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problems and mental illness. Mechanic and Rochefort (1992) document the deinstitutionalization of the mentally ill from public mental hospitals and the problems associated with inadequate mental health services. Inadequate housing and community health services, as well as the limits on mental health insurance coverage have all contributed to a general decline in mental health services.

CONSEQUENCES OF LIMITED ACCESS TO

HEALTH CARE

The United States and South Africa continue to hold the unenviable distinction as the only two existing industrialized countries without national health insurance. Thus, when the high U.S. expenditures per capita are compared with those of other industrialized counties, the majority of these nations have their populations covered by insurance, while the United States is excluding 43 million individuals. The lack of health insurance leads to a number of serious problems in access to health care services.

There are many other health-related problems that plague the U.S. population in comparison to those of other nations. Among the top twenty-four industrialized nations, the United States ranks sixteenth in life expectancy for women and seventeenth for men, while it ranks twenty-first in infant mortality (Andrews 1995, p. 38). Although there were substantial reductions in childhood mortality in the United States between l950 and l993 (Singh and Yu 1996), the United States is well behind many other industrialized countries in childhood mortality (two to four times higher than Japan and Sweden) not only because of higher mortality from medical causes (e.g., heart disease) but also because of injuries and violence. Moreover, there are large differences across groups, with male children experiencing higher mortality rates and African-American children experiencing rates of more than twice that of white children (Singh and Yu 1996).

A number of studies have been conducted on the barriers to access related to the inability to pay for services (Berk et al. 1995; Braveman et al. 1989; Berk et al. 1995; Hafner-Eaton 1994; Mueller et al. l998; Weissman et al. 1991). Mueller and colleagues (1998) confirmed that lack of health insur- ance—regardless of race or ethnicity, or living in a

rural environment—is the major determinant of the utilization of health care services.

Approximately 12 percent of all American families (12.8 million) experienced barriers to receiving needed health care services in 1996. Sixty percent of these families reported that the barrier to care was their inability to afford the care, and 20 percent cited insurance-related problems (AHCPR 1997). The barriers to health care included difficulties finding care, delays, or not receiving the care that was needed.

Nearly 46 million Americans were without a regular source of health care such as a doctor’s office, clinic, or health center in 1996 (AHCPR 1997). Those persons without insurance were two to three times more likely to have no regular source of health care and two to three times more likely to have encountered barriers in receiving needed health care than those persons with health insurance (AHCPR 1997). Hispanics (30 percent), the uninsured under age 65 (38 percent), and young adults (34 percent) were more likely to lack a stable source of health care. Those individuals with a history of serious medical illness were twice as likely to be unable to obtain care. African Americans and Hispanics were also more likely to be unable to obtain care than whites and others (Himmelstein and Woolhandler 1995).

OTHER BARRIERS TO HEALTH CARE

ACCESS

There are many other barriers to access to care. One is the lack of providers in areas close to people who need care. This is a problem for those persons living in rural areas as well as for those in centralor inner-city areas (Clarke et al. 1995). Weisgrau (1995) reviewed the myriad problems rural Americans confront in obtaining health care and mental health services due to the shortages of health care providers and the continued closures of rural hospitals. The stigma of obtaining mental health services in rural areas was also considered to be a problem.

Studies by Wennberg and colleagues (1989) have documented the wide geographic variations in health outcomes. These outcomes are considered to be, in part, related to variations in provider practices. A recent study by the Department of

Veterans’ Affairs found that even though the system predominantly serves low-income men, they found substantial geographic variation in service use for different diagnoses in hospitals and clinic use across the United States which they attribute to different practice styles (Ashton et al. 1999).

Another problem is cultural barriers to care. These include language differences between patients and providers and other communication problems. Escarce and colleagues (1993), Gornick and colleagues (1996), Friedman (1994), and Korenbrot and colleagues (1999) have identified these problems. Many studies have found persistent disparities across racial and ethnic groups in access to care (Escarce et al. 1993). Racial and ethnic minorities and rural residents were less likely to use physician services. This pattern was even stronger for rural Latinos and Asians (Mueller et al. 1998), particularly refugee populations. Mortality rates for black Americans are about 50 percent higher than for white Americans, and Native Americans also show very high death rates, especially among the young (Nickens l995). In part, the high mortality rates are related to lower socioeconomic status (SES) measured by occupation, income, and education attainment, which are generally lower for minorities. Mortality rates were more strongly related to SES in l986 than in l960. The substantial black and white differentials in infant mortality have been well documented (NCHS, 1994). High infant mortality rates for minorities are a function not only of poverty and low SES, but also of racial segregation in housing markets that are in close proximity to industrial pollution generators (incinerators, factories, etc.). These sources of pollution produce poor air quality in many communities of color and have a direct effect on infant mortality rates and adult morbidity (Hurley 1995).

