later life by intensifying the negative effects of stopping work and declining health on women's economic well-being. [ABSTRACT FROM AUTHOR]

This paper examines how multiple roles affect the mental health of the elderly in Japan and the United States, two countries with vastly different cultures. Hypotheses were drawn based on the cultural differences in role experiences, and these hypotheses are tested by analyzing nationally representative samples of the elderly in these countries. The results show that Americans are more likely to be involved in roles related to family, work, and community, while the Japanese are more likely to be involved in only those roles related to family and work. Multiple roles are also found to be less beneficialfor the mental health of Japanese elderly compared to American counterparts. National differences in the effects of individual roles and role configurations on mental health are also documented. Overall, the results show the importance of broad cultural contexts for understanding the relationship between roles and mental health. [ABSTRACT FROM AUTHOR]

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]

The context for contemporary research and policy is set through a theoretically informed history of the modern American health care system that draws on the concept of countervailing powers and Fligstein's theory of control In this context, the papers of this special issue are then introduced. [ABSTRACT FROM AUTHOR]

Over the past decade, different parties in the health care field have developed and disseminated clinical practice guidelines as part of evidence-based medicine. These formal tools based on a scientific evaluation of the research literature purport to tell health care professionals how to practice medicine. Because clinical practice guidelines shift the knowledge base in the health care field through standardization, they remain con troversial within and outside medicine. In this paper, we evaluate the predictive accuracy of four medical professionalization theories-functionalism, Freidson's theory of professional dominance, deprofessionalization theory, and the theory of countervailing powers- to account for (1) the shift from pathophysiology to epidemiology with guidelines, (2) the creation of practice guidelines, and (3) the effects of clinical practice guidelines on the autonomy of health professionals. In light of the mixed predictive record of professionalization theories, we conclude with a need for "evidence-based sociology" and a recalibration of basic premises underlying professionalization theories. [ABSTRACT FROM AUTHOR]

This paper examines the impact of changes in the medical marketplace on medicalization in U S. society. Using four cases (Viagra, Paxil, human growth hormone and in vitro fertilization), we focus on two aspects of the changing medical marketplace: the role of direct-to-consumer advertising of prescription drugs and the emergence of private medical markets. We demonstrate how consumers and pharmaceutical corporations contribute to medicalization, with physicians, insurance coverage, and changes in regulatory practices playing facilitating roles. In some cases, insurers attempt to counteract medicalization by restricting access. We distinguish mediated and private medical markets, each characterized by differing relationships with corporations, insurers, consumers, and physicians. In the changing medical environment, with medical markets as intervening factors, corporations and insurers are becoming more significant determinants in the medicalization process. [ABSTRACT FROM AUTHOR]

This paper presents an institutional analysis of organizational change and inertia in the US. field of long-term care. We employ a dialectic approach to concentrate on the contest between interests aligned with two templates of organization (archetypes) that draw from distinctive sets of beliefs and values (interpretive schemes) to specify appropriate structural forms, roles, and resource distributions. It is shown that the long-term care field was historically characterized by a nursing home archetype which legitimates the provision of care in residential facilities under the con trol of medical professionals. After a century of reformers' efforts to build legitimacy and resource support for alternative home and community-based services that maintain consumers' independence, the field now accommodates both the nursing home archetype and a home and community-based services archetype. While this new institutional framework reflects aspects of change, especially the establishment of the home and community-based services archetype, it also displays inertia including the continued dominance of the nursing home archetype. Roles played in these contested dynamics are traced along a key process of change in each archetype: (1) the growth of large multi-facility (chain) nursing home corporations, and (2) political advocacy for home and community-based services. [ABSTRACT FROM AUTHOR]

