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Constrained Choices: The Shifting Institutional Contexts of Aging and the Life Course

Phyllis Moen

INSTITUTIONS AS CONTEXTS AND PROCESSES

Institutions are taken-for-granted schemas about “appropriate” behavior—formal and informal rules and conventions representing collectively developed patterns of living that often reflect organizational and community answers to past problems and uncertainties (Biggart and Beamish, 2003; Sewell, 1992). According to Scott (1995, p. 13), institutions are “cognitive, normative, and regulative structures and activities that provide stability and meaning to social behavior. Institutions are transported by various carriers—culture, structures, and routines—and they operate at multiple levels of jurisdiction.”

This chapter proposes that institutional theory constitutes an important prism through which to advance understanding of the range and impacts of patterned social arrangements channeling age and aging processes, although its use is underdeveloped in the study of aging. While there are a multiplicity of social institutions (policies, programs, practices, and conventions) structuring the expectations and choices, transitions and trajectories, risks and resources of aging adults, they tend to serve as background “givens” in the existing research literature on aging, that is, as contexts and/or “neighborhood” effects (Angel and Settersten, 2013; Bengtson et al., 2009; Binstock and George, 2011; Cagney et al., 2013; Settersten and Angel, 2011; Shanahan, 2013), or else as social roles shaped by unique historical events experienced by different cohorts (see, Baltes and Baltes, 1990; Elder, 1974; Elder and Johnson, 2002; George, 1993). The closest ties to an institutional approach in the current aging field lie along three lines of



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9 Constrained Choices: The Shifting Institutional Contexts of Aging and the Life Course Phyllis Moen INSTITUTIONS AS CONTEXTS AND PROCESSES Institutions are taken-for-granted schemas about “appropriate” behavior—formal and informal rules and conventions representing collec- tively developed patterns of living that often reflect organizational and com- munity answers to past problems and uncertainties (Biggart and Beamish, 2003; Sewell, 1992). According to Scott (1995, p. 13), institutions are “cognitive, normative, and regulative structures and activities that provide stability and meaning to social behavior. Institutions are transported by various carriers—culture, structures, and routines—and they operate at multiple levels of jurisdiction.” This chapter proposes that institutional theory constitutes an important prism through which to advance understanding of the range and impacts of patterned social arrangements channeling age and aging processes, although its use is underdeveloped in the study of aging. While there are a multiplic- ity of social institutions (policies, programs, practices, and conventions) structuring the expectations and choices, transitions and trajectories, risks and resources of aging adults, they tend to serve as background “givens” in the existing research literature on aging, that is, as contexts and/or “neighborhood” effects (Angel and Settersten, 2013; Bengtson et al., 2009; Binstock and George, 2011; Cagney et al., 2013; Settersten and Angel, 2011; Shanahan, 2013), or else as social roles shaped by unique histori- cal events experienced by different cohorts (see, Baltes and Baltes, 1990; Elder, 1974; Elder and Johnson, 2002; George, 1993). The closest ties to an institutional approach in the current aging field lie along three lines of 175