In addition to poverty, low SES, and poor environmental quality, infant mortality rates of minorities are also influenced by continuing discrimination in society. The discrimination accumulates over time and results in perceived powerlessness, frustration, and negative self-images that in turn contribute to higher mortality rates. Discrimination against minority group members by health care providers may be a contributing factor that has not been eliminated. Using simulated video interviews of patients and physicians, a recent study documented that the race and sex of patients

have an independent influence on physician decisions regarding how to manage care for chest pain. Women, blacks, and younger patients were less likely to be referred for diagnostic tests (cardiac catheterization), and the interaction effects were also significant (Schulman et al. 1999).

SOCIOLOGICAL MODELS OF ACCESS TO

SERVICE USE

Much of the study of health care utilization and access has been developed using the theoretical model adopted by Andersen, Aday, and colleagues at the University of Chicago (Aday and Andersen 1974, 1991; Andersen 1995; Andersen and Aday 1978).

Andersen’s (1995) original model was designed to predict or explain the use of health services. Three major components were developed for the model. First, predisposing characteristics were considered to include those that were endogenous to use including (1) demographics, such as age, gender, and race; (2) social structure, such as education, occupation, and ethnicity; and (3) health beliefs, including attitudes, values, and knowledge about health. Various critics have suggested (and Andersen 1995 agreed) that social networks, social interactions, and culture are all concepts that can be incorporated into the social structural factors. Genetic makeup might also be added to the list of predisposing factors. Second, enabling factors were considered to be those community and personal resources that may enable an individual or family to use health services. These include the supply of health personnel and organizations or facilities to provide care. Enabling factors also include income, health insurance, regular source of care, travel and waiting times, and other such factors. Social relationships, or ‘‘social support,’’ are also important enabling factors according to Andersen (1995).

Finally, the original model included the need for health care services. ‘‘Need’’ included both the perceived need and the need as evaluated by health professionals. In the original model, the outcomes included the amount of physician, hospital, and other health services used. This model is one of the most widely used approaches by scholars, with hundreds of articles presenting the results of testing these factors. In Andersen’s original model,

access was described as potential access and realized access (actual use) of services. Access could be found to be equitable or inequitable, depending on value judgments. Inequitable access occurred when predisposing factors (such as race, ethnicity, or gender) or enabling factors (e.g., health insurance) determine who receives services rather than services determined by need. In later models, the health care system was incorporated, including national health policy, resources, and organizations. Outcomes of health services were revised to include consumer satisfaction about convenience, availability, financing, providers, and quality (Aday and Andersen 1974). The model was expanded further to include ethical criteria to measure equity, such as freedom of choice, equal treatment, and decent basic minimum care. Subsequently, the model has included understandings of effective and efficient access to services and improved health status as outcomes (Andersen 1995). Finally, Andersen sees the model as interactive and dynamic, with utilization and outcomes influencing predisposing, enabling, and need factors.

As a test of the importance of the behavioral model, a study in the late 1990s examined its use in the social science literature between 1975 and 1995. The study found 139 empirical research articles that used the model; of these articles, 45 percent included environmental variables and 51 percent included provider-related variables (Phillips et al. 1998). Extensive work has been done to examine health status as measures of health service outcomes. These include mortality, morbidity, well-being, and functioning. Outcomes can also include equity of service access. More elaborate conceptual models have been developed by the Institute of Medicine (Gold 1998; Millman 1993).

