Suffering the System: Professional Dominance, the Uninsured, and the
Healthcare Industry
By Stephanie Petty
Undergraduate
Saint Mary’s College
spetty01@saintmarys.edu
December 12, 2007
Susan Alexander
salexander@saintmarys.edu
Suffering the System: Professional Dominance, the Uninsured, and the
Healthcare Industry
By Stephanie Petty
ABSTRACT
The United States’ healthcare system is one of the many social institutions that can
advantage and disadvantage people because of their social status. A survey was administered to
7 people to assess the social inequalities that they have subjectively experienced in the South
Bend, Indiana healthcare system. Surveys provided data about the respondents’ demographic
background, perceptions of the healthcare system, treatment by physicians and other medical
personnel, and access to proper care. By applying Social Construction Theory to the claims of
inequalities as experienced by the working class and the poor in the healthcare system, this
research provides a lens for understanding the subjective nature of this social problem.
2
Suffering the System: Professional Dominance, the Uninsured, and the
Healthcare Industry
Standardized national healthcare is the American Dream for many, especially those who
are the most disadvantaged—the working class and the poor. For the purposes of this study,
working class is defined as among the poorest classes in most social class systems and includes
factory workers, miners, and others. Working for hourly wages rather than fixed (e.g. annual)
salaries, working class occupations typically include manual and industrial labor.
The purpose of this study on the working class and the poor, as it pertains to treatment
and access to healthcare, is to explore the unspoken and/or hidden inequalities in the United
States healthcare system. Specifically, this analysis examines the income and educational
attainment of patients with regard to the quality of care received. Key to the analysis is how the
professional dominance physicians may impact the patient’s perceptions of healthcare.
Professional dominance is defined as performing a role that is in high demand while making a
relatively high self-profit for the services performed.
LITERATURE REVIEW
According to the United States Census (2005), there are approximately 37 million poor
people living in the United States. Carruthers (2001:249) claims that due to high medical costs,
health problems can lead to financial distress. Starfield (2007:483) finds that approximately 40
million people in the United States do not have access to healthcare because of social and
economic inequalities. Starfield notes that the American healthcare system itself is the third
leading cause of death in United States after heart disease and cancer. Children in poverty are
particularly impacted by a lack of healthcare.
3
Quality of Healthcare
Dutton (1978:349) describes three different problems occurring within the healthcare
system that result in inconsistent access for the poor; “If costs are the problem, better health
insurance is the remedy; if inappropriate health attitudes are the problem, health educational
programs are the remedy; if inadequacies in the health delivery systems are the problem,
structural improvements in these systems are the remedy.” Dutton notes that although the
healthcare system has improved over the years, the services may not be distributed in ways
consistent with a person’s needs; the poor often cannot afford the services they need or obtain
access to physicians because the availability is scarce in lower income areas. Poorer patients find
it difficult to receive medical attention, and when poorer patients do receive medical attention, it
is for disease-oriented issues rather than preventative care.
In a more recent study, Nechas and Foley (1994:174) found that physicians often turn
working class and poor patients away because they see consultation as a waste of time for the
patient cannot afford the treatment.
Frank-Green (2004:1) described her experiences as a medical student treating individuals
who could not afford health insurance. Frank-Green interviewed clients at outreach centers and
free clinics and she surveyed approximately 260 people to produce an “annual report card of
community health indicators.” Frank-Green found that more than 80 percent of those surveyed
had a chronic illness, and over half said that the cost of care often prevents them from seeking
medical attention. Frank-Green describes shaking the hand of a drug-addict who expressed shock
because no doctor or nurse had ever before shaken his hand. A doctor interviewed by FrankGreen noted that almost every [poor] patient is rejected the first time they apply for medical help
4
or a critical surgery. Frank-Green (2004:1) adds, “With poor health and poor credit, they can do
little to improve their lives.”
Page (2007:1) analyzes Michael Moore’s documentary, Sicko (2007), which narrates
people’s experiences with the United States’ health care system. The stories that are shown are
those of people who have lost medical coverage, limbs, and lives. Most of the stories are from
working-class people. Page claims that Moore accurately presents the problems of the healthcare
system and offers an opinion on what could be done so that all Americans, regardless of income,
can have equal opportunities to live a healthy life and receive treatment when needed. Moore’s
solution includes, “Free lifelong universal health care for every resident, abolish all health
insurance companies and ‘strictly’ regulate pharmaceutical companies ‘like a public utility.’”
