Chapter 13 Health and Health Care

The Functionalist Approach

As conceived by Talcott Parsons (1951),Parsons, T. (1951). The social system. New York, NY: Free Press. the functionalist perspective emphasizes that good health and effective medical care are essential for a society’s ability to function. Ill health impairs our ability to perform our roles in society, and if too many people are unhealthy, society’s functioning and stability suffer. This was especially true for premature death, said Parsons, because it prevents individuals from fully carrying out all their social roles and thus represents a “poor return” to society for the various costs of pregnancy, birth, child care, and socialization of the individual who ends up dying early. Poor medical care is likewise dysfunctional for society, as people who are ill face greater difficulty in becoming healthy and people who are healthy are more likely to become ill.

For a person to be considered legitimately sick, said Parsons, several expectations must be met. He referred to these expectations as the sick roleExpectations of how people are supposed to think and act when they are ill.. First, sick people should not be perceived as having caused their own health problem. If we eat high-fat food, become obese, and have a heart attack, we evoke less sympathy than if we had practiced good nutrition and maintained a proper weight. If someone is driving drunk and smashes into a tree, there is much less sympathy than if the driver had been sober and skidded off the road in icy weather.

Second, sick people must want to get well. If they do not want to get well or, worse yet, are perceived as faking their illness or malingering after becoming healthier, they are no longer considered legitimately ill by the people who know them or, more generally, by society itself.

Third, sick people are expected to have their illness confirmed by a physician or other health-care professional and to follow the professional’s instructions in order to become well. If a sick person fails to do so, she or he again loses the right to perform the sick role.

Talcott Parsons wrote that for a person to be perceived as legitimately ill, several expectations, called the sick role, must be met. These expectations include the perception that the person did not cause her or his own health problem.

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If all these expectations are met, said Parsons, sick people are treated as sick by their family, their friends, and other people they know, and they become exempt from their normal obligations to all these people. Sometimes they are even told to stay in bed when they want to remain active.

Physicians also have a role to perform, said Parsons. First and foremost, they have to diagnose the person’s illness, decide how to treat it, and help the person become well. To do so, they need the cooperation of the patient, who must answer the physician’s questions accurately and follow the physician’s instructions. Parsons thus viewed the physician-patient relationship as hierarchical: the physician gives the orders (or, more accurately, provides advice and instructions), and the patient follows them.

Parsons was certainly right in emphasizing the importance of individuals’ good health for society’s health, but his perspective has been criticized for several reasons. First, his idea of the sick role applies more to acute (short-term) illness than to chronic (long-term) illness. Although much of his discussion implies a person temporarily enters a sick role and leaves it soon after following adequate medical care, people with chronic illnesses can be locked into a sick role for a very long time or even permanently. Second, Parsons’s discussion ignores the fact, mentioned earlier, that our social backgrounds affect the likelihood of becoming ill and the quality of medical care we receive. Third, Parsons wrote approvingly of the hierarchy implicit in the physician-patient relationship. Many experts say today that patients need to reduce this hierarchy by asking more questions of their physicians and by taking a more active role in maintaining their health. To the extent that physicians do not always provide the best medical care, the hierarchy that Parsons favored is at least partly to blame.

The Conflict Approach

The conflict approach emphasizes inequality in the quality of health and of health-care delivery (Weitz, 2013).Weitz, R. (2013). The sociology of health, illness, and health care: A critical approach (6th ed.). Thousand Oaks, CA: Wadsworth. As noted earlier, the quality of health and health care differs greatly around the world and within the United States. Society’s inequities along social class, race and ethnicity, and gender lines are reproduced in our health and health care. People from disadvantaged social backgrounds are more likely to become ill, and once they do become ill, inadequate health care makes it more difficult for them to become well. As we will see, the evidence of disparities in health and health care is vast and dramatic.

The conflict approach also critiques efforts by physicians over the decades to control the practice of medicine and to define various social problems as medical ones. Physicians’ motivation for doing so has been both good and bad. On the good side, they have believed they are the most qualified professionals to diagnose problems and to treat people who have these problems. On the negative side, they have also recognized that their financial status will improve if they succeed in characterizing social problems as medical problems and in monopolizing the treatment of these problems. Once these problems become “medicalized,” their possible social roots and thus potential solutions are neglected.

Several examples illustrate conflict theory’s criticism. Alternative medicine is becoming increasingly popular, but so has criticism of it by the medical establishment. Physicians may honestly feel that medical alternatives are inadequate, ineffective, or even dangerous, but they also recognize that the use of these alternatives is financially harmful to their own practices. Eating disorders also illustrate conflict theory’s criticism. Many of the women and girls who have eating disorders receive help from a physician, a psychiatrist, a psychologist, or another health-care professional. Although this care is often very helpful, the definition of eating disorders as a medical problem nonetheless provides a good source of income for the professionals who treat it and obscures its cultural roots in society’s standard of beauty for women (Whitehead & Kurz, 2008).Whitehead, K., & Kurz, T. (2008). Saints, sinners and standards of femininity: Discursive constructions of anorexia nervosa and obesity in women’s magazines. Journal of Gender Studies, 17, 345–358.

Obstetrical care provides another example. In most of human history, midwives or their equivalent were the people who helped pregnant women deliver their babies. In the nineteenth century, physicians claimed they were better trained than midwives and won legislation giving them authority to deliver babies. They may have honestly felt that midwives were inadequately trained, but they also fully recognized that obstetrical care would be quite lucrative (Ehrenreich & English, 2005).

According to conflict theory, physicians have often sought to define various social problems as medical problems. An example is the development of the diagnosis of ADHD, or attention deficit/hyperactivity disorder.

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In a final example, many hyperactive children are now diagnosed with ADHD, or attention deficit/hyperactivity disorder. A generation or more ago, they would have been considered merely as overly active. After Ritalin, a drug that reduces hyperactivity, was developed, their behavior came to be considered a medical problem and the ADHD diagnosis was increasingly applied, and tens of thousands of children went to physicians’ offices and were given Ritalin or similar drugs. The definition of their behavior as a medical problem was very lucrative for physicians and for the company that developed Ritalin, and it also obscured the possible roots of their behavior in inadequate parenting, stultifying schools, or even gender socialization, as most hyperactive kids are boys (Conrad, 2008; Rao & Seaton, 2010).Conrad, P. (2008). The medicalization of society: On the transformation of human conditions into treatable disorders. Baltimore, MD: Johns Hopkins University Press; Rao, A., & Seaton, M. (2010). The way of boys: Promoting the social and emotional development of young boys. New York, NY: Harper Paperbacks.

