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.

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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 Frank-

Green 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

receiving the very best in the healthcare system. Nechas and Foley (1994:176) found that doctors

5
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.

SOCIAL CONSTRUCTION THEORY

7
 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

misses the point that class is a product of more complex social-psychological relations.” Social

8
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 we do.”

9
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.

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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

Yes No Don’t know Depends on the

medical
problem
Do you feel
confident asking 6/7 (85%) 1/7 (15%) 0/7 N/A
your doctor
questions?

Do you think your

doctor discusses all 4/7 (57%) 0/7 1/7 (15%) 2/7 (28%)
options for
treatment?
Do you fear
challenging your 1/7 (15%) 6/7 (85%) 0/7 N/A
doctor’s advice?

Do you have the

option to change 4/7 (57%) 1/7 (15%) 2/7 (28%) N/A
your primary
doctor?

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 low-

paying 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
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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

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Sociology 30: 249-250.

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Dutton, Diana B. 1978. “Explaining the Low Use of Health Services by the Poor: Costs,

Attitudes, or Delivery Systems?” American Sociological Review, Vol. 43, No.3, pp.348-

368.

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August 11.

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August 18.

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United States Census. 2005.

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 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
______________________________________________________________________________
___________________________________________________________________

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