Medical sociology and health service research - Journal of Health and social behavior

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Social Behavior http://hsb.sagepub.com/

Medical Sociology and Health Services Research : Past Accomplishments and
Future Policy Challenges
Eric R. Wright and Brea L. Perry
Journal of Health and Social Behavior 2010 51: S107
DOI: 10.1177/0022146510383504

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Wright and Perry

Journal of Health and Social Behavior
Medical Sociology and 51(S) S107–S119
© American Sociological Association 2010
Health Services Research: DOI: 10.1177/0022146510383504
http://jhsb.sagepub.com

Past Accomplishments and
Future Policy Challenges

Eric R. Wright1 and Brea L. Perry2

Abstract
The rising costs and inconsistent quality of health care in the United States have raised significant questions
among professionals, policy makers, and the public about the way health services are being delivered. For
the past 50 years, medical sociologists have made significant contributions in improving our understanding
of the nature and impact of the organizations that constitute our health care system. In this article, we
discuss three central findings in the sociology of health services: (1) health services in the U.S. are unequally
distributed, contributing to health inequalities across status groups; (2) social institutions reproduce health
care inequalities by constraining and enabling the actions of health service organizations, health care
providers, and consumers; and (3) the structure and dynamics of health care organizations shape the
quality, effectiveness, and outcomes of health services for different groups and communities. We conclude
with a discussion of the policy implications of these findings for future health care reform efforts.

Keywords:
health services, health care delivery, health care organizations, health care quality

Public and professional interest in health services recently, sociological health services research has
has increased dramatically over the last two concentrated on the structure of and dynamics
decades driven primarily by persistent and grow- within health service organizations and how these
ing frustrations with the cost and quality of care. factors shape both access and clinical outcomes for
Medical sociologists have been interested in the different groups and communities.
structure, organization, dynamics, and impact of In this essay, we highlight three key findings
health services for well over 50 years. Our health that summarize the most important contributions of
care system has evolved and changed dramatically medical sociology to health services research. For
over the same period, shifting from one focused on the purposes of this paper, we define health services
providing acute care for immediate and emergent as the delivery of care by socially recognized,
health problems to a more diffuse system strug- professional health care providers that is intended
gling to support individuals with chronic and long- to respond to perceived illness and disease or to
term conditions while also controlling costs
(Wholey and Burns 2000). Not surprisingly, medi-
1
cal sociological interest in health services has fol- Indiana University-Purdue University Indianapolis
2
lowed suit and expanded to examine a wider vari- University of Kentucky
ety of settings, conditions, and processes within Corresponding Author:
the formal health care delivery system. Scholar- Eric R. Wright, Department of Public Health, Division
ship initially focused largely on understanding the of Health Policy and Management, Indiana University
structural and institutional underpinnings of health School of Medicine, 401 W. 10th Street, Suite 3100,
care systems, and later on exploring the variability Indianapolis, IN 46202
in access to health care across social groups. More E-mail: ewright@iupui.edu


S108 Journal of Health and Social Behavior 51(S)