Studies (see: Lee; Leonardi; McGory; Ko) have shown that racial minorities are more
prone to illness, experience more health complications, take longer to recover, and generally die
younger than do whites. Stein (2005:1) discusses how Black Americans are receiving far fewer
operations, tests, medications, and other life-saving treatments than whites. Stein notes that
Blacks have made strides in terms of equality of income and education but not in the health care
system. Only certain types of care improved for Blacks, Stein claims, because the federal
government put pressure on the health care system to meet minimum standards. Blacks are not
receiving the quality of health care that they need. Stein (2005; 2) believes that “women are less
likely to get appropriate care than men, and black women receive the worst care of any group.”
Knowledge and Education
Quality healthcare and education are related. Modern medicine is linked to professional
dominance (Light 2000:11). In essence, having an education is essential to understanding and
5
receiving the very best in the healthcare system. Nechas and Foley (1994:176) found that doctors
do not have time to sit and talk to low income individuals. Physicians subconsciously treat poor
populations unfairly because, as Nechas and Foley found, the poor face both language and
cultural barriers.
Gribbin (1975:10) argues that it is the responsibility of the patient/consumer to select
quality healthcare. He says that patients-consumers no longer regard doctors as the authority
figure. Additionally, Anspach (1993:247) finds that patients who have less education and who
are poor tend to have difficulty communicating their concerns and eliciting respect for those
concerns because healthcare providers do not value the opinions of less educated patients.
Patients who lack education or an understanding of the problem may fear challenging their
physicians, or they believe they have no authority to confront their healthcare provider. Malat
(2001:367) argues that for those patients with more education, their education provides cultural
capital. Educated patients have a more equal status with the healthcare provider, who is also
educated.
Appel (2007:1-3) argues that pharmaceutical companies exploit those who cannot afford
drugs and medical care; “Drug prices, health insurance, doctor visits and hospital stays are too
expensive for many people to afford, while insurance and drug company profits continue to
climb.” The United States has one of the poorest health profiles but, as Appel notes,
pharmaceutical companies, such as Pfizer, are some of the wealthiest companies in the nation
with profits of over eight billion dollars in a given year. Appel (2007:2) also notes that, “CEO
William McGuire, of United Health Group, a health insurance company earns an annual salary of
124 million dollar, possesses stock options worth more than 1.7 billion dollars, and will have free
health care for him and his spouse as long as they live.”
6
Professional Dominance
Physicians, just like any other professional occupation, are surrounded by colleagues with
a similar educational background. Light (2004:15) claims that because doctors are free to choose
their specialty and where they practiced, rural and poor areas are underserved. Healthcare is a
professionally driven system and this system, according to Light (2000:12), evolved from
medicine fulfilling the professional vision of what a good system should look like to a system
that provides the best clinical care only for patients who can pay.
Light (2004:1) claims that physicians are not the only ones exploiting the poorer citizens
of the United States; politicians are also responsible. Light states that much of literature
overlooks the ways in which healthcare organizations lobby legislators and governmental
agencies to make large sums of taxpayers’ money available to them, which takes away valuable
healthcare dollars for those at highest risk of illnesses—the working class and poor. Emanuel
(1991:12) states that if society sanctions a for-profit, financial system that does not reward
disease prevention and care of poorer patients, one cannot expect the medical profession alone to
make up the difference. Malat (2001:370) believes that more research is needed on how social
distance affects healthcare interactions. To improve the delivery of healthcare, it is essential to
study populations and the social inequalities they subjectively experience in the healthcare
system. These subjective experiences are better known as social problems, which are further
explained through Donileen Loseke’s Social Construction Theory.
7
SOCIAL CONSTRUCTION THEORY
Loseke (2003) argues that a social problem is not a stable category; rather its meaning is
subjective. Social problems are about conditions and people in those conditions, so there is
seemingly no end to conditions in America that might be called social problems. Social problems
can emerge when there are disagreements, such as different views on homosexuality, abortion, or
the cause of inequality. Loseke argues that social problems are constructed within a particular
time and place and this is the basic perspective of Social Construction Theory.
