Title: comparative study of health status, health behaviors, and health care delivery
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Title: comparative study of health status, health behaviors, and health care delivery
Physical Description: Book
Language: English
Creator: Mulle, Virginia, 1948-
Copyright Date: 1993
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Bibliographic ID: UF00100985
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Full Text










A COMPARATIVE STUDY OF HEALTH STATUS, HEALTH BEHAVIORS,
AND HEALTH CARE DELIVERY: THE UNITED STATES
AND GREAT BRITAIN














By


VIRGINIA


MULLE


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY


UNIVERSITY


OF FLORIDA













To my


son,


Douglas Robert Mulle
(1969-1988)













ACKNOWLEDGEMENTS


would


like


express


thanks


and


appreciation


Michael


Radelet


, Gary


, Ben


Gorman


Karen


Seccombe,


Otto


von


Mering


their


encouragement


and


support


during


graduate


career


have


learned


much


from


each


them.


In addition


Radelet


would


never


especially


losing


like


faith


thank


or giving


Michael


on me


standing


beside


me through


some


difficult


times


Special


appreciation


to David


Mitchell.


was


always


available


to offer


helpful


sugge


stions,


moral


support,


most


importantly


, friendship


during


our


graduate


years


together


at UF


, and


during


the


dissertation


process


I would


also


like


thank


Malcolm


Cross


useful


comments


on the


dissertation,


and


to Nadine


Gillis


invaluable


ass


stance


in the


preparation


this


dissertation.


Finally


owe


a great


deal


mother


Charlotte


Mappus.


Without


help


, which


ranged


from


taking


care


Terry


to love


and


support,


this


project


would


never


have


been


completed.
















TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS........................ ............... .i.l

LIST OF TABLES. ... ... . . . . . . .......................................... vl

ABSTRACT... .......................... ..... . . . . ....viii

CHAPTERS

1 INTRODUCTION.................. ................. . 1

Statement of the Problem........................... 3
Discrepancies in Health Status Based on Social Class
in the United States........................... 4
The Health Care System of the United States........ 6
The Health Care System of Great Britain: An


Alternative to Fee-for-Service.....
The Proposed Research...................


00"'. 0. .. ...
........." ...


A REVIEW OF THE LITERATURE.......................... 11


Health Status and Social Class...................... 11
Causes of Poor Health Status........................ 21
Environmental Factors/Living Conditions........ 22
Genetic or Biological Factors........... ...... 23
Personal Control. . . . . . . . . . . . . . .. 24
Need Hierarchy. .. . ... . . ... . . .. ....... 26
Lifestyle Behaviors............................ 27
Socioeconomic Status and Health Behaviors...... 36
Inadequate Health Care Services................ 45
The Health Care System of the United States........ 54
A National Health Service........................... 59
The Health Care System of Great Britain............. 61
Conclusion.. . .... . .. . . ........ .. . ........ 69


A THEORETICAL FRAMEWORK.............................


Introduction..................
'T'hc Connfl -i rn+- DoT~;renor.+*,xra


S. ......... . .. 72
r7aC












The Comparative Method..........
Selection and Comparison o1
Data.. .............. .... .....


Description of the
Description of the
Sample Characteristics..
United States......
Great Britain......
Variables of Interest...
Dependent Variable.
Independent Variabl
Socioeconomic


Data Set
Data Set


* . .
* . .
* .
* . .
* . .
es....
.....
.... *


Status..


Demographic Variables.
Health Behaviors......
Data Analysis..............


. . . ...... . . . . 93
fCountries.......... 95
. .. .. ... . .. ... .. ...110
- United States.... 111i
Great Britain....112
. . . . . . . . . .113
.... . ... ... ...113
................. 115
... ....... ........ 117
. ..................117
. .............. ... 118

.. . . 120
......... .. .. ....122
........... .. ...... 126


FINDINGS AND DISCUSSION.. ......................... 135


Correlation
Correlation
Comparison
Regression
Regression
Comparison


Analysis United States...
Analysis Great Britain...
of the Correlation Analyses.
Analysis United States....
Analysis Great Britain....
of the Regression Analyses..


S. . . . . ...135
. . . . .153
S. . . . . 157
S. . . . . .161
. . . . . . .167
. . . . . . 172


ASSESSMENT AND IMPLICATIONS ....... .... ............183


Support for the Existing Empirical Literature.
Contributing to the Knowledge Base............
Future Directions........................... .
Conclusion... .. ..... .... ............ .....


S. . ..183
. . . .190
S. . ..193
S. . 196


REFERENCES............................................... 198

BIOGRAPHICAL SKETCH......................................214


METHODOLOGY.. ....................... ........... 93

















LIST


OF TABLES


Table


Page


Percent


Population


Britain


Age,


U.S


. and


Great


, 1985


Percent


Employment


Indu


stry


U.S


. and


Great


Britain,


1985..


S. . . . 100


Labor


Force


Participation


Age


U.S


. and


Great


Britain,


1985.


Percent
Quintile


Distribution


, U.S


. and


of Family


Great


Net


Britain


Income


, 1985


. 103


Percent


of Population


Owning


Major


Appliances


U.S.


and


Great


Britain,


1985


Sample

Sample


Character

Character


stics


United

Great


States.

Britain.


Correlations


, All


Variabi


, United


States


. 137


Correlations


, All


Variabl


, United


Stat


es.


... 139


Correlations


Correlations,

Correlations,


Variable


Variables


Variable


United


United

United


States.

States.

States.


... 141

.. 143

.. 148


Correlations


, All


Variabl


, United


States


. 150


Correlations,


Variables


, United


States.


... 151


Correlations


, All


Variabl


, United


States


... 152


Correlations


Variables


, Great


Britain.


... 154


c in


C'C 4.A v


n a - a - - -e tv...i .5 1- d~ A-





II


1- f" 1


S . . . . 101


S. 103


. . . . 114

. . . . 116


n,


__


i A -


L ..









Stepwise


Regre


Education,


sslon


Age


of Health


, and


Health


Status


on Income


Promotion


Behaviors


, Great


Britain.........


. 168


Compari


son


United


of Stepwise
States and


Regre
Great


ssion


Model


Britain..


. . .174















Abstract


the


of Dissertation


University


Presented


of Florida


the


Partial


Graduate


School


Fulfillment


the


Requirements


Degree


of Doctor


of Philosophy


A COMPARATIVE


BEHAVIORS


, AND


STUDY
HEALTH


OF HEALTH


CARE


STATUS,


DELIVERY:


THE


HEALTH


UNITED


STATES


AND


GREAT


BRITAIN


Virginia

December


Mulle

1993


Chairman


Major


. Micha


Department


Radel


biology


Using


U.S


. Health


Interview


Survey


1985


sample


of 33


respondents


surveyed


1985


British


Health


and


Lifestyle


Survey


1984


-1985


sample


9,003


respondents


surveyed


1985


this


study


examined


the


relationships


socioeconomic


status


health


promotion


behaviors


to health


status


in both


country


and


how


those


relationships


differed


according


stem


of health


care


delivery


The data


sets


were


developed


each


country


eir


respective


national


health


departments.


The


relationships


between


socioeconomic


status


and


health


status


were


firs


t examined


separately


, in


order


to determine


within


-country


relationships


then


relationships


were


compared


across


Soc


es.


examining


the


SES-









countries,


and


that


socioeconomic


status


was


not


the


best


predictor


of high


health


status.


In both


countries


, the


health


promotion


behavior


of participation


in exercise


was


most


significant


affecting


positive


health


outcomes,


both


directly,


mediating


negative


effects


socioeconomic


status.
















CHAPTER


INTRODUCTION


In 1990,


was


estimated


that


33 million


citizens


, or


population


United


States,


had


no health


insurance


repre


. General


sents


Accounting


an increase


Office


of union


GAO],


sured


1991)


Americans


the


1980


s over


previous


decade


(Wait


zkin,


1989)


these


33 million


Americans


who


have


no health


insurance


, the


poor


are


disproportionately


represented.


Thirty


-four


percent


have


medical


the


no health


insurance


poor


(living


insurance


means


or below


GAO,


lack


1991)


of medical


poverty


Often,


care.


level


lack


In a nation


where


access


to vital


health


care


services


and


the


quality


that


care


depend


largely


on the


ability


pay,


health


care


become


more


of a privilege


than


a right


citizenship


According


dominant


values


in America


today


medical


ability


to purchase


care


secure


that


largely


medical


care


care


a market


commodity


determined


As a result,


way


where


the


which


ability


health


care


delivered


created


a sys


which


ass


biased.











relationship


between


social


class


and


health


status


pers


today


is contrary


to what


might


be expected


light


of several


major


changes


which


have


occurred


during


the


last


year


Infectious


seases


have


declined


as a


major


cause


of mortality


Adequate


nutrition,


housing,


water,


and


sanitary


conditions


have


become


available


to most


Americans.


In 1966


Medicare


Medicaid


were


created


which


were


designed


to place


medi


care


within


reach


poor


Yet,


spite


ese


developments


There


still


st socioeconomic


disparities


in morbidity


mortality


Socioeconomic


status


continues


to be linked


the


risk


of health


and


sease


in America.


In order


to address


problems


created


a cla


SS-


biased


health


medical


care


stem


, structural


system


. has


reform


been


the


suggested


sting


(Barber


1991;


Waitzkin


, 1989;


Williams


, 1990)


Pres


ident


Bill


Clinton


health


and


care


Hillary


reform


Rodham


which


Clinton


will


are


involve


developing


structural


a plan


change


present


system.


plan


will


guarantee


health


care


coverage


estimated


million


Americans


who


are


uninsured,


a benefits


package


cover


doctor


s and


hospital


s bill


, pres


cription


drugs


preventive


care


those


with


insurance


(Brink


et al.,


1993)


. The


pos


ition











economic


reasons


health


policy


nation


should


address


those


issues.


This


tem-barriers


approach


structural


health


areas,

cost c


reform


care


travel


:onstraints


focuses


: the


difficult


(Dutton,


on the


scarcity


inadequa


of phys


access


1986)


cles


icians


medical


may


the present


poverty


resources


that


and


the


adoption


program


some


with


form


of a centralized


provis


of medical


national


services


health


the


state


, would


increase


access


to medical


resources


Americans.


One


such


form


of national


health


program


the


National


Health


Servi


of Great


Britain,


which


been


existence


since


1948.


Statement


Problem


The


fact


that


many


Americans


do not


receive


adequate


health


care


lack


of financial


resources


access


stem


is a major


concern


of policy


makers


and


citizens


the


U.S


. today


Under


present


professional


-for-


service


the


health


resources


care


delivery


to purchase


stem


health


care


the

have


U.S.

good


those

health


with

and


those


who


cannot


have


poorer


health.


The


problem


addressed


research


whether


a structurally


different


system


of health


care


delivery


, the


National


Health


Service












within


each


country,


then


these


relationships


will


compared


across


countries


These


analy


ses


will


be used


determine


whether


a structurally


different


system


of health


care


delivery


from


profess


ional


-for


-service


U.S


. might


provide


better


health


care


to all


Americans.


DiscreDancies


Health
in the


Statu
United


Based
States


on Social


ass


The


strong


sitive


association


between


social


class


and


health


statu


has


been


observed


many


researchers


an early


systematic


review


of health


stati


stics


and


literature,


Antonovsky


(1967)


found


that


the


lower


asses


have


invariably


had


lower


life


expectancies


higher


death


rates


from


causes


of death


than


those


higher


social


exhaustive


asses.


and


Kitagowa


detailed


Hauser


review


(1973)


of mortality


conducted


differential


U.S


. and


found


that


lower


socioeconomic


groups


have


had


higher


death


rates


than


those


in the


higher


groups


, whether


income


, education,


or occupation


was


used


as an indicator


SES


Recent


studi


have


continued


to support


these


early


findings


Logue


and


Jarjoura


(1990) ,


example,


found


that


members


lower


class


ses


experienced


heart


disease


---.-.- IA-


.8- -


1- 2


__^ L -- -


-A1-


rl


_ I *


_











Dutton


(1986)


reported


similar


findings


as age


-adjusted


death


rates


from


four


five


major


causes


of death


(heart


disease


, cancers


strokes


, and


diabetes)


her


review


were


higher


among


poor


than


among


other


income


groups.


Recent


studi


have


focused


on the


infant


mortality


rate,


which


is considered


one


most


sensitive


indicators


the


health


of a society


because


the


indicator


most


dependent


on the


social


economic


well


rate


-being


of mothers


is defined


as the


children


number


The


of deaths


infant


mortality


of children


under


one


year


age


1,000


live


births


Rates


infant


mortality


pattern


United


as overall


States


mortality


have


rates.


followed


the


Groups


same


the


lower


income


areas,


especially


inner


cities


, have


long


been,


continue


to be,


characterized


infant


mortality


rates


that


are


substantially


above


those


the


higher


income


areas


(Bodenheimer


, 1989;


Stockwell


et al


, 1988)


In regard


to morbidity,


income


also


been


found


have


a strong


influence


on the


occurrence


illness


(Freund


McGuire


Santariano,


, 1991;


1986;


Hay


Susser


, 1988;


et al


McLeod


, 1985;


Kessler,


Wescott,


1990;


1990)


illnesses


and


specific


illnesses


such


as heart











infectious disea

technologically

increasing among


The Health


long thought


advanced medical


poor children


Care System of


controlled by


system,


our


have been


(Bodenheimer,


United


1989).


States


The medical


professional model


system


with an


U.S.


emphasis on


best described as a


fee-for-service and


professional


autonomy


(Freidson,


1970).


this


system,


least


"ideal


type"


form,


members of


the health


care


professions


(individual


practitioners and health


care


facilities)


are able to


levy


a charge for


each service


they


perform.


The amount


charged


is set by these members,


taking


into account market


forces.


The members


the health


care


profession


enjoy


socioeconomic and


technical


autonomy


their profession,


free from


interference.


National,


state,


local


professional


societies


(e.g.,


the American


Medical Association and American Hospital Association)


constitute

within which


profession


the basic,


formal


organizational


profession works.


lack


framework


Criticism of


responsiveness


the medical


to public


interest


is common


(Cockerham et al.,


1988;


Navarro,


1986;


Starr,


1982


Waitzkin,


1989).