improve an individual’s health status. While many Disease Control 1998; Powell-Griner, Anderson,
scholars are particularly interested in specific med- and Murphy 1997). However, men who do consult
ical technologies, medical sociologists assert that a health professional may receive better treatment
the delivery of health services is much more than than women for the same condition. The evidence
simply the application of scientific and technical is particularly strong in the case of heart disease.
knowledge. Health care services are delivered by Women who present with symptoms of cardiac
people to people within various social environ- disease are less likely to be referred for diagnostic
ments, which can influence the way medical tech- tests, given cardiac drugs, or instructed to make
nology is delivered or received and, perhaps most lifestyle changes. Conversely, they are three to five
important, the clinical outcomes for people seeking times more likely to be sent home without any
help. This review is necessarily selective. Our aims treatment (Lockyer and Bury 2002; McKinlay
here are to summarize a half-century of sociologi- 1996). These patterns delay diagnosis and contrib-
cal work and to call for a renewed interest in the ute to higher mortality rates among women with
sociology of health services. We conclude by out- heart disease relative to men.
lining the policy implications of these findings for
future health reform efforts.
Socioeconomic Status
Decades of research by sociologists suggests that
FINDINg 1. HEAlTH SERvIcES people with less income and education face greater
IN AMERIcA ARE UNEqUAlly obstacles accessing health services than their more
DISTRIBUTED, cONTRIBUTINg well-off counterparts, despite having higher health
care needs (Dutton 1978; Katz and Hofer 1994).
TO HEAlTH INEqUAlITIES Disparities are particularly marked in the area of
AcROSS STATUS gROUPS primary care (Rundall and Wheeler 1979). For
example, adults and children of lower socioeco-
One of the fundamental concerns of medical soci- nomic status (SES) are less likely to have routine
ologists over the past 50 years has been to docu- physical examinations and screening procedures,
ment and explain gender, socioeconomic, and such as prenatal care, immunizations, mammo-
racial-ethnic differentials in health outcomes (see grams, and colonoscopies (Goldman and Smith
Williams and Sternthal 2010 in this issue). Among 2002; Lantz, Weigers, and House 1997; McDonald
the early explanations for these patterns were dis- and Coburn 1988). Moreover, they are less likely
parities in the distribution of health services among to receive medical intervention in a timely manner,
social groups, and substantial attention was and they often receive less intensive and lower
devoted to documenting systematic differences in quality treatments (Williams 1990). Together,
access to health care. More recently, evidence has these patterns result in poorer long-term outcomes
emerged suggesting that the adverse impact of and higher emergency room and hospitalization
health care disparities on population health is rates for conditions that would not normally
increasing, highlighting the need for additional require them (Padgett and Brodsky 1992; Pappas
research (Lesser and Cunningham 1997). As a et al. 1997).
result, sociologists have taken a renewed interest
and adopted a more complex and comprehensive
approach to health services research, examining Race and Ethnicity
the nature, quality, and timeliness of care received Because income and educational attainment are so
under a variety of illness conditions. closely linked to race and ethnicity in America,
patterns of health care inequality observed in
racial-ethnic minority groups are similar to those
Gender found in low-SES populations (Williams and Col-
Sociological research has documented significant lins 1995). That is, racial-ethnic minorities gener-
gender differences in help-seeking. Women are ally have less access to health services, in particu-
more likely than men to visit a doctor for an array lar primary and preventative care, and they also
of both physical and mental health problems tend to receive delayed treatment and lower quality
(Courtenay 2000; Green and Pope 1999; Kessler, acute and long-term care than whites (Blendon
Brown, and Broman 1981). They are also more apt et al. 1989; Smedley, Stith, and Nelson 2003;
to have a regular physician and to obtain preventa- Williams 1990). Though these patterns are better
tive screenings (Bostick et al. 1993; Centers for established in African American populations, studies