Loseke discusses how social problems are constructed through “claimsmaking” and
“typification.” Claimsmaking occurs when a person or a group of people attempt to persuade an
audience that a particular problem exists. For example, physicians, who have one of the highest
statuses in American society, can convince citizens to believe certain illnesses are a problem.
Similarly, drug companies develop marketing strategies for television commercials showing
symptoms such as headaches, nausea, and fatigue that almost anyone, especially lower classes,
can feel on an everyday basis. In doing so, drug companies are creating more consumers for their
products. As long as there is an audience, then almost anyone can make a claim, develop
followers, and convince an audience that their solution is the one and only for that particular
problem. Loseke (2003:19) notes that the three major claims-makers are social movement
activists, scientists, and the mass media.
Working class citizens may experience inequalities in the healthcare system but feel they
have no power to take a stand. The middle and upper classes have power, but they do not always
see the problem because they are not highly disadvantaged by the “system.” Durgee (1986:73)
notes, “Unequal allocation of economic resources is a broadly acknowledged characteristic of
class. However, a view limiting examination of class resources to just the economic spheres
8
misses the point that class is a product of more complex social-psychological relations.” Social
inequalities are understood differently depending on one’s economic status. However, as Loseke
argues, it is not necessary to know whether a real problem exists; rather social construction
theorists examine the claim made by a particular group of people to see if and why an audience
believes the claim.
The historical context can shape how likely an audience is to believe a claim, including
claims about medical knowledge. Best (1995:13) states that, “the consolidation and
monopolization of medical organization and practice around the turn of the century enabled the
medical profession to achieve a position of social and professional dominance.”
Loseke explains how those in power construct situations by exaggerating problems
through the use of statistics or emotionally-striking images, which can create fear and, in turn,
create a “risk society.” In a risk society multiple types of social problems appear in numerous
sources, causing citizens to take unnecessary precautions to prevent risks. For example, mass
media sites construct a “social problem” through horrific pictures, sounds, and other propaganda
techniques in order to make people believe their message.
“Social problems” are not random claims; they are well-strategized forms of persuasion.
Take politics, for example. Politicians running for office may show support for the working class
and poor so as to gain their vote by being recognized as the “nice guy.” The strategy is to
campaign as a friend of the working class, but after the election voting records may reveal little
legislation to help those who got the politician elected.
Typification is the other important concept Loseke discusses. Loseke (2003: 21)
describes typicfications as, “how humans create the meaning of social problems; on what we
think about the world, on why we think that way, on what happens because we think the way that
9
we do.” Typifications help the audience understand the “typical” so that behavior or events
outside the typical are identified as a social problem.
The “social problems game,” as Loseke (2003:20) calls it, consists of a set of activities
and players who compete to have their claim acted upon. In the game, there are competitions and
strategies for winning; the prize for winning such a game is the “power to lead social change, to
change the objective world in which we live, to change the way we make sense of ourselves and
others.” Social Constructionists Berger and Luckmann (2004: 384) state, “Man’s self-production
is always, and of necessity, a social enterprise.” Loseke and Berger and Luckmann understand
that a person’s surroundings shape his/her view of the social structure. Those in power, often
politicians and physicians with the highest prestige, will most likely win the “prize,” which in a
capitalist society means the rich continue to get richer and the poor get poorer. This is not only
an annual income difference, the prize is also a difference of access to quality healthcare.
Domhoff (1986:73) states “Socioeconomic differences in health are not just a distinction
between the poor and the rest of society, rather the phenomena is gradational whereby the
highest income group is healthier than the group just below – and so forth.”
Berger and Luckmann (2004:385) argue that “any action that is repeated frequently
becomes cast into a pattern, which can then be reproduced with an economy of effort and which,
ipso facto, is apprehended by its performer as that pattern.” Similarly, Loseke discusses how
statistical evidence is used to “prove” there are reoccurrences of harmful behaviors happening
that are constructed as a social problem. Furthermore, social problems are marketable and the
people who create them may also be the same ones developing the solutions. However, the
experts may not completely fix the problem because the continued existence of a social problem
is part of maintaining power. For example, many medications and procedures are available but at
10
a price that disadvantages many. There are solutions available to sick patients, but if the sick
were cured then perhaps there would be fewer doctors needed, leading to an oversupply and
lower physician income.
