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