Critics say the conflict approach’s assessment of health and medicine is overly harsh and its criticism of physicians’ motivation far too cynical. Scientific medicine has greatly improved the health of people around the world. Although physicians are certainly motivated, as many people are, by economic considerations, their efforts to extend their scope into previously nonmedical areas also stem from honest beliefs that people’s health and lives will improve if these efforts succeed. Certainly there is some truth in this criticism of the conflict approach, but the evidence of inequality in health and medicine and of the negative aspects of the medical establishment’s motivation for extending its reach remains compelling.

The Symbolic Interactionist Approach

The symbolic interactionist approach emphasizes that health and illness are social constructions. This means that various physical and mental conditions have little or no objective reality but instead are considered healthy or ill conditions only if they are defined as such by a society and its members (Buckser, 2009; Lorber & Moore, 2002).Buckser, A. (2009). Institutions, agency, and illness in the making of Tourette syndrome. Human Organization, 68(3), 293–306; Lorber, J., & Moore, L. J. (2002). Gender and the social construction of illness (2nd ed.). Lanham, MD: Rowman & Littlefield. The ADHD example just discussed also illustrates symbolic interactionist theory’s concerns, as a behavior that was not previously considered an illness came to be defined as one after the development of Ritalin. In another example first discussed in Chapter 7 "Alcohol and Other Drugs", in the late 1800s opium use was quite common in the United States, as opium derivatives were included in all sorts of over-the-counter products. Opium use was considered neither a major health nor legal problem. That changed by the end of the century, as prejudice against Chinese Americans led to the banning of the opium dens (similar to today’s bars) they frequented, and calls for the banning of opium led to federal legislation early in the twentieth century that banned most opium products except by prescription (Musto, 2002).Musto, D. F. (Ed.). (2002). Drugs in America: A documentary history. New York, NY: New York University Press.

In a more current example, an attempt to redefine obesity is now under way in the United States. Obesity is a known health risk, but a “fat pride” or “fat acceptance” movement composed mainly of heavy individuals is arguing that obesity’s health risks are exaggerated and calling attention to society’s discrimination against overweight people. Although such discrimination is certainly unfortunate, critics say the movement is going too far in trying to minimize obesity’s risks (Diamond, 2011).Diamond, A. (2011). Acceptance of fat as the norm is a cause for concern. Nursing Standard, 25(38), 28–28.

The symbolic interactionist approach has also provided important studies of the interaction between patients and health-care professionals. Consciously or not, physicians “manage the situation” to display their authority and medical knowledge. Patients usually have to wait a long time for the physician to show up, and the physician is often in a white lab coat; the physician is also often addressed as “Doctor,” while patients are often called by their first name. Physicians typically use complex medical terms to describe a patient’s illness instead of the more simple terms used by laypeople and the patients themselves.

Management of the situation is perhaps especially important during a gynecological exam, as first discussed in Chapter 12 "Work and the Economy". When the physician is a man, this situation is fraught with potential embarrassment and uneasiness because a man is examining and touching a woman’s genital area. Under these circumstances, the physician must act in a purely professional manner. He must indicate no personal interest in the woman’s body and must instead treat the exam no differently from any other type of exam. To further “desex” the situation and reduce any potential uneasiness, a female nurse is often present during the exam.

Critics fault the symbolic interactionist approach for implying that no illnesses have objective reality. Many serious health conditions do exist and put people at risk for their health regardless of what they or their society thinks. Critics also say the approach neglects the effects of social inequality for health and illness. Despite these possible faults, the symbolic interactionist approach reminds us that health and illness do have a subjective as well as an objective reality.

International Disparities in Health and Illness

The nations of the world differ dramatically in the quality of their health and health care. The poorest nations suffer terribly. Their people suffer from poor nutrition, unsafe water, inadequate sanitation, rampant disease, and inadequate health care. One disease they suffer from is AIDS. Some 34 million people worldwide have HIV/AIDS, and two-thirds of these live in sub-Saharan Africa. Almost two million people, most of them from this region, died in 2010 from HIV/AIDS (World Health Organization, 2011).World Health Organization. (2011). Global response: Epidemic update and health sector progress towards universal access. Retrieved from http://www.who.int/hiv/en/index.html. All these health problems produce high rates of infant mortality and maternal mortality and high death rates. For all these reasons, people in the poorest nations have shorter life spans than those in the richest nations.

A few health indicators should indicate the depth of the problem. Figure 13.1 "Infant Mortality for Low-Income, Lower-Middle-Income, Higher-Middle-Income, and High-Income Nations, 2010" compares an important indicator, infant mortality (number of deaths before age 1 per 1,000 live births) for nations grouped into four income categories. The striking contrast between the two groups provides dramatic evidence of the health problems poor nations face. When, as Figure 13.1 "Infant Mortality for Low-Income, Lower-Middle-Income, Higher-Middle-Income, and High-Income Nations, 2010" indicates, 70 children in the poorest nations die before their first birthday for every 1,000 live births (equivalent to 7 out of 100), the poor nations have serious problems indeed.

Figure 13.1 Infant Mortality for Low-Income, Lower-Middle-Income, Higher-Middle-Income, and High-Income Nations, 2010

Source: Data from World Bank. (2012). World databank. Retrieved from http://databank.worldbank.org/ddp/home.do?Step=1&id=4.

Figure 13.2 "Percentage of Population with Access to Adequate Sanitation Facilities, 2008" shows how the world differs in access to adequate sanitation facilities (i.e., the removal of human waste from the physical environment, as by toilets). Whereas this percentage is at least 98 percent in the wealthy nations of North America, Western Europe, Australia, and New Zealand, it is less than 33 percent in many poor nations in Africa and Asia.

Figure 13.2 Percentage of Population with Access to Adequate Sanitation Facilities, 2008

Source: Adapted from World Bank. (2010). Improved sanitation facilities (% of population with access). Retrieved from http://www.worldbank.org.

Two-thirds of the 33 million people worldwide who have HIV/AIDS live in sub-Saharan Africa. This terrible fact illustrates just one of the many health problems that people in poor nations suffer.

Image courtesy of khym54, http://www.flickr.com/photos/khym54/144915009.