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176 NEW DIRECTIONS IN THE SOCIOLOGY OF AGING inquiry: (1) critical political economy and feminist approaches examining how existing institutional arrangements (norms, policies, and practices) are developed and maintained by those in power to promote their own positions of advantage, thereby preserving the existing distribution (across gender, race, and class) of resources (see Acker, 1992; Arber and Ginn, 1991; Estes, 2004; Harrington, Meyer, and Herd, 2007; Pampel, 1994; Quadagno, 1988); (2) age stratification/life course frameworks underscor- ing how social welfare and labor market policies have “institutionalized” the age-graded life course (Kohli, 2007; Kohli et al., 1991; Mayer, 2004, 2009; Meyer, 1986; Moen and Spencer, 2006; Mortimer and Shanahan, 2003; O’Rand and Henretta, 1999); and (3) sociological (c.f. House, 2002) and social epidemiological (c.f. Berkman et al., 2000) theorizing of so- cially structured conditions—more than individual attributes—as key to health and well-being, generating an emphasis in the interdisciplinary pub- lic health literature on the social causes of illness and health (Aneshensel, Rutter, and Lachenbruch, 1991; Berkman et al., 2000; Link and Phelan, 1995; Marmot and Wilkinson, 2006; Mechanic, 2000; Moen and Kelly, 2009; Moen et al., 2011; Siegrist and Marmot, 2006; Syme, 2007; Turner, Wheaton, and Lloyd, 1995; Wheaton, 2001; Wheaton and Clarke, 2003; Wickrama et al., 1997). Institutional theory “asks questions about how social choices are shaped, mediated, and channeled by the institutional environment” (Wooten and Hoffman, 2008, p. 130). This is in sharp contrast to classic economic models emphasizing choice as a (rational) function of perceived advantage or preferences (c.f. Becker, 1981; Gruber and Wise, 2004). Although insti- tutional theory is rarely explicitly invoked, sociological, demographic, and social epidemiological understandings of age, health, and the life course are implicitly if not explicitly about institutional forces, since scholars in- creasingly emphasize the embeddedness of individuals in particular social- structural contexts (see Figure 9-1). These contexts are replete with rules, claims, risks, and resources serving to open up or constrain choices, thereby shaping family-level and individual-level beliefs, behaviors, health, and life quality (see Berkman and Kawachi, 2000; Fry and Keyes, 2010; House, 2002; Kawachi and Levin, 2004; Link and Phelan, 1995; Lutfey and Freese, 2005; Phelan and Link, 2005; Phelan et al., 1998; Turner, Wheaton, and Lloyd, 1995). Nevertheless, the state of the field is such that the preponder- ance of research on aging examines individual-level predictors of individual outcomes, not the institutional-level contexts and processes shaping both. Three things make something an institution: language, customs, and a body of rules and laws—and all serve to “regularize” behavior (Biggart and Beamish, 2003). What is key is that all three are in flux around ag- ing processes, pointing to the importance of institutional change and even deinstitutionalization across cohorts and history. Thus, Boomers (born

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CONSTRAINED CHOICES 177 Institutionalized Schema, Patterns of Living Cohorts in Contemporary Context: Organizations, Work, Retirement, Family Global Institutions Structures: Stressors: O Income Climate, O Layoffs, Mergers as Laws, O Reemployment Health Insecurity Unstable O Job/Care Policies, Discrimination O Societal Participation Demands Economic Regulations Options O Job Exits O Uncertainty Contexts O Retirement Packages, Policies About Future Resources: O Supportive Spouse, Network O Sense of Control O Health, Ed, Income, Assets Institutionalized Age-, Gender-, Status-Graded Resources FIGURE 9-1  Multilayered institutionalized contexts shaping aging. Fig5-1.eps 1946-1964) now moving to and through the retirement years are confront- ing unraveling labor market exit and pension expectations, policies, and practices that their parents and grandparents took for granted. In this way, cohorts responding to outdated policies and new circumstances become the engines of social change (Alwin and McCammon, 2007; Ryder, 1965). It is now members of the Boomer cohort who are reshaping what it means to retire and grow old in contemporary society. Consider how taken-for-granted language (about elders, the aged, se- niors, retirement, being/becoming old) is being redefined or challenged. For example, Gilleard and Higgs (2005, p. 157) conclude: “to be done and outside the labour market is no longer to be old. Old age is a status conferred by others. . . . For the majority, what continues is the symbolic connectedness of individualized lives.” In terms of customs as well as a body of rules and laws, systems of educational, labor-market, corporate, retirement, social-welfare, fam- ily, and health-care policies and practices constitute a web of age-graded

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178 NEW DIRECTIONS IN THE SOCIOLOGY OF AGING institutionalized regimes (social structures of resources and schema) based on a very different workforce and “retired” force in the middle of the past century (de Vroom and Bannink, 2008; Ebbinghaus, 2006; Kohli, 2007). These regimes continue to define and shape age, aging, the life course, and health with different logics (and not always internally consistent ones). Moreover, note that such institutional arrangements cannot usefully be studied separately, because they are closely connected and interdependent. They both constrain and facilitate individuals’ options as they confront emerging 21st-century risks and realities in family life, the economy, and life expectancy. Consider, for example, the mismatch between presumed institutionalized protections and the disappearing employment contract. Today older workers confront the off-shoring of jobs, heightened job in- security, unemployment, and nonstandard employment—all of which have been shown to affect health (c.f. Price and Burgard, 2008). But institutions need not be seen as immovable. Some also provide impetus for change (see, Friedland and Alford, 1991; Sewell, 1992), such as the ways higher education as an institution has equipped many Boom- ers with the tools to redefine age in their own biographies and rewrite their own scripts around the aging process. And social forces—a tumultu- ous global economy, an aging population, technological shifts, and other social dislocations—are challenging taken-for-granted institutionalized conventions and practices around work exits, retirement timing, life post- retirement, Social Security, pension policies, and health care. This means that social actors (individuals, groups, organizations, governments), facing often contradictory rules, laws, and realities about labor market and retire- ment exit and entry portals, pensions, and health-care eligibility, must make strategic adaptations, which can then become the seeds of innovation and institutional change. For example, a competitive uncertain global economy has increased concerns of older workers about their job security, retirement timing, and future pensions, including whether they can “afford” to retire. This is the impetus for the development of bridge and part-time jobs, self- employment, and delayed retirement options for a growing older segment of the workforce. Another example is the rising costs of a currently institu- tionalized arrangement for long-term care—nursing homes. Such facilities are being challenged as unsustainable in their present form, in light of the coming age wave of Boomers. Arrangements like continuing care retirement communities, home care, and new technologies to facilitate aging in place are among proposed alternatives. Institutions may seem static and intractable, but they are transformed through nonconformity, negotiation, improvisation, institutional entre- preneurs, and social movements (DiMaggio, 1988). It is often the mis- match or structural lag among existing institutional logics, or between institutions and the social forces rendering them obsolete, which generates