Two trends have been


identified as especially problematic


in relation


the











growth


of corporate


medicine


(Freund


McGuire,


1991) ,


both


of which


affect


ability


access


system.


Part


problem


S'S


tent


patterns


the


state


-funded


Medicaid


program.


Although


Medicaid


was


designed


to provide


health


insurance


poor,


actually


covers


ess


than


of children


who


live


below


poverty


level


(Harvey


, 1990)


While


each


state


determines


own


level


of eligibility


one


the


50 states


has


level


The


that


Health


is on a par


Care


with


of Great


to Fee


-for


federal


Britain
service


poverty


: An


level


Alternative


The


National


Health


Servi


of Great


Britain


highly


centralized


stem


of health


care


delivery


which


delivers


medical


services


uniformly


to all


members


society,


quality


care


is uniform


across


the


soc


iety


(Hollingsworth,


1981)


Phy


sicians


are


either


employed


the


local


authority


health


service


or are


self


-employed


general pr

to provide


actitioners


primary


who


care.


contract


with


British


the


health


hospital


service


sec


national


zed;


thus


the


government


owns


mos


t hospitals


Regional


variations


the number


of phy


sicians


and


stribution


of hospital


beds


have


significantly


dimini


shed


Iur~i 1 4 EY~n4 1~ .'nl' m 1-. a a- r. n -1 1n-'- 8.aa


/Unll 1 ^^


n~.tA~C ~


ino1\


mt, ,,,


~Lr


AAAL A u











according


to Gill


(1990)


one


Britain


need


be without


medical


care


because


financial


barriers"


. 478)


Proposed


Research


The


purpose


research


to examine


the


relationship


between


socioeconomic


status


health


status


studying


relations


hips


: (1)


within


a country


without


national


health


service,


within


a country


with


national


health


service


comparing


the


two.


Results


this


comparison


will


suggest


whether


a structural


change


the


health


care


delivery


stem


the


U.S.


one


similar


health


care


service


of Great


Britain,


may


provide


that


better


there


health


ess


care


to all


variance


Americans.


health


status


found


as a function


a country


with


a NHS


than


in a country


without


NHS


then


service


support


may


institution


be warranted.


this


of a national


found,


health


or other


variable


are


found


to play


a more


significant


role,


then


new


knowledge


critical


to health


planning


on a national


level


may


sugg


ested.


Chapter


surveys


the


literature


on health


status


and


socioeconomic


status


U.S.


It begins


with


discussion


the


SES-health


status


relationship


the


U.S











is a des


cription


the


professional


fee-for


-service


health


care


stem


review


the


literature


continues


with


a description


the


National


Health


Service


of Great


Britain


a discussion


the


SES-health


status


relationship


within


that


country


Reasons


the


failure


an NHS


to develop


.are


explored.


Chapter


presents


a macro


theoretical


framework


focusing


on the


relationship


between


elements


the


social


structure


patterns


of behavior


This


theoretical


framework


uses


a conflict


approach


to offer


an explanation


the


per


sistent


association


between


and


health


status


This


chapter


concludes


with


development


hypothesis


regarding


-health


status


relationships


between


two


countries.


The


hypothesis


developed


Chapter


tested


using


the


methodology


presented


Chapter


This


chapter


begins


with


a discussion


comparative


method


used


this


study


next


section


contains


a description


the


two


data


sets


used,


Health


Lifestyle


Survey


1984


-1985


Great


Britain,


the


U.S


. Health


Interview


Survey


1985.


Variables


intere


this


study


are


then


described.


Analytical


mod


use


the


hypotheses


are


presented.


Multiple


regression


analy


S1S


is used











Chapter


presents


findings


the


correlates


levels


of health


status


with


other


predictor


variables


partic


including


ipation


age,


health


level


promotion


of education


behaviors.


and


The


level


analyst


will


include


a discussion


of within


country


relationships,


and


a comparison


these


relationships


to determine


differences


similarities


between


the


U.S.


and


Great


Britain.


Chapter


presents


implications


study


Focus


is on how


findings


relate


back


add


previous


research.


The


utility


conceptual


framework


presented


the


study


is evaluated,


directions


future


research


are


suggested.

















A REVIEW


CHAPTER
OF THE


LITERATURE


Health


Status


Social


Class


One


the


most


consis


tent


findings


in epidemiological


research


has


been


positive


relation


ship


between


health


status


social


class


or the


inverse


relationship


between


various


indicators


of health


status


.g.


morbidity


levels


and


social


class.


Regard


ess


measure


employed,


whether


income,


education,


or occupation,


Americans


lower


socioeconomic


status,


at all


ages,


have


been


found


have


higher


mortality


, morbidity


, and


disability


rates


than


those


in the


middle


and


upper


asses


(Navarro,


1990)


In addition


, health


problems


poor


are


typically


more


serious,


complex,


difficult


treat


(Dutton,


1986)


. the


inverse


relationship


between


mortality


rates


has


been


studied


various


community


rural


and


urban,


with


reporting


similar


patterns


(Williams,


1990)


While


there


been


an overall


decline


in mortality


rates


century


difference


mortality


rates


between


classes


has not


been


eliminated


rr% aC'a CNf; ^ r m I = fl a


J.~k 1 *1


rpl- n


rnm~


anrl


Pl~n


&


e


"7 _F











Freund


and


McGuire,


1991;


Kitagowa


and


Hauser


, 1973;


McLeod


and


Kess


ler,


1990).


Thi


phenomenon


peculiar


the


U.S


A number


of studies


of diverse


populations


have


found


that


there


are


widespread


sease


and


persistent


in many


SOC


social


ieti


class


Marmot


differences


et al. (1987)


health


in a


comparative


study


of social


class


mortality


different


society


found


that


mortality


varies


class


Great


Britain


(England


and


U.S.


Denmark


, Norway


Finland


, France,


New


Zealand


Japan.


In a comparative


study


Great


Britain


France


Behm


and


Vallin


(1982)


found


no change


since


World


War


the


higher


rates


of mortality


among


lower


asses


In the


U.S


ass


differentials


mortality


rates


have


been


especially


pronounced


heart


sease


(Freund


McGuire


, 1991)


The


rese


archers


found


that


the


heart


disease


mortality


rates


lower-middle


class


were


nearly


twice


rates


upper-middle


upper


classes,


the


rates


working


ass


were


over


four


times


the


rates


upper-middle


and


upper


cla


sses


Analysis


mortality


rate


heart


sease


occupation


1986


reveal


that


people


with


lower


income


and


belonging


to the


working


class


were


more


likely


to die











occupational


class


(laborers,


operators,


and


fabricators)


was


per


population


while


those


in the


highest


ass


(managers


prof


ess


ional)


had


a mortality


rate


per


100,000


Stati


stical


Abstract


U.S


. 1988,


1988).


Data


from


1986


National


Mortality


Followback


Survey


show


that


most


those


who


died


of cerebrovascular


disease


and


other


causes


had


family


incomes


ess


than


$25,000


1985,


and


the


largest


proportion


those


who


died


had


worked


main


occupational


groups


the working


class


(Powell


-Griner


, 1990).


Additionally,


strong


gradient


increases


from


the


higher


to lower


cla


sses


have


been


found


infectious


and


parasitic


seases


cancers


lung


, stomach,


bladder,


esophagus;


res


piratory


seases


including


tub


erculosi


and


seases


genito-urinary


stem.


The


ass


gradients


have


been


moderately


strong


hypertensive


diseases


stroke


disea


ses


circulatory


system;


digestive


disorders;


endocrine


disease,


and


metabolic


seases


(Susser


et al.


, 1985)


In a study


variations


asthma


deaths


Carr


et al. (199


found


household


income


be a significant


hospitalization


predi


rates


ctor


of both


Segal


and


asthma


Kotler


deaths


(1991)


and


conducted


longitudinal


study


of mortality


rates


of residents











disease,


and


other


natural


causes


with


exception


malignant


neoplasms.


researchers


concluded


that


resident


s high


mortality


rates


were


likely


due


their


income


status.


Similarly


Port


et al. (1990)


found


that


residing


lower


income


areas


had


a strong


negative


effect


on survival


of chroni


c-dialy


S1S


patients.


The


infant


mortality


rate


of a nation


regarded


the


most


sens


itive


indicator


health


status


population


because


has


long


been


seen


as an indicator


the


economic


(Pampel


development


Pillai,


1986)


social


It is al


equality


ess


of a country

contaminated


sundry


environmental


behavioral


factors


influen


cing


the


health


of adults.


U.S.


,rates


infant


mortality


have


infant


declined


mortality


steadily


rate


over


in the


last


. in


several


1981


was


decades.


The


(per


live


births);


1985


was


10.6;


1990


the


infant


mortality


rate


was


(Chapman


, 1992)


Lower


income


groups


, however


, have


long


been


, and


continue


to be,


character


infant


mortality


rates


that


are


stantially


above


those


higher


income


areas


Stockwell


et al


, 1988;


Wilkinson,


1986) .


has


been


particularly


evident


in several


urban


areas


since


1984


, where


the


infant


mortality


rates


have


increase


(Stockwell


et al


, 1987;











mortality


rates


in selected


metropolitan


areas


ranged


from


16.2


Dallas


to 31.1


Fort


Worth,


(Madigan,


1991)


A recent


study


public


shed


Antonio,


Metropolitan


Health


trict


exemplifies


problem


of high


infant


mortality


rates


found


American


citi


Thi


study


compared


infant


mortality


rates


various


income


groups


from


1980


to 1989


Antonio.


For


those


who


lived


1989


below


was


poverty


increase


level


of 11%


infant


from


mortality


1980


rate


comparison,


those


who


lived


from


to 50%


above


the


poverty


level


rate


was


a decrease


(San


Antonio


Metropolitan


Health


District,


1989a)


Social


class


also


correlates


with


maternal


health.


Marmot


et al.


(1987)


found


that


women


in the


lower


asses


had


higher


rates


of maternal


mortality


(death


from


pregnancy


or birth


related


problems)


; the


maternal


mortality


rate


(per


100,000


the


per


lowest


year)


ass


was


highest


In a comprehen


sive


class


study


and


inequalities


pregnancy


outcomes,


Rutter


Quine


(1990)


found


social


class


deaths


differences


at 0-6 days


in stillbirth,


neonatal


perinatal


-27 days


stillbirths


postneonatal


months)


mortality


rates


In 1986


stillbirth


rate











compared


to 11.4


members


lowest


class


; the


neonatal


rate


was


highest


class


compared


to 6.0


lowest


ass


postneonatal


rate


the


highest


ass


was


, compared


to 5.2


lowest


ass


The

indicator


birth


weight


because


it is


of a child


considered


also


one


an important


the


health


best


predictors


of a child


s future


well-being


(Partnership


Hope,


1990)


Low-birth


weight


defined


as weight


at birth


ess


than


.5 pounds,


expre


sse


per


100


live


births)


has


been


rate


shown


, serious


to be strongly


childhood


linked


illness


infant


lifelong


mortality


handicaps


HHS


, 1990)


The


U.S


. Office


of Technical


Assessment


has


estimated


that


the


yearly


health


costs


resulting


from


low-


birth


weight


can


range


from


$14,040


to $30,525


per


child


nationwide


(Population


Reference


Bureau,


1990)


The


previously

Metropolita


mentioned

n Health


study p

District


published

compared


Antonio


rate


birth-weight


babi


born


city


between


1980


and


1989


found


a pattern


similar


that


infant


mortality


rates.


In 1988,


national


incidence


infants


born


with


low-birth


those


Antonio,


weights


persons


the


was


living


(Children


below


birth-weight


rate


s Defense


poverty


1989


Fund


level


was


, 1991)


San


11.4











The


literature


has


shown


that


there


are


clear


social


class


differentials


in mortality


These


differences


mortality


however


are


preceded


inequalities


morbidity


In 1986


those


making


or less


per


year


reported


times


more


morbidity


than


did


those


making


over


$35,000


per


year


("Health,


United


States


1987


" 1988)


similar


pattern


observed


when occupation


used


rather


than


income.


Between


1983


1985


blue-collar


workers


reported


a morbidity


rate


.5%)


that


was


times


higher


than


that


of professionals


("Health


Character


stics


Occupation


Industry


U.S.


1983


-1985,


" 1989)


Higher


rates


of morbidity


among


those


the


lower


class


ses


have


been


observed


a vast


array


of conditions


Gradients


have


been


stable


consis


tent


over


time


rates


of chronic


illness


(Haan


Kaplan


, 1986;


Jaco


, 1958;


Susser


et al


, 1985)


ecially


coronary


heart


sease


Many


studi


have


shown


that


SOC


class


inversely


associated


with


heart


sease


morbidity


and


mortality


McGuire


in most


, 1991)


industrial


a survey


zed country


conducted


(Freund


1987


and


, subjects


the


lowest


social


asses


reported


higher


rates


angina


1990).


than


The


did


same


subjects


study


in the


found


highest


higher


classes


blood


(Smith,


pressure











system.


In a study


of Canadian


males


, Hay


(1988)


found


that


number


of reported


health


problems


increased


significantly


as family


income


decreased.


Satariano


(1986


conducted


a study


among


depressed


residents


Alameda


County


, CA,


concluded


that


health


status


(measured


number


of chronic


conditions)


was


more


strongly


associated


with


income


than


with


race


He al


found


that


groups


health


status


was


significantly


lower


more


severely


financially


depressed


(income


below


$6500)


than


the


ess


severely


financially


depressed


(income


above


$6500)


Poor


children


have


been


found


to be particularly


affected


high


rates


of morbidity.


Egbuono


Starfield


(198


found


that


poor


children


were


more


likely


to become


ill,


to suffer


chronic


adver


conditions


consequences


to be


in poor


from


or fair


illness,


health,


to have


and


die


than


children


in higher


asses.


In a study


the


relationship


between


children


s health


and


single


motherhood,


Angel


Worobey


(1988)


found


a cons


istent


association


between


income


reports


of children


poor


health


They


concluded


that


a significant


amount


the


"less


than


optimal"


reported


health


was


associated


with


economic


strain.


