Chapter 11: Health and Society

Social construction of illness

*What it means to be sick or healthy varies across time and place* - The clash between modern Western and other cultures explores the different meanings of health and illness corresponding to the same phenomenon

What are the "three legs" of the Affordable Care Act?

*1. Guaranteed Issue* - All individuals and their families can buy insurance - Consumers CANNOT be denied coverage due to pre-existing conditions - Prices can only differ based on age, location, size of family and tobacco use *2. Individual Mandate* - Individuals must have qualifying insurance, or pay a penalty - Employers with 50+ FTEs must provide health insurance to their employees, or pay a penalty *3. Subsidies* - Qualified individuals can receive government subsidies to purchase health insurance - Individuals earning <138% of federal poverty level are eligible for Medicaid - Individuals earning 138%-400% are eligible for subsidies - Individuals 26 and under can remain on parent's insurance

Historical Development: Phase I

*1929*: Baylor University Hospital found that teachers who used the hospital were not able to pay their hospital bills - Saw this as unfair, being that teachers are so important - *Establishment of Blue Cross* to cover hospitalizations --- They estimated the cost of covering hospitalizations, divided that by the number of teachers in the system (51 cents per month) --- Premium is established by "Community rating" - Initial appearance of some historical problems --- *Cost shifting*, where some people have coverage they don't need, and some people need coverage they don't have - Earliest emergence of *perverse incentives* --- Blue Cross won't pay for doctor's visits. Doctors just admit patient to the hospital. - Earliest emergence of *peer review* --- Once Blue Cross started to pay bills, they started to question certain operations/x-rays doctors would perform --- Physicians accept that insurance accountants will be reviewing their decisions; incursion on professional sovereignty

What are the bright and dark sides of medicalization?

- Can help people suffering from an illness gain legitimacy for their claims - Can lead to stigmatization - Can mask the moral valence of a problem or treatment (hiding behind "medical science") - Can depoliticize social problems --- Treatment of kids with ADHD

Levels of medicalization: *Conceptual vs Institutional*

*Conceptual:* Using medical language to "order" a problem - Widespread disagreement about medical/biological explanations for ADD/ADHD among professionals (especially in educational and psychological service sectors) and lay public *Institutional:* Organization embraces a medical explanation, but the work of social control is carried out by non-medical personnel - Medical social control requires collaboration between medical professionals and non-medical professionals (e.g., educators) - If this unfolds differently in different organizations or places, it may create space for people (parents) to resist the medicalized label and refuse medication or medical social control

Blue Cross vs Blue Shield

*Cross:* Covered hospital treatment *Shield:* Aimed at non-hospital medical care

Dynamic Psychiatry vs Diagnostic Psychiatry

*Dynamic:* Focused on identifying the internal conflicts that produced a mental illness *Diagnostic:* Seeks to identify the symptoms of specific underlying diseases - Surpassed dynamic psychiatry

*True or False:* The larger a group gets, the harder it is to accurately adjust prices and benefits to match the risk.

*False*: This is true for smaller groups. - With larger corporations, it's easier to guess based on the age and family composition of the workforce

The emerging health care industry (Blue Cross/Blue Shield) was characterized by the _________________.

*Fee-for-service Model* - If you go to the doctor for a sore throat, you pay $25 for the visit and the insurance company pays for the rest

Medicare vs Medicaid

*Medicare:* Covers most people ages 65+ and some younger people with disabilities *Medicaid:* Joint federal and state program that helps cover medical costs for poor people with limited resources - Both change constantly, and qualification criteria/benefit packages vary widely by state

What happens if an employer overestimates or underestimates the amount of healthcare their employees will need?