Life expectancy is another important measure of a nation’s health and is very relevant for understanding worldwide disparities in health and health care. Figure 13.3 "Average Life Expectancy across the Globe (Years)" illustrates these disparities. Not surprisingly, the global differences in this map are similar to those for adequate sanitation in the map depicted in Figure 13.2 "Percentage of Population with Access to Adequate Sanitation Facilities, 2008". North America, Western Europe, Australia, and New Zealand have much longer life expectancies (75 years and higher) than Africa and Asia, where some nations have expectancies below 50 years. The society we live in can affect our life span by more than a quarter of a century.

Figure 13.3 Average Life Expectancy across the Globe (Years)

Source: Adapted from http://en.wikipedia.org/wiki/File:Life_Expectancy_2011_Estimates_CIA_World_Factbook.png.

Health Care in Industrial Nations

Industrial nations throughout the world, with the notable exception of the United States, provide their citizens with some form of national health care and national health insuranceA system of medicine in which the government pays all or most of the costs of health care, prescriptions, and other items for the entire population. (Russell, 2011).Russell, J. W. (2011). Double standard: Social policy in Europe and the United States (2nd ed.). Lanham, MD: Rowman & Littlefield. Although their health-care systems differ in several respects, their governments pay all or most of the costs for health care, drugs, and other health needs. In Denmark, for example, the government provides free medical care and hospitalization for the entire population and pays for some medications and some dental care. In France, the government pays for some of the medical, hospitalization, and medication costs for most people and all these expenses for the poor, unemployed, and children under the age of 10. In Great Britain, the National Health Service pays most medical costs for the population, including medical care, hospitalization, prescriptions, dental care, and eyeglasses. In Canada, the National Health Insurance system also pays for most medical costs. Patients do not even receive bills from their physicians, who instead are paid by the government.

Although these national health insurance programs are not perfect—for example, people sometimes must wait for elective surgery and some other procedures—they are commonly credited with reducing infant mortality, extending life expectancy, and, more generally, for enabling their citizenries to have relatively good health. Their populations are generally healthier than Americans, even though health-care spending is much higher per capita in the United States than in these other nations. In all these respects, these national health insurance systems offer several advantages over the health-care model found in the United States (Reid, 2010)Reid, T. R. (2010). The healing of America: A global quest for better, cheaper, and fairer health care. New York, NY: Penguin Press. (see Note 13.11 "Lessons from Other Societies").

The Poor Status of American Health

Unfortunately, the bad news is also considerable. Despite all the gains just mentioned, the United States lags behind most other wealthy democracies in several health indicators, as we have seen, even though it is the wealthiest nation in the world. Moreover, 14.5 percent of US households and almost 49 million Americans are “food insecure” (lacking sufficient money for adequate food and nutrition) at least part of the year; more than one-fifth of all children live in such households (Coleman-Jensen, Nord, Andrews, & Carlson, 2011).Coleman-Jensen, A., Nord, M., Andrews, M., & Carlson, S. (2011). Household food security in the United States in 2010. Washington, DC: US Department of Agriculture. More than 8 percent of all infants are born at low birth weight (under 5.5 pounds), putting them at risk for long-term health problems; this figure has risen steadily since the late 1980s and is higher than the 1970 rate (National Center for Health Statistics, 2011).National Center for Health Statistics. (2011). Health, United States, 2010. Hyattsville, MD: Centers for Disease Control and Prevention. In other areas, childhood rates of obesity, asthma, and some other chronic conditions are on the rise, with about one-third of children considered obese or overweight (Van Cleave, Gortmaker, & Perrin, 2010).Van Cleave, J., Gortmaker, S. L., & Perrin, J. M. (2010). Dynamics of obesity and chronic health conditions among children and youth. JAMA, 303(7), 623–630. Clearly the United States still has a long way to go in improving the nation’s health.

There is also bad news in the social distribution of health. Health problems in the United States are more often found among the poor, among people from certain racial and ethnic backgrounds, and, depending on the problem, among women or men. Social epidemiologyThe study of how health and illness vary by social and demographic characteristics such as social class, race and ethnicity, and gender. refers to the study of how health and illness vary by sociodemographic characteristics, with such variations called health disparitiesDifferences in health and illness according to social class, race and ethnicity, and gender.. When we examine social epidemiology in the United States, we see that many health disparities exist. In this way, health and illness both reflect and reinforce society’s social inequalities. We now turn to the most important health disparities, starting with physical health and then mental health.

Health Disparities: Physical Health

Social Class

Not only do the poor have less money, but they also have much worse health, as the news story that began this chapter illustrated. There is growing recognition in the government and in medical and academic communities that social class makes a huge difference when it comes to health and illness (Centers for Disease Control and Prevention, 2011).Centers for Disease Control and Prevention. (2011). CDC health disparities and inequalities report—United States, 2011. Morbidity and Mortality Weekly Report, 60, 1–114.

Many types of health indicators illustrate the social class–health link in the United States. In an annual survey conducted by the government, people are asked to indicate the quality of their health. As Figure 13.5 "Family Income and Self-Reported Health (Percentage of People 18 or Over Saying Health Is Only Fair or Poor), 2009" shows, poor people are much more likely than those with higher incomes to say their health is only fair or poor. These self-reports of health are subjective indicators, and it is possible that not everyone interprets “fair” or “poor” health in the same way. But objective indicators of actual health also indicate a strong social class–health link (National Center for Health Statistics, 2011).National Center for Health Statistics. (2011). Health, United States, 2010. Hyattsville, MD: Centers for Disease Control and Prevention.

Figure 13.5 Family Income and Self-Reported Health (Percentage of People 18 or Over Saying Health Is Only Fair or Poor), 2009

Source: Data from National Center for Health Statistics. (2011). Health, United States, 2010. Hyattsville, MD: Centers for Disease Control and Prevention.

Children and Our Future

The Poor Health of Poor Children

When we consider health disparities, some of the most unsettling evidence involves children. As a recent report by the Robert Wood Johnson Foundation concluded, “The data illustrate a consistent and striking pattern of incremental improvements in health with increasing levels of family income and educational attainment: As family income and levels of education rise, health improves. In almost every state, shortfalls in health are greatest among children in the poorest or least educated households, but even middle-class children are less healthy than children with greater advantages.”

Some government data illustrate the difference that poverty makes for the nation’s children:

• Children of poor mothers are more than twice as likely as children born to wealthier mothers to be born with low birth weight.
• By the age of 9 months, poor children are already more likely to exhibit poor health and lower cognitive and socioemotional development.
• By age 3, poor children are two-thirds more likely to have asthma than children whose families’ incomes are more than 150 percent of the poverty line.
• Based on their parents’ reports, poor children are almost five times more likely (33 percent compared to 7 percent) to be in less than very good health (i.e., their parents rated their children’s health as poor, fair, or good rather than as very good or excellent).

