Health Equity and the Dynamism of Structural Racism and Public Policy

Abstract

Policy Points.

• Both public policy and structural racism are dynamic systems that reinforce each other. Efforts to address the health effects of structural racism must account for the nature of these systems.

• Politics and policy are critical for understanding the persistence of racial health inequities and creating policies and interventions that can mitigate the effects of structural racism on health.

Racial health inequities are well‐documented and pervasive in the United States, but there is still resistance to naming structural racism—and the resultant public policies—as the root cause of those inequities. ¹ Although structural racism has the most profound effect on population health, the health effects of it are understudied, ² , ³ and divorced from politics and policy. ⁴ Structural racism has previously been conceptualized and has largely focused on the criminal legal system, racial residential segregation, health care, and environmental justice. ² , ³ , ⁵ , ⁶ With a few exceptions, most of the empirical research in this area has operationalized structural racism using measures of racial residential segregation and redlining with less attention to other manifestations. ⁷ , ⁸ However, research is underway to create indices that better reflect the multidimensional nature of structural racism. ⁹ , ¹⁰ , ¹¹ As the discourse around and measurement of structural racism continues to develop, the dynamism of both structural racism and public policy should be considered.

Structural racism is dynamic in that is composed of multiple reinforcing systems that allow its continuation even in the absence of individual actions, ¹² and its manifestations change over time. ¹³ Those systems are embedded and integrated into a federalist system of policymaking where responsibilities and relationships between federal, state, and local governments are constantly shifting. Public policies enacted within this federalist structure also affect future politics and policy development. ¹⁴ Furthermore, the United States “has been pervasively constituted by systems of racial hierarchy since its inception.” ^{15 (p75)} It is imperative that scholarship on the health effects of structural racism account for the dynamic nature of public policy and racism, racism as a foundational aspect of public policymaking, and the federalist nature of governance in the United States.

Structural and policy changes are required to eliminate racial health inequities and improve overall population health. Michener notes that “the distance between policy intentions and policy outcomes cannot be bridged without attending to the constraints of profoundly racialized social, economic, and political systems.” ¹⁶ Bridging the distance between policy intentions and realized health equity will require interdisciplinary approaches and understanding invisible rules and processes. ¹⁷ The current paper integrates scholarship from the fields of law, political science, public finance, and public health to elucidate how structural racism produces racial health inequities. As this paper is bringing together ideas from multiple disciplines, I would like to clarify the use of inequality and inequity throughout the paper. Health literature makes a clear distinction between inequality and inequity, and these terms are not interchangeable. ¹⁸ Other disciplines do not have this same distinction and typically use the term inequality. I will use inequity and inequities to refer to differences in health that are unfair, avoidable, and unjust. ¹⁹ Outside of health, I will use the term inequality to be consistent with the literature I am referencing. The goals of this paper are to 1) describe how the dynamic nature of both structural racism and public policy produces and perpetuates racial health inequities, 2) discuss how federalism contributes to racial inequity in health and the determinants of health, and 3) use the COVID‐19 pandemic as an example of how all these factors converge. These concepts can help inform our approach to identifying and measuring structural racism, understanding the role of politics in the production racial health inequities, and informing the development of policies that move us toward health equity.

Dynamic Public Policy Through Policy Feedback Effects

A robust policy feedback literature has shown that public policies are outputs of politics, but those policies also affect future policy choices and the attitudes and behaviors of citizens, interest groups, and political elites, also known as policy feedback effects. ²⁰ Policy feedback effects can be negative, positive, or nonexistent and are dependent upon the political context, characteristics of the policies, target population of the policies, and how the policies are administered. ²¹ , ²² For example, the development of Social Security and Medicare facilitated the growth of one of the most powerful and influential interest groups, the American Association for Retired People (AARP). ¹⁴