By applying Loseke’s Social Constructionist Theory to the claims of inequalities as
experienced by the working class and the poor in the healthcare system, this research provides a
lens for understanding the subjective nature of this social problem. Specifically, this paper argues
that professional dominance is created and maintained by the physicians as their “prize,” and this
power affects doctor-patient relationships.
METHODOLOGY
Participants
Adults were non-randomly selected through a gatekeeper at the Hope Rescue Mission
and a gatekeeper at Chapin Street Health Clinic. Participants were chosen because they have
experienced the healthcare system in South Bend, Indiana. A survey was distributed to clients
seeking services at Hope Rescue Mission and Chapin Street Health Clinic, Indiana. Although 55
surveys were distributed, only three males and four females, who have lived and received
medical attention in South Bend, Indiana for at least a year, ranging in age from 20-61,
participated in the survey giving a response rate of approximately 13%. Six of the seven
participants were Caucasian, one was Hispanic. Participants were fluent in English.
The population surveyed, who live at or below the poverty line, answered 30 questions on
their background, their perceptions of the healthcare system, their treatment by the physicians,
and their access to the proper care. The survey consisted of open and close-ended questions (See
Appendix A). Upon completion, the survey and the consent form were then returned to me by the
participant via mail.
11
Strengths and Weaknesses
One strength of this method is that participants may answer the survey at their
convenience, thus facilitating a higher response rate. Additionally, participants may have been
more apt to answer difficult personal questions because of the anonymity of a survey. However,
a weakness of survey research is that some participants did not fully complete the survey and/or
return it for analysis. Another weakness is that surveys were not all returned by the date
requested, so the analysis is incomplete. Additionally, Chapin Street Clinic had a zero response
rate due to the increasing Hispanic, non-English speaking population and patients who could not
read or understand some of the questions.
FINDINGS
Due to the small sample size, the findings here are exploratory; however, they are
concurrent with previous research on stratified healthcare systems. The data collected from the
seven participants from the Hope Rescue Mission in South Bend, Indiana, illustrates that the
working class and the poor receive regular medical attention—approximately every three
months. Specific responses to questions regarding the patient’s experience with their doctor are
shown in Table 1.
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Table 1: Patient’s Perceptions of His/her Doctor
Do you feel
confident asking
your doctor
questions?
Do you think your
doctor discusses all
options for
treatment?
Do you fear
challenging your
doctor’s advice?
Do you have the
option to change
your primary
doctor?
Yes
No
Don’t know
Depends on the
medical
problem
6/7 (85%)
1/7 (15%)
0/7
N/A
4/7 (57%)
0/7
1/7 (15%)
2/7 (28%)
1/7 (15%)
6/7 (85%)
0/7
N/A
4/7 (57%)
1/7 (15%)
2/7 (28%)
N/A
When asked, “Do you feel confident asking your doctor questions about your health?”
participants were given the opportunity to explain if they responded “no.” One participant stated
that his doctor “was a snot nosed kid who seemed that he didn’t care about his patients.” More
commonly, five of the seven respondents answered “no” when asked if they thought their doctor
was superior to him/her, while two of the seven were unsure.
Probing into the relationship between socio-economic status and access to healthcare, it is
important to look at educational attainment, employment status, and annual income. Two of the
seven respondents have less than a high school diploma, two are high school graduates, one has
an Associate’s degree, and one has a Master’s degree. Four of the seven respondents are
currently employed but only one of the four has medical insurance. Annually, five of the seven
13
respondents reported earning less than $10,000, while one person reported an income of
$10,000-$15,000, and the other person earned $25,000-$30,000.
Over the course of any given year, six of the seven respondents in this research indicated
that they receive medical attention approximately every three months, while one respondent
simply cannot afford any type of medical care and has not been seen by a doctor since 1999.