Rates


of reported


disability


the


lower


asses


have











with


an income


below


$10,000


was


and


per


sons


with


an income


greater


than


$35,000


, was


Stati


stical


Abstracts


. 1991


, 1991)


Arthriti


, the


leading


cause


of disability


after


heart


disease,


been


found


twice


as common


poor


non-poor


(Dutton,


1986)


a consequence


these


higher


rates


, members


the


lower


classes


have


also


been


shown


to have


both


a higher


number


of restricted


activity


days


per


year,


and


res


tricted


activity


days


which


extend


a greater


period


time


(Lerner,


1975;


Marmot


et al.,


1987)


Hay


(1988)


found


that


number


income


of disability


decreased


days


increased


Canadian


males


significantly


In a study


family


of children


and


disability,


Egbuono


Starfield


(1982)


found


that


poor


children


had


twice


as many


-disability


days


, and


four


times


as many


hospital


days


compared


to children


the


middle


class.


Other


studi


confirm


strong


connection


between


income


and


limitation


of mobility


or activity


In 1983


, of


those


earning


ess


year,


reported


activity


limitation


to chronic


conditions.


For


those


earning


or more


per


year,


9.4%


reported


activity


limitation


1988


due


to chronic


percentage


conditions.


those


earning


Five


$10,000


years


per


later


year











1989,


" 1990).


According


report


published


the


National


Center


Health


Stati


, Health


of Black


and


White


Americans


, 1985


-1987


(1990) ,


the


years


1985-


1987,


those


earning


less


than


20,000


per


year,


21.4%


of whites


18.3%


of blacks


reported


activity


limitation


due


chronic


conditions.


those


earning


$20,000


or more


per


year


, 9.7%


of whites


of blacks


reported


limitation


activity


longitudinal


Maddox


study


Clark


on functional


(199


conducted


impairment


-year


in later


life


years)


, and


found


that


, for


educational


level


, the


poor


had


higher


level


functional


impairment


over


the


decade.


this


study


, both


initial


and


subsequent


level


were


higher


poor


In general


, life


expectancy


shorter


persons


lower


social


classes


than


among


persons


higher


social


asses.


These


social


ass


differential


life


expectancy


are


greater


acute


communicable


diseases


such


infective,


respiratory


dig


estive


seases


rather


than


ma3or


chronic


seases


such


as stroke


, cancer


, or


heart


disease


(House,


1981a;


Statistical


Abstracts


the


U.S.


1991,


1991;


Susser


et al.,


1985)


Since


the


differential

communicable


life


seases


expectancy


it has


are


been


greater


suggested


for

that


acute

these











Some


their


studies have


health,


investigated people's


or self-assessment of health,


perceptions of


it relates


social


class.


For those


persons earning


less


than


$20,000


per year,


16.6%


whites and


of blacks self-assess


their


health status as


fair


or poor


compared


those who


earn


$20,000


or more


per year


where 5


of whites and


of blacks rate


their health as


fair


or poor


("Health


Black and White Americans,


1985-1987


" 1990).


Cockerham et


(1988)


found that


the more affluent


persons


in the


U.S.


have rated


their health more


positively,


concluded


that


higher


income


promotes higher self-assessments of health.


Similarly,


Harris and


Guten


(1979)


found


that persons who


rated


their


health


as poor were more


likely to


poor.


these studies,


self-reported perceptions were almost


identical


to objective health status as


reported by


physicians.


A sustained


and health status has


inverse relationship


been found


between social


to exist


class


for rates of


morbidity


and mortality,


both general


and


disease-specific,


for disability rates,


and for perceptions of health,


while a


positive relationship exists


expectancy.


for social


Why these relationships exist


class and


will


life


the next


topic of


discussion.











morbidity


and


mortality


than


those


higher


asses


Four


ma or


contributing


factors


have


een


postulated


environmental


factor


s/living


conditions,


genetic


biological


factors,


unhealthy


life


styles


and,


inadequate


access


to health


care


services


Department


of Health,


Education,


Welfare


, 1979) .


Other


explanations


have


focused


on the


widespread


belief


among


members


the


lower


asses


in a lack


of personal


control


over


one


life


(Kohn


1972


and


notion


of a need


hierarchy


(McKinlay


1990)


The


two


perspe


ves


which


have


received


the


most


attention


and


are


considered


to be most


valid


are


the


two


which


focus


on unhealthy


lifestyle


behaviors


and


inadequate


health


servi


ces


primary


cause


poor


health


status


among


members


lower


sses


Poor


people


get


sicker


than


the


wealthy,


sick


poor


people


have


more


limited


access


to health


care


services


than


do equally


sick


wealthy


people.


Environmental


Factors


/Livina


Conditions


Early


explanations


the


link


between


and


health


focused


on the


living


conditions


poor


Overcrowding


substandard


housing


malnutrition


were


some


the


factors


identified


as responsible


high


rates


: (a)











outcomes


(Syme


improvements


Berkman,


have


been


made


1990;


Williams,


environmental


1990)


Enormous


quality,


and


the


impact


infectious


seases


on health


status


has


declined.


standards


Environmental


living,


advances


improved


have


living


included


conditions


risi


(such


housing


advances


in nutrition,


ean


air


and


water


, and


sewage


Brown


control)


, 1955;


and


Dubos


improved


, 1959;


food


McKeown


handling


Record,


(McKeown


1962;


and


McKeown


et al


, 1975)


sanitation


As public


mass


immuni


health


zations


measures


became


such


more


improved


widespread,


was


predicted


that


differential


health


status


would


disappear


expected


prediction


was


fully


reali


zed,


other


explanations


gained


more


attention


and


credibility


Geneti


(Williams


or Biological


, 1990).


Factors


The


genetic


or biological


explanation


posits


that


person


a predisposition


increased


risk


incurring


disease


based


on one


s ge


neti


composition


(Stone,


1989)


The


logic


that


a di


sease


appeared


in a person


who


was


a member


lower


ass


, and


was


left


untreated,


that


disease


would


reappear


in future


generations


was


theorized


that


because


people


lower


asses


continued











susceptibility.


Some disease entities


for which


this has


been suggested are coronary-artery disease,


diabetes,


hypertension,


of which appear with greater


frequency


the


lower


classes


(Stone,


1989).


This hypothesis,


however,


is highly


controversial,


and


today


appears to


lack


significant


support.


is believed


that


combination of


complex factors which determines whether


gene will


find


expression as a


disease,


and not merely


result


of being


a part


one


s genetic makeup


(Lapp6,


1987).


Personal


Control


Melvin Kohn


(197


believes


that members of


the


lower


classes are


vulnerable


to forces


that


they cannot


control,


often are


unable


take advantage of


options


that might


otherwise be available


to them.


His research has


shown


that


the


lower one's


social


class


position,


the more


likely an


individual


to value conformity to external


authority


to develop a


fatalistic belief


that


one


is at


the mercy of


forces


people beyond


one's control.


Kohn


(1972)


has


hypothesized that


this conception of


social reality


fostered by the


type


of work


in which people


in the


lower


class engage.


This work


characterized as having


little











Kohn


has


found


these


conditions


to be


those


which


reduce


one


s sense


of personal


control.


Black


(1980)


found


that


lack


of personal


control


was


important


factor


linking


social


status


with


poor


health,


Syme


Berkman


(1976)


argued


that


has


contributed


to a general


susceptibility


to disease


among


the


lower


classes


Lack


of personal


control


affects


how


people


respond


to life


changes,


life


stress


, and


the


ability


cope


with


ess


, all


of which


affect


personal


health


For


example,


been


shown


that


stress,


lowering


immunity,


can


aggravate


one


s vulnerability


infectious


microorganisms


(Freund


McGuire


, 1991)


House


(1981b)


found


that


social


stress


increased


the


effect


of physical


stressors


on the


body


Workers


who


were


exposed


chemical


known


cause


respiratory


problems


suffered


even


higher


level


disord


ers


they


were


simultaneously


exposed


intense


supervisory


pressures.


Given


that


members


the


lower


asses


frequently


work


under


conditions


of close


supervi


sion,


as described


Kohn


theory


of social


reality,


one


may


conclude


that


they


may


indeed


be particularly


susceptible


this


effect.


A belief


that


one


little


control


over


one


life


may


produce


a fatal


orientation


toward


one


s health,











because


early


detection


is an important


variable


in the


cure


illness


prevention


of escalation


in severity


While


may


true


that


lower


ass


membership


may


foster


one


s sense


lack


individual


control,


the


real


problem


explaining


why


belief


occurs


In regard


health


care,


people


lower


classes


are


those


who


have


restricted


access


a sy


stem


which


could


help


them.


Due


financial


constraints


, they


often


have


little


control


over


the


deci


sion


to enter


seek


care


, treatment,


and


cure.


may


that


because


they


cannot


enter


system


, they


feel


a lack


of control


over


their


health


Need


Hierarchy


McKinlay


belief


(1990)


that


notion


of a need


members


lower


hierarchy


asses


refers


, primary


needs


such


as food


, clothing


shelter


are


perceived


related


to survival


take


precedence


over


secondary


needs


such


as medical


dental


care.


members


the


affluent


class


ses


resources


are


available


that


allow


secondary


needs


to be


recogni


important,


a priority


position


to be assigned,


attention


to be directed


toward


them.


For


poor


, secondary


needs


such


as medical


care)


assume


a position


importance


and


are


eclipsed


the











with


immediate


dangers,


such


as hunger


inadequate


shelter.


The


idea


of a need


hierarchy


explains


why


some


members


the


however


lower

, the


asses


problem


do not


may


seek

one


medical


access.


care.


Again,


Members


lower


asses


to financial


cons


traints,


are


forced


rate


medical


care


as a secondary


priority


. It


receives


lower


priority


on the


need


hierarchy


than


those


concerns


defined


as primary


survival


needs


Lifestyle


Behaviors


A position


which


rece


ived


maintained


cons


iderable


support


in the past


three


decades


as an


explanation


poor


health


has been


one


that


promotes


individual


responsibility


health


through


living


healthy


lifes


tyle.


"life


style


-factor"


theory


states


that


much


sease


ability


is caused


behavioral


factors


that


are


within


individual


s control


such


diet,


exercise,


smoking


, alcohol


use


other


forms


risk


-taking


behaviors.


believed


that


these


factors


are


additive


: The


more


them


one


has,


the


greater


the


increased


likelihood


or total


risk


of di


sease.


Healthy


styles


increase the


ability


of each


American


to avoid











increase accordingly


(Knowles,


1990;


Sullivan,


1990b).


Health promotion,


or healthy


behaviors,


are defined by


Harris and


Guten


(1979)


as any


behavior which


performed


a person,


regardless of his or


her perceived health


status,


health


in order to protect


whether


, promote,


or not such behavior


or maintain his


is purposely


or her


directed


toward


that end.


Some researchers


(McKeown,


1979;


Susser,


Hopper


and Richman,


1983)


believe


that


lifestyle and social


factors determine a


person's


state of health more


than


does


medical


treatment.


It has


been suggested


that each


the


top


ten


causes


of premature death


U.S.


are


significantly


influenced


by personal behavior


lifestyle choices


(Sullivan,


1990b),


and that control


present major


health


problems


in the


U.S.


today


(heart disease,


cancer,


and


stroke)


depends directly


on modifications


the behaviors


and


living


habits of


individuals.


Heart disease


and stroke


have


been shown


to be related


to dietary


factors,


smoking,


lack


exercise.


Smoking


and


diet are


also


related


the


incidence of


cancer


(Berkman and Breslow


, 1983;


Knowles,


1990).


Advocates of


lifestyle choice


theory


argue


that


people need


to stop or reduce


the frequency


of behaviors











Smoking


alone


cited


as the


most


preventable


cause


death


killed


millions


Americans


(Sullivan,


1991)


estimated


that


better


control


health


sk factors


, along


with


prenatal


care


and


use


seat


belts,


could


prevent


between


premature


deaths


a third


cases


active


ability


and


two-thirds


of all


cases


of chronic


disability


(Sullivan


1990b)


Over


a decade


ago,


Healthy


People


: The


Surgeon


General


s Report


on Health


Promotion


Disease


Prevention


(U.S


. Department


of Health


, Education,


and


Welfare,


1979)


concluded


that


seven


leading


causes


of death


could


be reduced


citizens


did


five


things


--used


antihypertensive


drugs,


improved


their


diets


exercised


more,


and


ended


smoking


alcohol


abuse


Former


Secretary


of Health


Human


Services


Louis


Sullivan


has


advocated


the


creation


"culture


of character"


the


fostering


people


With


of a climate


would


individual


be encouraged


Americans


practicing


engage


health


respon


sibility


healthy


promotion


which


behaviors


behaviors,


they


would


assisting


in the


prevention


of di


sease


, and


the


preservation


of a healthy


society


Prevention


sease


has


been


indicated


to be


single


most


important


factor


in maintaining


good


health


(Sullivan


1990b).


I











(Glassner


, 1989)


Gillick


(1984)


has


proposed


that


the


jogging


craze


1960


s was


a result


recognition


a large


part


American


population


that


medicine


alone


could


be relied


upon


to prevent


death.


Thomas


McKeown

together


(1979)

with


wrote

social


that

and


was


environment


individual

al factors


s lifestyle,

that


determined


a person


s state


of health


more


than


medical


treatment


This


belief


was


perhaps


best


exemplified


Ivan


Illich


book


, Medical


Nemis


s: The


Exporpriation


Health


(1975),


Thomas


Szasz


in The


Myvth


of Mental


Illness;


Foundations


of a Theory


of Personal


Conduct


(1961) ,


Rene


Dubos,


in Miraqe


of Health


, (1959)


Each


these


books


suggested


that


one


s best


hope


medical


physical


health


was


to be found


outs


modern


medicine


early


1960


s Belloc


Bres


(197


conducted


a preliminary


study


ch analyzed


relationship


between


health


status


health


practi


ces.


The


study


was


undertaken

significant


in order to

lv affected


determine


life


which


expectancy


health


and


habits


health.


most

They


concluded


that


there


were


seven


health


habits


which


did


significantly


affect


life


expectancy


health


: (1)


eating


three


meals


a day


at regular


times


with


no snacking,


eating


breakfa


every


day,


getting


moderate


exerci











alcohol


or drinking


only


moderation


(Belloc


and


Bres


1972


The


first


and


largest


American


study


of health


practi


ces


which


became


known


as the


Alameda


County


Study


began


Human


Population


Laboratory


(HPL)


the


Univers


of California


at Berkeley.