Administrative burdens are another example of policy feedback effects. Burden et al. ²³ define administrative burdens as “an individual's experience of policy implementation as onerous.” Burdens are the primary way citizens interact with their governments. They help citizens determine if government is responsive to their needs, if their voices are valued, and if they are being treated fairly by their government. ²⁴ All social programs have administrative burdens, but means‐tested programs like Medicaid and Temporary Assistance for Needy Families (TANF) are more burdensome than universal programs like Social Security and Medicare. ²⁵ People are sensitive to these differences. Kumlin and Rothstein found that citizens had higher levels of social trust and perceived more fair treatment by their government when they received universal welfare services compared to means‐tested services. ²⁶ Reducing administrative burdens is associated with increased Medicaid take‐up in Wisconsin ²⁵ and increased voter turnout in presidential elections. ²⁷

Policy feedback effects are not limited to individuals but also occur at the community level. ²⁸ Michener found that as the proportion of county residents enrolled in Medicaid increased, civic and political membership associations and aggregate rates of voting declined. ²⁸ She attributes her findings to a phenomenon called policy concentration which is a “form of concentrated disadvantage that happens when particular geographic locales have disproportionate numbers of residents affected by a given policy.” ²⁸ Jones explored a different form of policy concentration in the Mississippi Delta. ²⁹ The residents of the Delta are disproportionately Black compared to other parts of the state and have some of the worst health outcomes in the nation. Jones found that state legislators from the Delta have less influence in state‐level policymaking compared to legislators from other parts of the state. ²⁹ In this case, the policy concentration manifested in decreased influence of elected representatives from the Delta instead of less political participation by the residents of the Delta.

Population Health as a Policy Feedback Effect

The policy feedback literature does not include health as a policy feedback, but research suggests that it operates like other feedbacks. Health, like other policy feedback effects, is both an input and output of policy. ³⁰ , ³¹ A relationship between health status and political participation is well established, but the direction and strength of the relationship varies by race/ethnicity, health condition, income, and education. ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ As the focus of this paper is on racial health inequities, I will focus my discussion on the political consequences of health inequities.

Structural Racism, Population Health, and Policy Feedback

Pacheco and Ojeda found that health status is associated with political representation with healthier individuals having better congressional representation than unhealthy individuals at the national level. ³⁹ They theorize that health disparities result in increased inequalities in representation, and inequalities in representation result in the passage and implementation of policies that are detrimental to health. The authors note that it is unknown if this relationship exists at other levels of government and across other types of inequities such as racial health inequities.

Research by Rodriguez demonstrates that political participation is dependent on the survival of citizens. ⁴⁰ Racial and socioeconomic disparities in mortality mean that the individuals who are most likely to advocate and support redistributive policies that are needed to reduce disparities are unable to do so. As time goes on, political participation among higher socioeconomic status people and white people helps perpetuate inequity through these groups’ ability to participate in the political process and the enactment of policies that are beneficial to them. ⁴¹ , ⁴² Higher mortality rates among Black and low‐income people means the electorate is increasingly composed of groups that are supportive of the very policies that produce and perpetuate racial health inequities. Hence, the cycle continues.

The health effects of voter suppression laws serve as another example of health as a policy feedback affect. Voter suppression laws (e.g., strict identification laws, mass voter purging, reductions in early voting access) are a form of structural racism. ⁴³ States with higher numbers of Black voters and higher rates of voter turnout among racially minoritized voters are more likely to implement voter suppression laws and policies. ⁴⁴ As a result, people of color are disproportionately affected by these policies. Hing posits that voter suppression tactics exacerbate racial health inequities through multiple pathways. ⁴⁵ Voter suppression laws decrease voter turnout and civic participation among people of color. Consequently, they are unable to influence policies that shape the distribution of resources and social conditions that are important for their health. Consistent with findings by Rodriguez, ⁴⁰ , ⁴¹ , ⁴² the pathway between voter suppression and poor health is likely bidirectional. Being subject to voter suppression tactics may harm health through feelings of exclusion, disempowerment, ⁴⁶ and perceived discrimination, ⁴⁷ which are all associated with poorer health outcomes. The adverse health effects of voter suppression may be further compounded by the relationship between poor health and being less likely to vote. ⁴⁸