Research on the social determinants of health has increasingly sought to understand the relative importance of different features of socioeconomic status. Much of the ensuing debate has wavered between education and income, with recent research leaning increasingly toward income. This research has not, however; consistently explored interactions between different features of socio economic status and, in trying to understand the independent effects of different components of socioeconomic status, may have missed important features of socioeconomic position. With an eye toward examining how features of socio economic status combine and coalesce, this paper examines variation in the income-health association by level of education. Theories derived both from medical sociology and health economics suggest synergistic interactions between income and education, but they are unclear as to the direction and magnitude of these interactions. Results from two large and nationally representative data sets (the 1996-1997 Community Tracking Study and the 1972-2000 General Social Survey) indicate that the positive relationship between income and health varies substantially in both its strength and shape by level of education. Education improves health, and its effects are larger at lower levels of income. Moreover; education reduces the strength and curvature of the income-health relationship. Consequently, those with more education have better health for all levels of income, and fewer income-based disparities exist among the well educated than among the less well educated. The linear "gradient" relationship between income and health is, thus, more characteristic of groups with higher levels of education. Additional analyses indicate that these interactions existed in the United States in each of the last three decades. The results are discussed in light of theory regarding the perpetuation of health disparities, as well as current debates regarding the apparent incompatibility of distributive versus aggregative goals in health policy. [ABSTRACT FROM AUTHOR]

Life events checklists have been the predominant method for estimating variations in stress exposure. It is unknown, however, whether such inventories are equally meaningful for estimating differences in exposure between men and women, African Americans and whites, and those in lower and higher socioeconomic categories. In this paper, we employ a wider range of measures of stress-recent life events, chronic stressors, lifetime major events, and discrimination stress-to examine the extent to which these dimensions collectively yield conclusions about status variations in stress exposure that are similar to or different from estimates based only on a life events checklist Our analyses of data collected from 899 young men and women of African American and non- Hispanic white ancestry suggest that status differences in exposure to stress vary considerably by the measure of stress that is employed. Although women are more exposed to recent life events than men, males report more major events and discrimination stress than females. Our results also reveal that life event measures tend to substantially under-estimate differences between African Americans and non-Hispanic whites in exposure to stress. A similar pattern also holds for socioeconomic status. When stress is more comprehensively estimated, level of exposure profoundly affects ethnic differences in depressive symptomatology, accounting for almost half of the difference by socioeconomic status but contributing little to the explanation of the gender difference in distress. The implications of these findings for the debate over the relative mental health significance of exposure and vulnerability to stress are discussed. [ABSTRACT FROM AUTHOR]

This paper attempts to answer a series of questions regarding the interaction of income and birth weight across generations. First, does the effect of the income of a mother during her pregnancy on her infant's birth weight depend on the family's birth weight history (genetic predisposition)? Second, does the effect of low birth weight status on adult life chances depend on income during early childhood? These questions have implications for the way we envision the biological and social worlds as interacting across generations. To address these issues, this study uses intergenerational data from the Panel Study of Income Dynamics, survey years 1968 through 1992. Results of sibling comparisons (family-fixed-effects models) demonstrate that maternal income has a significant impact on birth weight for those infants who are already at high risk hereditarily (i.e., who have a low birth weight parent). However, it is not clear whether income acts as a developmental buffer for low birth weight infants as their lives progress. These findings suggest the existence of biosocial interactions between hereditary predisposition and socio-economic environment. [ABSTRACT FROM AUTHOR]

Racial inequity in the provision of healthcare is widely recognized. In this paper I assess the role of social distance from healthcare providers in accounting for whites' higher rating of healthcare providers. Using data from the Detroit Area Study, I test whether having higher socioeconomic status, like most healthcare providers, and racial concordance with healthcare provider account for the gap in satisfaction between whites and African Americans. I find that socioeconomic status and racial concordance variables account for a portion of whites' higher rating of the respect shown by their healthcare provider Racial differences in evaluation of time spent with healthcare provider are accounted for by socioeconomic status, but not racial concordance. As researchers explore the causes of and remedies for the racial disparity in use and evaluation of healthcare, the subtle and indirect effects of race on the patient-healthcare provider relationship must be considered. [ABSTRACT FROM AUTHOR]