In 1959


, a planning


grant


from


National


Institutes


of Health


established


the


HPL


with


three


object


ves


: (1)


assess


the health


(phys


ical


mental


social


dimensions)


persons


living


Alameda


County,


California


to ascertain


whether


particular


associated


level


with


one


comparable


dimension


level


of health


other


tend


to be


dimensions


, and,


to determine


relationships


various


ways


living


selected


demographic


characteristics


to level


of health


(Berkman


and


Breslow


, 1983)


study


progressed,


third


objective


became


more


prominent


than


first


two


attracted


ma] or


attention.


Prior


this


study


there


was


little


evidence


to support


idea


that


the


health


behaviors


identified


Belloc


Breslow


could


affect


personal


health.


the


Alameda


County


Study


data


were


collected


from


survey


participants


1965


nine


years


later


1974


The


conclu


sion


longitudinal


study


was


that


five











associated


independently


other


health


practices


Those


who


engaged


high-risk


health


practices


had


life


expectancies


significantly


shorter


than


others


the


same


who


did


not.


high


-risk


behaviors


identified


were:


smoking


cigarettes


consuming


excessive


quantities


alcohol,


being


phy


sic


ally


inactive,


being


obese


or overweight,


sleeping


fewer


than


seven


or more


than


eight


hours


per


night


(Berkman


Breslow


, 1983)


Since


the


landmark


Alameda


Study


was


conducted,


subsequent


research


continued


to support


these


findings


(Haan


et al


, 1987;


Morris


1990


; Ott,


1990;


West,


1988)


In regard to smoking behavior, the Alame

clear gradient among both men and women.

smokers experienced higher rates of mort

had never smoked. Smokers had worse hea

follow-up than did those who were smokir

wave of data collection, and reported mc

chronic health conditions (Berkman and B

10-year longitudinal study of mortality,

(1989) found that smoking was the strong

mortality in their sample. Numerous nat

Department of Health, Education, and Wel

Department of Health and Human Services,


da Study found a

Present and past

.ality than those who

Llth status scores at

ig during the first

re symptoms of

Ireslow, 1983). In a

Hirdes and Forbes

rest predictor of

.ional surveys (U.S.

fare, 1979; U.S.

1980a; U.S.











with


miscarriages


fetal


neonatal


mortality,


birth


weight,


developmental


retardation;


the


link


between


smoking


morbidity


especially


heart


disease


, cancer,


emphysema)


to be undeniable


Further


, smokers


themselves


recognize


these


links


SA recent


study


Thorlindsson


al. (1991)


found


a significant


inverse


association


between


smoking


and


perceived


health


status.


Recently,


increasingly


strong


body


of evidence


purports


link


second


hand


smoking


with


mortality


(Janerich


et al


, 1990;


Raeburn,


1991).


The


Alameda


Study


also


looked


at frequency


and


amount


alcohol


consumption.


The


highest


mortality


rates


occurred


among


respondents


who


a high


drinking


index


(more


than


45 drinks


per


month)


Moderate


drinkers


those


who


had


17 to 45 drinks


month


, had


the


lowest


mortality


rates,


and


their


rates


were


lower


than


abstainers


, light


drinkers


, and


heavy


drinkers


Those


who


did


drink


had


even


more


negative


health


status


scores


than


heavy


drinkers


(Berkman


Breslow,


1983)


However


, other


studi


have


shown


that


moderate


to heavy


alcohol


consumption


been


linked


to greater


risk


of stroke


men


(Gill


, 1990)


, and


higher


death


rates


from


cirrh


OS'S


liver


and


malignant


neoplasms


both


sexes


(Fuchs


, 1990)











diseases;


cancer


mouth


, pharynx,


larynx


and


esophagus


to 75%


of all


deaths


and


injuries


due


automobile


accidents


Thorlindsson


et al. (1991)


found


significant


negative


association


with


perceived


health


status


and


drinking.


Health


scores


participants


phys


activity


were


higher


every


sex


group


considered


the


Alameda


Study


Those


who


reported


least


activity


also


had


a higher


risk


of mortality


Of special


note


was


the


marked


difference


activity


those


between


who


parti


reported


cipants


even


who


reported


little


activity


(Berkman


Bres


low,


1983)


Other


researchers


have


also


identified


significant


relationships


between


physical


activity


and


health


status


A study


conducted


Lamb


Roberts


(1990)


showed


that


sports


participants


rated


their


health


significantly


better


than


non


-participants


and


these


beneficial


consequences


of perceived


health


were


reflected


reduced


sks of


mortality


, higher


morale


, a tendency


abandon


sick


role


sooner


faster


return


employment


following


heart


surgery.


In another


study


Roberts


et al.


(1989


found


that


participation


indoor


sports


was


positively


related


to health


status


and


sex


groups


studied.


Phys


ical


exercise


and


sports











were


found


to smoke


drink


ess


(Thorlindsson


et al.,


1991).


Berkman


Breslow


(1983)


reported


that


individual


who


were


within


their


optimal


weight


had


the


best


health


scores


on the


follow-up


study


People


who


were


extremely


underweight


(30%


or more


under


their


desirable


weight)


had


the


poorest


health


scores.


However


obese


parti


cipants


or more


over


their


desirable


weight)


were


at greater


ris


k of dying


than


group


, although


the


extremely


weight


underweight


a serious


displayed


health


a high


problem


risk.


been


Excess


associated


with


high


rates


coronary


heart


and


other


circulatory


seases


, hypertension,


diabetes


, gall


bladder


disease


degenerative


joint


sease


some


types


cancer,


respiratory


sease


arthritis


liver


and


biliary


tract


disorders


high


mortality


rates


from


these


disea


ses


The


reduction


has been


found


or maintenance


to reduce


of weight


risk


at normal


severity


level


of several


these


chronic


conditions


(Dwyer


et al


, 1970;


Ross


and


Mirowsky,


1983;


Stuart


Jacobson,


1979;


U.S


. Department


of Health


Human


Services


, 1980b)


-term


babi


obese


mothers


have


been


found


to have


an increased


likelihood


birth


weight


or to die


infancy


(Lucas











had


less


than


seven


hours


had


the


least


favorable


health


scores


at follow-up


while


those


with


more


than


eight


hours


also


had


scores


As for


mortality


rates


both


men


and


women


who


reported


that


they


slept


seven


to eight


hours


each


night


had


significantly


lower


mortality


rates


than


those


who


had


ess


than


six


or more


than


nine


hours


of sleep


Persons


who


reported


or fewer


hours


of sleep


had


the


highest


mortality


rates


was


mos


t pronounced


the


year


-old


group


(Berkman


Breslow


, 1983)


Sleep


generally


received


little


attention


as a factor


health


and


mortality,


a study


Kripke


et al. (1979)


did


find


that


extremely


long


hours


or more)


or short


less


than


four


hours


of nightly


sleep


was


ass


ociated


with


mortality


from


heart


sease


, stroke,


cancer


and


cide.


And


since


sleep


deprivation


will


ultimately


lead


to death


clearly


necess


survival


(Kleitman,


1963)


Socioeconomic


Status


Health


Behavior


In addition


to looking


relationship


between


health


behaviors


and


health


status,


the


Alameda


County


Study


also


looked


relationship


between


engagement


in health


behaviors


socioeconomic


status


Considerable


similarity


has


been


found


to exist


within


each


social


ass











reported


that members


low-income group were


three


four times more


likely to engage


in the high risk health


practices


than members of


the highest group.


The


poor were


more


likely to


be heavy drinkers and


smokers


, to be


overweight


, and


to eat a


diet high


fat.


Quine


(1990)


found


that


in Great Britain members of


the


lower


classes


engage


in more adverse health behaviors than members of


the


higher


found to


upper


classes


Preventive health


be affected by


SES participate


SES,


in more


care behaviors


those


have been


in the middle and


preventive behaviors,


and


visit physicians more


frequently


for preventive care


(Cockerham et al.,


1986;


Harris and


Guten,


1979) .


Rosenblatt


and Suchman


(1964)


have


suggested


that members of


the higher


classes

because


apply themselves more


they


fully to


focus more on maintaining


preventive activity

their health for the


future,


while poorer people


tend


to be more


present-oriented


and deal


with symptoms as they may


arise.


Each health behavior that Berkman and Breslow


(1983)


found


to be associated with health status


also


related to


SES.


Smoking


far more common


in the


lower


classes


than


the higher


classes,


longitudinal


studies which have


shown a


reduction


in smoking


behavior


show the


least


reduction


the


lower


classes


(Khosla


and Lowe,


1972;











Smoking


is more common in


classes of


lower


SES,


and,


previously


cited,


also


strongly


associated with specific


causes


of death such as


lung


cancer


respiratory


diseases.


It is not surprising,


therefore,


that


these


specific causes of


death


also


have higher


frequencies


the


lower


classes.


There


is a


particularly high mortality for


lower


class men


from


lung


cancer


and


other respiratory


diseases;


they


are almost


three


times as


likely to smoke


than men


in higher classes


(Marmot


et al.,


1987).


The


relationship


between


soc


class


and mortality


, may,


some extent,


be affected by health behaviors.


The same chain


of causation


can be


seen


in alcohol


use.


Alcohol


consumption


is highest among the


lower


classes


(Dutton


, 1986;


Ott


, 1990;


West


, 1988)


As mentioned,


alcohol


related to high mortality rates


stomach


disorders


These are


, muscular disorders,


the same diseases


mortality rates


than


strokes,


for which


the more affluent


and


cirrhosis.


poor


("Health


have higher


United


States


1988,


" 1989).


Exercise habits differ


between


classes


in much


the same


way


as those


for smoking and


drinking.


Members of


the


lower


classes exercise


less


frequently than


those of


the higher


classes


(Lamb et al.,


1988;


Ott,


1990)


In a


longitudinal











exerci


more


frequently


than


those


in the


lower


classes.


Over


the


past


decades


a wid


spread


growing


interest


among


has


the


been


middle


documented


upper


sses


national


in the


surveys


pursuit


and


the


fitness


consumer


marketplace.


The


members


these


asses


have


been


the


purchasers


of exerci


equipment,


diet


foods


vitamin


products


, and


health


club


memberships


(Glas


sner,


1989)


Prior


mention


been


made


positive


assoc


nation


of phys


ical


activity


with


health


status


A study


conducted


Lamb


et al. (1988


found


that


fewer


class


males


reported


good


or exce


llent


health


than


their


higher


ass


counterparts.


They


found


that


income


differences


health


status


indi


cators


were


narrower


among


sports


participants


members


exercise


higher


the


have

asses


than


among


lower


health

than


the

asses


statues


what


general


who


more


seen


population.


do participate


equal


in the


That


physical


to members


general


population.


The


researchers


concluded


that


low-income


per


sons


were


exerci


the


gap


health


status


between


the


rich


and


poor


would


narrow.


strong


inverse


relationship


between


and


obesity


has


consistently


been


recorded


literature


relationship


which


ecially


strong


among


women


(Dutton,











recently


become


an increasing


problem


among


-income


youth


(Freedman,


1990a) .


relates


to patterns


of morbidity,


members


lower


classes


suffer


from


higher


rates


diseases


associated


with


obes


than


those


the


higher


asses.


These


include


heart


sease


and


other


circulatory


temr


disorders


, hypertension,


diabetes


, arthriti


, and


respiratory


sorder


. Department


of Health


and


Human


Services


, 1990).


Researchers


have


consistently


reported


that


people


the


lower


classes


engage


in more


health


risk


behaviors


and


fewer


health


Cockerham


promotion


et al


, 1986;


behaviors


Cockerham


(Berkman


et al.


Breslow


, 1988;


, 1983;


Dutton,


1986;


Harri


and


Guten


, 1979,


Khosla


Lowe,


1972


Morri


1990;


Quine,


1990)


Thus


as a cause


poor


health,


people


the


lower


asses


appear


to be


more


at risk


due


their


individual


style


behaviors


We have


seen


that


there


an inverse


relationship


between


various


indicators


of health


status


, that


practicing


healthy


lifestyle


behaviors


is associated


with


positive


health


status


that


member


the


lower


groups


tend


engage


in healthy


behaviors.


que


stion


to be addr


esse


why


group


with


poorest


health


status


in the


U.S


. does


engage


in healthy


lifestyle











The


Kohn


first


(1972)


explanation,


theory


which


of control.


been


Previously


discussed,


was


presented


as a direct


effect,


that


that


a belief


lack


of control


over


external


conditions


members


the


lower


asses


could


account


their


poor


health


status


explanation,


an indirect


effect


through


health


behaviors.


Thi


explanation


suggests


that


feeling


lack


of control


over


external


forces


that


constrains


persons


from


engaging


in healthy


behaviors


thus


negatively


affecting


their


health


status.


explanation


behaviors


looks


a healthy


on the


acquisition


lifestyle


of healthy


as behaviors


learned


through


family


social


zation.


(198


Lau


et al


(1990)


have


found


that


parents


are


much


more


important


sources


influence


over


health


behavior


practi


ces


than


any


other


source.


Thus,


good


health


habits


learned


as a


child


could


affect


later


beliefs


regarding


control


health.


Persons


with


a feeling


a sense


of control


over


their


lives


or an


actions


internal


deci


sons


locus


help


of control


shape


believe


outcome


that


their


their


lives.


These


people


believe


that


they


are


responsible


their


own


health


and


that


illn


ess


can


result


in part


from


not











health


related


behaviors


as a result,


these


people


enjoy


better


health


(Hayes


Ross


, 1987;


Seeman


and


Seeman,


1983)


People


with


an external


locus


of control


believe


that


others


and


external


forces


shape


their


destiny


They


believe


that


there


nothing


they


can


to prevent


illness


that


good


health


result


luck


or chance


therefore


do little


to actively


protect


Many


researchers


Cockerham


et al


, 1986;


Harri


and


Guten,


1986;


Hayes


and


Ross,


1987;


Seeman


Seeman,


1983)


report


that


people


lower


SES


splay


sense


lack


control


regarding


health


care


have


found


to be


significantly


ass


ociated


with


: (1)


less


self-initiated


preventive

of early


care,


less optimism


treatment,


poor


concerning


self-rated


the


health,


efficacy


more


illness


episodes


, bed


confinement


, and


dependency


physician


intervention


and,


frequent


mention


of health


care


stem


use


as a health


promoting


behavior.