ISSUES RAISED BY TRENDS IN HEALTH CARE UTILIZATION AND EXPENDITURES

The macro-level and micro-level patterns of health care utilization and expenditure suggest that consumers, workers, the poor, people of color, the elderly, nurses, and even physicians are losing ground with respect to access to care and decision making within the health care system. Each year— indeed, every month—thousands more individuals join the ranks of the uninsured and thousands more remain underinsured (Kuttner 1999). At the same time, expenditures for the nation’s health

care system are expected to rise steeply in the first decade of the twenty-first century. While most policy makers and health policy analysts regard the American health care system as characterized by ‘‘private insurance,’’ less than 50 percent of health insurance is in fact paid for by private employers— and these payments are subsidized by the government at a total of $100 billion (Carrasquillo et al. 1999). Thus, the role of employers in paying for insurance has been overstated and employers have played a prominent role in health policy discussions. And while the number of employers offering their employees health insurance has either remained unchanged or even decreased in recent years, the cost of these plans has been prohibitive for many workers, who then go without coverage. The result is a nationwide decline in persons with employer-sponsored health coverage (NCH Statistics 1994).

These trends raise questions about the role of the U.S. health care system in providing care to the nation’s population. What becomes clear is that while the system is heavily supported by public funds, the benefits are accruing more and more to private corporations. Thus, we suggest that in order to understand changing patterns in health care utilization and expenditure, a political economy perspective is useful. A political economy perspective recognizes the enduring underlying conflicts among different interest groups (workers, purchasers, providers, doctors, insurers, nurses, the elderly) in gaining access to the myriad benefits a health care system provides. For example, many scholars argue that while the U.S. medical system is officially designed to provide the best possible care to any person who needs it and can pay for services, health care is actually only a secondary or tertiary function of this system (Navarro 1976; Relman 1980; Waitzkin 1983). Profit, above all else, is the ‘‘driving force’’ behind the health care system (Woolhandler and Himmelstein 1995).

The benefits and costs of health care in the United States are hotly contested, and stakeholders are engaged in a continuous struggle to gain access to the former and to externalize the latter. Doctors and nurses have organized unions; consumers have demanded a ‘‘patient’s bill of rights’’ and a long list of other legislative reforms, producing a ‘‘managed care backlash’’; health care providers

and insurers have consolidated in a flurry of mergers and acquisitions in the 1990s; pharmaceutical and other health care firms have sought out markets around the globe; and managers of health care systems have slashed wages and jobs in an effort to contain costs (Andrews 1995). The results have been: (1) less regulation of the health care industry; (2) increasing profits for industry; (3) declining consumer satisfaction and less access to care and insurance under managed care; (4) loss of control and autonomy by doctors and nurses; (5) rising health care expenditures; and (6) no discernible improvement in the quality of health care. Our health care system is transforming rapidly without a coherent national approach to either the structure of the delivery of care or to the problem of rising expenditures. It is incumbent upon sociologists studying the health care system of this nation and others to provide a counterbalance to the currently dominant economic costbenefit analytical approach to this topic. A sociological perspective offers a balanced understanding of the social basis on which the health care system operates and can, therefore, lead the way toward improvements in both theory and policy making in the areas of health and health care.

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CHARLENE HARRINGTON

DAVID N. PELLOW

HEALTH POLICY ANALYSIS

Health policy analysis is of increasing interest to sociologists in the areas of medical sociology and health services research. Health policy analysis draws on perspectives from across the social science disciplines: from anthropology and economics to political science and sociology, as well as law, medical ethics, and the applied fields of public health, public administration, and public policy. Leading sources of policy analysis are scholars in twenty to thirty university-based health policy and health services research centers and institutes and the myriad and growing number of private sector ‘‘think tanks’’ such as the Brookings Institution, the Urban Institute, RAND, the National Bureau of Economic Research, Project Hope, and the American Enterprise Institute. An early indicator of advances in the field of policy studies was the publication of the Policy Studies Review Annual, which commenced in 1977 (Nagel 1977) and continues to cover the field with an editorial advisory board made up of distinguished social scientists.

Major federal agencies that both sponsor and conduct health policy analysis include the National Center for Health Statistics (NCHS); the Health Care Financing Administration (HCFA); the Agency for Health Care Policy and Research (AHCPR); the Alcohol, Drug Abuse, and Mental Health Administration (ADMHA); the Social Security Administration; the National Institute on Aging (NIA); and the Office of the Assistant Secretary for Planning and Evaluation. Federal research funding is the mother’s milk of health policy analysis; although limited, it has assured the slow but gradual accumulation of health services research knowledge.