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CONSTRAINED CHOICES 179 opportunities for social change. Such mismatches (lag) help to deinstitu- tionalize conventional arrangements and legitimate new institutions, often through a recombination or reconfiguration of existing elements. This chapter illustrates the value of a program of future research using a combined institutional and life course approach to advance understanding of aging as a social process embedded in multilayered institutional contexts, with both individuals and institutions changing over time. It provides an overview of (1) current concepts and research in the sociology of aging, demography, and social epidemiology that articulate (although not always explicitly) with institutional theory and the ways institutions target and/or impact different subgroups of the population; (2) how institutions intersect and change over time in intended and unintended ways as a result of both social actors’ behavior and other large-scale social forces; and (3) potential scientific and societal pay-offs of an innovative program of future research crossing levels of analysis to address ways (taken-for-granted, age-graded) institutions systemically open up and constrain life chances and life quality for those at different ages and life stages, often in distinctively gendered ways. The chapter is organized around several major social science con- structs that, when married with an institutional/life course approach to age and aging, offer a promising agenda for a program of research over the coming decades: (1) stratification and inequality (including cumulative dis/ advantage and the life course); (2) risk and uncertainty; (3) social support, integration, isolation; (4) agency, control, and adaptive strategies; and (5) time and place. It concludes with a section on future directions. STRATIFICATION AND INEQUALITY OVER THE LIFE COURSE One hallmark of sociology is its emphasis on the effects of social en- vironments on behavior, resources, and health, the seemingly fundamental social structure of inequality (House, 2002; Link, 2008; Link and Phelan, 1995; Lutfey and Freese, 2005; Phelan and Link, 2005; Phelan et al., 2004; Phelan, Link, and Tehranifar, 2010). Some social structures—such as gender, race, education, and income—are markers of location in (insti- tutionalized) status hierarchies. Social environments tied to these attributes produce and reproduce enduring inequalities (Tilly, 1998). Scholarly analy- sis of disparities associated with these social locations has been essential in spotlighting the role of existing and emerging social arrangements in the production and reproduction of inequalities. But while race, gender, and even education are enduring factors, other aspects of social structure, such as neighborhoods, work, and social networks, do change with age, as individuals select or are allocated to different social ecological niches (see also Brooks-Gunn et al., 1993) over the life course. Moreover, the deleteri- ous effects of social-locational markers can be lessened or exacerbated by