This paper is a revision of an address given upon receipt of the Leo G. Reeder Award for Distinguished Scholarship in Medical Sociology. It was presented on August 24, 1991, to the Medical Sociology Section of the American Sociological Association during its annual meetings, held in Cincinnati, Ohio. [ABSTRACT FROM AUTHOR]

This paper presents a measurement model of a ten-item scale of maternal anxiety during pregnancy. Using confirmatory factor analysis, its reliability and validity are examined in a hospital sample of mothers (N = 266) surveyed postpartum in Galveston, Texas. According to several indices of overall fit as well as individual parameter estimates, a latent internal structure of three interrelated dimensions is confirmed for the scale items. These first-order constructs are anxiety about being pregnant, childbirth, and hospitalization. This model exhibits a considerably better fit than both a no-factors model and a model in which the dimensions are uncorrelated. Finally, several exogenous constructs expected to be associated with pregnancy anxiety—age, marital status, and worry over health—exert significant effects on dimensions of the model or on a second-order factor. [ABSTRACT FROM AUTHOR]

The paper focuses on two forces (stressors and resources) in the life stress process as they affect psychological distress. Utilizing three waves of panel data from a representative community sample in upstate New York, six causal models of the life stress process are tested with indicators of two types of stressors (social and physiological) and two types of resources (social and psychological). Both deterring and coping models are tested. Analysis shows that: (1) stressors and resources in the social environment have a direct impact on depressive symptoms, (2) social resources mediate the effects of social stressors on psychological distress, and (3) psychological resources indirectly affect distress by enhancing social resources. The critical role played by the social environment in the life stress process involving psychological distress is substantiated. The implications of these and other findings are discussed. [ABSTRACT FROM AUTHOR]

This paper examines self-perceptions of risk for AIDS and factors that contribute to estimations of risk. On the basis of a telephone survey of 1,540 adults age 18 to 60, we address the question: What heuristic factors predict perception of risk for AIDS? Results show that five heuristic categories determine self-perceptions of risk: sexual practices, moral evaluations of people with AIDS, emotional response to AIDS, protective actions in response to AIDS, and demographic characteristics. Number of sexual partners over the past five years and knowledge of sexual partners' past sexual behavior are associated significantly with increased perceptions of risk. Fear of AIDS and worry about one's health also contribute significantly to self-perception of risk, as does shame associated with having AIDS. Asian-Americans and persons with no particular religious affiliation report greater perceptions of risk. These findings call attention to heuristic factors in considering theories of risk and in designing interventions to change preventive actions associated with high risk for AIDS. [ABSTRACT FROM AUTHOR]

More than 100 studies have cited M. Harvey Brenner's (1973) claim that fluctuations in the economy increase the onset of mental illness and thus generate increases in mental hospitalization. Published attempts to replicate Brenner, however, have considered only twentieth-century data. One of Brenner's most memorable claims was that a stable inverse relationship between mental illness and the economy could be seen over a 127-year span beginning in the early nineteenth century. Unfortunately, no research since Brenner's has considered nineteenth-century populations. In this paper we analyze the hypothesis that economic change provokes a substantial fraction of first admissions to mental hospitals. We used admissions registers from the three institutions to construct a data base that approximates a psychiatric case register for a nineteenth-century American city from 1881 to 1891. Time-series tests show no support for the "provocation" hypothesis. [ABSTRACT FROM AUTHOR]

In the late 1950s American pediatricians began to place increased emphasis on psychosocial and behavioral issues in medical training and research. An intraprofessional movement for psychosocial pediatrics led to alterations in the specialty's stated jurisdiction. One explanation for the movement's origins is that demand for treating sick children was eroding; primary-care providers took up the delivery of behavioral services to avoid extinction. This paper shows that routinization of work, not market decline, preceded psychosocial pediatrics. Academicians rather than community practitioners spearheaded boundary expansion. The movement's major consequence appears to be a new division of labor between pediatricians and other health care professionals rather than increased pediatric treatment of children's psychosocial disorders. [ABSTRACT FROM AUTHOR]