Wright and Perry S109

suggest they also extend to Latinos, Asian Ameri- illness experiences and outcomes among members
cans, and Native Americans (Angel and Angel of different social groups making contact with a
2006; Collins, Hall, and Neuhaus 1999; Fiscella stratified medical system (Kahn et al. 1994).
et al. 2002). While much of the disparity in health This point is illustrated by the case of type two
services use can be explained by SES differentials, diabetes, a disease whose incidence as well as
race-ethnicity tends to exhibit a modest, indepen- resulting mortality and complications are related to
dent effect on health services use. These effects SES (Cowie and Eberhardt 1995; Phelan et al.
have been attributed to racial discrimination by 2004). Health services disparities probably con-
health services providers and racial segregation of tribute little, relative to diet and exercise, to the
minorities into communities with less access to overall risk of developing diabetes. Low SES
high-quality health services (Polednak 1993; affects risk for diabetes onset through a variety of
Williams and Collins 1995). dynamic, intervening mechanisms that reflect
access to resources. For instance, living in working
class neighborhoods without safe recreational
Do Health Services Inequities Explain facilities and stores that carry fresh fruits and veg-
Group Differences in Health? etables makes it more difficult to exercise regu-
larly and eat a balanced diet. In contrast, subsequent
For many decades, equalizing access to quality to onset, differences in mortality rates and the inci-
health services was held up as the most promising dence of complications secondary to diabetes (e.g.,
solution to reducing health disparities (Mirowsky, blindness, amputations, kidney damage, etc.) are
Ross, and Reynolds 2000). However, the national directly related to glucose management and the
health insurance systems in the United Kingdom diabetes regimen developed by health care providers
and Canada, which provided universal access to and implemented by patients (i.e., medication, diet,
care, fell short of high expectations for equalizing and glucose monitoring). Remarkably, according to
health care utilization (Black et al. 1988; Marmot, an ethnography conducted by sociologists Lutfey
Kogevinas, and Elston 1987; Roos and Mustard and Freese (2005), SES shapes the outcomes of
1997). In the 1970s, sociologists began to assert diabetes services at every point in the treatment
that access explains only a small proportion of the career—including access to particular kinds of
differences in morbidity and mortality across services, the organization of care, patterns of health
social groups, and many of them began to turn services utilization, the success of patient–provider
away from health services research (Marmot, communication, and the types and quality of treat-
Kogevinas, and Elston 1987; Miller and Stokes ments received—even among those who consist-
1978; Monteiro 1973; Ross and Wu 1995). Instead, ently have access to long-term diabetes care. In
medical sociologists pioneered efforts to focus on short, to the degree that health services are a criti-
persistent determinants of health and illness that cal component of disease management and recov-
are more distal in the chain of causation, i.e., “fun- ery, social status differences in health care are a
damental social causes” (Link and Phelan 1995). primary mechanism of health inequalities, particu-
Yet some caution that it may be too early to larly given the demographic shift in the United
throw the proverbial baby out with the bath water States toward chronic diseases requiring long-term
where health services are concerned (Robert and intervention by medical professionals.
House 2000). There has very recently been a resur-
gence of interest in health services among medical
sociologists, who are now using improved measures FINDINg 2. SOcIAl
to reexamine the role of health care systems in INSTITUTIONS REPRODUcE
health inequalities. For instance, health is increas- HEAlTH cARE INEqUAlITIES
ingly being conceptualized in terms of functional
status and quality of life rather than only by morbid- By cONSTRAININg AND
ity or mortality (Bunker, Frazier, and Mosteller ENABlINg THE AcTIONS
1994; Levine 1987). There has been a greater focus OF HEAlTH SERvIcE
on the impact of chronic conditions and disease
management on daily living. Thus, while health
ORgANIzATIONS, HEAlTH cARE
services disparities may account for relatively little PROvIDERS, AND cONSUMERS
of the inequality in rates of disease onset, they might A unique strength of the sociological perspective is
still explain a large proportion of the variation in the focus on underlying social structural mechanisms



of phenomena that ostensibly occur at the individual Managed Care and Medical
level (McKinlay 1996). Sociologists have long con- Decision-making
ceptualized medicine as a social institution, highlight-
ing the influence of macro factors on help-seeking One of the most significant consequences of insti-
and the practice of health care in everyday life (Fre- tutional change for everyday medical practice has
idson 1970; Mechanic 1975; Parsons 1951). The been that most physicians are now rewarded for
institution of medicine is characterized by a powerful providing fewer services at lower cost. This has
set of social norms, rules, values, and practices that caused concern among sociologists about the
provides a blueprint for the behavior of individuals impact of third-party payers on equitable access
and organizations (e.g., physicians, patients, hospi- and quality of care (Mechanic 2001, 2004). Man-
tals, HMOs, etc.), and systematically structures the aged care increases the use of primary care, pre-
relationships between them. Sociologists have con- ventative medicine, and outpatient treatment, but it
tributed much to our understanding of the ways that reduces hospitalizations, visits to specialists, and
culturally and historically shaped institutional forces more intensive, costly procedures (Wholey and
constrain the behavior of health care providers and Burns 2000). In fact, there is evidence that man-
consumers, reproducing health care inequalities aged care changes the way that individual doctors
across social groups (Light 2004). practice medicine. For instance, physicians in
Sociologists have been instrumental in docu- health maintenance organizations (HMOs) are sig-
menting changes in the institution of medicine nificantly less likely than those in a hospital or
over the twentieth century. In what Scott and col- private practice settings to diagnose the exact same
leagues (2000) call the era of professional domi- case of chest pain as cardiac disease, a diagnosis
nance (1945–1965), the motivating ideology in with high-cost implications (McKinlay, Potter, and
medicine was commitment to quality care. Addi- Feldman 1996). A critical role of sociologists has
tionally, there was a strong sense of obligation to been to identify how managed care unintentionally
provide health care to all, regardless of a person’s influences physicians and organizations to treat
ability to pay for it (Klarman 1963). Accordingly, individual patients in ways that reinforce broader
the poor received free care from physicians and patterns of structural inequality.
hospitals, and the population at large paid on a Using a controlled experimental design, sociolo-
sliding scale according to their means. In the era of gist John McKinlay and colleagues (1996) demon-
federal involvement (1966–1982), concern with strate that the resource environment in which a
equitable access prevailed, but the government physician operates interacts with patients’ sociode-
increasingly took over responsibility for funding mographic characteristics to shape physicians’ deci-
and regulating the fair distribution of health care sions about how to diagnose and treat signs and
(Scott et al. 2000). At the same time, health serv- symptoms of illness. For instance, ample evidence
ices expenditures began to increase rapidly, and indicates that medical practitioners provide lower
concerns about cost containment began to over- quality care to older patients relative to younger
shadow the long-standing commitment to quality ones, i.e., they are less likely to make referrals to a
care and equity that had characterized the institu- specialist, prescribe expensive medications, and
tion of medicine since its inception (Brown 1979). perform costly tests and procedures (Wenger et al.
In the current era of managerial control and 2003). However, sociologists emphasize that these
market mechanisms (Scott et al. 2000), the health biases are exacerbated by cost considerations.
care sector is conceptualized as an industry, or Among patients over the age of 65 presenting with
economic system, and efficiency and profit are chest pain, having health insurance coverage is a
central motivating values. Changes in health pol- strong predictor of receiving a diagnosis of cardiac
icy (and ultimately practice) enacted by the Rea- disease rather than a condition requiring less expen-
gan administration began as part of a broader sive medical interventions (McKinlay et al. 1996).
political movement characterized by welfare state Conversely, health insurance has no significant
retrenchment and by the shifting of government effect on patterns of diagnosis in younger patients.
control to competitive market forces (O’Connor Along these same lines, physicians practicing in a
1998). These events, described in greater detail by fiscally conscious, managed care environment are
Mechanic and McAlpine (2010, in this issue), cul- over nine times as likely to attribute women’s chest
minated in the corporatization of health care and pain to psychiatric problems (e.g., panic disorder,
the managed care ethos that pervades the institu- generalized anxiety, etc.) relative to men reporting
tion of medicine today. the exact same symptoms, and they are nearly seven