Health may also act as a policy feedback effect of administrative burdens. Many social programs like unemployment insurance, Earned Income Tax Credit (EITC), food stamps, and Medicaid are associated with improved health outcomes. ⁴⁹ However, the health benefits of these programs may be limited or unrealized if people are unable to utilize these programs due to administrative burdens. Administrative burdens may also directly harm health through increased psychological stress and its sequelae from trying to navigate these programs. ⁵⁰

Policy feedback effects and policy concentration may be potential pathways that connect structural racism, public policy, and health inequities (Figure 1). In addition to incorporating policy feedback approaches, research will be more impactful by understanding the macro‐level environment in which public policy is created and implemented in the United States.

Figure 1.

Linkages Between Structural Racism, Public Policy, and Health Equity

Public Policy Within a Federalist System

The federalist system of governance in the United States was and is a response to economic, social, political, and cultural forces. ⁵¹ The relationship between federal and state governments is not fixed. Before the Civil War, states and the federal government practiced dual federalism characterized by limited cooperation and the belief that states were equal to and/or superior to the federal government. ⁵² The original framers associated strong national governments with tyranny and regarded state governments as a mechanism for ensuring freedom and individual rights. ⁵³ Yet, federalism has not been viewed as a structure that enhances the freedom and individual rights of Black people and other people of color. ⁵⁴ , ⁵⁵

The enslavement of people of African descent and the accompanying racial hierarchy were creatures of state law. Following the Civil War, the former confederate states were uninterested in protecting the individual liberty of formerly enslaved people. As a result, the federal government extended its powers by enacting the 13th, 14th, and 15th amendments (i.e., Reconstruction Amendments). These amendments authorized Congress to limit state authority to combat racial inequality. ⁵⁴ Bacigal describes federalism as a pendulum and credits the 14th amendment with setting the previously stagnant pendulum in motion. ⁵³ The Reconstruction Amendments established equal citizenship for Black people nationally, but Southern lawmakers shaped and utilized federalism to continue systemic racial segregation and discrimination. ⁵⁶

The tension between federalism and racial equality is arguably a feature not a bug. Federalism provides political autonomy for geographically based groups (i.e., states), not for minority groups within those geographies. As envisioned, federalism was meant to empower states and protect them from subordination from majoritarian institutions and constituencies even when state politics diverged from the national majority. ⁵⁷ Even though the national government can promote and legislate racial equality, states have the autonomy to create and operate under racist systems.

Blumstein describes this as the “federalism deal” where the political autonomy of states is linked with national assurance of civil rights for racial, ethnic, political, and gender‐based groups within those autonomous geographic areas. ⁵⁷ Yet, federal empowerment to assure civil rights is at odds with state autonomy. Understanding and addressing the health effects of structural racism through public policy should engage with the “federalism deal.” I will highlight two potential pathways that federalism breeds racial health inequities: 1) fiscal federalism, and 2) regulatory federalism.

Fiscal Federalism, Place‐Based Inequality, and Race

Fiscal federalism—the division of finances between federal, state, and local governments—has created inherent social and economic inequality based on where people live and is consequential for health equity. States provide their residents with various public goods and services and have different abilities to fund those services. For example, all states fund education and Medicaid, but states have different abilities to generate revenue to provide those resources to their residents. This results in citizens in wealthier states having one and half to two times larger access to resources than citizens in poorer states. ⁵⁸

State fiscal capacity varies substantially due to variation in state tax systems and the total amount of taxable resources across states. ⁵⁹ Richer states spend more on public goods and services than poorer states, ⁵⁸ and states with fewer economic resources struggle to provide a similar level of public goods and services as wealthier states. ⁶⁰ Massachusetts, a wealthier state, spends two times as much on education per pupil than Mississippi, a poorer state. Yet, Mississippi dedicates a larger share of its total taxable resources to education and public spending. ⁵⁹ Consequently, state disparities in fiscal capacity result in differential access to basic public goods for residents, ⁵⁸ and the likelihood of accessing adequate public services depends on where one lives. The current structure means that there are inherent state disparities in the amount and quality of resources and services available, and those disparities translate into social and economic inequality among the people in states. ⁶⁰ In simple terms, “the inequality of states undermines the equality of their residents.” ⁵⁸