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180 NEW DIRECTIONS IN THE SOCIOLOGY OF AGING events (such as the Great Recession of 2007-2009) or with age, in light of institutionalized age-graded policies and practices (such as Social Security and Medicare) offering an income and health-care safety net for older Americans that in the past century served to legitimize retirement as nor- mal life transition (see Atchley, 1982; Costa, 1998; Han and Moen, 1999; Hayward and Grady, 1990; Henretta, 1992; Wise, 2004). Social forces, as well as deliberate policy changes, can also shift social structures, chal- lenging taken-for-granted institutionalized expectations and practices that disadvantage some segments of the population while advantaging others (Blossfeld and Hofmeister, 2006; Blossfeld, Buchholz, and Hofäcker, 2006; Hudson, 2009; Warner, Hayward, and Hardy, 2010; Williamson, 2011). Consider, for example, public and corporate policy directives aimed at re- ducing age and/or gender discrimination (Shuey and O’Rand, 2004) or the development of “bridge” jobs as a way of gradually easing older workers into retirement (Kim and Feldman, 2000; Quinn and Kozy, 1996). Age and Gender Stratification Age and gender are not simply characteristics of individuals shaping their preferences; rather, they are themselves social institutions, key axes organizing social life and “channeling” social choices, such that women and men of different ages and life stages are both allocated to and socialized to expect distinctive roles, resources, and relationships (Dannefer, 2011). While concerns about gender stratification are deeply embedded (institu- tionalized) in social research on inequality (c.f. Grusky, 2001), Riley (Riley, Riley, and Foner, 1994) also emphasized the importance of age stratifica- tion: age as a key marker of unequal access built into existing institutions (e.g., the labor market, education, social-welfare policies) that perpetuate age differentiation and inequalities within and across organizations, com- munities, and societies. (See also Settersten and Lovegreen, 1998, for the ways that education is constrained to certain ages and stages.) Others point to the intersection of age and gender stratification as institutionalized in families as well as public and organizational policies (Allen and Walker, 2000; Harrington Meyer and Herd, 2007; Harrington Meyer and Parker, 2011; Moen, 1994, 2001; Moen and Chermack, 2005; Moen and Spencer, 2006). The ways work and retirement are organized through legislation, regulation, and convention are based on a (male) breadwinner model pre- suming full-time, full-year investment in one’s job, with family responsibili- ties off-loaded to someone else (a wife). These built-in assumptions make it difficult for women (or men) with family care obligations to work con- tinuously throughout adulthood in “good” jobs that provide high wages, pensions, and security (Han and Moen, 1999; Moen and Roehling, 2005). Moreover, Social Security in the United States is predicated on this lock-step

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CONSTRAINED CHOICES 181 model, presuming one’s highest wages just prior to retirement. But women’s movement in and out of jobs, in and out of the labor force in light of their family responsibilities, has meant lower wages, lower pensions, lower Social Security benefits, fewer assets, and great risk of economic insecurity in old age, especially for widows and divorcees (Budig and England, 2001; Budig and Hodges, 2010; Harrington Meyer and Herd, 2007; Harrington Meyer and Parker, 2011). Gendered scripts also guide relationships with organizations and insti- tutions. For example, among dual-earner couples, it is wives who tend to time their retirements around their husbands’ retirement plans (Moen et al., 2005, 2006). The processes by which people are allocated to different roles, re- sources, and relationships and socialized to expect and choose different life paths depending on their age and gender (as well as their race and class) are the direct result of social policies as well as cultural conventions—norms and practices—related to them. European scholars have pointed to the ways social-welfare policies have constructed and institutionalized the life course as a series of patterned role entries, trajectories, and exits based on men’s occupational careers in the mid-20th century (Guillemard and Rein, 1993; Kohli, 2007; Kohli et al., 1991; Krücken and Drori, 2009; Marshall, 2009; Mayer, 2009; Meyer, 1986). Thus the institutionalized life course is in reality a gendered life course (Arber and Ginn, 1991, 1995; Harrington Meyer and Herd, 2007; Harrington Meyer and Parker, 2011; Moen, 1994, 2001; Moen and Roehling, 2005; Moen and Spencer, 2006; Pavalko, 2011; Venn, Davidson, and Arber, 2011), grounded in gendered norms and social policies about work, family, and social relations that intersect with age. As an example, in the United States, unemployment insurance is typically based on men’s experience of being laid off. People (women) who have spent time out of the workforce raising children are not “eligible” for unemployment insur- ance when they re-enter the labor market but cannot find jobs. And women who “work” at home taking care of children or infirm adults do not earn Social Security credits. The distinctive life courses of women and men tend to disadvantage older women, in particular, in light of the gendered nature of their care- work obligations, along with discriminatory practices in the labor market and in welfare distributions throughout the life course (such as the ways part-time jobs do not provide pensions, unemployment insurance, or even health insurance). Family obligations and gender discrimination made it unlikely that current cohorts of older women followed the conventional lock-step of continuous full-time work, often for the same organization, that became the “hook” for the development of labor market and social welfare policies (Barley, 1989; Moen and Roehling, 2005). The result?