times as likely to diagnose African Americans’ sector; (3) Community and geographic barriers may
symptoms as gastrointestinal in origin compared to restrict access to private facilities and providers,
whites. Importantly, the diagnoses more commonly even when patients are publicly insured (Macintyre,
applied to lower-status groups are associated with MacIver, and Sooman 1993; Williams and Collins
less costly and time-intensive medical tests and 2001); (4) Finally, private facilities and providers
treatments. In short, when cost containment forces may overtly or subtly discourage publicly-insured
physicians to make difficult decisions and ration (and uninsured) patients from using their services
care, they frequently rely on biases that, while prob- (see Mechanic and McAlpine 2010 in this issue). At
ably unconscious, nonetheless result in inferior care even greater risk for slipping through the cracks of
and poorer health for vulnerable social groups. our health care system are the working poor and
lower middle class—those whose incomes neither
qualify them for public insurance nor allow them to
Separate and Unequal:The Public and afford private coverage (Seccombe and Amey
Private Health Care Sectors 1995). Indeed, public emergency room departments
have effectively become the safety net for Ameri-
Some sociologists have also criticized managed ca’s marginally poor, compensating for changes in
care and competition as a socioeconomic environ- eligibility criteria and cuts in government funding
ment that draws resources away from sectors of the for other social services (Billings, Parikh, and
health care system that are less profitable but none- Mijanovich 2000; Dohan 2002). However, most
theless critical (Cunningham et al. 1999; Mechanic agree that emergency room services are an ineffec-
1994). Again, this trend has important implications tive, inefficient, and costly solution to gaps in cover-
for the types and quality of care received by lower- age.
status groups. For instance, managed care organiza- Inequality between private and publicly avail-
tions minimize risk by denying coverage to sicker, able health services and facilities is growing
less profitable patients and spreading the risk out (Andrulis 1998). The resource environment associ-
among a large consumer group that contains both ated with managed care is partially responsible,
healthy and sick individuals. These practices shift but rationing care does not inevitably lead to ine-
much of the financial responsibility for indigent quality. Rather, this trend is consistent with Ameri-
care (i.e., those who are unable to pay for services) can political, economic, and cultural ideologies,
to physician groups and hospitals, pressuring them biases, and practices characterized by individual-
to balance their budgets by cutting costs associated ism and the privatization and dismantling of the
with uninsured or publicly insured patients. At the social safety net. Unlike in every other industrial-
same time, professional resources and government ized nation, health care in the United States is a
funds are increasingly being diverted to the profit- commodity rather than a right, and rationing of
able private sector (Waitzkin 2000). This has forced health services is based on socioeconomic status
many public health facilities to close their doors, rather than clinical need (Jost 2003). Thus, health
shrinking the public sector and widening the health care available to the uninsured and publicly insured
gap between the rich and the poor. Sociologists is inferior to the care received by individuals with
have demonstrated that the result of this profit- employer-based or other private insurance, exacer-
driven funding environment is essentially two bating health disparities in underserved groups
divergent health care systems, public and private, (Institute of Medicine 2004).
characterized by radically different experiences and
outcomes (Dutton 1978; Lutfey and Freese 2005;
Smedley et al. 2003). FINDINg 3. THE STRUcTURE AND
Supporters of the for-profit sector have argued DyNAMIcS OF HEAlTH cARE
that those without private insurance can still access ORgANIzATIONS SHAPE THE
private health services through Medicare and Medi-
caid reimbursements. On the contrary, sociologists qUAlITy, EFFEcTIvENESS, AND
have identified numerous barriers that minimize use OUTcOMES OF HEAlTH SERvIcES
of the private sector by the publicly insured: (1) FOR DIFFERENT gROUPS AND
Medicare and Medicaid often pay less than private
market value for a given service, forcing the patient
cOMMUNITIES
to pay the difference in cost; (2) Medicare and Med- Seeking to understand the implications of organi-
icaid policies are notoriously complex, prompting zational structure and dynamics in health services
confusion and fear of incurring fees in the private settings, a number of medical sociologists have