*Overestimate:* Another company could swoop in and steal the business with lower rates *Underestimate:* They suffer a loss

Historical Developments: Stage IV

*Prepaid care in the Nixon Era* *Medicare established in 1965* to provide guaranteed healthcare coverage for senior citizens - Costs soon skyrocketed *Nixon embraces prepaid healthcare as a means of controlling costs*; proposes that more regions of the country also establish HMOs - Both physicians and patients sign up with HMO - Physician either takes salary or agrees to capitation - Patients sign up through employer; employer pays premium; patients have to stay "in network" *More problems* - Avoiding communist labels and trying to reframe healthcare --- "Health maintenance" instead of "socialized medicine"

Historical Development: Phase III

*Prepaid care* 1938: Henry J. Kaiser lands a contract to build the *LA Aquaduct* - At this time, LA was a remote area, so no physicians wanted to relocate there --- Solution: Kaiser "guarantees" physician salary, paying doctors 5cents/worker/day, whether or not the workers need care --- 1942: Establishment of *Kaiser Permanente*, which becomes one of the country's largest HMOs *More problems* - Getting healthcare into rural areas - "Prepayment" becomes "capitation"

The Biomedical Model of Psychiatry: Pros and Cons

*Pro:* Recognizing that mental illnesses are diseases with biological components can alleviate some of the stigma *Con:* Such diseases aren't completely biological, so if we describe them as illnesses, we may ignore the importance of contexts and blame the sufferers when they aren't cured by a drug

Effects of categorizing the sick role

*Puts emphasis on the individual rather than on the social context, and thus brings about a paradox* - EX: Because we know that certain behaviors are linked to specific diseases, Individuals are often seen as being at least partially responsible for their diseases, rather than unaccountable (as presumed in the rights of the sick role)

Describe the different types of narratives. - Restitution - Chaos - Quest

*Restitution:* - Patient is restored to health - Position of narrator (Patient may present as struggle to gain control over their health; provider might present it as heroic tale of their skill as a healer) *Chaos:* - Patient's status goes from bad to worse; spirals *Quest:* - Patient's search for resolution to the illness; the "diagnostic odyssey"

According to Parsons, what are the 2 rights and 2 obligations that come with the sick role?

*Rights:* 1. Not to perform normal social roles (the degree of exemption from rights and responsibilities depends on the severity of the illness) 2. Not to be held accountable for his or her condition *Obligations:* 1. To try to get well 2. To seek competent help and comply with doctors' orders

How do narratives operate at multiple levels?

*Small N narratives:* Stories we tell ourselves to help make sense of what is happening to us *Organizational narratives:* Legitimize power of dominant ideas and actors (present them as "truth") - "Ask your doctor ads" hinges on trust in doctors as professionals

Whitehall study

*Study:* The differences between men in different occupations and the differences between men of different social classes in similar occupations *Process:* Everyone has access to healthcare regardless of their SES. None of the participants are poor/malnourished and all have a sufficient living salary. *Results:* Lower Ranks (and lower status) men had more risk factors, such as obesity, higher levels of stress and low levels of physical activity. *Conclusion:* Our demographics play a major role in our health.

Historical Development: Phase II

*WWII breaks out* - Federal government institutes wage/price controls - Labor unions had nowhere to go when it came to bargaining on salary --- Instead, they bargained on benefits *Employers and unions follow the historical precedence set by the Blues* - Same price schedule *More problems surface* - Shift from "community rating" to "experience rating" --- Women and smokers have to pay more - "*Cherry picking*" --- Insurers want to insure healthy people, and don't want to ensure unhealthy/at risk people

Common elements of a narrative

- Cast of characters - Plot devices --- Suffering creates tension in the story --- Crisis, turning point, or epiphany --- Transformation

Biographical disruption

- Chronic illness presents a crisis that violates taken-for-granted assumptions and behaviors - Challenges our explanatory frameworks, often in a way that forces us to re-think our biographic trajectory or self-concept - Requires us to mobilize resources differently, to cope with different abilities or life circumstances

What drives medicalization?

- Declining physician authority - Increased scrutiny on the role of: --- Consumers --- Pharmaceutical industry --- Managed care

Physician's concerns about DTCA

- Disrupt the patient-physician relationship --- But in fact, physicians are happy to get info about pharmaceuticals from sales reps, but not from patients

*Sociological Diagnosis for Healthcare:* Professional sovereignty

- Doctors have high prestige, and weren't used to being told what to do - Doctors don't want to expand healthcare coverage because they're worried about losing turf

What were the effects of the system of licensing in the 19th century?

- Excluded other forms of medicine practiced widely during this time - Constrained the types of doctors who were able to practice - Gave doctors more economic clout --- Physicians were allowed to sue for payment, but only if they were licensed

How does family structure affect health?