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182 NEW DIRECTIONS IN THE SOCIOLOGY OF AGING Older women find themselves with no or low pensions, Social Security pay- ments based on lower wages, and caregiving obligations for ailing spouses or infirm parents that often precipitate unexpected and early labor market exits (Dentinger and Clarkberg, 2002; Harrington Meyer and Herd, 2007). But institutional innovations in the form of greater flexibility offering em- ployees greater control over the time and timing of work and opportunities for more customized careers (Benko and Weisberg, 2007), together with the greater proportions of women attending college and having fewer children (along with men’s declining wages), mean that some women’s career paths are becoming more continuous than discontinuous, suggesting that future cohorts of older women may have different sets of resources. However, women’s greater engagement in the labor market is occurring even as both men and women are increasingly at risk of (1) discontinuities due to lay- offs and forced early retirement buyouts and (2) declining pension/income security (Shuey and O’Rand, 2004; Sweet, Moen, and Meiskins, 2007). Whether this has implications for narrowing gender differences in aging processes (compared to gender disparities among prior cohorts) in future cohorts is an empirical question. Similarly, Bonilla-Silva (2006) proposes a racialized social system framework emphasizing racism as a structure and a set of social practices developed to maintain the advantages of the dominant group, not merely a set of ideas or beliefs, with this system of racialization developing “a life of its own” (p. 32) (see also Jackson, Govia, and Sellers, 2011; Mutchler and Burr, 2011). Future research is necessary to identify the ways women and men of different minorities, immigrants, and other dis- advantaged subgroups are aging, and whether institutionalized safety nets narrow or accentuate inequalities within and across gender in intersection with these identifiable subgroups. An institutional/life course theoretical approach points to the ways the social, economic, and political institutions of particular societies—public and business policies and practices embedded in work, career paths, family, unemployment, pensions, retirement norms, and disability regimes—were developed based on the everyday experiences of mostly white-collar and unionized blue-collar men in the middle of the 20th century, but then came to organize the lives of everyone, including women who entered the work- force, along with other displaced and disadvantaged groups. These outdated templates continue to shape the lives of those in new cohorts now working, retiring, and aging in the 21st century in gendered ways. The range of in- stitutionalized options in the wake of certain biographical events (such as illness, retirement, divorce, death of a spouse, or long-term unemployment) depends on a person’s age, gender, and education (see also Dannefer, 2011). For example, there are both pull factors (such as Social Security, Social Se- curity’s Supplemental Security Income [SSI], and pensions) and push factors (corporate hiring, training, firing, pension, health insurance, and retirement

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CONSTRAINED CHOICES 183 policies) that shape the timing of and pathways through the retirement transition (Ebbinghaus, 2006; Guillemard and Rein, 1993; Henretta, 1992; Kohli et al., 1991; Rix, 2011; Williamson, 2011; Wise, 2004), but these may well operate in different ways for men and women. Future research is needed on the different resources and experiences of different cohorts as they age—and on the heterogeneity of resources and experiences depending on one’s gender, but also on one’s race/ethnicity, nativity, education, occupa- tion, and disability status—in the context of both outdated and innovative institutional arrangements. Cumulative Advantage/Disadvantage A key theoretical and empirical question that could benefit from an in- stitutional/life course approach to advance the study of aging is: Does grow- ing older amplify or reduce existing disparities (by gender, socioeconomic position, race/ethnicity, and their intersections) in stressors, health risks, and material or emotional resources? Cumulative advantage/disadvantage theory proposes that the amplifying process has been the case historically (Dannefer, 2011; O’Rand, 1996; Wilson, Shuey, and Elder, 2007). A variant of cumulative advantage/disadvantage proposes heightened disadvantage as a result of a cumulation of adverse risk factors (Ferraro, Shippee, and Schafer, 2009), and the fundamental cause approach holds that existing social-locational inequalities persist throughout adulthood despite medical advances that are disproportionately allocated to or adopted by those with higher levels of education (Link and Phalen, 1995). But an alternative, age as leveler hypothesis suggests that institutional arrangements advantaging older Americans may help to attenuate economic and health disparities with age (Berkman, Ertel, and Glymour, 2011; Herd, Robert, and House, 2011). However, studies of age as a leveler need to take into consideration the differential mortality of different subgroups. Life course scholars have shown that rewards in later adulthood accrue to those following the standardized lock-step life course of first education and then continuous full-time work, an option available to increasingly fewer individuals and never a reality for most women, the poorly educated, or minorities (Han and Moen, 1999; Moen and Roehling, 2005). As an example, Elman and O’Rand (2004) find that those Boomers who went back to school to obtain college degrees in midlife (typically women and minorities) did not receive earnings commensurate with those who obtained their degrees prior to beginning their full-time labor market participation. An important question for future research: Is it still the case that being “off-time” in transitions continues to matter, in light of the fact that labor market and family transitions no longer adhere to strict templates as to timing, sequence, or duration?