McKinlay


(1990)


notion


of a need


hierarchy


another


perspective


which


has been


used


to explain


why


the


poor


not


engage


in healthy


lifestyle


behaviors.


The


need


hierarchy


is seen


as exerting


an indirect


effect


on health


status,


mediated


perspective


through


poor


health


concentrate


behaviors.


more


From


on their


this

daily











weight


control


We have


seen


that


members


tend


more


obese


than


their


middle


and


upper


class


counterparts.


Freedman


(1990a)


, in


writing


about


inner


city


poor


, has


found


that


hazards


that


may


result


from


a poor


diet


and


obesity


pale


when


placed


next


to problems


like


crime


and


crack


use.


inner


-city


resident


interviewed


Freedman


stated,


"I should


be concerned


about


health


but


the


way


figure


might


as well


live


high


hog


while


I can"


(1990a


: 1A)


Another


aspec


t of


need


survive


demons


treated


interview


with


owner


McDonald


s franchise


Harlem


He compared


the


food


served


the


McDonald


s franchi


ses


in different


parts


of New


York


City


said


that


salads


are


bought


downtown,


here.


s eat


survive.


..people


are


trying


to get


the


biggest


sandwich"


(Freedman,


1990b


. 6A)


many


instances,


poor


people


do not


healthy


food


simply


because


they


cannot


afford


to buy


foods


such


fresh


meats


produce


(Freedman


, 1990b)


A cultural


explanation


has


also


been


proposed


explain


lifes


why


tyle


people


behaviors


do not


, especially


engage


in regard


healthy


to obesity


Proportionately


more


members


lower


asses


, than


other


asses


may


regard


obesity


as culturally











associated


with


undesirable


traits


of hunger,


being


welfare,


having


AIDS,


drug


addiction


(Dwyer


et al.,


1970;


Freedman,


1990a)


Some


researchers


have


blamed


health


care


and


educational


stems


failure


people


engage


healthy


lifestyle


behaviors.


Cockerham


et al


(1986)


argue


that


medical


system


inept


in explaining


health


illness


behavior


the


poor


, and


discourages


interaction


health


care


professionals


with


group


Health


care


profess


ional


also


do not


encourage


or reinforce


self-management


this


group,


believing


that


they


are


unable


to under


stand


carry


such


technique


es.


The


poor


suffer


from


teams


which


have


not


adequately


taught


them


adequate


health


information


, and


as a consequence


have


a real


lack


of knowledge


assuming


responsibility


their


health


(Feldman


, 1968;


Freedman,


1990a,


1990b;


Knowles

Barber


, 1981;

(1991)


Susser

believe


et al

that


., 1985)

health e


Morri


education


(1990)


needs


and


to be


intense


ified


health


promotion


campaigns


focused


on this


at ri


group.


The


lifestyle


-behaviors


explanation


differential


health


status


views


individuals


producers


of health


rather


than


simply


consumers


of health











discrepancies


health


care


in the


Changes


individual


changes


behavior,


in SES


model


differential


proposes


health


, will


care


lead


status.


An alternative


theoretical


orientation


focu


ses


on the


social


cause


structure


poor


rather


health


than


among


on individual


members


behaviors


groups


as a


This


orientation


focuses


on structural


barriers


pres


within


society


which


prevent


poor


from


access


the


health


care


system.


Inadequate


Health


Care


Servi


ces


Inadequate


access


to health


care


servi


ces


poor


the


second


major


explanation


offered


to account


for


SES


differentials


health


status


This


approach


suggests


that


the


lower


classes


have


poorer


health


because


members


the


lower


asses


have


ess


access


medical


resources


available


in our


present


health


care


stem.


According


view


there


are


several


cons


traints


which


prevent


access


to the


stem.


The


st is


economic.


Members


the

the


lower


system.


asses

The


have

second


fewer

cons


resources


traint


to purchase


political,


care


and


found


within


organization


of health


care


services


Poor


people


are


more


likely


receive


health


care


public











likely


receive


their


care


private


offi


ces


and


hospitals


(Reissman,


1990)


A third


constraint


, however,


could


be ideological


or cultural,


would


include


lifestyle


-behavioral,


health-producing


factors


the


previous


section.


Those


unable


access


system


are


a diverse


group.


Approximately


33 million


Americans,


or 15%


the


population,


have


no health


insurance


GOA,


1991)


hence


make


ess


use


of health


services


(Riessman,


1990)


Thirty


-four


percent


nation


s poor


have


no health


insurance


GAO


, 1991)


Included


this


group


are


the


self


-employed


, part-time


worker


season


workers


, the


unemployed,


and


full


-time


workers


ose


employers


offer


either


unaffordable


or no


insurance.


Two-thirds


the


uninsured


and


uncovered


are


empl


oyees


or dependents


employees


More t

cannot


han


(Bodenheimer,


two-thirds


afford


or are


1989;


of full


Harvey,


-time


offered


union

health


1990;


Tupper


workers e

insurance


, 1990)


either

(Sulvetta


Swartz


, 1986)


Fourteen


percent


service


workers


the


U.S


of workers


manufacturing


indus


have


no health


insurance


GAO


, 1990)


In 1987


worker


the U.S.


aged


to 64


year


who


were


full


-time/


full


-year


employ


ees


no health


insurance


Forty


-two











working Americans,


the working poor


are


those most


likely


to have health


insurance.


In Michigan


1987,


workers earning $1,000 to


$9,999 per year


had no


insurance,


those earning


to $19,999,


those earning


$20,000


to 29,999,


3% of


those earning


$30,000


to 39,999,


and


3% of


those earning


$40,000


above had no


health


insurance


(US GAO,


1990)


In addition


the presence or


absence of health


insurance,


other


economic


factors which have been


shown


greatly


influence


use of health


care services


include


the


cost


services,


family


income


(Riessman,


1990) .


The


cost


of health


care has


steadily


increased as a percent


the gross


national


product


(GNP)


since


1929,


when data


were


first


collected,


showing


especially dramatic


increases


from


1980 to


1986.


From 1970 to


1979


health


care expenditures


increased


1.2%


from


7.4% to


8.6%


the GNP.


From


1979


1986,


they


increased


from 8


to 10.9%


the GNP


("Health


United States


1987,


" 1989) .


Expenditures


medical


care are greater than


expenditures


and have been


other


increasing


consumer


at a more rapid rate.


In 1987,


the consumer price


an increase of


6.6%


index


from the


(CPI)


for medical


previous


year,


care was


1986.


comparison,


the CPI


for food was


an increase of


.2%;











composite


index


relating


to pri


ces


of specific


consumer


goods


services


, is used


as a primary


measure


inflation


It is


based


on the


average


pri


ces


some


different


items


purcha


sed by


consumers


(Strauss,


1988)


1966


, the


Medicaid


program


was


instituted


the


. to


help


provide


medical


care


the


poor


A federally


and


state


-funded


indigent


-care


insurance


program


, over


years


has dimini


shed


size


declined


in capacity


provide


medical


services


poor.


In 1976


, 65%


poor


were


covered


Medicaid,


1984


number


had


decreased


to 46%


Waitzkin,


1989)


As previously


stated


poor


children


are


especially


vulnerable


to inadequate


medical


services


1990


Medicaid


covered


fewer


than


children


who


lived


below


poverty


line


(Harvey


, 1990)


During


the


1980


s there


were


increases


in deductibles


federal


state


funding


program


was


greatly


reduced


In addition


to Medicaid


cutbacks,


public-


sector


health


programs


which


had


been


targeted


to help


the


poor


suffered


similar


fates.


Block


grants


maternal


child

center


health


birth


, migrant


control


health services,

services, health


community

planning


health

services


National


Service


Health


experience


Service


Corps,


ed signifi


cant


the Indian


reductions


Health


funding











important


factor


in maintaining


good


health


(Sullivan,


1990a)


preventive


Prevention


behaviors


however


It also


includes


includes


more


the


than


just


willing


ess


opportunity


to receive


preventive


medical


care.


Adequate


prenatal


care


pregnant


women


has


been


shown


to play


large


role


in preventing


infant


mortality


and


other


adverse


pregnancy


outcomes


such


as Down


s syndrome,


yet


poor


pregnant


women


are


ess


likely


receive


prenatal


care


than


are


pregnant


women


in other


groups


(Beeghley


, 1983;


Nersesain,


1988;


Susser


et al.,


1985)


Screening


the


early


detection


of di


sease


can


reduce


the


risks


from


cancer


the


neck


, uterus


, and


breasts.


study


conducted


Mamon


et al. (1990)


looked


at factors


related


to receiving


adequate


screening


cervical


cancer


They


found


that


women


who


had


incomes


those


without


medical


insurance


were


significantly


ess


likely


receive


adequate


Pap


testing


In a similar


study,


Ackerman


et al. (1992)


found


that


percentage


women


who


had


had


a Pap


smear


within


the


previous


year


was


positively


associated


with


income.


Early


intervention


medical


management


disease


, especially


chronic


illness


, can


affect


both


survival


rates


and


quality


life.


The


higher


social


classes


have


consis


tently


been


shown


to benefit


most


from











reduced


the


1980


This


resulted


in a decline


the


proportion


poor


children


who


are


immunized,


and


corresponding


decrease


their


health


status


(Bodenheimer,


1989).


Apart


researchers


from


direct


(Beeghley


, 1983;


costs


of medical


Dutton


, 1986;


care


Reissman,


, several


1990;


Roth,


1990;


Williams


, 1990)


have


suggested


that


there


are


additional


indirect


costs


borne


poor


They


include


the


time


expenditures


necessary


to obtain


care,


the


fragmentation


system,


dehumani


zing


aspect


system.


example,


employed


poor


generally


do not


have


sick


time


built


into


their


jobs


a result,


a vi


to a health


care


provider


during


work


day


means


reduction


that


day


s salary


Taking


a day


sickness


results


oss


an entire


day


s wages


(Beeghley


, 1983)


The


time


needed


access


system


another


problem


faced


lower


class


individual


The


geographical


stribution


of phys


icians


finds


most


phy


sicians


located


outs


poor


neighborhoods.


Corporate


hospitals


choose


not


to locate


in impoverished


areas


(Starr


, 1982)


Thi


means


increased


time


poor


travel


to medical


facility


, often


public


transportation


(Reissman,


1990)











treated


with


less


consideration


respect


than


those


who


are


not


poor,


those


labeled


as "welfare


cases"


are


often


perceived


as not


deserving


the


best


care


(Roth,


1990).


The


fragmentation


system


also


works


against


the


poor


seeking


medical


care,


affects


the


quality


care


received.


The


poor


are


more


likely


receive


ambulatory


care


clini


, in


hospital


emergency


rooms


, and


outpatient


departments


(Reissman,


1990)


phys


ical


organi


zation


the

thus


hospital


emergency


discouraging


entry


room

into


and

the


clinics

system


can


be confusing


(Beeghley,


1983)


Members


the


middle


upper


asses


are


more


likely


receive


their


treatment


in a doctor


s office.


The


poor


are


more


likely


see


a different


health


care


provider


on each


and


receive


care


from


non


board


-certified


physicians


(Nerse


sian


, 1988).


The


dehumanizing


atmosphere


clini


and


hospitals


has


been


identified


as a reason


why


poor


people


choose


not


to enter


system.


health


care


providers


these


stitutions


are


generally


busy,


they


have


often


been


found


to be


impersonal


and


insulting


lower


come


class


sooner


persons.


care


poor


, and


are


might


admonished


given


not


unrealistic


having


plans


care


(Roth,


1990)


Beeghley


(1983)


suggests


that


the











There


is a


vast


social


distance


perceived by most


physicians


between


themselves and lower


class


patients.


Miller


(1978)


studied the patient-physician relationship and


found


that


physicians are


less


interested


lower


class


patients,


are


inclined to pass


them off


to other


practitioners,


accord


them less personalized


treatment.


The more affluent members of


the society


are accorded


preferential medical


treatment because


physicians


feel


they


share


the same values as


physician,


and are more willing


and able to


pay


for their treatment.


Miller


(1978)


reports


that


the poor


are considered the


least desirable


patients


because


they


are believed to


"dirty


smelly,


follow


poor


health practices,


fail


to observe directions and keep


appointments,


and live


in a


situation


that makes


impossible


to establish appropriate health regimes"


(Miller,


457).


An argument


often presented to counter the


structural


or systems-barrier


approach


that


poor have


less access


to medical


care


is that


poor do have


the highest rates


of physician visits


per year


, a measure of


system


utilization.


The argument


is that since


poor


have


higher rates


of physician utilization,


inaccessible to them.


According to a


the system cannot be

Public Health Service











a family


income


of $35,000


or more


the


number


of physician


contacts


per


person


was


5.4.


What


argument


neglects


consider,


however,


is that


a disproportionate


number


persons


in the


lowest


income


group


are


over


(Williams,


1990)


Most


these


persons


have


Medicare


coverage


since


many


have


multiple


chroni


illnesses,


have


greater


needs


medical


care.


When


the need


services


consider


among


different


income


groups


, the


poor


receive


fewer


services


than


wealthy


In addition


, the


attenuation


relationship


between


income


and


use


medical


services


has


been


primarily


to a decreasing


average


use


high


income


sons


(Williams,


1990)


The


growth


of corporate


medicine


in the


U.S


. has


contributed


the


diff


erential


access


to health


care


(Freun

large


and


health


McGuire,

care cc


1991;


McKinlay


>rporations


have


and


Stoeckl


become


center<


, 1988). A

al elements


system


, there


been


a change


in ownership


and


control


the


medical


stem


to include


more


-profit


components


eidson,


1986)


These


-profit


chains


are


interested


treating


people


who


cannot


pay


They


not


wish


locate


their


hospitals


in poor


areas


with


large


numbers


of Medicaid


patients.


They


aggravate


the


already


gross


geographical


stribution


of physicians


the


U.S.