In these and other ways, children in low-income families are more likely than children in wealthier families to have more health problems, many of which last into adolescence and adulthood. Poor children’s poor health thus makes a critical difference throughout their lives. As sociologist Steven A. Haas and colleagues observe, “A growing body of work demonstrates that those who experience poor health early in life go on to complete less schooling, hold less prestigious jobs, and earn less than their healthier childhood peers.”

One reason for the poor health of poor children is that their families are more likely to experience many kinds of stress (see Chapter 2 "Poverty"). Another reason is that their families are more likely to experience food insecurity and, if they are urban, to live in neighborhoods with higher levels of lead and pollution. Low-income children also tend to watch television more often than wealthier children and for this and other reasons to be less physically active; their relative lack of physical activity is yet another reason for their worse health. Finally, their parents are much more likely than wealthier parents to smoke cigarettes; the secondhand smoke they inhale impairs their health.

The clear evidence of poverty’s effects on the health of poor children underscores the need of the United States to do everything possible to minimize these effects. Any money spent to reduce these effects will pay for itself many times over throughout these children’s lifetimes: They will have fewer health problems as they grow up, costing the United States much less in health care, and be better able to do well in school and to have higher incomes as adults. In both the short run and long run, then, improving the health of poor children will also improve the economic and social health of the whole nation.

Sources: Haas, Glymour, & Berkman, 2011; Kaplan, 2009; Murphey, Mackintosh, & McCoy-Roth, 2011; Robert Wood Johnson Foundation, 2008Haas, S. A., Glymour, M., & Berkman, L. F. (2011). Childhood health and labor market inequality over the life course. Journal of Health and Social Behavior, 52, 298–313; Kaplan, G. A. (2009). The poor pay more: Poverty’s high cost to health. Princeton, NJ: Robert Wood Johnson Foundation; Murphey, D., Mackintosh, B., & McCoy-Roth, M. (2011). Early childhood policy focus: Health eating and physical activity. Early Childhood Highlights, 2(3), 1–9; Robert Wood Johnson Foundation. (2008). America’s health starts with healthy children: How do states compare? Princeton, NJ: Author.

For example, poor adults are also at much greater risk for many health problems, including heart disease, diabetes, arthritis, and some types of cancer. Rates of high blood pressure, serious heart conditions, and diabetes are at least twice as high for middle-aged adults with family incomes below the poverty level than for those with incomes at least twice the poverty level. All these social class differences in health contribute to a striking difference in life expectancy, with Americans whose family incomes are more than four times the federal poverty level expected to live 6.5 years longer than those living in poverty (Kaplan, 2009).Kaplan, G. A. (2009). The poor pay more: Poverty’s high cost to health. Princeton, NJ: Robert Wood Johnson Foundation.

Several reasons account for the social class–health link (Pampel, Krueger, & Denney, 2010).Pampel, F. C., Krueger, P. M., & Denney, J. T. (2010). Socioeconomic disparities in health behaviors. Annual Review of Sociology, 36, 349–370. One reason is stress, which, as Chapter 2 "Poverty" explained, is higher for people with low incomes because of unemployment, problems in paying for the necessities of life, and a sense of little control over what happens to them. Stress in turn damages health because it impairs the immune system and other bodily processes.

A second reason is that poor people live in conditions, including crowded, dilapidated housing with poor sanitation, that are bad for their health and especially that of their children. Although these conditions have improved markedly in the United States over the last few decades, they continue for many of the poor.

Another reason for the poor’s worse health is their lack of access to adequate health care. As is well known, many poor people lack medical insurance and in other respects have inadequate health care. These problems make it more likely they will become ill in the first place and more difficult for them to become well because they cannot afford to visit a physician or to receive other health care. Still, social class disparities in health exist even in countries that provide free national health care, a fact that underscores the importance of the other reasons discussed here for the social class–health link (Elo, 2009).Elo, I. T. (2009). Social class differentials in health and mortality: Patterns and explanations in comparative perspective. Annual Review of Sociology, 35, 553–572.

Many people who are poor or near poor lack medical insurance and in other ways have inadequate health care. These problems make it more likely they will become ill and, once ill, less likely they will become well.

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A fourth reason is a lack of education, which, in ways not yet well understood, leads poor people to be unaware or unconcerned about risk factors for health and to have a fatalistic attitude that promotes unhealthy behaviors and reluctance to heed medical advice (Elo, 2009).Elo, I. T. (2009). Social class differentials in health and mortality: Patterns and explanations in comparative perspective. Annual Review of Sociology, 35, 553–572. In one study of whether smokers quit smoking after a heart attack, only 10 percent of heart attack patients without a high school degree quit smoking, compared to almost 90 percent of those with a college degree (Wray, Herzog, Willis, & Wallace, 1998).Wray, L. A., Herzog, A. R., Willis, R. J., & Wallace, R. B. (1998). The impact of education and heart attack on smoking cessation among middle-aged adults. Journal of Health and Social Behavior, 39, 271–294.

A final reason for the poor health of poor people is unhealthy lifestyles, as just implied. Although it might sound like a stereotype, poor people are more likely to smoke, to eat high-fat food, to avoid exercise, to be overweight, and, more generally, not to do what they need to do (or to do what they should not be doing) to be healthy (Pampel et al., 2010).Pampel, F. C., Krueger, P. M., & Denney, J. T. (2010). Socioeconomic disparities in health behaviors. Annual Review of Sociology, 36, 349–370. Scholars continue to debate whether unhealthy lifestyles are more important in explaining poor people’s poor health than the other factors just discussed. Regardless of the proper mix of reasons, the fact remains that the poor have worse health.

Race and Ethnicity

Health differences also exist when we examine the effects of race and ethnicity, and they are literally a matter of life and death. We can see this when we compare life expectancies for whites and African Americans born in 2006 (Table 13.2 "US Life Expectancy at Birth for People Born in 2007"). When we do not take gender into account, African Americans can expect to live about five fewer years than whites. Among men, they can expect to live almost six fewer years, and among women, four fewer years.

Table 13.2 US Life Expectancy at Birth for People Born in 2007

African American	Both sexes	73.6
	Men	70.0
	Women	76.8
White	Both sexes	78.4
	Men	75.9
	Women	80.8

Source: Data from National Center for Health Statistics. (2011). Health, United States, 2010. Hyattsville, MD: Centers for Disease Control and Prevention.