This paper reports the first results from a survey of unemployment in Southeastern Michigan. The study includes samples of currently unemployed, previously unemployed and stably employed respondents. Special efforts were made to obtain information about the context surrounding each job loss reported, thus allowing the explicit analysis of selection bias in the estimation of unemployment effects. The analysis documents the substantial influences that unemployment has on self-reported physical health, somatization, anxiety, and depression that cannot be explained by selection bias. [ABSTRACT FROM AUTHOR]

This paper presents a cohort analysis of the use of health services by elderly Americans. Standard cohort tables are constructed using data on approximately 50,000 individuals from the 1972, 1976, and 1980 Health Interview Surveys. Six 4-year age cohorts are tracked: the youngest, 56-59 years old in 1972: the oldest, 84-87 years old in 1980. Significant age and period effects on physician and hospital contact have been detected; for example the aging effect reflects an increase in the percentage of individuals who either saw a physician on an outpatient basis or were hospitalized in the previous year. Analysis of the volume of physician visits reveals an inverse J-curve relationship with age, with the pivotal point occurring at or about age 80. Consideration of nine alternative explanations of the J-curve phenomenon shows that three are plausible on either conceptual or empirical grounds. Two of these explanations suggest the substitution of either (1) hospital-based services for ambulatory-based services or (2) social supports (especially in the form of older children as care givers) for physicians' services: the third explanation focuses on the involuntary severance of patient-practitioner relationships. resulting from the retirement or death of longstanding family physicians. Finally, competing policy implications of these explanations are discussed. [ABSTRACT FROM AUTHOR]

This paper attempts to explain the higher psychological distress and psychological vulnerability of women and the unmarried as a function of greater exposure to uncontrollable life events (including network events) and perceived lack of control over life circumstances. Panel data on a sample of 1,106 adult heads of household living in Chicago provide measures of relevant variables. Contrary to expectation, event exposure is inconsistently associated with gender and marital status; instead, exposure depends on the types of roles held by individuals. Although group members at higher risk of disturbance perceive less control over their lives, these perceptions neither singly nor jointly with event exposure, explain gender or marital status differences in psychological distress or in vulnerability to negative events in general. In light of these findings, the utilities of a "common stress" and a "unique stress" approach for explaining status differences in symptoms are contrasted. [ABSTRACT FROM AUTHOR]

Over the past decade, a body of research has developed which purports to show that the well-established relationship between race and psychological distress is duc entirely to social class. In our paper we demonstrate that this view is incorrect: Most prior research has assumed that the effects of race and social class are additive; our analysis shows that they are actually interactive. The form of interaction is such that thc true effect of race is suppressed and tire true effect of social class is magnified in a model that fails to take the interaction into consideration. An analysis of eight different epidemiologic surveys documents this result and shows that race differences in psychological distress are particularly pronounced among people with low incomes. On the basis of this result we call for renewed interest in the effect of race on mental health. [ABSTRACT FROM AUTHOR]

Although the dramatic rise in national expenditures for medical services the past quarter century is due to a number of factors, this paper investigates the hypothesis that an increase in the supply of physicians is one major factor. Longitudinal analysis of trends for the United States from 1940 to 1981, and the cross-sectional analysis of eight industrialized countries and nine census regions in the United States, support the hypothesis. Since the increase in physicians is largely due to deliberate policy decisions in the past, the increase in costs, which policymakers are now trying to contain is in large part the result of actions that policymakers themselves have made. The increase in the supply of physicians (the "physician surplus") will put upward pressures on the national expenditures for medical care in the years ahead. [ABSTRACT FROM AUTHOR]