One


study,


conducted


Rawlings


Weir


(199


, may


well


serve


status


to demonstrate


access


to health


connection


care.


between


disparity


health


in infant


mortality


black


rates


infants


between


being


black


twice


white


that


infants


of white


(the


infants)


rate


has


been


attributed


large


part


higher


incidence


poverty


and


limited


access


to health


care


among


black


Americans.


These


researchers


investigated


race


and


military


rank


-specific


infant


mortality


rates


among


dependents


military


personnel


nationwide


infant


mortality


rate


black


of military


infants


1987


personnel


was


rate


, while


was


very


black


ose


infants


that


whites


11.1


The


rese


archers


concluded


that


the


lower


rates


infant


mortality


among


dependents


black


military


personnel,


as compared


to nationwide


rates


, was


due


guaranteed


access


to health


care


higher


levels


of family


income


the


military


subpopulation.


The


Health


Care


the


United


States


The


system


of health


care


delivery


U.S.


described


Freidson


(1970)


as a prof


ess


ional


mod


el with


emphasis


on fee


-for-servi


professional


autonomy


The


primary


actors


in the


health


care


system


the


U.S.


are


the











suggests that

occupation has


three n

gained


necessary

command


conditions


be met:


exclusive


the


competence


determine


the


proper


content


and


effective


control


performing


some


task;


the


occupational


group


the


prime


source


criteria


that


qualify


a person


to work


in an acceptable


fashion


; and


general


public


believes


in the


consulting


occupation


s competence


in its


professed


knowledge


skill


The


occupation


of phy


sician


has


met


these


conditions;


thus


one


can


define


the


tem


health


care


delivery


as a profess


ional


model.


The


national


stem


of health


care


the


U.S


described


as a sy


stem


comprised


individual


practitioners


and


facilities


organized


loose


network


within


which


services


are


provided


(Kurtz


Chalfant


, 1991).


Facilities


within


health


care


system


include


hospitals


clinics,


insurance


companies


, pharmaceutical


companies


other


ancillary


organizations


, and


can


be under


the


auspices


of either


public


(federal,


state


or county)


or private


control


(Glaser


, 1986).


Just


as physicians


are


the


primary


actors


the


practitioner


component


health


care


system,


hospitals


are


the


primary


institution


in the


facilities


component.


U.S


. today


, most


hospitals


are


under


private


control


(Freidson


, 1986)


While


each


the











each


component


depends


on the


others


referral


and


consensus


in deci


sion


making


which


can


affect


parts


the


stem


(Kurtz


Chalfant,


1991).


The


health


care


in the


based


on a


-for


-service


market


philosophy


Under


a fee


-for


-service


orientation


members


system


levy


a charge


each


service


their


specific


practices.


The


charge


the


individual


practitioners


and


facility


based


economic


market


forces


Since


individual


practitioners


are


not


controlled


stri


ct fee


schedules


, they


can


set


their


charges


sufficiently


high


cover


the


costs


of practice,


depreciation


of equipment


, repayment


of debts


, while


reali


zing


profit


(Glaser,


1986).


Profess


ional


autonomy


refers


the


monopoly


that


the


profession


has


over


exercise


control


work.


The


medical


prof


session


has


control


over


the


quality


and


terms


of medical


practice


, and


members


are


free


practice


with


very


formal


constraints


not


their


own


making


The


profe


sslon


been


able


to maintain


control


over


markets


interests


(Freidson


other


, 1970;


organi


Starr


zations


, 1982


that


Thi


affect


professional


autonomy


was


allowed


to develop


due


the


stinctive


type


of dependency


condition


which


exists


between


members











authoritative


definitive.


knowledge


is completely


unknown


those


in the


system


, thus


they


must


defer


the


judgment


the


health


care


professionals


The


superior


competence


expert


authority


attributed


members


the


have


gained


them


preeminence


and


autonomy


in the


field


of health


care


(Freidson,


1970;


Starr


, 1982)


The


profess


ional


health


care


temr


remain


free


from


interference,


thus


maintaining


both


socioeconomic


and


technical


autonomy


over


their


work.


The


one


organize


action


which


has


been


able


gain


control


over


this


loose


system


American


Medical


Association


(AMA).


The


AMA


is a private


national


organization


whose


influence


extends


beyond


phy


sician


members.


It has


been


described


as exerting


greatest


single


influence


on the


organization


of medical


care


in the


U.S.


(Freidson,


1970).


The


power


AMA


is rooted


within


the


local


community


through


membership


membership


in the


local


AMA


medical


critical


societies.


career


While


the


phys


ician


individual


practitioner


, compliance


with


AMA


policies


critical


to all


other


occupations


and


organizations


within


health


care


tem.


The


AMA


influential


setting


promoting


technical


standards


of all


health


care


servi


ces


, occupations,


and


organizations.











administrative,


review,


sanctioning


functions


connected


with


health


care


in the


. (Freidson


, 1986).


Not


system


only


free


are


from


profess


ional


interference


the


but


they


health


are


care


relatively


free


from


governmental


or state


interference


as well


The


state


has


also


left


hands


profess


control


over


the


technical


side


work,


and


the


most


part


members


fees


schedule


. It


, in


fact


, through


the


interactions


agents


medical


profession


and


official


state


that


this


control


has been


established


and


shaped


(Freidson


, 1970;


Kurtz


and


Chalfant,


1991)


The


formal


representatives


the


medical


organizations


have


been


remarkably


successful


directing


the


efforts


the


state


to make


policies


which


are


desired


the


medical


community


in assuring


that


the


interests


the


community


prevail


political


deci


sion


making


(Starr,


1982).


While


state


does


have


ultimate


authority


in matters


licensing


prosecution


of health


care


profe


ssionals


Friedson


(1970)


argues


that


much


authority


has


fact


these


been


given


matters


AMA


are


based


because


on the


deci


sions


advice


concerning


AMA.


Freidson


(1970)


o points out


that


states


require


that











school


are


acceptable


criteria


acceptability


are


ose


standards


that


are


approved


of by


a joint


committee


the


AMA


and


the


Association


American


Medical


Colleges


Additionally


, the


state


official


who


on the


state


boards


are


nominated


representatives


the


local


medical


Soc


ieti


es.


a more


recent


analysis


health


care


tem,


Freidson


(1986)


says


that


despite


recent


changes


the


organization


the


health


care


stem,


specifically


the


for-profit


enterpri


ses


owned


and


operated


investors,


monopoly


control


the


over


over


medical


key


prof


ess


functions


the nature


retained


of health


work


, and


care,


the


basic


including


ability


supervise


, review,


evaluate


work


The


crite


which


the


technical


work


of health


care


professionals


are


judged


continue


to be established


members


the


profession.


The


formal


review


bodies


continue


to be


dominated


members


profession.


A National


Health


Service


access


the


health


care


system


U.S


determined


structural


barrio


ers


present


within


the


society,


may


be possible


that


a structurally


different











that


society


One


alternative


health


care


system


national


health


service


The


ins


titution


of a national


health


service


would


create


a different


organizational


structure


with


the


intent


to create


a centralized


coordinated


system


of health


care


Waitzkin


(1989)


suggests


that


basic


principles


national


health


service


include:


The


provis


of comprehensive


care


, including


diagnostic


, therapeutic,


preventive,


rehabilitative,


environmental,


and


occupational


health


services;


dental


care;


social


work;


Services


couns


that


eling


do not


servi


ces;


require


-of-pocket


payments


point


of delivery;


Financing


accomplished


through


taxation


individual


corporate


incomes;


Initiation


of public


health


programs


, including


prevention,


risk


reduction


maternal


and


infant


care,


occupational


environmental


health,


and


long


-term


services


the


elderly;


Improvement


of geographical


distribution


providing


free


phy


sician


education


and


training


return


required


periods


service


medical











work


together


in quality


control


efforts


planning


, and


feedback.


Theoretically,


a national


health


service


would


provide


universal

elimination


entitlement


to health


necessity


care


of having


services


the


through


requi


the


site


resources


access


stem.


Since


it would


but


eliminate


private


profit,


regional


variation


the


number


of physicians


stribution


of hospital


beds


reduced


(Hollingsworth,


1981) .


Medical


care


services


would


delivered


uniformly


to all


members


of society,


and


quality


care


would


be uniform


across


the


society


(Hollingsworth,


1981)


The


Health


Care


System


Great


Britain


The


structurally


National


Health


different


Service


health


of Great


care


Britain


than


the


prof


The


ess


NHS


ional


emphasis


-for


zes


-service


central


health


zation


care


of servi


system


ces


the


and


U.S.


universal


access


citizens


It is a system


based


on socialist


economic


values


theories


of social


stice


, values


which


attempt


marketplace


remove

(Kurtz


economic


and


factors


Chalfant,


from


1991) .


health


According


to Gill


(1990),


the


basic


principles


NHS


are


universality,











services


are


uniform


throughout


nation,


and


no one


barred

system


from

must


access

answer


them.

the


Accountability


populationn


means


serves


that


rather


the

than


the


profess


of medicine.


The


autonomy


the


medical


industry


and


phy


sicians


limited


government


control.


The


health


NHS


care


a public


delivery


rather


, where


than


control


private


system


of hospitals


, clini


phy


sicians


, and


other


medical


care


services


under


the


Mini


stry


Health


Briti


sh Government


Hospitals


clinics


are


owned


government


, and


the


majority


physicians


financed


are


tax


employed


revenues,


the


with


government.


essentially


The


NHS


no cost


the


patient


the


point


of delivery


of services


(Hollingsworth,


1981)


Each


year,


the


Department


of Health


submits


a budget


to Parliament


consideration.


Parliament


then


accepts


budget


as submitted,


or revises


and


then


accepts


(Kurtz


and


Chalfant,


1991).


A general


practitioner


initial


contact


citizens


entering


health


care


system.


Primary


medical


care


is provided


registered

general pr


patients


actitioner


family


Individuals


their


physician


can


choice


to hi


register


long


or her


with

as the











system


of free


care.


Access


to specialized


care


and


hospitals


obtained


only


through


referral


from


the


primary


care


physician


(Kurtz


Chalfant


, 1991)


There


does


a private


afford


element


private


or her


the


insurance


choice,


stem


is abl


also


the


to select


to decrease


patient


the


the


able


physic


waiting


time


elective


services.


to the


rationing


of elective


services


Great


Britain,


patients


often


must


wait


two


three


years


elective


care


(Gill


, 1990).


One


service


major


system


difference


is that


the


between


a NHS


able


and


a fee-for-


to control


the


geographical


stribution


of hospitals


physi


cians


the


NHS


owns


hospitals,


to build


hospitals


and


allocate


resources


where


they


are


needed,


rather


than


where


insured


patients


are.


Physicians


, though


employed


the


NHS


are


ass


signed


locations


which


pra


ce.


Employment


possibilities


are


eliminated


in areas


that


are


overserved


incentives


are


offered


to locate


underserved


areas


(Gill


, 1990)


summary


description


the


British


National


Health


Service


as follows


Within


a welfare


state


philosophy


, the


government


has


established


the


National


Health


Service


(NHS)











Medi


and


other


health


servi


ces


are


readily


available


First


the


point


contact


generalist


of entry


system


an offi


people


usually


or clinic


who


with


makes


deci


sion


about


whether


patient


needs


the


services


of a hospital


-based


specialist.


Although


much


emphasis


placed


on preventive


care

phys


in the


ical


society,


examinations


mass

are


screening


and


strongly


routine

supported.


Care


of patients


their


homes


rather


than


hospitals


emphasis


(Fry


, 1969).


According


World


Health


Organi


zation,


Great


Britain,


"all


population


have


access


treatment


family


doctors


and


denti


, to


the


dispensing


of prescribed


drugs


, to ophthalmic


services


, and


to community


nursing


health


sitor


services"


(World


Health


Organi


zation,


1987


. 211)


The


was


introduced


Great


Britain


1948


, but


there


was


already


a history


of state


programs


which


had


both


improved


access


to medical


servi


ces


and


increased


central


zation


those


services


Concern


health


the


citizenry


was


first


directed


toward


children


when,


1907,


state


medical


inspection


of school


children


was











her


child


s medical


care


was


assisted


the


local


government.


Medical


care


from


the state


was


provided


elderly


with


passage


the Old


Age


Pension


Act


1908


In 1918


, Parliament


urged


local


provis


of maternity


clini


infant


welfare


programs


and


1938


over


half


the


pregnant


result


labor


the


movement


women

active


, the


in Britain

e support


cone


received


and


soc


free


involvement


insurance


care.


of a strong


was


pioneered


Britain


1911


Compulsory


sickness


insurance,


or a national


health


insurance,


was


provided


the


state


income


working


people


who


had


insurance


(Hollingsworth,


1981)


was


involvement


labor


Great


Britain


in support


the working


ass


, and


the


lack


of a similar


involvement


the U. S


that


some


believe


charted


the


eventual


course


the


two


country


would


follow


regard


their


attitudes


actions


toward


the


delivery


of health


care


(Navarro,


1989;


Starr,


1982).


During


its 45


-year


history


NHS


has


eliminated


financial


barriers


access


, made


temr


more


rational


and


equitable


, provided


care


on a community


level


with


community

of medical


based

care


primary

quality


physic


ians,


maintained


controlled


costs


a high


(Gill


level


, 1990)


In 1985,


Great


Britain


spent


6.1% of


oss


national











1989) .


In 1987


Great


Britain


spent


6.1%


and


the


U.S


spent


11.2%


(Demographic


Yearbook


1988,


1990)


The


central

Britain


zation


the


resulted


medical delivery

in equality across


system


regions,


Great

social


asses


groups


(Hollingsworth,


1981)


Theoretically


, it could


be postulated


that


thi


equality


access


would


bring


about


equality


of results,


and


there


would


a convergence


in level


of health


status


across


social


asses.


true


, then


the cl


ass


bias


level


of health


status


found


medical


temr


the


U.S


. would


reduced


the


institution


a sys


tern


similar


that


Great


Britain.