At the beginning of the life course, infant mortality also varies by race and ethnicity (Table 13.3 "Mother’s Race/Ethnicity and US Infant Mortality, 2006 (Number of Infant Deaths per 1,000 Live Births)"), with African American infants more than twice as likely as white infants to die before their first birthday. Infant mortality among Native Americans is almost 1.5 times the white rate, while that for Latinos is about the same (although the Puerto Rican rate is also higher, at 8.0), and Asians a bit lower. In a related indicator, maternal mortality (from complications of pregnancy or childbirth) stands at 8.1 maternal deaths for every 100,000 live births for non-Latina white women, 7.2 for Latina women, and a troubling 23.8 for African American women. Maternal mortality for African American women is thus about three times greater than that for the other two groups.

Table 13.3 Mother’s Race/Ethnicity and US Infant Mortality, 2006 (Number of Infant Deaths per 1,000 Live Births)

African American	12.9
Asian or Pacific Islander	4.5
Latina	5.4
Central and South American	4.5
Cuban	5.1
Mexican	5.3
Puerto Rican	8.0
Native American	8.3
White	5.6

Source: Data from National Center for Health Statistics. (2011). Health, United States, 2010. Hyattsville, MD: Centers for Disease Control and Prevention.

In other indicators, African Americans are more likely than whites to die from heart disease, although the white rate of such deaths is higher than the rates of Asians, Latinos, and Native Americans. African Americans are also more likely than whites to be overweight and to suffer from asthma, diabetes, high blood pressure, and several types of cancer. Latinos and Native Americans have higher rates than whites of several illnesses and conditions, including diabetes.

Commenting on all these disparities in health, a former head of the US Department of Health and Human Services said a decade ago, “We have been—and remain—two nations: one majority, one minority—separated by the quality of our health” (Penn et al., 2000, p. 102).Penn, N. E., Kramer, J., Skinner, J. F., Velasquez, R. J., Yee, B. W. K., Arellano, L. M., et al. (2000). Health practices and health-care systems among cultural groups. In R. M. Eisler & M. Hersen (Eds.), Handbook of gender, culture, and health (pp. 101–132). New York, NY: Routledge. The examples just discussed certainly indicate that her statement is still true today.

Why do such large racial and ethnic disparities in health exist? To a large degree, they reflect the high poverty rates for African Americans, Latinos, and Native Americans compared to those for whites. In addition, inadequate medical care is perhaps a special problem for people of color, thanks to unconscious racial bias among health-care professionals that affects the quality of care that people of color receive (see discussion later in this chapter).

An additional reason for racial disparities in health is diet. Many of the foods that have long been part of African American culture are high in fat. Partly as a result, African Americans are much more likely than whites to have heart disease and high blood pressure and to die from these conditions (Parra-Medina et al., 2010).Parra-Medina, D., Wilcox, S., Wilson, D. K., Addy, C. L., Felton, G., & Poston, M. B. (2010). Heart healthy and ethnically relevant (HHER) lifestyle trial for improving diet and physical activity in underserved African American women. Contemporary Clinical Trials, 31(1), 92–104. In contrast, first-generation Latinos tend to have diets consisting of beans, grains, and other low-fat foods, preventing health problems stemming from their poverty from being even worse. But as the years go by and they adopt the typical American’s eating habits, their diets tend to worsen, and their health worsens as well (Pérez-Escamilla, 2009).Pérez-Escamilla, R. (2009). Dietary quality among Latinos: Is acculturation making us sick? Journal of the American Dietetic Association, 109(6), 988–991.

In a significant finding, African Americans tend to have worse health than whites even among those with the same incomes. Several reasons explain this racial gap. One is the extra stress that African Americans of all incomes face because they live in a society that is still racially prejudiced and discriminatory (Bratter & Gorman, 2011).Bratter, J. L., & Gorman, B. K. (2011). Is discrimination an equal opportunity risk? Racial experiences, socioeconomic status, and health status among black and white adults. Journal of Health and Social Behavior, 52, 365–382. In this regard, studies find that African Americans and Latinos who have experienced the most racial discrimination in their daily lives tend to have worse physical health (Lee & Ferraro, 2009).Lee, M.-A., & Ferraro, K. F. (2009). Perceived discrimination and health among Puerto Rican and Mexican Americans: Buffering effect of the lazo matrimonial? Social Science & Medicine, 68, 1966–1974. Some middle-class African Americans may also have grown up in poor families and incurred health problems in childhood that continue to affect them. As a former US surgeon general once explained, “You’re never dealing with a person just today. You’re dealing with everything they’ve been exposed to throughout their lives. Does it ever end? Our hypothesis is that it never ends” (Meckler, 1998, p. 4A).Meckler, L. (1998, November 27). Health gap between races persists. Ocala Star-Banner, p. 4A.

African Americans have worse health than whites, even when people with the same incomes are compared. One reason for this racial gap is the continuing racial discrimination that African Americans experience and the stress that accompanies this experience.

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To some degree, racial differences in health may also have a biological basis. For example, African American men appear to have higher levels of a certain growth protein that may promote prostate cancer; African American smokers may absorb more nicotine than white smokers; and differences in the ways African Americans’ blood vessels react may render them more susceptible to hypertension and heart disease (Meckler, 1998; Ricker & Bird, 2005).Meckler, L. (1998, November 27). Health gap between races persists. Ocala Star-Banner, p. 4A; Ricker, P. P., & Bird, C. E. (2005). Rethinking gender differences in health: Why we need to integrate social and biological perspectives. Journals of Gerontology Series B, 60, S40–S47. Because alleged biological differences have been used as the basis for racism, and because race is best thought of as a social construction rather than a biological concept (see Chapter 3 "Racial and Ethnic Inequality"), we must be very careful in acknowledging such differences (Frank, 2007).Frank, R. (2007). What to make of it? The (Re)emergence of a biological conceptualization of race in health disparities research. Social Science & Medicine, 64(10), 1977–1983. However, if they do indeed exist, they may help explain at least some of the racial gap in health.