Several journals are sources for the latest developments in health policy analysis: Health Affairs,

Health Care Financing Review, Health Services Research, Journal of Health and Social Behavior, Journal of the American Medical Association, Milbank Quarterly, International Journal of Health Services, New England Journal of Medicine, and Journal of Health Politics, Policy and Law. A recent, comprehensive

text, Understanding Health Policy (Bodenheimer and Grumbach 1998), though written by physicians and with a clinical orientation, is nonetheless critical of chronic systemic tensions and inequalities in U.S. health care delivery. The authors integrate social science literature throughout, one indication of a growing consensus regarding salient problems among scholars, practitioners, and ‘‘patients’’ alike, in a nation shaken by unprecedented corporate intrusions into health and medical encounters.

There are multiple paradigms in and approaches to health policy analysis in schools of public policy, public health, public administration, and social work. The same diversity is present in sociology and other social science disciplines. However, we detect and discuss important areas of convergence between current controversies in U.S. health policy and perspectives and methods that are well established in sociology. We believe these areas of convergence are likely to enhance the stature and usefulness of the discipline in the analysis of health policy, in public as well as in academic life.

The various disciplines, substantive specializations, and methodologies represented in such work have contributed an array of perspectives to the definition of health policy analysis, how it is conducted, and how professional training is oriented and organized. As the number of programs offering health and related policy training has increased, the academic respectability of such work has grown apace. In sociology, vestiges of an invidious distinction between ‘‘basic’’ and ‘‘applied’’ research are still with us, and policy research is both less visible and less valued than is warranted, given its potential public impact. Nonetheless, an expanded topical definition of health policy analysis, following from the recent political and cultural tumult over changes in health care, is conducive to research in several vibrant research genres in sociology, including political economy (see, e.g., International Journal of Health Services), constructionist approaches to medical encounters and social problems (Brown 1995; Spector and Kitsuse 1987), phenomenology of illness and medical practice (Benner 1994), community-based studies (Israel et al. 1998), and comparative sociocultural studies of health systems (Mechanic 1996; Kleinman 1980). The latter, bordering medical anthropology, encompasses conventional treatment regimen, as

well as ‘‘self-help’’ and various nonbiomedical, ‘‘alternative’’ health practices, be they traditional or sacred (Baer 1995). Such topical breadth is also evident in ‘‘mainstream,’’ medically oriented outlets. In recent years, the Journal of the American Medical Association (JAMA) has devoted sustained attention to public health issues such as gun violence (Sinauer et al. 1996), domestic violence, motor vehicle accidents, and terrorism.

For sociologists, the primary point of entry into health policy analysis has been medical sociology, which has long been sustained by its applied relevance to and sponsorship by agencies in government and medicine (Cockerham 1988). Other contributing subfields include aging/social gerontology, political sociology, gender studies, and social stratification. Despite productive cross-polli- nation between these related fields of scholarship, the number of sociologists working in health policy analysis is small relative to those involved overall in studies of health care and of social policy, broadly conceived. Though medical sociologists continue to comprise one of the largest sections of the American Sociological Association (ASA)— with more than 1,000 members—their presence in the smaller Association for Health Services Research (AHSR), a major professional association, is modest: only 5 percent of its 1,400 members report primary disciplinary training in sociology, compared to 20 percent from medicine and 14 percent from economics (other members were trained in other social sciences, the allied health fields, and business). Health policy analysis is not, however, confined to conventional research roles and careers; many working in health policy analysis hold master’s degrees, are employed on the staffs of governmental and private agencies, and are not oriented toward academic theory or publication (Luft 1999).

Sociologists’ limited involvement in health policy analysis reflects the sources of, and agendas driving, health services research funding. Many problems in the planning and administration of large, complex programs favor orientations and methodological skills others can best provide, primarily those in economics and business. It reflects as well an unfortunate trend in which ‘‘the division of intellectual labor in our discipline tends to replicate program divisions. Experts on aging study

Social Security; experts on health care study Medicare; experts on poverty study Aid to Families with Dependent Children’’ (Quadagno 1999, p. 8). More generally, the American health care system is itself increasingly governed by business principles of cost control and administrative efficiency, under corporate managed care. The dramatic growth of for-profit health maintenance organizations (HMOs), ‘‘now accounting for 75 percent of all HMOs and enrolling over 50 percent of all subscribers’’ (Fein 1998, p. 10), has intensified public debate over quality, access, and humanity in health care.