One of the six respondents that indicated receiving medical attention at least every three months
stated that she was pregnant and goes to a women’s clinic about every two weeks, but would
normally see a doctor about twice a year if she were not pregnant.
While the doctor-patient relationship is important in this study, there is also the influence
of the institution to maintain certain restrictions and obligations. According to four of the seven
respondents, politicians are not adequately addressing the issue of healthcare treatment and
access, two are indifferent on the topic, and one person did not respond to this question.
Additionally, only two of the six who responded elaborate on the topic of politicians addressing
healthcare issues. All seven of the respondents indicated that there has been a time when they
needed medical treatment, but they had no way to pay. Additionally three of the seven
respondents have experienced delays and or access problems to receiving healthcare, while three
have not and one was unsure of the reason he/she was denied medical attention.
MAKING ENDS MEET
Although the findings here are exploratory, implications can still be drawn about the
working class and the poor in the healthcare system. Starfield (2000:483) states that there are
approximately 40 million people in the United States who do not have access to healthcare
because there are social and economic inequalities that exist to maintain the stratified American
14
society. While the seven survey respondent’s annual average of doctor’s visits is concurrent with
the general population, as Dutton (1978:349) notes, when poorer patients do receive medical
attention, it is for disease-oriented issues rather than preventative care. Thus, the working class
and the poor need more medical attention and greater access to the healthcare system because
they are occupying the low-paying, high-risk jobs.
There is an unmistakable separation between people who work hourly-wage jobs and
those who receive an annual salary. Such is the case with the respondent who felt his doctor was
a “snot nose kid” who did not care about his patients. This negative attitude towards his doctor
could be caused by the social status differences between the doctor and himself. The respondent
makes less than $10,000 a year, while the annual salary of a doctor is approximately $180,000. It
is unlikely that the survey participants and their doctor would cross paths, socially, unless it was
in a doctor’s office or similar setting. Such segregation by class may foster stereotypes about
“the other,” regardless of one’s own class position.
Additionally, social mobility within one’s job is extremely difficult for those in lowpaying jobs, so they often accept their social status. Lower income members of society are more
likely to have lower educational levels, lower self-esteem, and limited options so, as Loseke
implies through Social Construction Theory, working class citizens may see inequalities in the
healthcare system but feel they have no power to take a stand. Thus, as the working class gets
poorer, physicians are getting what they want—the power to maintain professional dominance.
As Light (2004:15) claims, “because doctors are free to choose their specialty and where
they practiced, rural and poor areas are underserved.” The result is that the working class and the
poor have more difficulties in obtaining access to healthcare in the areas in which they reside. By
definition, Americans living in the lower classes rarely achieve the American Dream; meaning
15
they do not have the summation of two cars, a steady income, and a comfortable living. Thus,
even the simplest tasks-getting to a hospital or other healthcare facility—is more complicated for
the working class and the poor. Taking ambulances costs money, often billed to insurance,
which many working class citizens and poor people do not have. Also, a car or other means of
transportation is not always readily available—making it a struggle just to get to a place where
they may or may not receive medical attention.
Upon arriving at a healthcare facility, a poor person may be denied medical attention for
lack of insurance or the monetary funds to pay for the visit. Unless the reason for seeking
medical attention is life-threatening, a person may be turned away because for-profit medical
institutions are increasing in number and have no social obligation to help the poor as do most
non-profit hospitals. Working class and poor Americans that seek out medical attention and
receive treatment may need follow-up visits or additional treatment. In most cases, working class
and poor Americans will have had more serious diseases or conditions that have been pushed
aside until absolutely necessary to treat.
Due to the exploratory nature of this research, a follow-up study would benefit the
current findings. Perhaps administering the survey to various geographic areas would lead to a
more diverse demographic background and experience pool. Another option to consider would
be to interview low-income individuals, so as to receive further explanation to the questions
posed.
16
References
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Berkley, CA: University of California Press.
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Pharmacy Profits.” Common Dreams.org, April 6. Retrieved September 14, 2007
(http://www.commondreams.org/archive/2007/04/06/343/).
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384-388 in Social Theory: Multicultural and Classic Readings. 3rd Edition. Edited by
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Sociology 30:
249-250.