A final factor contributing to racial differences in health is physical location: poor people of color are more likely to live in urban areas and in other locations that are unhealthy places because of air and water pollution, hazardous waste, and other environmental problems (Walker, 2011).Walker, A. K. (2011, November 20). Where you live can help determine your health, studies say. Bangor Daily News. Retrieved from http://bangordailynews.com/2011/11/20/health/where-you-live-can-help-determine-your-health-studies-say. This problem is termed environmental racism (Michney, 2011).Michney, T. M. (2011). White civic visions versus black suburban aspirations: Cleveland’s Garden Valley urban renewal project. Journal of Planning History, 10(4), 282–309. One example of this problem is found in the so-called Cancer Alley on a long stretch of the Mississippi River in Louisiana populated mostly by African Americans; 80 percent of these residents live within three miles of a polluting industrial facility (Cernansky, 2011).Cernansky, R. (2011, February 8). Cancer alley: Big industry & bigger illness along Mississippi River. Retrieved from http://www.treehugger.com/corporate-responsibility/cancer-alley-big-industry-bigger-illness-along-mississippi-river.html.

Gender

The evidence on gender and health is both complex and fascinating. Women outlive men by more than six years, and, as Table 13.2 "US Life Expectancy at Birth for People Born in 2007" showed, the gender difference in longevity persists across racial categories. At the same time, women have worse health than men in many areas. For example, they are more likely to suffer from migraine headaches, osteoporosis, and immune diseases such as lupus and rheumatoid arthritis. Women thus have more health problems than men do even though they outlive men—a situation commonly known as the morbidity paradox (Gorman & Read, 2006).Gorman, B. K., & Read, J. G. (2006). Gender disparities in adult health: An examination of three measures of morbidity. Journal of Health and Social Behavior, 47(2), 95–110. Why, then, do women outlive men? Conversely, why do men die earlier than women? The obvious answer is that men have more life-threatening diseases, such as heart disease and emphysema, than women, but that raises the question of why this is so.

Several reasons explain the gender gap in longevity. One might be biological, as women’s estrogen and other sex-linked biological differences may make them less susceptible to heart disease and other life-threatening illnesses, even as they render them more vulnerable to some of the health problems already listed (Kuller, 2010).Kuller, L. H. (2010). Cardiovascular disease is preventable among women. Expert Review of Cardiovascular Therapy, 8(2), 175–187. A second reason is that men lead more unhealthy lifestyles than women because of differences in gender socialization. For example, men are more likely than women to smoke, to drink heavily, and to drive recklessly. All such behaviors make men more vulnerable than women to life-threatening illnesses and injuries. Men are also more likely than women to hold jobs in workplaces filled with environmental and safety hazards that kill thousands of people—most of them men—annually.

A final reason is men’s reluctance to discuss and seek help for their medical problems, owing to their masculine socialization into being “strong, silent types.” Just as men do not like to ask for directions, as the common wisdom goes, so do they not like to ask for medical help. As one physician put it, “I’ve often said men don’t come in for checkups because they have a big S tattooed on their chests; they think they’re Superman” (Guttman, 1999, p. 10).Guttman, M. (1999, June 11–13). Why more men are finally going to the doctor. USA Weekend, p. 10.

Studies find that men are less likely than women to tell anyone when they have a health problem and to seek help from a health-care professional (Emmers-Sommer et al., 2009).Emmers-Sommer, T. M., Nebel, S., Allison, M.-L., Cannella, M. L., Cartmill, D., Ewing, S., et al. (2009). Patient-provider communication about sexual health: The relationship with gender, age, gender-stereotypical beliefs, and perceptions of communication inappropriateness. Sex Roles: A Journal of Research, 60, 9–10. When both sexes do visit a physician, men ask fewer questions than women do. In one study, the average man asked no more than two questions, while the average woman asked at least six. Because patients who ask more questions get more information and recover their health more quickly, men’s silence in the exam room may contribute to their shorter longevity (Foreman, 1999).Foreman, J. (1999, June 14). A vist most men would rather not make. The Boston Globe, p. C1. Interestingly, the development of erectile dysfunction drugs like Viagra may have helped improve men’s health, as men have had to see a physician to obtain prescriptions for these drugs when otherwise they would not have seen a physician (Guttman, 1999).Guttman, M. (1999, June 11–13). Why more men are finally going to the doctor. USA Weekend, p. 10.

We have just discussed why men die sooner than women, which is one of the two gender differences that constitute the morbidity paradox. The other gender difference concerns why women have more nonfatal health problems than men. Several reasons explain this difference (Read & Gorman, 2010).Read, J. G., & Gorman, B. M. (2010). Gender and health inequality. Annual Review of Sociology, 36, 371–386.

Women more than men tend to have more health problems that are not life threatening. Two reasons for this gender difference are gender inequality in the larger society and the stress accompanying women’s traditional caregiving role in the family.

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One reason arises from the fact that women outlive men. Because women are thus more likely than men to be in their senior years, they are also more likely to develop the many health problems associated with old age. This suggests that studies that control for age (by comparing older women with older men, middle-aged women with middle-aged men, and so forth) should report fewer gender differences in health than those that do not control for age, and this is indeed true.

However, women still tend to have worse health than men even when age is taken into account. Medical sociologists attribute this gender difference to the gender inequality in the larger society (Read & Gorman, 2010).Read, J. G., & Gorman, B. M. (2010). Gender and health inequality. Annual Review of Sociology, 36, 371–386. For example, women are poorer overall than men, as they are more likely to work only part-time and in low-paying jobs even if they work full time. As discussed earlier in this chapter, poverty is a risk factor for health problems. Women’s worse health, then, is partly due to their greater likelihood of living in poverty or near poverty. Because of their gender, women also are more likely than men to experience stressful events in their everyday lives, such as caring for a child or an aging parent. Their increased stress impairs the immune systems and thus worsens their health. It also is an important cause of their greater likelihood of depression and the various physical health problems (weakened immune systems, higher blood pressure, lack of exercise) that depression often causes. Finally, women experience discrimination in their everyday lives because of our society’s sexism, and (as is also true for people of color) this discrimination is thought to produce stress and thus poorer physical health (Landry & Mercurio, 2009).Landry, L. J., & Mercurio, A. E. (2009). Discrimination and women’s mental health: The mediating role of control. Sex Roles: A Journal of Research, 61, 3–4.