Recent


data


from


Great


Britain


have


revealed


that


the


overall


health


status


of all


British


citizens


has


improved


since


development


the NHS


(Williams,


1990)


While


overall


health


status


improved


, some


studi


have


suggested


that


inequalities


morbidity


and


mortality


social


class


continue


to exi


st and


have


not


been


reduced


(Marmot


et al


, 1987;


Smith,


1990)


On August


, 1980


Department


of Health


and


Social


Security


Working


in Great


Group


Britain


released


on Inequalities


a report


Health.


the


Known


Research


as the


Black


Report,


thi


longitudinal


study


dealt


with


official











the


elimination


the


gradient


health


status


the


contrary


, data


revealed


that


differential


Great


Britain


(England


and


had


decreased


For


seven


seases


which


data


were


available


(leukemia;


cancer;


trachea;


malignant


neoplasms


hypertensive


sease


lungs,


diabetes


bronchiti


bronchiti


, and


and


respiratory


tuberculosis


mortality


rates


between


the


upper


and


lower


asses


had


not


narrowed.


With


the


exception


bronchiti


, the


gaps


fact


widened


(Hollingsworth,


1981)


The


central


finding


study


was


that


there


were


large


differential


in mortality


morbidity


that


favored


higher


asses.


Social


class


was


found


to be


the


single


most


powerful


predictor


of morbidity


and


mortality


the


course


of a lifetime.


of premature


death


Poverty


shorter


remained


life


the


principal


expectancy


the


cause


lowest


classes


(Townsend


Davidson,


1982).


The


Whitehall


Report,


a longitudinal


study


public


shed


ten


years


after


the


Black


Report,


followed


a sample


cohort


identified


1971


study


looked


at class


gradients


in only


one


occupation


, the


civil


service,


order


to eliminate


confounding


variable


that


could


result


from


use


of different


occupations


The


report


showed


that


compared


men


in the


highest


grade


(admini


strators),


men











disease


but


including


lung


other


cancers,


cerebrovascular


and


other


cardiova


scular


sease,


chronic


bronchiti


other


respiratory


disease


, and


gastrointestinal


disease.


The


report


concluded


that


social


class


differences


had


widened;


better


measures


socioeconomic


position


showed


greater


inequalities


mortality;


social


class


differences


sted


health


during


life


as well


as for


length


of life;


and


trends


the


stribution


income


suggested


that


further


widening


of mortality


differentials


may


be expected


(Smith


et al


1990) .


Class


mortality


differential


presented


were


considerably


greater


Whitehall


Report


than


those


revealed


Black


Report


(Morris


, 1990;


Smith,


1990)


Social


class


differentials


also


continued


to persi


rates


infant


mortality.


U.S


there


has


been


steady


decline


infant


mortality


es.


However,


those


the


lower


sses


continue


to have


rates


higher


than


those


the


wealthier


sses


(Humphrey


Elford,


1988;


Pamuk


1990;


Rutter


and


Quine


, 1990)


In 1984,


example


, the


infant


mortality


rate


highest


social


class


was


and


lowe


was


13.0


(Carr-Hill,


1988)


An explanation


these


inequalities


that


members


the


lower


sses


have


been


found


engage


high


risk


: (a)











association


of poverty


ability


access


the


system,


even


though


system


there


Great


universal


Britain.


access


He found


that


the


not


health


having


care


access


acar


was


the


single


most


important


ctor


the


assoc


nation


of mortality


rates


and


Soc


class,


with


those


the


lower


asses


having


access


a car


more


frequently


than


those


in the higher


sses


Inequalities


in mortality


soc


ass


exist


Great


Britain,


fact


have


appeared


to have


widened


become

1986;


more

Marmot


striking

et al.,


since

1987;


1950

Smith


(Carr

eta


-Hill


, 1988;


, 1990;


Hart,


Smith,


1990;


Whitehead,


1987)


Despite


an NHS,


social


inequalities


access


use


treatment


or benefit


from


the


health


servi


per


sist


Great


Britain


(Marmot


et al


, 1987;


Susser


et al


1985


Williams


, 1990)


Conclusion


The


major


review


explanations


the

have


literature


been


has


offered


indicated

to explain


that

the


two

positive


ass


ociation


of SES


and


health


status


the


U.S


. today


One


that


members


lower


sses


engage


health


risk


behaviors


such


as smoking,


drinking


alcohol


, avoiding


exercise


, practice


unhealthy


dietary


habits,


and


getting











necessity


of having


financial


resources


access


the


health


care


stem


, which


negatively


affect


members


the


lower


asses


in obtaining


adequate


medical


care.


The


health-risk


behaviors


may


exert


an independent


effect


on health


status,


or may


mediate


the


relationship


between


social


ass


and


health


status.


relationship


In either


among


case


Soc


ass


, the


strength


, health


the


behaviors,


and


health


status


deser


ves


examination,


in addition


examination


the


relationship


between


soc


ass


and


health


status


alone.


The


review


literature


also


shows


that


a number


of authority


believe


that


a structurally


different


type


health


care


system


prof


ess


ional


-for


-service


system


the


U.S.


today


may


help


reduce


the


strong


positive


association


of socioeconomic


status


and


health


status.


One


such


structurally


different


type


of health


care


tem


the


National


Health


Service


of Great


Britain.


What


has


been


examined


the


literature


is a comparison


the


relationship


between


health


status


in each


country


While


has


been


found


that


there


is a positive


assoc


nation


of SES


health


status


within


each


country,


a comparison


the


strength


these


assoc


nations


across


country


has


been


attempted


We have


no definitive


answers


as to











importance


to citizens


policy


makers


alike


The


purpose


thi


study


is to


examine


the


-health


status


relationship


within


each


country,


and


compare


them


across


countries,


in order


to address


this


question.
















CHAPTER


THEORETICAL


FRAMEWORK


Introduction


In order


to develop


an hypothesis


dealing


with


the


issues


comparing


forms


of health


care


systems,


necessary


to explore


theoretical


framework


from


which


the


hypothesis


may


be derived.


this


chapter,


the


theoretical


framework


from


which


the


hypothe


SIS


study


was


derived


presented.


In addition,


this


chapter


includes


a discussion


, from


a socio


-historical


perspective,


of why


explanation


theoretical


framework


of differences


utilized


in health


care


offers


teams


the


best


and


stem


outcomes


The


individual


relationship


behavior


macro


long


social


been


structures


a concern


to rates


of sociological


theory.


This


inquiry


seeks


explain


the


consequences


particular


set of


institutional


arrangements


on groups


individual


(Inkeles


, 1959)


The


macro


perspective


, or structural


theoretical


perspective


,focuses


on the


relationship


between


social


I-Il -


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This


study


will


use


a structural


perspective


as the


theoretical


and


analytical


framework


which


to understand


persis


tent


association


between


and


health


status


It will


allow


evaluation


of whether


ability


access


the


health


care


stem


can


help


explain


the


relationship


between


socioeconomic


status


and


health


status


Thi


theoreti


perspective


posits


that


the


system


health


care


delivery


(whether


or not


there


an NHS)


structural


attribute


change


in part


the


structure


will


influence


change


in outcome


The


system


of health


care


delivery


is a structural


attribute


the


society


which


found


, thus


is a creation


that


particular


structural


arrangement.


outcome


the


health


care


tem,


i.e


health


status


, is a consequence


that


arrangement.


Williams


(1990)


states


that


the


macro


perspective


Predict


that


cause


social


struc


tures


shape


individual


values


behaviors


differential


in
par


morbidity


t


mortality


to conditions


life


are
that


due


derive


least
from


individual


s structural


sition.


Cons


equently,


adequate


under


standing


social


statu


s-health


relationship
identification


is contingent


on the


the empirical


theoretical
verification


links


between


social


structure


and


health


outcomes


The


indication


here


that


health


status


the


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The


literature


reviewed


this


study


pointed


two


factors


which


may


be considered


as critical


links


the


relationship


between


social


structure


and


health


status


These


are


access


to health


care


and


awareness


proper


health


behaviors


behaviors


viewed


not


Engagement


in health


as an individual


preventive


characters


tic,


rather


as the


patterned


response


of social


groups


the


realiti


constraints


external


environment


(Williams,


1990)


The


ability


of social


groups


access


medical


care


is a consequence


system


of health


care


delivery


society,


determined


particular


structural


arrangement


the


society.


this


study,


comparison


of health


status


will


be made


between


members


a society


care


system


which


has


created


structural

financial


arrangement


barriers


the


access


health

the


stem


, and


those


which


financial


barriers


access


have


been


eliminated.


The


review


literature


revealed


that


important


correlate


of health


status.


Engagement


health


promotion


behaviors


ability


access


the


system


health


care


delivery


were


found


to be


linked


to social


status


also


to health


status


individual


as members


of social


groups.












The


Conflict


Perspective


The


conflict


approach


sociology


is a structural


theoretical


perspective


which


allows


examination


of how


the


respective


structural


arrangements


health


care


systems


the


U.S.


Great


Britain


affect


health


status


outcomes.


The


conflict


perspective


based


on two


general


assumptions


health


a highly


valued


resource


and


tends


to be di


stributed


unequally


in soc


iety


, and


competition


over


this


scarce


resource


shapes


a health


care


system.


While


the


economic


structures


of both


the


U.S.


and


Great


Britain


follow


a free


market


stem


, a primary


distinction


between


systems


is the


ownership


resources


used


to produce


health


services.


In Great


Britain,


state


owns


the


resources


of production,


while


the


U.S


the


resources


of production


are


privately


owned.


The


treats


scarce


resource


of health


care


as a


"private


good"


and


relies


on the


market


stem


production


distribution


this


resource.


Great


Britain


, on the


other


hand


, treats


the


scarce


resource


health


care


as a


"public


good"


the


production


and


distribution


this


resource


are


pursued


the


government,


A I--- 1- A- -----2---. - a - I - Z - n - - A


C ~YI ~ Y ~


1 -*


* *


1


-- - -











free market system questions concerning what goods


and services and how much


to provide are decided


on a


open


market


through


the competitive


forces of


supply


and


demand


(Spencer


, 1990)


Normand


(1991)


suggests


that


the reasons why


health


care


is viewed by


some as a


public rather than private good


are


threefold:


health plays an


important role


in an


individual's ability to enjoy many


aspects of


life,


there


is extraordinary


suffering that can accompany the need


of health


about when an


care services,


individual


there


is great


will need medical


care.


uncertainty


The most


important


feature of


treating


a service as


a public rather


than private good


service,


is that no one can be excluded


from using


regardless of whether or not he or she can


pay


(Spencer,


1990).


The basic


idea


is that


essential


goods,


such


as health services,


should


take more account


of need


than


income as


the basis


access


(Normand,


1991).


The


treatment of health care as a


"public good"


Great Britain


is a result of


strength


the working


class and socialist political


parties


the


1900's


(Navarro,


1983) .


Support


for universalism,


the entitlement


of all members of


society,


a society to the resources of


is a basic component


that


of socialist philosophy.











program


was


related


primarily


establishment


and


influence


the


labor


movement


within


that


country,


which


was


realized


through


labor


s economic


(unions)


and


political


(socialis


working


t party)


class


sectors


labor


movement,


other


hand,


in combination


a weak


with


strong


good"


capital


temr


ass


of health


was


care


found


where


encourage


emphasis


"private


is placed


voluntary


membership


, benefits


do


sely


connected


one


contributions,


meager


public


benefits


standards


encourage


private


insurance


alternatives.


Navarro


(1989)


found


the


health


care


stem


U.S


. to be unequaled


any


other


western


capitalist


country


in the


provis


such


"private


good"


system


of health


care


delivery


A Socio-Hi


storical


Discussion


Paul


Starr


(1982)


and


Vicente


Navarro


(1989)


believe


that

Great


was


Britain


Political


strength


which


dissent


created


the

the


through


organized


creation


labor


labor

the


s social


movement

NHS.


st parties,


and


labor


unrest


supported


economic


strength


the


labor


unions


, preceded


introduction


of social


insurance.


Navarro


(1989)


argues


that


social


st working


class


parties


have


as a ma)or


goal


fight


universalism


within


the











1900'

Great


The


Britain


compuls


1911


sickness


was


part


insurance


of a general


instituted

program o


social

income.


insurance


The


against


insurance


risks


protected


continuity


workers


against


of workers'

industrial


accidents


, sickness


disease


, old


age,


and


unemployment.


Thus


, the


original


function


of health


surance


in Great


Britain


was


that


income


stabilization


the


workers


and


was


insured


state


(Starr


, 1982)


In contrast


labor


movement


in the


U.S


. was


social


st movement.


Labor


did


encourage


the


development


of social


welfare


programs


government


fear


workers


would


become


more


loyal


the


government


than


unions


fighting


Starr,

their


1982)


own


The


power


unions


the


influence,


U.S


rather


. were


than


coordinating


efforts


to better


working


class


as a whole.


Without


the


centralized


strength


one


economically


and


politically


related


interest


group


to represent


them,


the


working


class


the


. had


no one


to fight


programs


of universal


entitlement


In 1914,


there


was


a movement


a private


voluntary


action


group,


American


Association


Labor


Legis


lation,


institute


state


-sponsored


health


insurance


workers.


Strong


opposition


came


from


the


American


Medical


Association


which


this


time


was











insurance


industry


which


recognized


that


the


institution


state


sponsored


health


surance


would


be contrary


interests


both


organic


zations


played


active


opposing


any


social


reform


stem.


Against


organic


opposition


, reformers


who


attempted


introduce


social


welfare


policies


were


defeated.


movement,


which


had


begun


social


reformers


institute


national


health


insurance


special

lack of


died


intere


support


1917


groups


from


, falling


(AMA


labor


victim


insurance


representing


the


the


work


industry)

working


and

class


Starr,


1982


In addition


entry


U.S.


into


World


War


again


st Germany


in 1917


exacerbated


anti-German


feeling


, including


denouncing


German


social


health


insurance


(Starr


, 1982)


the


early


1930


President


Franklin


Roosevelt


supported


inclusion


of a health


care


insurance


amendment


the


Social


Security


Insurance


Bill


which


was


before


Congre


SS.


In 1935


, the


AMA


announced


opposition


the


inclusion


the


amendment


, and


Pres


ident


became


convinced


that


health


surance


amendment


would


cause


the


defeat


entire


bill


Thus


health


care


insurance

Insurance


amendment

Bill. Th


was


is


omitted


defeat


from


would


the


mean


Social


that


Security


health











plan.