The products of health policy analysis range from journalistic and descriptive accounts to sophisticated quantitative analyses and projections. But over the last decade or more, health policy analysis has reflected a societal struggle to come to terms with a secular change in the organization and financing of medical care, away from solo, fee- for-service practice toward corporate managed care. Given the current emphasis on cost savings and efficiencies, and on mechanisms for achieving them such as capitation, risk adjustment, and ‘‘utilization management’’ or ‘‘practice guides’’ for physicians’ clinical discretion, economic models and analyses have been paramount in health policy analyses funded by government agencies and large corporate entities. The justification advanced for these competitive efforts has typically been a need to check inflationary costs and ‘‘excessive’’ demands for medical services by consumers, ostensibly free to operate in a ‘‘market’’ for such services.

Consequently, traditional foci of sociological interest—including professional status and autonomy, access to and stratification of health care services, and continuity Federal safety-net policies rooted in the postwar social contract (Quadagno 1999; Rubin 1996)—have been pushed to the margins of public and policy debates. However, sociological perspectives are both rejuvenated and needed at this time. One important line of critique has been to challenge attributions of market choice and consumer autonomy in the face of corporate managed care (Freidson 1994; Freund and McGuire 1999). Another is to reject the very notion of ‘‘system’’ in relation to health care and medical coverage in the United States and instead to document, as does Diamond (1995), the collective vulnerability and implications arising from the arbitrary and confusing patchwork quilt that is American

health policy—a paradox of ‘‘excess and deprivation’’ (Bodenheimer and Grumbach 1998). Yet another is to demonstrate how health care professions may act to mediate between users of health services and their often remote provider organizations. In an important analysis of how doctors are implicated in this process, Freidson (1994) argues for a rebirth of professionalism, based on client service and trust, as bases for health care reform. Although one may question the likelihood of this scenario, given the mistrust of doctors at the heart of the consumer backlash of recent decades, the answers are sure to be significant both for social theory and policy. These are but a few examples of the distinctive contributions sociologists are making to health policy analysis, broadly defined.

Consistent with this public spotlight, sociological research on health policy and other segments of the welfare state is gaining momentum. The 1998 president of the American Sociological Association devoted her address to a historical analysis of changes in welfare policy provision, including social security and medicare, as central to understanding the erosion of the postwar social contract in the United States (Quadagno 1999). Furthermore, the demographic aging of America, along with a dramatic increase since mid-century in women’s labor-force participation (with resultant strains in traditional sources of familial care), are propelling the neglected problems of chronic illness, community-based care, and allocation of resources—that is, between capital-intensive hospital treatments and more equitable provision of basic health care—to the forefront of the national and research agendas.

In recent years, then, the inventory and scope of topics subsumed under the heading health policy analysis have expanded in ways that energize and demand the attention of sociologists. The legislative failure of the Clinton administration’s national health plan demonstrated the necessity for a coherent set of principles—moral and political, as well as technocratic—in order to implement largescale policy reform; resistance to ‘‘environmental racism’’ by those unduly exposed to hazardous jobs and industrial toxins has assumed global dimensions; and such widely publicized conflicts as those over public versus corporate liability for the expense of tobacco-related illness (Glantz et al.

1996) and firearms and other forms of violence (Prothrow-Stith 1998; Sinauer et al. 1996)—all these have underscored the political, economic, and cultural forces that shape the health problems, as well as the spectrum of policy options, that analysts address. Indeed, health policy analysts have periodically been buffeted directly by political currents. During the Reagan administration, conservative forces in Congress sought to curtail sharply the collection of health-related data at the federal level; and spokespersons for the failed Clinton plan were attacked as proponents of a federal ‘‘takeover’’ of health care. This attack reflected and accelerated the devolution of federal discretion and responsibility for health care and other policies to state and local governments. Thus, health policy analysis, like health policy itself, has become increasingly politicized.

Research in health policy analysis necessarily concerns itself most directly with timeliness, pragmatism, and specificity in an effort to improve health and health care delivery. Research and analysis are conceived to inform social policy by

(1) illuminating features of social organization and social action that are relevant to health policy planning, (2) identifying the social and health problems that require formulation in attempts to develop health policy, and (3) organizing and interpreting data that monitor the effects and outcomes of health policy decisions and the relative impact of programmatic alternatives.