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184 NEW DIRECTIONS IN THE SOCIOLOGY OF AGING In contrast to the medical model focusing on helping individuals who are already sick, a growing body of scholarship emphasizes illness pre- vention, and with it the value of theorizing inequalities in illness and dependency as the consequence of existing, but modifiable social condi- tions (Berkman and Kawachi, 2000; Syme, 2007). Health is improved or hindered by age- and gender-graded paths and possibilities embedded in existing systemic arrangements shaping family, education, work, retirement, religion, health care, and communities. An example, Medicare insurance becomes available only at age 65, constraining the health care of those older Americans (often women) out of work or without work-related health insurance. Future research advances can come from understanding the ways institutionalized social factors affect health, as well as from investigations of the health impacts of emerging innovative arrangements. This promising research agenda could capture the significance of existing—and emerging— institutional conventions and conditions for both life chances and life qual- ity over the life course. RISK AND UNCERTAINTY IN THE CHANGING LIFE COURSE An example of ways institutions reflect past solutions to past social problems: earlier 20th-century concerns about economic insecurity and mortality hazards produced historically organized ways of insuring against risk in old age, in the form of the taken-for-granted institutionalization of life insurance, Social Security, SSI, disability policies and long-term care insurance (see also Costa, 1998; Gruber and Wise, 2004). In the middle of the past century, Social Security provisions (such as linking levels to earn- ings histories), mandatory retirement ages, and the development of defined benefit pensions served to institutionalize retirement as a taken-for-granted one-way, one-time status transition protected from extreme income inse- curity (Costa, 1998; Henretta, 1992; Kohli, 2007). But, as an example of unequal distribution of risk in later adulthood, Quadagno (1994) describes how domestics and farm workers were initially excluded from Social Secu- rity policy, thereby fostering racial disparities. Scholarship reinforces that insurance against risks continues to be unevenly distributed, with a distinc- tion between public policies framed as “insurance” and policies framed as providing (often means-tested) “assistance” (Estes et al., 2009). Aging as a Risk for Society Research underscores that risk is also a way policy makers and practi- tioners are framing the “problems” of an aging society, producing a focus on older individuals as inherently “at risk” (Carr and Muschert, 2009). This risk approach to later adulthood defines old age (and population

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CONSTRAINED CHOICES 185 changes producing rising numbers and proportions of older people) as a social problem, creating challenges for the larger society. This framing, in turn, sets the stage for a politics of aging grounded in a scarcity model of intergenerational conflict and a medical/biological model of the inevitabil- ity of disability and dependency with increasing age (Estes and Associates, 2001; Estes et al., 2009; Hudson, 2005, 2009; Pampel, 1994). It also produces social arrangements (such as health-care practices, residential fa- cilities, and the potential privatizing of Medicare and Social Security) that both diminish the autonomy of older adults and emphasize the dependence of frail older adults, often ignoring others in the same age group who are not at risk. Another potentially rich area for inquiry involves the ways age is being socially constructed (Berger and Luckmann, 1966) to take on biomedical, commodified, privatized, and rationalized aspects (Estes, 2004; Estes and Associates, 2001; Estes et al., 2001, 2009). The biomedicalization of ag- ing emphasizes aging as a medical problem associated with disability and dependence, along with the behavioral and policy implications of this medicalization approach. “Commodification” of old age relates to services and goods that are bought or sold. What Estes and Associates (2001) call the aging enterprise—pension programs and businesses focused on older people—further serves to differentiate older from younger adults through the use of age thresholds and programs that effectively “commodify” old age. Commercial efforts amplified in the mass media create age groups and cultures as “cultural fields,” such as the youth culture, a set of products and practices of young people (especially related to their leisure and buying of goods and services; see Capuzzo, 2001) that continue to define the beliefs and behavior of the large Boomer cohort. “Privatization” has to do with the financing of health insurance, social services, and health care through the private sector, a trend that may promote rather than reduce inequality. “Rationalization” of old age refers to the provision of care in the most ef- ficient ways, with cost concerns and cutbacks often trumping the quality of the care provided, even in nonprofit organizations providing medical and social services. Exposure and Vulnerability In another body of literature sociologists, demographers, and social epidemiologists theorize exposure and vulnerability to the risks of poor health and mortality as systematically stratified by age, gender, and other social-locational markers (such as education, income, labor force status, na- tivity, occupation, race/ethnicity, and marital status). Pearlin’s (1989, 2010) stress process model theorizes the importance of the structural contexts of lives contributing to disparities in the risks of chronic stress exposure and

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