- Larger families have higher mortality rates - When kids are spaced closer together, there is a higher mortality rate This is because... - Lack of resources (especially in developing countries) - Child supervision is spread thin - First-born children are more likely to die than others This is because... - Parents are less experienced - First-borns are more likely to be the result of unintended pregnancies - Firstborns are more likely to be older children; if they die, the parents are less likely to have another child

Malaria epidemics

- Not only has the malaria problem yet to be solved in many of the world's poorer regions, but it's also reemerging in parts of the world where we believed we had conquered it - Malaria is becoming more difficult to treat because of antibiotic-resistant strains of the disease

What are some social determinants of health?

- SES - Stress - Early life factors - Social exclusion - Workplace factors - Unemployment - Social support - Addiction - Food - Transportation

Why do we view doctors with prestige?

- Scarcity of doctors - The amount of education it takes to become a doctor - The apparent difficulty of mastering the skills of being a doctor - The number of medical schools and medical graduates is strictly regulated --- Allows doctors to maintain the exclusiveness of their profession - Doctors offer a universally valued product: health and longevity - Individualized objectivity gives them a certain power in their relationship with clients --- They are simultaneously very intimate with you while also highly objective and technical

Why are women more likely to live longer than men?

- Specific diseases - Men are more likely to work high stress jobs --- However, this is changing overtime - Women are more likely to see a doctor for a minor health concern

*Sociological Diagnosis for Healthcare:* Power and framing

- Stakeholders do not have equal power in framing the debate - Powerful actors can redefine what the healthcare system's goals should be

Why do people with higher SES live longer?

- They are more likely to live a healthier lifestyle - They often have more knowledge to work with when facing their own health choices + interactions with the healthcare system

"Quack"

A professional who violates this unstated ethic by seeking to make a client - the customer or patient - happy at the expense of the esteem of his or her peers - EX: A college professor cancels the finals and gives all of the students A's (Page 409)

What are the 2 types of medicalization?

1. "From badness to sickness" - EX: Medicalization of gun violence reflects a struggle for control 2. Normal physical processes fall under the purview of medicine

An Alternative 10 Tips For Better Health

1. Don't be poor. If you are, stop. If you can't, try not to be for much longer. 2. Don't have poor parents, or parents with low education levels. 3. If you're a man, get married. If you're a woman, don't. If you're a married woman, don't let your partner die before you. 4. Own a car, a house, and inherit or save lots of financial assets. 5. Don't choose a job that is low-paid, stressful, or that provides you low decision-making authority or control. 6. Practice not becoming unemployed. 7. If you must get sick, make sure to do so after buying health insurance. Do not choose an illness that requires expensive prescription drugs. 8. Be sure you grew up in a neighborhood wit low crime, good schools, high social cohesion, places for safe recreation and physical activity, and available/affordable healthy food. 9. Make sure to choose family members, neighbors, and work colleagues who all practice healthy behaviors themselves, since their practices will likely affect your own. 10. If you must live in a poor neighborhood or one with a high proportion of African-Americans, don't read any advertisements, particularly if you're a kid.

By 1990, why did doctors' authority begin to decline?

1. Market forces had infiltrated medicine - Concerns about the rising costs of healthcare became a political issue and led to changes in the way we pay for care (ex: HMOs) 2. Rise in external regulation - Emergence of the medical "bill of rights" 3. Rise of technology - Less training for certain procedures is required

What are the 3 interpretations encompassed in the Social Determinant's Theory?

1. Psychosocial interpretation 2. Materialistic interpretation 3. Fundamental Causes interpretation

What are the 3 theories that may explain the correlation between SES and health?

1. Selection Theory 2. Drift Explanation 3. Social Determination Theory

What are the 3 important aspects of medicalization?

1. Types 2. Bright and dark sides 3. Levels (Conceptual and Institutional)

Scholars claim that doctors' power peaked in the ______ and is now on the decline.

1980s

Epigenetic mark

A chemical regulator of gene activity that may be switched "on" or "off" in response to environmental influence

How is the ACA paid for?