In response to this mission, health services research contributes two major types of knowledge: engineering and enlightenment knowledge (Weiss 1978). In turn, these models imply distinctly different roles for analysts in the policy process (Marris 1990). In the engineering model, researchers seek to provide instrumental knowledge for practical assessment of alternatives and problem solving, accepting the values and goals inherent in existing policies largely as givens. Many influential health policy analyses first appear as fugitive documents directed to internal governmental audiences, addressing particularistic needs and interests of government agencies and actors, and are based on reports designed with an evaluative purpose. Policy analysis of this kind is, again, primarily funded and supported by government, with a lesser role played by such private foundations as the Robert Wood Johnson Foundation.

In the enlightenment model, researchers criti- cally—even irreverently—scrutinize the implicit empirical, moral, and political assumptions embedded either in discrete policies or in broader debates (e.g., about the ‘‘right to die’’ or national health insurance). Rather than dealing with how policies work in a technical or engineering sense, enlightenment research contributes to the root understanding of how, by whom, and with what unintended consequences problems in health policy are socially constructed. Often, enlightenment research promotes shifts in what Thomas Kuhn (1970) calls ‘‘paradigms,’’ that is, fundamental ways of looking at problems. The enlightenment model is rooted as well in a critical, Weberian tradition in which the formal rationality of internal program functioning is juxtaposed with the substantive rationality of such programs, as they affect individual freedom and social equity.

As Marris (1990) shows, the engineering model is most effective and appropriate when policies have clear goals, enjoy broad consensual support, and can be linked directly to social outcomes. At the macro level especially, such conditions have rarely obtained regarding health policy in the United States. Moreover, experienced observers have concluded that however well conceived and conducted, research has had a limited direct role on the adoption and implementation of health policy (e.g., Lee 1998; Mechanic 1974). Important, though less often discussed, is that analysts in the engineering model are dependent on access to reliable, comprehensive, and timely data sets. Such a research infrastructure is difficult to develop and maintain, even where data collection is mandated at state or federal levels of government (Mechanic 1974). Given the present trend of privatization in the management and delivery of health services, sources, collection, and linkage of data are correspondingly more varied and less subject to public oversight. For example, while public health departments have a responsibility to serve the population at large, HMOs, however carefully they document utilization of services among their thousands of subscribers, have no such obligation to the public. This poses serious questions regarding the coordination of public and private health entities (Goldberg 1998).

Among other fertile research questions being posed in the expanding, multidisciplinary field of

health policy analysis are the following: How is the global resurgence in infectious disease—termed the third epidemiologic transition (Barret et al. 1998)— linked to our more global economy and consumer culture, and what strains is it likely to impose on outdated public health networks? To what extent is globalization leading to convergence in the organization of health care systems internationally (Mechanic 1996)? How are the successes of the American health care system in increasing human longevity creating new conceptions of and practices in medical ethics? Inasmuch as chronic illnesses are often peripheral to direct treatment by doctors, what roles are nurses and other medical practitioners playing in the revision of medical ethics and practice (Thomasma 1994)? What is the place and role of communities in our increasingly corporate health care system? And how might we rethink research practices to better conceptualize and tap community-level perspectives and dynamics (Israel et al. 1998)? Many contemporary problems in health care—from mechanisms by which AIDS and other diseases are transmitted, to discrimination against minority groups seeking care— would seem to rest on understanding communitylevel dynamics.

Sociology has a long tradition of reformism and interest in finding solutions to applied problems. Robert Lynd’s Knowledge for What? (1986) called sociologists to the task, and a long line of American sociologists have worked within the applied tradition. Particular examples are from the Chicago School (Bulmer 1984; Deegan 1988; Deegan and Burger 1981; Park 1952) and Columbia University, where Lazarsfeld and his colleagues advanced the field of applied research after World War II. These efforts were followed by work on the uses of sociology (Lazarsfeld et al. 1967) and a burgeoning of critical scholarship in the wake of the ‘‘counterculture’’ of the 1960s. These forerunners laid the foundation for what has become an increasingly exciting enterprise: the study of health policy. Freeman’s (1978) observation on the nature of health policy analysis as a scientific enterprise remains applicable: that policy studies are rather specialized and ‘‘content limited,’’ demonstrating few attempts to develop overriding conclusions about the policy process; hence, ‘‘there is practically no effort at ‘grand theory’ and little at ‘middle-range theory’ either’’ (Freeman 1978, p.