The Cost of Representation: Insurance Status, Gender, and Cardiac Outcomes in Emergency Department Care

• Published date: 01 November 2021
• Author: Austin M. McCrea
• Date: 01 November 2021
• DOI: http://doi.org/10.1111/puar.13354

1092 Public Administration Review • November | D ecember 2 021

Research Article

Abstract: Recent innovations in representative bureaucracy push the theory toward the micro-foundations of who

represents and who receives representation. Contributing to the micro theory, I draw from street-level bureaucracy

which recognizes how certain client characteristics beyond a shared identity may make representation too costly.

Using data on emergency department visits to Florida hospitals, I explore how the impact of physician-patient gender

matching on client outcomes is moderated by a patient’s insurance status. While emergency departments offer universal,

public access, services performed on publicly insured and uninsured individuals are reimbursed at a lower rate than

the privately insured. These features present an opportunity to test how responsive representation is to different client

costs and benefits. The findings suggest that public insurance status is not a barrier for women’s representation.

However, uninsured women do not see any improvement in outcomes when receiving representation.

Evidence for Practice

• Facilitating greater gender-matching in public services may not address all distributional inequities.

• Public administrators should be cognizant of how organizational design shapes bureaucratic behavior.

• Representation is not a panacea and may be responsive to client costs and benefits.

The theory of representative bureaucracy argues

that a workforce reflective of the population

it serves helps improve legitimacy and

outcomes in public services. After several decades of

research across myriad public service contexts and

social identities, recent innovations focus on the

micro-foundations of representative bureaucracy

as an individual-level phenomenon (Guul 2018;

Meier 2018; Nicholson-Crotty et al. 2016;

Vinopal 2017, 2019; Zamboni 2019; Zwicky and

Kübler 2019). Contributing to the micro-theory,

this paper explores how client costs moderate who

represents and who receives representation.

Beyond the usual focus on a shared racial or gender

identity with a bureaucrat, other client characteristics

such as socioeconomic status, age, ability, motivation,

program affiliation, or national origin can provide

heuristics on client costs and benefits (Andersen

and Guul 2019; Jilke, Van Dooren, and Rys 2018;

Lipsky 1980; Tummers et al. 2015; Watkins-

Hayes 2011; Zamboni 2019). A large literature

suggests that these social identities can be embedded

within organizational design structures that shape

bureaucratic discretion and organizational behavior

(Lipsky 1980; Maynard-Moody, Musheno, and

Musheno 2003; Tummers 2017). While a bureaucrat

may hold a positive affect toward clients who

share one identity with them, other costly social

characteristics may trigger processes that crowd out

representative behavior.

Existing theory suggests that costly social

characteristics can impose both direct and indirect

barriers to representation. As direct effects, individual

bureaucrats may engage in discriminatory behavior

because the identity signals a costly change in

workload (Andersen and Guul 2018; Jilke, Van

Dooren, and Rys 2018; Tummers et al. 2015) or

activates sentiments of undeservingness (Lipsky 1980;

Maynard-Moody, Musheno, and Musheno 2003; Soss

et al. 2011; Watkins-Hayes 2011; Zamboni 2019).

In both cases, the bureaucrat makes an assessment

that the costs associated with one identity exceeds

the benefit in representing the other. As indirect

effects, client characteristics may trigger organizational

processes such as longer wait times or other forms

of administrative burden (Goodsell 1977; Herd

and Moynihan 2019; Lipsky 1980). A bureaucrat

may possess a desire to represent yet is incapable

of doing so because the client possesses certain

characteristics that trigger negative administrative

responses that occur prior to their interaction with the

client. Regardless of the pathway, both explanations

suggest that identity-matching alone is incomplete.

Clientele can possess other salient social characteristics

Austin M. McCrea

American University

The Cost of Representation: Insurance Status, Gender,

and Cardiac Outcomes in Emergency Department Care

Austin McCrea is a doctoral candidate in

the Department of Public Administration

and Policy at American University. His

research interests include representative

bureaucracy, street-level bureaucracy,

diversity management, and the

generalizability of public administration

theories to high-risk, time-critical public

service contexts.

Email: am3471a@student.american.edu

Public Administration Review,

Vol. 81, Iss. 6, pp. 1092–1101. © 2021 by

The American Society for Public Administration.

DOI: 10.1111/puar.13354.