The misalignment of institutional "pillars": consequences for the U.S. health care field

This paper uses an institutional perspective (Scott, 1994; 2001; DiMaggio and Powell, 1991) to analyze the history and current state of the American health care field in terms of the alignment of its normative, cognitive, and regulatory elements. I depict the relation between institutional elements in each of three historical eras of the health care field (Scott et al. 2000): the era of professional dominance (1945--1965), the era of federal involvement (1966--1982), and the era of managerial control and market mechanisms (after 1983 to the present). I argue that a weakening of alignment between these elements, beginning in the 1970s and increasing in the 1980s, led to consumer and provider dissatisfaction with managed care, and that the state of the field in the beginning of the 21st century suggests that a new era is emerging with renewed alignment between normative beliefs and values, cognitive models, and regulation. Implications for the future of health care and institutional theory are discussed.