Inequalities and Disparities in Health Care and Health: Concerns of Patients, Providers and Insurers: Volume 25

While Americans have often believed that the United States has the best health care system in the world and that, as one of the wealthiest nations, we therefore must have the best health care available to our citizens, researchers in medical sociology, public health and health services research have emphasized for decades that America tolerates extremes of wealth and poverty much greater than in many European countries. This toleration of extremes extends to the approach to the delivery of social and health services, as well as to consumer goods. Over 40 million Americans do not have health insurance and thus have limited access to expensive health care services (Morone & Jacobs, 2005b). Even more may have very poor health coverage, so that if a serious illness were to occur, the person would have a very hard time finding care and paying for that care. Even if people have coverage for major health care problems, many people do not have insurance that covers areas of health care such as vision care, dental care and audiology services. While these are not life threatening health care concerns, they are health care concerns that impact quality of life and even ability to achieve. A child who cannot see well has trouble succeeding in school. A person in pain from tooth problems has trouble concentrating on tasks, and poor oral health is one contributor to nutrition concerns among the elderly. Lack of access to hearing aids increases the social isolation of the elderly, but these services are not covered by Medicare, the federal program that does provide access to health care services for most of the elderly in the United States.

Social networks have been a central focus of sociological research on inequalities but less has focused specifically on chronic illness and disability despite a policy emphasis on resources necessary to support self-management. In this chapter, we seek to unpack overlaps and distinctions between social network approaches and research on the experience and management of chronic illness. We outline four main areas viewed as central in articulating the potential for future work consistent with a critical realist perspective: (1) body–society connections and realist/relativist tensions; (2) the controversy of ‘variables’ and accounting for social and cultural context in studying networks for chronic illness support; (3) conceptualising social support, network ties and the significance of organizations and technology; and (4) translating theory into method.

In this chapter organizational theory is used to clarify and synthesize the large and diverse literature on the relationship between managed care (MC) and ethnic differences in access to health services. MC practices are classified by whether they are used by health care organizations to define their boundaries or to coordinate care. MC practices used to coordinate care are further categorized as one of five types: rules and programs, authority, goal setting, culture, or client coordination. This review also presents hypotheses derived from this literature that specify the predicted effects of MC practices on ethnic differences in access to health services. It was found that few of these hypotheses had been empirically investigated and although some evidence was found that MC boundary-setting practices disadvantage minorities, there were not consistent findings with respect to those practices used to coordinate care.

As an ethnic group, Korean Americans have one of the highest uninsured rates in the U.S. (Brown et al., 2000). Through in-depth interviews (n=14) and surveys (n=268), this study found that one-third of the sample was uninsured. High premiums prevented the uninsured from purchasing health insurance. Although health insurance has been a strong predictor of health services utilization, this study also found that when examining the utilization of various health services by health insurance status, there were no major significant differences with the exception of Korean traditional health services. High deductibles prevented insured persons from utilizing health services.

The past few years have seen the emergence of a research literature dedicated to defining and understanding trust in physicians. Much of this research, however, focuses on a narrow set of explanations for the generation of physician trust. The purpose of this chapter is to expand on research by introducing new ideas to the study of physician trust. Employing data from the 1998 General Social Survey, the chapter shows that social resources, vulnerability in finances and in perceptions about the end of life, and exposure to unstable environments all are fairly consistent predictors of physician trust.

The “baby-boom” generation is poised for retirement. Yet the American states exhibit sharp inequalities in the public support they provide for nursing facility long-term care for the elderly, a form of health care that few Americans can afford to purchase privately. Further, remarkable disparities exist, both within and among states, in the quality of nursing facility care. We describe cross-state variation in Medicaid support for and the quality of nursing facility care, offer regression models that provisionally explain the sources of these inequalities, comment on the social implications of these disparities and recommend a solution.

