William A. Rushing

Socioeconomic Status and Mental Disorder: New Evidence and a Sociomedical Formulation

Despite numerous studies which show that socioeconomic status and mental illness are inversely related, it is possible that this relationship exists for some disorders but not others. Study of approximately 10,000 first admissions to state hospitals in one state covering the period 1956-65 shows an inverse relationship only for organic and schizophrenic disorders. In light of the etiological and predisposing factors that are involved in these two disorders, physical and medical factors appear to be more important than psychological (e.g., stress) factors in mediating the relationship with socioeconomic status. It is concluded, therefore, that a sociomedical formulation (in contrast to a sociopsychiatric formulation) is a plausible interpretation of the relationship between socioeconomic status and mental disorder.

Medical Care: Actual Effects and Public Perception

The rapidly escalating costs of medical care over the past quarter century, from 4.5% of the gross national product GNP in 1955 to 10.6% in 1984 (Levit, et al., 1985), has directed attention increasingly to aspects of the delivery, organization, and financing of medical care. Critics have claimed that there is excessive and unnecessary use of tests and procedures, too much duplication of facilities, and large inefficiencies in the organization of health services. Critics frequently focus on the “nonsystem” of medical care in which the various parts are not linked in a coherent pattern in which there is rational control over the allocation of resources. Many contend, therefore, that national resources employed in the medical area could be used better (that is, more rationally) if they were employed in other sectors. Others charge that it is the public’s utilization of medical care that is irrational in that public expectations of the medical sector are frequently unrealistic. Still others claim that we spend too much for medical care for what we get, some contending we get little if any benefit at all, and a few believe the care we get does more harm than good. In this chapter I will review these issues by examining what people and society apparently do get from medical care and how people view its value. While this does not deal with health insurance per se, the review will be drawn upon in chapters that follow.

Health Insurance and Institutionalizing Marginal Utility Decisions

The most common interpretation of health insurance emphasizes the reduction of economic risk. As noted in the previous chapter, however, risk reduction fails to account for the fact that people want health insurance for others and not just for themselves. Further, it does not explain why people want health insurance despite the questionable medical and economic benefits it apparently provides; other factors besides medical and economic outcomes must be involved. And some economists question the economic utility of health insurance because of moral hazards and administrative costs. In addition, health insurance has significant social consequences for society that are simply beyond the purview of frameworks that emphasize the reduction of economic risk. In this and the next chapter an alternative interpretation of health insurance will be presented in which social consequences are central. The interpretation will be in the tradition of functional theory in anthropology and sociology. In this framework a clear distinction is made between the causes and the consequences of social institutions. The causes of any social institution involve historical, social, economic, and political events and processes. Some of these were described with respect to health insurance in the previous two chapters.

Economic Costs Versus Social Benefits of Health Insurance

Since so little evidence shows that health insurance leads to better physical health, the argument that health insurance costs more money than it is worth would appear to be a compelling argument for reducing health insurance coverage. However, this ignores that the benefits of health insurance include more than medical benefits.

Health Insurance, Cost Containment, and Social Conflict: A Future Perspective

In the late 1960s and 1970s much public medical policy in the United States was designed to use public insurance to increase access to medical care for low-income and older people and, thus, to bring about a closer relationship between the need for medical care and the utilization of it. In addition, the increase in private insurance made medical care more accessible to more people. Therefore, the primary method used to assure access to medical care regardless of cost was to extend health insurance coverage to more people. Now, during the 1980s, after more than two decades of rapidly rising expenditures for health services, “cost containment” has begun to replace access as a major policy issue. In order to lower the national cost of medical care, some contend that the scope of government (and private) insurance programs should be reduced; the beneficiaries of such programs should be required to share the cost of those programs more than they do now (e.g., raising the deductible feature of Medicare, taxing the health insurance premium paid by private employers on behalf of their workers, which is not presently taxed). Just as health insurance was the primary mechanism used in policies designed to reduce income barriers to access, its reduction is central in programs of cost containment.

Insurance, Social Relations, Moral Community, and the Cost of Medical Care

In the analysis of any group or collective unit, sociologists examine the social relations and the rules or norms that regulate the behavior of individuals toward each other. In some groups individuals are dependent on each other in a number of ways, so that social relations are diffuse with obligations of members to each other extending over a range of areas, as in kinship relations. Individual allegiance to other members and to the group as a whole may be strong. Social allegiance and commitments may be reinforced by the norms of conduct, which stipulate that one’s behavior must follow rather narrow channels and be in conformity with the community morality. Such morality generally requires that members of the group come to the aid of others in time of need. The needs of others and of the group itself compete with the needs of the individual.

Health and Economic Factors in Health Insurance

Government insurance was first established in 1883 in Germany, where Bismarck introduced a national health insurance program for industrial workers; other European countries followed and today most industrialized countries have some form of universal public health insurance program. In countries where publicly funded universal insurance does not exist, a combination of private and public sources makes health insurance almost universal, as in the United States where over 90% of the population has some form of coverage (Aday, Fleming, and Anderson, 1984) (though the comprehensiveness and quality of such coverage varies widely), and over 90% of hospital expenditures and approximately 68% of all health-service expenditures are paid by a third party (Gibson, Waldo, and Levit, 1983:8–9). Despite the apparent growing popularity of health insurance, it has long been controversial and in recent years has been severely criticized.

Cultural Factors in Health Insurance

Even if health and economic factors are important in health insurance, they do not operate in a cultural vacuum. Two major cultural factors are involved. They are medical technology and a value system which holds that medical care should be available to persons who need it regardless of economic circumstance.

Health Insurance, Social Integration, and Social Cohesion

Although irrational economic behavior may lead to economic inefficiencies, anthropologists and sociologists have long observed that such behavior may have significant psychological and social utility. In the previous chapter, we saw that even if health insurance is irrational from an economic perspective, it may have positive consequences for individuals not unlike those associated with ritual in preliterate societies. Some functional theorists argue, however, that ritual performs a more important service than simply to alleviate anxiety. (Indeed, some argue that rather than anxiety leading to ritualized behavior, it is the failure to perform ritualized behavior that leads to anxiety.) (See Radcliffe-Brown, 1938:46.) Although a rain dance does not lead to the objective that is intended (e.g., to produce rain and, thus, a good crop yield), it may have significant social benefits nevertheless. It brings people together to share in common group activity and thus enhances social integration. In doing so it also promotes a sense of group identity or social cohesion. Health insurance may also promote social integration and cohesion, though for different reasons.