focused more narrowly on organizations. Indeed, as the inter- and intra-organizational dynamics that
much of the classical work in medical sociology are occurring within increasingly complex health
during the 1960s and 1970s explored various care systems (Flood and Fennel 1995; Light 2004;
aspects of health care organizations, especially the Scott et al. 2000).
general, acute-care hospitals (Coe 1978; Goss Understanding these organizational changes is
1963; Wilson 1963), as well as medical schools, critical because they reflect fundamental shifts in
physician offices, and psychiatric hospitals (Coe the nature of medical work and the delivery of
1978; Freidson 1970; Strauss et al. 1963). With health services. As health care organizations have
advances in technology and economic opportuni- become more highly specialized, internally differ-
ties in the health care sector, and with the epide- entiated, technologically oriented, and more tightly
miological shift from acute to more chronic and integrated (Scott et al. 2000), the professional
long-term health conditions, the types and varieties boundaries of medical work have blurred. Initially,
of health care organizations expanded dramatically medical sociologists suggested that these organiza-
from the 1960s onward. Nevertheless, these early tional changes had the potential to lead to the
studies had enormous descriptive value and con- “deprofessionalization” of medicine (Haug 1973)
tributed to a fundamental understanding of our and to undermine physicians’ professional domi-
emerging health system. They also highlighted a nance within the health care system (Light 2004).
myriad of organizational challenges in delivering Indeed, the greater emphasis on the “business of
health services, including the depersonalization health care” and the rise of health administrators
and devaluing of patients (Coe 1978); the interper- clearly have changed the traditional role of physi-
sonal dynamics between doctors and patients (Fre- cians by reducing or restricting their authority over
idson 1970; Glaser and Strauss 1965; Goffman clinical decision-making (Hafferty and Light
1961) the power relationships and conflicts among 1995). Today’s complex health systems represent
health professional groups (Goss 1963); and the fundamentally new configurations of an increas-
tendency toward bureaucratic medical decision- ingly broad array of professional expertise that is
making and treatment (Freidson 1970; Goss 1963; altering the long-standing system of professional
Strauss et al. 1963). Most importantly, this body of boundaries of technical expertise and knowledge.
work sensitized a generation of medical sociolo-
gists to the nature of medical work and established
a reference point that continues to inform the field. Consequences of Organizational Structure
In more recent years, medical sociologists have and Dynamics for Clinical Outcomes
examined critical organizational changes that have
had implications for how and what types of care Sociological health services research emphasizes
are delivered, as well as how effective the care is the central role that structural arrangements and
for various social groups. organizational dynamics play in shaping the qual-
ity, effectiveness, and outcomes of health services.
Eliot Freidson (1970), in his classic book The Pro-
Complex Health Care “Systems” fession of Medicine, laid the sociological founda-
Changes in the institution of medicine and its fund- tion for this line of research. While Freidson’s
ing environment in the latter half of the twentieth focus was on the work of physicians, he was
century, described above, have dramatically among the first to theorize that performance was
reshaped health care organizations. Before man- largely determined by structural and organizational
aged care, hospitals operated largely as autono- factors.
mous units. Today, most are evolving to become the Since 1990, interest in more applied research
nuclei of wider, regionally focused health networks on the organizational context of health services has
formed through the acquisition or merger of spe- expanded dramatically. Burns and Wholey (1991),
cialty and allied health care agencies and the devel- for example, demonstrated that structural and
opment of new ambulatory care facilities (e.g., organizational features of hospitals—including
urgent care centers, outpatient surgery centers) and size, type, and whether a hospital is part of a for-
specialty branch hospitals (e.g., children’s, cardiac, mal system (e.g., public vs. private, teaching vs.
orthopedic hospitals; Andersen and Mullner 1989; nonteaching, urban vs. rural)—are associated with
Cuellar and Gertler 2003; Weinberg 2003). Sociol- length of stay and mortality. Similarly, Aiken and
ogists have been instrumental in highlighting the colleagues have highlighted the impact of the
challenges associated with integrating care, as well organization of care and the degree of autonomy in