A combination of taxes and penalties, only some of which directly affect average Americans - EX: Both the Individual and Employer Mandates carry some penalties, which are expected to generate some revenue

John Henryism

A pattern of prolonged, high-effort coping with psychosocial demands and stressors, including barriers to upward social mobility - EX: African Americans with hypertension

Health inequities

A subset of health disparities that are: 1. Modifiable 2. Associated with social disadvantage 3. Considered ethically unfair Health inequities should be viewed as a *chain of events* signified by difference in: - Environment - Access to, utilization of, and quality of care - Health status - A particular health outcome Involves assessment of: - Avoidability - Ethical judgement

Affordable Care Act

AKA Obamacare - Expanded Medicaid eligibility - Allowed young adults to stay on their parents' insurance through age 26 - *Created a mandate for all Americans to purchase insurance* - Eliminated risk adjustment

Premium

Amount of money you pay an insurer annually to provide health insurance coverage for you Trend: Fewer and fewer companies have provided health insurances to their employees, especially after the 90s - More and more companies require their employees to pay a portion of the premium

Narrative reconstruction

An attempt to reconstruct or impose order on the disruption and fragmentation brought about by illness

SES and Health: *Drift Explanation*

Asserts that reverse causality exists-that health causes social position (as in the education example given in the previous paragraph).

Materialistic interpretation (Social determinant's theory)

Asserts that the differential access to a healthy life (including monetary, psychological, and environmental factors) is a result of SES factors - Living a health lifestyle is expensive - Poor neighborhoods are more likely to be exposed to toxic chemicals

Identify the reasons why medical doctors enjoy high prestige in the United States. A. Medicine is a lucrative line of work. B. A legal cap on the number of medical degrees awarded maintains exclusivity. C. Being a physician requires both inborn talent and extensive training. D. Doctors are seen as following a moral calling.

B and D

What accounts for the health disparities between races?

Being a minority race in itself can increase stress

Identify the reasons why doctors wield power in today's health care system. A. They can usually create their own demand by ordering more treatment. B. They can bill however much they like for services. C. They decide what counts as a medical disorder. D. They have broad authority to write prescriptions. E. They are self-regulating.

C, D and E

Sick role

Concept describing the social rights and obligations of a sick individual - Coined by Parsons

Does direct-to-consumer advertising matter?

DTCA is an important (but not the only) driver of RX sales growth - Did not affect market share of individual drugs within classes

Healthy disparities

Differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental and geographic contributions

Change in FDA rules (1997)

Direct-to-consumer ads should focus on diseases rather than specific products

"Supplier-induced demand"

Doctors create excess demand for their services Ex. "Take two aspirin, make an appointment with my secretary for tomorrow, and then we'll follow up with you again in two weeks and run some tests." Every time the doctor met with you, they billed you, and because you (most likely) only paid part of the bill (thanks co-pay) you trust that they know what's best.

Problem with the fee-for-service model

Doctors have the incentive to over-treat (*supplier-induced demand*) and to see you again and again in order to bill the insurance company

Problem with HMOs

Doctors have the incentive to under-treat, because they generally don't get much extra money each time you come in

Why is the prestige surrounding doctors relatively new?

Doctors were often incompetent, and unable to provide the longevity/health that gives them such prestige today

HMOs

Emerged as an attempt to hold down costs by paying doctors a salary based on the number of patients they take on - Medical provider receives a capitation, meaning a fee per person as opposed to a fee per treatment - Patients pay a co-pay every time they visit the doctor

Employer based health insurance

Employers required to pay for all or part of private health insurance policies of their employees

Fundamental Causes interpretation (Social determinant's theory)

Focuses on examining how social factors shape illness and health in order to understand the link between SES and health - Because resources are differentially distributed across the SES hierarchy, elites have more resources at their disposal than others, and are therefore better able to maintain good health - Multiple and ever-changing mechanisms exist by which SES (and other dimensions of power) affect health --- What these causes have in common is the greater ability of elites to make use of the info/resources as it becomes available

Psychosocial interpretation (Social determinant's theory)

Focuses on individual's social class status relative to those around them - Feelings of inadequacy cause stress that leads to poor health - Can indirectly cause negative health effects (ex: Stress could cause you to start smoking)

Ripple effect of changing medical care

Given that healthy care makes up one-sixth of the U.S. economy, such a dramatic change will play out over years, and possibly even decades, in realms of life well beyond medical care

Homeopathy

Giving the patient a little bit of the disease in order to cure them/prevent illness - Was a widely followed medical practice in the 19th century, until what we now call "traditional medicine" became thee dominant paradigm