Health Disparities: Mental Health

Health consists of mental well-being as well as physical well-being, and people can suffer mental health problems in addition to physical health problems. Scholars disagree over whether mental illness is real or, instead, a social construction. The predominant view in psychiatry, of course, is that people do have actual problems in their mental and emotional functioning and that these problems are best characterized as mental illnesses or mental disorders and should be treated by medical professionals (McNally, 2011).McNally, R. J. (2011). What is mental illness? Cambridge, MA: Belknap Press. But other scholars say mental illness is a social construction or a “myth” (Szasz, 2010).Szasz, T. S. (2010). The myth of mental illness: Foundations of a theory of personal conduct. New York, NY: Harper Perennial. In their view, all kinds of people sometimes act oddly, but only a few are labeled as mentally ill. If someone says she or he hears the voice of an angel, we ordinarily attribute their perceptions to their religious views and consider them religious, not mentally ill. But if someone instead insists that men from Mars have been in touch, we are more apt to think there is something mentally wrong with that person. Mental illness thus is not real but rather is the reaction of others to problems they perceive in someone’s behavior.

This intellectual debate notwithstanding, many people do suffer serious mental and emotional problems, such as severe mood swings and depression, that interfere with their everyday functioning and social interaction. Sociologists and other researchers have investigated the social epidemiology of these problems. Several generalizations seem warranted from their research regarding disparities in mental health (Cockerham, 2011).Cockerham, W. C. (2011). Sociology of mental disorder (8th ed.). Upper Saddle River, NJ: Prentice Hall.

Social Class

First, social class affects the incidence of mental illness. To be more specific, poor people exhibit more mental health problems than richer people: They are more likely to suffer from schizophrenia, serious depression, and other problems. A major reason for this link is the stress of living in poverty and the many living conditions associated with it. One interesting causal question here is whether poverty leads to mental illness or mental illness leads to poverty. Although there is evidence of both causal paths, most scholars believe that poverty contributes to mental illness more than the reverse (Warren, 2009).Warren, J. R. (2009). Socioeconomic status and health across the life course: A test of the social causation and health selection hypotheses. Social Forces, 87(4), 2125–2153.

Women are more likely than men to be seriously depressed. Sociologists attribute this gender difference partly to gender socialization that leads women to keep problems inside themselves while encouraging men to express their problems outwardly.

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Private Health Insurance and the Lack of Insurance

Medicine in the United States is big business. Expenditures for health care, health research, and other health items and services have risen sharply in recent decades, having increased tenfold since 1980, and now costs the nation more than $2.6 trillion annually (see Figure 13.6 "US Health-Care Expenditure, 1980–2010 (in Billions of Dollars)"). This translates to the largest figure per capita in the industrial world. Despite this expenditure, the United States lags behind many other industrial nations in several important health indicators, as we have already seen. Why is this so?

Figure 13.6 US Health-Care Expenditure, 1980–2010 (in Billions of Dollars)

Source: Data from US Census Bureau. (2010). Statistical abstract of the United States: 2010. Washington, DC: US Government Printing Office. Retrieved from http://www.census.gov/compendia/statab.

An important reason is the US system of private health insurance. As discussed earlier, other Western nations have national systems of health care and health insurance. In stark contrast to these nations, the United States relies largely on a direct-fee systemA system of medicine in which patients pay for health care, prescriptions, and other medical costs themselves., in which patients under 65 (those 65 and older are covered by Medicare) are expected to pay for medical costs themselves, aided by private health insurance, usually through one’s employer. Table 13.4 "Health Insurance Coverage in the United States, 2010" shows the percentages of Americans who have health insurance from different sources or who are not insured at all. (All figures are from the period before the implementation of the major health-care reform package was passed by the federal government in early 2010.) Adding together the top two figures in the table, 54 percent of Americans have private insurance, either through their employers or from their own resources. About 29 percent have some form of public insurance (Medicaid, Medicare, other public), and 16 percent are uninsured. This final percentage amounts to almost 50 million Americans, including 8 million children, who lack health insurance.

Their lack of health insurance has deadly consequences because they are less likely to receive preventive health care and care for various conditions and illnesses. For example, because uninsured Americans are less likely than those with private insurance to receive cancer screenings, they are more likely to be diagnosed with more advanced cancer rather than an earlier stage of cancer (Halpern et al., 2008).Halpern, M. T., Ward, E. M., Pavluck, A. L., Schrag, N. M., Bian, J., & Chen, A. Y. (2008). Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: A retrospective analysis. The Lancet Oncology, 9(3), 221–231. It is estimated that 45,000 people die each year because they do not have health insurance (Wilper et al., 2009).Wilper, A. P., Woolhandler, S., Lasser, K. E., McCormick, D., Bor, D. H., & Himmelstein, D. U. (2009). Health insurance and mortality in US adults. American Journal of Public Health, 99(12), 1–7. The Note 13.22 "Applying Social Research" box discusses a very informative real-life experiment on the difference that health insurance makes for people’s health.

Although 29 percent of Americans do have public insurance, this percentage and the coverage provided by this insurance do not begin to match the coverage enjoyed by the rest of the industrial world. Although Medicare pays some medical costs for the elderly, we saw in Chapter 6 "Aging and Ageism" that its coverage is hardly adequate, as many people must pay hundreds or even thousands of dollars in premiums, deductibles, coinsurance, and copayments. The other government program, Medicaid, pays some health-care costs for the poor, but many low-income families are not poor enough to receive Medicaid. Eligibility standards for Medicaid vary from one state to another, and a family poor enough in one state to receive Medicaid might not be considered poor enough in another state. The State Children’s Health Insurance Program (SCHIP), begun in 1997 for children from low-income families, has helped somewhat, but it, too, fails to cover many low-income children. Largely for these reasons, about two-thirds of uninsured Americans come from low-income families.

Not surprisingly, the 16 percent uninsured rate varies by race and ethnicity (see Figure 13.7 "Race, Ethnicity, and Lack of Health Insurance, 2008 (Percentage of People under Age 65 with No Insurance)"). Among people under 65 and thus not eligible for Medicare, the uninsured rate rises to almost 22 percent of the African American population and 32 percent of the Latino population. Moreover, 45 percent of adults under 65 who live in official poverty lack health insurance, compared to only 6 percent of higher-income adults (those with incomes higher than four times the poverty level). Almost one-fifth of poor children have no health insurance, compared to only 3 percent of children in higher-income families (Kaiser Family Foundation, 2012).Kaiser Family Foundation. (2012). State health facts. Retrieved from http://www.statehealthfacts.org. As discussed earlier, the lack of health insurance among the poor and people of color is a significant reason for their poorer health.

Figure 13.7 Race, Ethnicity, and Lack of Health Insurance, 2008 (Percentage of People under Age 65 with No Insurance)

Source: Data from Kaiser Family Foundation. (2012). Kaiser state health facts. Retrieved from http://www.statehealthfacts.org.