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Consumer Research.
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Dutton, Diana B. 1978. “Explaining the Low Use of Health Services by the Poor: Costs,
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Women are treated in the Medical Community. New York, NY: Simon & Schuster.
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Institute, August 11.
Freidson, Eliot. 1970. Professional Dominance. New York, NY: Dodd, Mead.
Gribbin, August. 1975. “The Arrogance of Physicians.” National Observer, July: 10.
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CA: University of California Press.
Lee, Christopher. 2006. “Studies Look for Reasons Behind Racial Disparities in Health Care.”
Washington Post. October 25.
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Leonardi, M.J. and M. L. McGory, and C. Y. Ko. Quality of Care Issues in Colorectal Cancer.
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19
United States Census. 2005.
20
Appendix A
Is Healthcare an All-serving System?
1. What is your gender?
___male
___female
2. How old are you?
____years old
3. Check all that apply to your race/ethnicity.
___American Indian and Alaska native
___White
___Asian
___Black or African American
___Native Hawaiian and Other Pacific Islander
___American Indian and Alaska Native and White
___Asian and White
___Black or African American and White
___Other, please specify_________________________________
4. What is your highest level of education obtained?
___Not a High School graduate
___High School graduate
___Some College, no degree
___Vocational
___Associate Degree
___Bachelor’s Degree
___Master’s Degree
___Doctorate
___Professional
5. How many years have you lived in the South Bend community?
___years
6. Are you currently employed?
___Yes
___No
If so, how many years have you been with the company/organization?
___less than a year OR
___years
7. Do you have medical insurance through your employer?
___Yes
___No
___don‘t know
8. My medical plan fits my wants/needs.
___Strongly disagree
___Disagree
___Neither disagree nor agree
___Agree
___Strongly Agree
9. What is your annual income?
___less than $10,000
___$10,000 to $15,000
___$15,000 to $25,000
___$25,000 to $35,000
___more than $35,000
10. Is English your first language?
21
___Yes
___No
If no, what is your first language?
____________________________
Note: Please do not use any doctor/nurse’s name.
11. How often do you go to the doctor?
12. Approximately, when was your most recent doctor’s visit?
___________________________
13. Where did you see this doctor?
___Free clinic
___Doctor’s office
___Emergency room
___Other, please specify_______________________________________
14. What was the gender of the last doctor who treated you?
___Male
___Female
15. What was the race of the last doctor who treated you?
___American Indian and Alaska native
___White
___Asian
___Black or African American
___Native Hawaiian and Other Pacific Islander
___American Indian and Alaska Native and White
___Asian and White
___Black or African American and White
___Other, please specify_________________________________
___Not sure
16. Do you feel confident asking your doctor questions about your health?
___Yes
___No
___Don’t know
If no, why?
______________________________________________________________________________
______________________________________________________________________________
17. Do you think your doctor discusses all options for treatment with you?
___Yes
____No
____Depends on the medical problem
___Don’t
know
18. Do you think that your doctor is superior to you?
___Yes
___No
___Don’t know
If yes, why?
_____________________________________________________________
19. Do you fear challenging your doctor because of your educational level?
___Yes
___No
___Don’t know
20. Do you fear challenging your doctor’s advice?
___Yes
___No
___Don’t know
If yes, why?
22
______________________________________________________________________________
______________________________________________________________________________
21. Do you have the option to change your primary doctor?
___Yes
___No
___Don’t know
22. Have you ever needed medical treatment, but had no way of paying for it?
___Yes
___No
___Don’t know
23. Have you ever needed medical treatment and been turned away because you lacked the
funds/insurance?
___Yes
___No
___Don’t know
24. Have you ever experienced delays and/or access problems to receiving healthcare?
___Yes
___No
___Don’t know
25. On the issue of healthcare treatment/access, do you feel politicians are adequately
addressing this issue?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
26. What improvements would you like to see in the healthcare system?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
27. Which healthcare facility do you use? Check all that apply.
___Chapin Street/ Sister Maura Brannick Clinic
___Hope Rescue Mission’s recommended caregivers
___Other, please explain
______________________________________________________________________________
___________________________________________________________________
23