Emergence of more important roles for large institutions

Hospitals, formerly places to die, became places to heal (at least sometimes). By the late nineteenth century, hospitals had become important social institutions, and doctors relationships to hospitals changed. - Previously, doctors were merely employees of hospitals, but then they gained rights to admit patients to 1+ hospitals - Hospitals came to depend on doctors for their supply of customers (patients)

*Sociological Diagnosis for Healthcare:* Location matters

Premiums in rural states are higher

Morbidity

Illness in a general sense - EX: Having the chicken pox (an acute condition) or not being able to walk well because you have lower back pain (a chronic condition)

"Fee for service" basis

In the past, this is how insurance was reimbursed. *If the doctor took your insurance, there was a set billable rate* - This allowed doctors to create the "supplier-induced demand"

Patients consider ___________ the most important factor in rating their doctors

Interpersonal confidence

What was the main provision of the "medical bill of rights" passed by Clinton?

It eliminated "drive-through deliveries" by requiring insurance companies to pay for a woman's stay in the hospital after giving birth

"Bedside Manner"

Patients wanted a compassionate and understanding doctor who listens to their questions and explains their diagnosis

How does marital status affect one's health?

People who are married tend to live longer, particularly married men This is because... - People are more likely to get married if they are healthy - Marriage may also benefit one's health

Heterodoxy

Non-traditional medicine - EX: Biofeedback, massage therapy, acupuncture, etc

State Children's Health Insurance Program (SCHIP)

Provides health insurance coverage for children whose families meet income eligibility standards

1986 Emergency Medical Treatment and Active Labor Act

Requires emergency rooms to treat you, at least enough to stabilize your condition, regardless of your ability to pay for services

SES and Health: *Selection Theory*

Says that the relationship between lower income and higher morbidity is spurious (that is, false or not really casual) because other factors such as genetics and biology affect both health and SES.

SES and Health: *Social Determination Theory*

Social position determines health Ex. Being of a lower income level or SES causes higher morbidity and lower general health

Insurance works by __________, so the health insurance market cannot function if only the sickest people participate

Spreading risk

Medicalization

The process by which problems or issues not traditionally seen as medical come to be framed as such. EX: Alcoholism - People used to think it was not a form of addiction, instead they thought it was just a sin of excess, a moral failing, and a problem of self control.

Demedicalization

The process through which a condition is taken out of the realm of medicine - Often involves intense jurisdictional disputes between physicians and other healthcare providers, or physicians and patients *Examples:* - Homosexuality listed as a psych disorder until 1973 - Demedicalization of abortion by Roe v. Wade

Lifecourse theory

The theory that children undergo a succession of role and status changes as they grow older

*Sociological Diagnosis for Healthcare:* Stakeholders

There are a lot of people who have a stake in healthcare delivery - not just patients and physicians, but the people who pay for it (employers, insurers, labor unions and the public)

Why did the people who received less social security (as a result of the Social Security Policy of 1977) live longer?

They compensated by working part-time longer - Because social isolation increases mortality among the elderly, staying in the labor market had a positive impact on these peoples' longevity

History of doctors

Up until recently, being a medical professional was a commoners job, not one of the elite classes. *Ancient Rome:* Physicians were often slaves or low-ranked freedmen/foreigners *England:* Physicians had a higher status than those in ancient Rome, but they were still low class. Surgeons were ranked even lower.

What is the leading killer worldwide? Why is this a social issue?

Waterborne illnesses This is a social issue because... -The technology/know-how for clean water exists, as well as the amount of money necessary to fund it

Adverse selection problem

When individuals have choice, they tend to sort themselves out by their own risk, which they know much better than the insurance company ever could (*information asymmetry*) - *Result*: Individual insurance market goes into a death spiral in which only the sickest people buy insurance and prices increase, thereby further driving away potential healthy purchasers

Infant Mortality Rates (Per 1,000 births)

White: 5.3 Hispanic: 5.29 Black: 12.4 Asian American and Pacific Islander: 4.4 American Indian and Alaskan Native: 8.47

Paul Farmer

Wrote Infections and Inequalities(1999) and Haiti after the Earthquake(1999) The book demonstrates links between poverty and illness. (Page 408)