The High Cost of Health Care

As noted earlier, the United States spends much more money per capita on health care than any other industrial nation. The US per capita health expenditure was $7,960 in 2009, the latest year for which data were available at the time of this writing. This figure was about 50 percent higher than that for the next two highest-spending countries, Norway and Switzerland; 80 percent higher than Canada’s expenditure; twice as high as Frances’s expenditure; and 2.3 times higher than the United Kingdom’s expenditure (Organisation for Economic Co-operation and Development, 2011).Organisation for Economic Co-operation and Development. (2011). Health at a glance 2011: OECD indicators. Paris, France: Author. The huge expenditure by the United States might be justified if the quality of health and of health care in this nation outranked that in its peer nations. As we have seen, however, the United States lags behind many of its peer nations in several indicators of health and health care quality. If the United States spends far more than its peer nations on health care yet still lags behind them in many indicators, an inescapable conclusion is that the United States is spending much more than it should be spending.

Why is US spending on health care so high? Although this is a complex issue, two reasons stand out (Boffey, 2012).Boffey, P. M. (2012, January 22). The money traps in US health care. New York Times, p. SR12. First, administrative costs for health care in the United States are the highest in the industrial world. Because so much of US health insurance is private, billing and record-keeping tasks are immense, and “hordes of clerks and accountants [are] needed to deal with insurance paperwork,” according to one observer (Boffey, 2012, p. SR12).Boffey, P. M. (2012, January 22). The money traps in US health care. New York Times, p. SR12. Billing and other administrative tasks cost about $360 billion annually, or 14 percent of all US health-care costs (Emanuel, 2011).Emanuel, E. J. (2011, November 12). Billions wasted on billing. New York Times. Retrieved from http://opinionator.blogs.nytimes.com/2011/2011/2012/billions-wasted-on-billing/?ref=opinion. These tasks are unnecessarily cumbersome and fail to take advantage of electronic technologies that would make them much more efficient.

Second, the United States relies on a fee for service model for private insurance. Under this model, physicians, hospitals, and health care professionals and business are relatively free to charge whatever they want for their services. In the other industrial nations, government regulations keep prices lower. This basic difference between the United States and its peer nations helps explain why the cost of health care services in the United States is so much higher than in its peer nations. Simply put, US physicians and hospitals charge much more for their services than do their counterparts in other industrial nations (Klein, 2012).Klein, E. (2012, March 2). High health-care costs: It’s all in the pricing. The Washington Post. Retrieved from http://www.washingtonpost.com/business/high-health-care-costs-its-all-in-the-pricing/2012/02/28/gIQAtbhimR_story.html. And because physicians are paid for every service they perform, they have an incentive to perform more diagnostic tests and other procedures than necessary. As one economic writer recently said, “The more they do, the more they earn” (Samuelson, 2011).Samuelson, R. J. (2011, November 28). A grim diagnosis for our ailing health care system. The Washington Post. Retrieved from http://www.washingtonpost.com/opinions/a-grim-diagnosis-for-our-ailing-us-health-care-system/2011/11/25/gIQARdgm2N_story.html.

A few examples illustrate the higher cost of medical procedures in the United States compared to other nations. To keep things simple, we will compare the United States with just Canada (see Figure 13.8 "Average Cost of Selected Medical Procedures and Services"). The average US appendectomy costs $13,123, compared to $3,810 in Canada; the average US hip replacement costs $34,354, compared to $10,753 in Canada; the average US normal childbirth costs $8,435, compared to $2,667 in Canada; and the average US bypass surgery costs $59,770, compared to $22,212 in Canada. The costs of diagnostic tests also differ dramatically between the two nations. For example, a head CT scan costs an average of $464 in the United States, compared to only $65 in Canada, and an MRI scan costs and average of $1,009 in the United States, compared to only $304 in Canada (International Federation of Health Plans, 2010).International Federation of Health Plans. (2010). 2010 comparative price report: Medical and hospital fees by country. London, United Kingdom: Author.

Figure 13.8 Average Cost of Selected Medical Procedures and Services

Source: Boffey, P. M. (2012, January 22). The money traps in US health care. New York Times, p. SR12.

Managed Care and HMOs

To many critics, a disturbing development in the US health-care system has been the establishment of health maintenance organizationsPrepaid health plans with designated providers that typically enroll their subscribers through their workplaces., or HMOs, which typically enroll their subscribers through their workplaces. HMOs are prepaid health plans with designated providers, meaning that patients must visit a physician employed by the HMO or included on the HMO’s approved list of physicians. If their physician is not approved by the HMO, they have to either see an approved physician or see their own without insurance coverage. Popular with employers because they are less expensive than traditional private insurance, HMOs have grown rapidly in the last three decades and now enroll more than 70 million Americans (see Figure 13.9 "Growth of Health Maintenance Organizations (HMOs), 1980–2007 (Millions of Enrollees)").

Figure 13.9 Growth of Health Maintenance Organizations (HMOs), 1980–2007 (Millions of Enrollees)

Source: Data from US Census Bureau. (2012). Statistical abstract of the United States: 2012. Washington, DC: US Government Printing Office. Retrieved from http://www.census.gov/compendia/statab.

Although HMOs have become popular, their managed care is also very controversial for at least two reasons (Kronick, 2009).Kronick, R. (2009). Medicare and HMOs—The Search for Accountability. New England Journal of Medicine, 360, 2048–2050. The first is the HMOs’ restrictions just noted on the choice of physicians and other health-care providers. Families who have long seen a family physician but whose employer now enrolls them in an HMO sometimes find they have to see another physician or risk going without coverage. In some HMOs, patients have no guarantee that they can see the same physician at every visit. Instead, they see whichever physician is assigned to them at each visit. Critics of HMOs argue that this practice prevents physicians and patients from getting to know each other, reduces patients’ trust in their physician, and may for these reasons impair patient health.

The managed care that HMOs provide is controversial for several reasons. These reasons include restrictions on the choice of physicians and especially on the types of medical exams and procedures that patients may undergo.

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The second reason for the managed-care controversy is perhaps more important. HMOs often restrict the types of medical exams and procedures patients may undergo, a problem called denial of care, and limit their choice of prescription drugs to those approved by the HMO, even if their physicians think that another, typically more expensive drug would be more effective. HMOs claim that these restrictions are necessary to keep medical costs down and do not harm patients.