Gender hierarchies in the health labor force.

Rapid growth and increasing diversity characterize trends of the U.S. health labor force in recent decades. While these trends have promoted change on many different fronts of the health system, hierarchical organization of the health work force remains intact. Workers continue to be stratified by class and race. Superimposed on both strata is a structure that segregates jobs by gender, between and within health occupations. While female health workers outnumber males by three to one, they remain clustered in jobs and occupations lower in pay, less prestigious, and less autonomous than those of their male counterparts. What has prevented women from improving their economic and leadership status as health workers? Is work performed by men of higher prestige because men perform it? Would curative and technical fields have less status if dominated by women? Would health promotion be funded more generously if most health educators were men? In this article, two analytical constructs are presented to take a closer look at occupational categories, selected structural characteristics, differential rewards, and their relationship to gender segregation. Taken together, they demonstrate how women always cluster at the bottom and men at the top, no matter which dimension is chosen.

Estimating hospital service areas using mortality statistics.

This article reports research testing an alternative methodology for patient origin studies that uses hospital deaths as a proxy measure for all discharges from a selected group of urban tertiary hospitals. Results indicated that mortality data from vital statistics records provide a reasonable approximation of patient travel patterns to acute care hospitals. Hospital service area indexes constructed from mortality statistics accurately predicted, on an aggregate regional basis, the results of a conventional patient origin study based on all hospital discharges. Hospital service areas, an important element of locational analysis in health planning, can be identified with the suggested methodology for states and areas lacking statewide uniform hospital discharge systems. A number of caveats are suggested for applying this methodology and interpreting its results.

Implementing regulatory reform: the saga of Michigan's debedding experiment.

This paper traces the implementation of Michigan's program for hospital bed reduction through four phases in the critical first 30 months following enactment: standard-setting, plan development, plan approval, and legislative oversight. Procedural complexity and goal conflict complicated implementation from the start: what began as a simple proposal to close unneeded beds soon became enmeshed in efforts to address long-standing issues of equity in access to care. A combination of administrative, political, and economic factors peculiar to Michigan, as well as the more generic problems incurred in applying a regulatory approach to containing medical care costs, contributed to the difficulties encountered in implementing bed reduction. Long-range prospects for the program depend upon whether the modest results it is likely to achieve are deemed to be worth the costs incurred in administering it.

Legislating hospital bed reduction: the Michigan experience.

A variety of programs aimed at health care cost containment have been initiated at the state level. This article presents a case study of one state's effort to deal with health care cost issues, focusing on the formulation of adoption of legislation to reduce the number of hospital beds. The Michigan bed-reduction legislation was the creature of a coalition of powerful, organized "professional consumers" of health services who placed hospital cost containment on the political agenda and framed a solution. The provisions of the legislation were reshaped during the legislative process to grant concessions to a variety of interest groups, particularly the Michigan Hospital Association. Many additional criteria for determining excess bed capacity, some subjective, were added. Cost containment as a goal was, if not subordinated, at least made competitive with other goals--access to care, equity among types of providers, and quality of services. While the initial proposal was attractive as a seemingly simple extension of the certificate-of-need process within the existing regulatory framework, the legislation became increasingly complex in response to new issues raised by political actors who contributed to the shaping of the final version of the legislation. The formulation and adoption of Michigan's overbedding legislation appears to underscore what many other observers have noted: there are no purely technical solutions to health policy problems.

State health manpower planning in the 1980s.

Despite the importance of the state role in health manpower, past studies have documented fragmentation of effort, isolation of health manpower planning from other health policy channels and a relatively low level of interest in manpower issues on the part of state and local health planners. In evaluating the current capabilities of state level agencies to undertake increased responsibility for health manpower planning, this paper: 1) assesses the level of interest and involvement of state health planning and development agencies (SHPDAs) in health manpower planning; 2 (examines health manpower policy issues in states as evidenced in state health plans; and 3) describes the policy environment in which state health manpower planning is currently conducted.

Children's health care and the changing role of women.

The pivotal role of women as wife, mother or adult daughter in performing health-related activities for family members has received little attention from health researchers or policymakers. Yet the majority of health problems do not reach the medical care system, but are dealt with informally or through other social systems. This article discusses the impact of family health care responsibilities on women's market and nonmarket roles in two areas: home nursing care for children's illnesses and escorting children to sources of formal medical care. National data on the incidence of children's illnesses provide the basis for an analysis of the contribution to absenteeism among employed women represented by care of an ill child. Similarly, data from the National Ambulatory Care Survey form the basis for estimates of the economic value of escort time involved in children's medical care. The analysis suggests that policies directed to assuring adequate health care for children take account of the informal, nonmarket health services in which women now play the major role. It must also be recognized that women's changing labor market roles are affecting the availability of these services and increasing their costs to the women who provide them.

Women in male-dominated health professions.

Analysis of survey data on six health professions in Michigan suggests the extent to which sex-role stereotypes are reflected in the distribution of women within and among those professions which typically function as independent practitioners. The particular emphasis of the analysis is the structural or organizational aspects of the professions which facilitate or hinder the recruitment and participation of women. Distribution of women among professions is associated with relative levels of sex-segregation and with the relative availability of career opportunities in nonentrepreneurial settings. Implications of these findings for future trends in the sex structure of the health professions are discussed and a research agenda on women health professionals is proposed.

Empirical designation of health service areas.

A method for identifying viable health service areas for a state is described. A computer program was developed that evaluates combinations of contiguous counties using a set of 56 variables strategic to the construction of health planning areas and the spatial context of health care delivery, in keeping with the structural requirements of the National Health Planning and Resources Development Act of 1974. The objective of the evaluation is to minimize differences among planning regions and between planning regions and the state.