nursing on various health outcomes (Aiken, externalities that influence clinical interaction.
Clarke, and Sloane 2002; Aiken et al. 1999; Aiken, Hohmann’s model acknowledges that the organi-
Smith, and Lake 1994). Finally, sociologists have zational structure and context within which clinical
examined how organizational features, such as work occurs is essential for understanding out-
leadership centralization, differentiation, hierar- comes, but her framework also highlights the
chy, and size, can influence both outcomes and the external social environments, including personal
extent and nature of the adoption of effective networks and community contexts, which influ-
medical technologies in hospitals and health sys- ence both the providers and recipients of health
tems (Fennell and Warnecke 1988; Flood 1994; care services, as well as clinical outcomes.
Flood, Scott, and Shortell 1994; Scott 1990).
In more recent years, social theory has been
incorporated into health services research, moving HEAlTH SERvIcES IN THE
the field toward a better understanding of complex TWENTy-FIRST cENTURy:
mechanisms underlying organizational effective- POlIcy IMPlIcATIONS, FUTURE
ness. For example, the fragmented and unstable
nature of today’s health care organizations has led cHAllENgES, AND REFORM
to the rapid adoption of clinical care teams to inte- In a study of consumer attitudes in five industrial-
grate services. Health services researchers have ized nations, Davis and colleagues (2004) found
described and studied these teams using sociologi- that the United States ranked lowest in efficiency,
cal theories of group processes and social interac- effectiveness, and equity, and most Americans
tion, ranging from social network conceptualizations believe that the health care system is in desperate
of teams (Pescosolido, Wright, and Sullivan 1995) need of reform (Mechanic 2004). In late March
to more process-related dynamics (Wright et al. 2010, President Obama and the U.S. Congress
2006). Similarly, sociological theory is central to were successful in passing major health reform.
research on the social dynamics of provider–patient The final reform package, however, focuses pri-
interaction, focusing on how organizational factors marily on expanding access to health insurance
influence providers’ attitudes toward patients and and generally avoids the deeper and more complex
the approaches they take in communication and challenges in the structure and organization of our
services delivery (Waitzkin 1991). Indeed, it has health service delivery system. In this regard,
been argued that interactional and organizational sociological work on health services has clear
characteristics of public and private health care policy implications.
providers and settings may contribute to the afore-
mentioned health and health services disparities
across gender, socioeconomic, and racial-ethnic Policy Recommendation 1:The State and
groups and communities (Lutfey and Freese 2005; Federal Governments Should Become
Malat and Hamilton 2006; Williams 1990). More Involved in Regulating the Delivery of
From a broader sociological perspective, Health Services in the United States
research and theory linking organizational dynam-
ics and processes to clinical outcomes represent an The persistent health inequalities across social
effort to open up the black box of health services. groups and communities documented by medical
Fifty years of medical sociology has clearly dem- sociologists raise serious doubts about the capacity
onstrated that improving health services, while of our current health system to improve the health
necessary, is not sufficient to improve the health of of our nation’s population. In cross-national studies
all communities and populations. In this regard, the United States does not compare favorably, par-
medical sociologists should help to sensitize health ticularly with regard to other advanced, industrial-
services researchers to factors from sources other ized Western European nations (Davis 2004). Some
than health care organizations that nonetheless have argued that the key to better outcomes in these
fundamentally shape the experience of health care countries is the strong role of central government in
and, in turn, the impact that care has on individu- regulating the delivery of health services. Not only
als. Hohmann (1999) has offered a helpful multi- do these governments guarantee access to care
level framework in this regard. While developed through a single payer or a tightly regulated non-
with mental health services in mind, the frame- profit health insurance system, but they also sup-
work has more general utility. The central concern port and manage the distribution and quality of
is the array of system-related factors and social critical health resources. As documented by Scott