With


Roosevelt


stating


that


can


up against


the


State


Medical


Societies


we just


can't


Starr


1982


, p.


279),


AMA


was


once


again


able


to successfully


defeat


the


challenge


of national


health


insurance.


President


Harry


Truman


, who


was


strongly


committed


plan


of national


health


insurance,


advanced


a proposal


adoption


1949


single


health


insurance


system


would


and


include


the


members


comprehensive


of society


universal


just


features


the


of his


needy


program


were


central


identity


(Starr,


1982)


Again,


opposition


from


AMA,


with


support


of big


business


was


able


to defeat


proposal.


this


same


time,


there


was


a crusade


U.S


. against


communist


influence


and


the


institution


of a socialized


medical


system


had


little


public


support


According


to Starr


(198


the


idea


of a national


health


insurance


stem


U.S


. was


defeated


this


time


three


major


reasons


strong


negative


feelings


about


political


ideology


of Germany


and


the


Soviet


Union,


which


included


their


social


medical


teams;


the


cooperation


of big


business


with


the


AMA,


and


agreement


that


national


health


insurance


was


opposition


to both


of their


interests


the


imbalance


in material


resources


AMA


government.


1950











a budget


$36,000


garner


support


national


health


insurance,


while


AMA


spent


opposition


(Starr


, 1982).


There


was


however


, a need


medical


insurance


rising


hospital


costs


threatened


access


of middle


class


persons


the


stem.


defeat


of a national


health


insurance


Blue


program


Cross


opened


commerce


door


insurance


to private


companies


teams


grew


, and


and


flour


shed


Labor


unions


this


time


were


attempting


secure


power


themselves


taking


power


away


from


industry


One


way


gain


power


was


to offer


health


insurance


coverage


to members


as part


an overall


benefits


package


(Starr


, 1982)


In 1970


, with


support


of Walter


Reuther


, President


the


United


Auto


Workers


Massachusetts


Senator


Edward


Kennedy


Michigan


Representative


Martha


. Griffiths


introduced


a comprehen


sive


program


of free


medical


care--a


federally


-operated


health


insurance


stem.


Pres


ident


Nixon


countered


with


a new


national


health


strategy


which


introduced


the


concept


of health


maintenance


organic


zations


(HMO)


The


AMA


insurance


industry


adamantly


opposed


both


proposals


an attempt


a compromise


was


presented


. Kennedy


Arkansas


. Wilber


Mills


This











program


of free


a compromise


medical


care


no chance,


Without


again


the

a vi


support


sion


labor


of a national


health


care


program


vanished


(Starr


1982


Historically


, the


value


stem


of America


differs


from


that


of Great


Britain


relates


provi


sion


medical


care.


According


to Cockerham


et al.


(1988)


, except


the


aged,


considered


a governmental


normative


welfare


U.S.


The


system


is not


dominant


value


regarding


the


medical


stem


that


is a commercial


entity


, in


which


medical


services


are


viewed


as a commodity


(Cassal


1986


While


Great


Britain,


like


the


U.S


is a


market


economy


, the


history


of governmental


responsibility


to all


citizens


found


Great


Britain


has


not


developed


the


U.S.


The


ineffectiveness


the


labor


movement


represent


the


working


class


fight


social


reform


over


the


last


eighty


years


left


working


ass


without


the


political


structure


Pescosolido


et al.


and e

system


(1985


economic

. This


compared


support

legacy


eight


needed

continue


indu


to change

s today.


strializ


market


economy


nations


on their


public


s evaluation


governmental


responsibility


health


care.


They


found


that


the


public


Great


Britain


negatively


evaluated


government


s performance


believed


government


was











was


taking


less


responsibility


providing


health


care.


This


suggests


that


the


people


of Great


Britain


value


social


responsibility


to provide


health


care


the


members


that


society


Americans


value


individual


response


ibility


one


s health


status


over


that


Soc


response


ibility


and


hence

what


do not


they


blame


do not


government


think


should


failing


provide


anywa


to provide

y. Americans


have


allowed


government


to reduce


welfare


spending,


which


has


most


significantly


affected


unemployed


and


income


working


class


Recent


health


policy


the


U.S


. has


stressed


cost


reduction


market


competition


over


quality


care


and


equal


access


(Bodenheimer


, 1989).


In addition


weakness


labor


movement


and


social


st parties


the U.S


strength


the


medical


stem


and


the


institutional


arrangements


that


structure


health


care


U.S


. continue


to permit


and


encourage


good.


medicine


Medical


care


to operate


as a business


. today


a private


undergoing


transformation


institutional


structure


toward


"medical


-industrial


complex"


where


profit-making


corporations


are


gaining


domination


(Starr,


1982


Large


health


care


corporations


are


becoming


a central


element


the


health


care


tem,


thus


there


been


an increased











accounted


much


recent


growth


in hospital


beds


(Starr


, 1982)


Consequences


this


change


society


are


that


these


hospitals


have


incentives


to admit


patients


not


needing


hospital


zation


overuse


technological


servi


ces


that


receive


high


reimbursement,


to duplicate


expensive


equipment


as costs


can


be recovered


through


insurance,


not


want


serving


own


only


hospitals


privately-


depressed


insured


patients


areas


(Starr


to prefer


1982


Profit-making


hospitals


benefit


from


reimbursement


private


sector


health


health


insurance.


care


As such


would


, a private


interested


corporate


the


formation


type


of national


health


care


system;


nor


will


improve


inequalities


in access


to health


care.


Starr


(198


believes


that


-tier


system


of medical


care


present


profit-making


. will


enterpri


ses


become


are


more


interested


conspicuous


treating


people


who


can


pay


. Health


care


is becoming


controlled


conglomerates


whose


interests


are


determined


the


rate


of return


on investments


private


rather


than


public


regulation.


growth


of corporate


medicine


promotes


medical


care


as a private


good.


The


in for-profit


enterpri


ses


owned


operated


investors


entry


of management


organizations


and











medical


system has been


the ability


the medical


profession

control ov


to exert an


er the medical


extraordinary


system


amount of


(Freidson,


power


1970) .


and


Even with


the advent


of corporate medicine


U.S.


, physicians


still hold authority


and strategic positions


the


system.


The


for-profit hospitals owned by


concerned with being


attractive


corporations


to physicians,


remain

as physicians


are


those who


bring


patients.


As a result


this


concern,


a new trend has developed where members


the


medical

these f


staff


are offered seats on the governing


or-profit hospitals,


and are co-opted


boards of


as shareholders


with a


financial


stake


the hospital


(Freidson,


1986)


the


last


few years,


there has also


been change


the organization


of physician


practices


with more


physicians


entering


into group practice and


organizations


which


afford


them more


personal


time.


More


than half


office


physicians


in the


U.S.


today are organized


partnerships and


in single or multispecialty


groups;


many


individual


physicians have become


professional


corporations


order to


insulate


themselves


from financial risks


and


take advantage of


favorable


tax


laws


(Glaser,


1986)


The


AMA is not opposed to the corporate


practice of medicine,


and would be opposed


only to


interference by


organizations











Physicians,


represented


AMA,


and


with


little


governmental


interference,


have


developed


a control


medical


complete


practice


functional


a professional


autonomy.


dominance


As a result,


with


they


almost


have


"cornered


the


medical


market"


controlled


deci


sion


making


regarding


the


fate


and


future


that


market.


unlikely


to expect


that


this


group,


with


the


support


has


from


insurance


industry


, the


American


Hospital


Association,


medical


school


, would


choose


to relinquish


the


economic


success


professional


autonomy


enjoys


encourage


development


As self-employed


small


of a national


businessmen


health


service.


, physicians


prefer


serve


customers


who


can


pay.


Higher


ces


can


charged


more


time


resource


consuming


services


The


phy


sician


has


an incentive


to perform


more


complex


treatments


to subs


titute


more


technically


specialized


work


avoid


ess


primary


specialized


-care


work


work.


Thus,


yields


they


lower


are


motivated


income


the


practitioner


As phys


icians


become


more


and


more


specialized


, they


prefer


customers


who


can


afford


their


fees


, and


they


have


tended


to cluster


in geographical


areas


containing


largest


number


paying,


including


insured,


patients


(Glaser,


1986)











of patients


treated


per


hour.


If a physician


does


not


keep


with


the


financial


ectations


of corporate


headquarters


could


, and


fails


jeopardy


to produce


or his


or her


, hi


or her


contract


may


practice


not


renegotiated


physician


(Starr


be self


1982


-employed,


In either


or part


case,


whether


of a corporation,


market


concerns


are


a priority.


Consequen


ces


stem


have


been


that


high


quality


medical


care


is available


to part


population,


while


others


do not


receive


basi


care


, and


that


medical


decision


making


may


tied


physician


s ability


to profit


from


the


patient


insurance


status


or the


patient


s ability


pay

per


. For

sonally


example,

profited


one study

from test


found

s and


that

x-ray


when


physicians


procedures


, they


subjected


their


patients


more


tests


than


did


phys


icians


who


did


personally


profit


from


such


procedures


(Hillman


et al.,


1990)


There


also


evidence


which


has


suggested


that


surgeons


have


been


overutili


zing


coronary


bypass


surgical


procedures


which


have


benefitted


neither


the


patient


nor


phys


ician,


may


in fact


have


been


unnecessary


(Winslow


et al.,


1988;


Varnaus


and


European


Coronary


Study


Group


, 1988


Another


study


comparing


three


common


yet


expensive


surgical


heart


procedures


reported


that


these











surgeries


were


performed


on patients


who


could


afford


them


or that


necessary


surgeries


were


performed


on patients


who


could


not


afford


them


(Wenneker


et al


, 1990)


The


AMA


Pediatri


health


(Tupper,


(AAP)


care


1990)


(Harvey


reform


Ameri


, 1990)


increase


have


access


can


developed


Academy


proposals


the medical


system


poor


propo


Employers


Americans,


remains


would


yet


employer


be required


basic


-based


principle


insurance


to provide


of both


coverage.


medical


insurance


workers


dependents


with


employees


paying


a portion


premium


based


on their


salary


the unemployed


the


AMA


suggests


enactment


major


Medicaid


reform,


where


coverage


would


be extended


to all


those


100%


the


poverty


level


The


AAP


recommends


a revi


sion


the


stem


which


each


state


would


contract


with


private


insurers


provide


coverage


those


with


no employers


, and


the


insured


would


pay


a sliding


sca


premium


based


on their


respective


income


level


Each


these


proposals


retains


the


professional


model,


with


-for


-service


and


profess


ional


autonomy


Commercial


insurance


carriers


remain


integral


part


system,


corporate


medical


system


could


be accommodated


as well.


structure


medical


stem


would


change


, and


part


the financial


burden











be extended


to all.


The


same


would


true


the


Medicaid


or contract


system,


where


deductible


would


remain


effect


and


coverage


would


vary


based


on state


funding


market


system


U.S.


, the price


of servi


ces


determines


who


gets


the


services.


Those


willing


and


abl


pay


the price


service


get


that


service


while


those


unwilling


or unable


pay


price


do not


get


the


service


(Mansfi


eld,


1992


market


stem


, health


care


viewed


as a private


good,


a service


which


sold


on the


market


those


who


can


afford


Anyone


who


is not


willing


or abl


pay


servi


is excluded


from


use


There


are


, however


, examples


services


the


U.S.


which


are


delivered


as public


goods


through


a command


tem.


The


armed


forces


which


provide


social


defense


police


forces


which


provide


Soc


safety


are


two


such


example


es.


When


defined


as a public


good


, provision


of health


care


is handl


as an obligation


Soc


ety


rather


than


as a


profit-making,


competitive


business


on the


free


market


(Navarro,


social


1989)


structure


Where


fosters


economic


arrangement


an obligation


duty


within


care


citizens,


a sys


eve


lops


which


does


not


treat


health


care


as a scarce


resource


as a right


of citi


zenship









90

Summary


the


U.S.


, health


treated


as a private


good


and


competition


developed


over


provision


consumption


that


resource.


Consumers


with


ability


to purchase


the


good


(health


care)


will


acquire


the


product


or outcome


(high


health


status)


Those


without


the


ability


will


Consumers


of health


care


in the


U.S


. are


stratified


according


their


ability


to purchase


good.


Income


affects


health


outcomes


affecting


amount


consumption


items


(medical


care)


that


people


consume.


Great


Britain


health


care


is not


a product


sale


on a


medical


market,


thus


ability


to purchase


product


subject


to stratification


or SES.


The


consumers


health


care


Great


Britain


may


benefit


from


the


outcome


product


(high


health


status)


regard


ess


SES.


It is the


treatment


of health


care


as either


a private


or public


good


which


affects


relationship


between


and


health


status


in each


society


According


the


conflict


perspective


, when


health


care


is treated


as a


private

society


good

based


becomes


on their


available

ability to


some


purchase


members

the re


the


source.


The


ownership


the


means


to purchase


health


care


(either


-1 -1- .- 2 _- ---


* -^ -


1 - ^ _


I_


L


L


- I_


_











competition


Britain)


will


that


be able


resource


on the


to acquire


the


medical

outcome,


market

or higi


(Great

h health


status.


Those


who


can


afford


to compete


the


scarce


resource


of health


care


in a social


system


where


there


competition


that


resource


on the


medical


market


will


not


be able


acquire


outcome.


The


Functionali


st Perspective


recognized


that


use


the


conflict


theory


only


care


helps


one


useful


systems


fuel


to under


health


expectation


standing


outcomes


differences


Functionali


that


health


health


theory


status


also


are


more


argued


related


the


the


differences


. than


health


Great


care


Britain.


tems


It could


found


society


are


functional


that


society


example


the


U.S.


health


care


stem


reinforces


the


favored


view


of a capitalist


as a private


economic


good.


system


It also


where


reinforces


health


care


a value


is treated


stem


which


states


that


those


members


the


society


who


work


hard


will


be rewarded.


case


of health


care,


the


members


who


work


hard


are


rewarded


salari


adequate


to purchase


health


care,


or benefit


packages


which


offer


medical


insurance.


There


is an


incentive


therefore


to work


and


, in




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