Rural areas that are struggling to recruit and retain qualified health practitioners are caught in the crossfire of turf battles between allied health practitioners and physician groups. The most intensely political of these inter-occupational turf battles is between anesthesiologists (MDAs) and certified registered nurse anesthetists (CRNAs), who are the sole providers of anesthesia in two-thirds of rural hospitals (American Association of Nurse Anesthetists (AANA), 2007a, 2007b). The ability of many rural hospitals to provide anesthesia services is dependent on CRNAs. This study uses data collected from CRNAs in Iowa and Arizona in 2005 to focus on the impact of the turf battle on the professional interactions and opinions of CRNAs. Arizona and Iowa were chosen for this study because not only do the policies in these states contrast with each other, but the contexts in which CRNAs practice are also dissimilar. The majority of Arizona's CRNAs work in urban areas in close proximity with MDAs. Most CRNAs in Arizona report that their workplace interactions with MDAs have suffered as a result of the turf battle, despite the lack of any action to opt out of the federal Medicare requirement of physician supervision of CRNAs. While most CRNAs in Iowa perceive that job opportunities and the quality and cost of health care have improved as a result of opting out of the federal supervision requirement of CRNAs, the impact on their social interactions in the workplace depends on location and the structural context of their work. Most CRNAs in Iowa's urban areas continue to work in a structural context of de facto supervision by MDAs. As a result, only a minority report that their professional interactions in the workplace have improved. The outcome for Iowa's rural CRNAs is decidedly different. The majority function as independent practitioners and have experienced an improvement in their social interactions in the workplace and greater economic reward. These occupational privileges should improve the ability of Iowa's rural hospitals to recruit and retain CRNAs and, as a consequence, surgical services in rural areas.

Despite continuing socioeconomic and racial/ethnic gaps in many health care services, the National Healthcare Disparities Report (2004) documents parity in substance abuse treatment provision among individuals of varying socioeconomic and racial/ethnic backgrounds. This study investigates that achievement by analyzing the relationship between community socioeconomic and racial/ethnic disadvantage and organizational provision of substance abuse treatment, treatment need and utilization across United States counties, 2000, 2002 and 2003. Results confirm equity in service provision in poorer communities and those with higher concentrations of African Americans. Significant disparities remain, however, in communities with higher concentrations of Hispanics, youth and female-headed households. Limitations and implications for future studies of health care provision are discussed.

The purpose of this chapter is to examine geographic variations in utilization and need for mental health services. Data for this study were obtained from the 2002 National Survey of American Families. The total sample size was 23,327 adults of aged 18 years and older. Both logistic and linear regression were used to test the possibility of geographical variations. Disparities were found among the 13 U.S. states examined in this study. Results also showed that the percentage of African Americans, state mental health budgets, and mean length of stay in psychiatric hospitals in the state are important predictors of variations in mental health utilization and need variables. These findings suggest that although individual sociodemographic characteristics are important in examining mental health utilization, state characteristics (especially percentage of African Americans, state mental health laws, and mean length of stay in psychiatric hospitals) are also important predictors of variation in utilization of mental health services.

“Disparity” implies the existence of a “markedly distinct in quality or character,” difference between one group and another. Some groups, due to elevated stigma associated with group membership, are invisible as a disparate minority and therefore, while there may be a great inequity in healthcare between that group and the normative population, the invisible minority is ignored. This chapter addresses the issue of healthcare for the transgender-identified population. We address how the normative viewpoint of mental illness and unacceptable religious status, along with lifelong perceived and actual abuse and violence, creates a socially sanctioned inequality in healthcare for this population.

The purpose of this study was to examine the prevalence of social suffering among a non-random sample of Canadian women working in socially and economically marginalized “frontline” service occupations. Participants identified a number of health concerns that they link to the everyday suffering they endure – i.e. feeling inadequate, incompetent, lonely, self-conscious, disenfranchised or dissatisfied. The complex etiology of these women's suffering bars many from finding appropriate health care. As a result, there are health disparities among our vulnerable populations. While they often articulated a desire for alternative/complementary care, the Canadian health care system does not currently fund these services and many of the women are unable to afford the out-of-pocket costs.

This chapter focuses on the differences that younger, middle-aged, and older women with breast cancer experience, particularly in health knowledge and treatment. These differential experiences, in part, stem from our youth oriented culture. This ideology extends into medicine and can affect day-to-day medical practice. Differential experiences are, therefore, likely to result in inequality and disparity in health and in healthcare. It is argued that older women are less empowered than their younger counterparts to display the same degree of agency. This analysis has important implications for health care professionals in the treatment of older women with breast cancer.

Many individuals are concurrently eligible for multiple sources of government-reimbursed health care services (e.g. Department of Veterans Affairs (VA) and Medicare). Unclear is whether combined eligibility translates into increased access to care and/or improved outcomes of care. Alternatively continuity of care may suffer, promoting health inequalities when patients receive health services from multiple unrelated sources of care. The current study examines the impact of dual eligibility for government-reimbursed care on long-term outcomes of care for a population of veterans diagnosed with colorectal cancer and initially treated surgically at Department of Veterans Affairs Medical Centers.