and colleagues (2000), health services have oper- Society
ated and developed relatively independently
because of the weak regulatory structure within the Sociological contributions to health services
United States and because government agreed to research reviewed in Findings 1 and 2 above
take over financial responsibility for providing emphasize ways that the existing medical system
health care for uninsured and other vulnerable privileges some social groups at the expense of oth-
populations during the 1960s and 1970s. As a ers, and thus reproduces broader structural inequal-
result, private health care systems have continued ities rooted in gender, race-ethnicity, and socioeco-
to make significant economic gains and have nomic status. In short, profit motivation in the pri-
secured resources that have allowed them to resist vate health care sector and underfunding in the
many efforts to impose stricter regulations (Quad- public sector influence physicians and organiza-
agno 2004). More importantly, the broader U.S. tions to make medical decisions that in effect ration
health care system remains a fragmented, uncoordi- care on the basis of social status rather than on
nated patchwork of remarkably independent orga- health care needs. Because it seems unlikely that
nizations driven largely by the pursuit of immediate the United States will move away from a partially
organizational and economic interests, not by the privatized system (see Mechanic and McAlpine
longer-term health care needs of the country. 2010 in this issue), and because these sectors are
Expanding government’s regulatory role in the inherently profit-driven, the most promising area
delivery of health services must necessarily be for instituting real policy change may be the under-
accompanied by a better marriage of research and funded public sector. As argued in Finding 3, many
policy. In recent years, policy makers have called of our nation’s low-income and racially segregated
for more “comparative effectiveness” research, communities are being served by a public system
specialized research that compares the cost and that is struggling to maintain the organizational
clinical efficacy of treatments for particular condi- structure, culture, and leadership afforded to the
tions. Recent efforts to improve care have gravi- private sector by government investment.
tated toward performance measurement and Current proposals for health care reform will
linking payment to concrete outcomes. While a work to improve access to private services among
focus on outcomes is undoubtedly valuable, exist- the publicly insured and underserved. However,
ing research has barely scratched the surface of the the public/private stratification of our existing
broad and complex social and organizational fac- health services system necessitates a two-pronged
tors that shape efficiency and effectiveness. In this strategy. Equally critical is the need to move
regard, sociological research is important because beyond access issues to consider qualitative differ-
it underscores that quality care is determined not ences in the health services being utilized by those
only by what services are provided, but also how on the margins of society—the most sick, impov-
they are delivered, by whom, and to whom. erished, and structurally disadvantaged individuals
In sum, increasing state and federal regulation (Mechanic 1994). As described above, existing
requires that the government be optimally informed sociological research suggests that members of
about the best new directions for health policy and structurally disadvantaged groups face myriad
practice. While many argue against an expanded obstacles to utilizing efficient, cost-effective, and
role of government in health care because of fears health-promoting preventative and primary health
of limiting access and innovation, government services, even when they ostensibly have access to
already pays for nearly half of our national health these through public insurance (Dutton 1978; Lut-
care expenditures (Sisko et al. 2009). History tells fey and Freese 2005; Macintyre et al. 1993). Thus,
us that reducing state and federal regulation in the it is necessary to focus on improving the quality
health care marketplace will only result in limiting and organization of services and facilities that ben-
access to health services for the most vulnerable, efit, for example, those with severe and persistent
expanding health inequalities and ultimately weak- mental illness, those in remote rural areas, indi-
ening the foundations of our democratic society. viduals near or below the poverty line, and mem-
bers of disadvantaged racial-ethnic minority
groups. The goal, then, is not only to provide uni-
Policy Recommendation 2: Federal and State versal access to the private sector, but also to lift
Governments Should Invest in Public Health the public sector up to the standards of the private.
Service Systems that Reach out to the Most Such a strategy requires careful planning. Policy
Structurally-disadvantaged Members of makers should identify locations for building



