Categorical inequality, institutional ambivalence, and permanently failing institutions: the case of immigrants and barriers to health care in America

Abstract

I draw on the theories of Charles Tilly, Robert K. Merton, Eleanor Barber, Marshall Meyer, and Lynne Zucker to develop a three-part framework for understanding the organizational and institutional interface between social services like health care and disadvantaged minorities like immigrants. Tilly's theory of durable inequality is transposed to categorical inequalities in organizations and law. His vocabulary of motives is expanded to include categorical entrenchment, restitution, and compensation. These embedded inequalities lead to institutional ambivalence in the provision of services and to permanently failing institutions that work poorly, waste resources, or provide uneven quality, yet do not collapse but endure while resisting reform. One rationale for resistance is ‘moral hazard’ by individuals; but the theory of moral hazard is biased and partial, because provider moral hazard and insurer moral hazard are more prevalent. The specific manifestations of these concepts and dynamics between them warrant further research in different contexts.

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