facilities, increasing funding, and augmenting serv- Andersen, Ronald and Ross M. Mullner. 1989. “Trends
ices and providers that are optimally useful and in the Organization of Health Services.” Pp. 144–165
attractive to those in underserved communities. in Handbook of Medical Sociology, edited by H. E.
Likewise, it is necessary to consider how the unin- Freeman and S. Levine. Englewood Cliffs, NJ: Pren-
sured and underinsured currently utilize those serv- tice Hall.
ices that are available, and how to bring people at the Andrulis, Dennis P. 1998. “Access to Care is the Cen-
margins into the health care system. For instance, terpiece in the Elimination of Socioeconomic Dis-
incentivizing the use of primary, preventative, and parities in Health.” Annals of Internal Medicine
follow-up health care among those currently relying 129:412–16.
on emergency room services may be an effective Angel, Jacqueline L. and Ronald J. Angel. 2006. “Minor-
strategy. In all, we may simultaneously reduce the ity Group Status and Healthful Aging: Social Struc-
cost of health care and improve the health of U.S. ture Still Matters.” American Journal of Public
citizens by thoughtfully investing in groups and com- Health 96:1152–59.
munities that need it most, rather than by allocating Billings, John, Nina Parikh, and Tod Mijanovich. 2000.
them on the basis of profit and stakeholder interests. “Emergency Department Use in New York City: A
Substitute for Primary Care?” Pp. 1–5 in Issue Brief,
Commonwealth Fund, New York.
cONclUSION Black, Douglas, Jerry Morris, C. Smith, Peter Townsend,
Over the past 50 years, medical sociology has and Margaret Whitehead. 1988. Inequalities in
improved our understanding of the U.S. health care Health: The Black Report/The Health Divide. Lon-
system and the wide array of providers and organi- don, England: Penguin UK.
zations that comprise it. More important, this body Blendon, Robert J., Linda H. Aiken, Howard E. Freeman,
of research has put a spotlight on how the distribu- and Christopher R. Corey. 1989. “Access to Medical
tion and delivery of health services contributes to Care for Black and White Americans. A Matter of
fundamental social inequalities and health dispari- Continuing Concern.” Journal of the American Medi-
ties across many social groups and communities. cal Association 261:278–81.
The extraordinary fragmentation and lack of coor- Bostick, R. M., J. M. Sprafka, B. A. Virnig, and J. D.
dination suggests a need for more centralized Potter. 1993. “Knowledge, Attitudes, and Personal
management, something that the health care mar- Practices Regarding Prevention and Early Detection
ket has not been able to achieve on its own. When of Cancer.” Preventive Medicine 22:65–85.
taken as a whole, sociological research on health Brown, E. Richard 1979. Rockefeller Medicine Men:
services highlights the need for a stronger role of Medicine and Capitalism in America. Berkeley: Uni-
government in coordinating and managing the U.S. versity of California Press.
health care system. Bunker, John P., Howard S. Frazier, and Frederick Mosteller.
1994. “Improving Health: Measuring Effects of Medical
Care.” The Milbank Quarterly 72:225–58.
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and Ethnic Disparities in Health Care. Washington,
DC: National Academies Press. Bios
Strauss, Anselm, Leonard Schatzman, Danuta Ehrlich, Eric R. Wright is professor and division director for health
Rue Bucher, and Melvin Sabshin. 1963. “The Hos- policy and management in the Department of Public Health
pital and Its Negotiated Order.” Pp. 147–69 in The at the Indiana University School of Medicine. He also serves
Hospital in Modern Society, edited by E. Freidson. as the director of the Center for Health Policy at Indiana
New York: The Free Press. University-Purdue University Indianapolis. In addition, he



holds an adjunct appointment in the Department of Sociol- focuses on the interrelated roles of social networks and
ogy in the Indiana University School of Liberal Arts. His interaction, social structure, culture, and biological sys-
research interests center on health policy, social responses to tems in disease etiology and the illness career. She has
health problems, and the social organization and effective- published research on dynamic social network processes,
ness of health services and public health programs. stigma and its consequences, youth in foster care, mental
illness in children and adults, and gene–environment
Brea L. Perry is assistant professor in the Department of interactions in disease pathways.
Sociology at the University of Kentucky. Her research


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