Subnational fiscal disparities are common, and federal equalization programs are generally successful at reducing those disparities. Many federated countries such as Canada, Australia, Germany, India, Nigeria, South Africa, Uganda, Philippines, and China have fiscal equalization programs. ⁶¹ However, the United States is an outlier because it does not have a stand‐alone equalization program which “…is a crucial structural feature that exacerbates regional inequalities while distinguishing the United States from other federal countries.” ⁶²

The federal government does subsidize state budgets, but not in a way that reduces fiscal disparities among states. ⁵⁹ Over the past decade, the federal government has provided roughly one‐third of all revenue collected by state governments. ⁶³ Two‐thirds of federal grants to states are for Medicaid, and Medicaid is the fastest growing budget item for states. ⁶⁴ Medicaid is jointly funded by states and the federal government through a matching grant using the Federal Medical Assistance Percentage (FMAP) formula. The federal share of traditional Medicaid is based on states’ per capita income relative to other states with the federal government covering a larger share in poorer states. In FY 2022, the FMAP ranged from 50% to 78% .⁶⁵ The amount of funding a state receives depends on the amount of dollars it spends from its own revenues. Although wealthier states have a lower FMAP, they can afford to spend greater sums of their own revenue. The statutory minimum of 50% means that even high fiscal capacity states receive at least a 50% match. As a means‐tested program, poorer states have a higher demand for Medicaid spending and a lower ability to fund the program because of limited fiscal capacity. This structure does not reduce fiscal disparities between wealthier and poorer states, but instead exacerbates them. ⁵⁹

For example, in 2018, California, a wealthier state, had an FMAP of 50%. Two poorer states, Mississippi and Missouri, had FMAPs of 75.6% and 64.6%, respectively. ⁶⁶ While these states have different levels of federal support, they all applied similar fiscal effort (Figure 2). Although the FMAP provides higher levels of federal support for poorer states, the higher FMAPs for poorer states do not necessarily reduce fiscal disparities among states because wealthy and poorer states are applying similar fiscal efforts to support their programs.

Figure 2.

State Medicaid Fiscal Effort, 2018. [Colour figure can be viewed at wileyonlinelibrary.com]

Author's analysis of US Treasury (2020) Total Taxable Resources Estimates ⁶⁷ and MACPAC (2020) and MACStats: Medicaid and CHIP Data Book. ⁶⁸ State Medicaid Fiscal Effort was calculated as states’ own spending on Medicaid relative to their fiscal capacity, measured by their total taxable resources.

Policymakers in nonexpansion states express concern about the impact of Medicaid expansion on their budgets, and McCabe ⁵⁹ suggests that fiscal capacity disparities may have contributed to the politicization of Medicaid expansion in poorer states. The majority of nonexpansion states, like Mississippi, have lower than average fiscal capacity. ⁵⁹ Although states would receive a 90% percent matching rate for expansion enrollees, Mississippi would have to spend a higher proportion of its total taxable resources to receive the same federal funding per capita as Connecticut, a much wealthier state. ⁵⁹

In the face of regional inequalities, the United States has not implemented a standalone fiscal equalization program like those used by numerous other federalized countries. The reasons for that absence may be provide insight into if and how fiscal federalism contributes to racial health inequities. Public finance and fiscal policy are racialized with race and racism influencing the structure of tax systems and government expenditures. ⁶⁹ Before the Civil War, wealth and political power in the US South was concentrated among a few large plantation owners. ⁷⁰ Financial policy was driven by a commitment to states’ rights and protecting slave assets and the associated racial hierarchy. The Southern states opposed a national bank and large public debt and were hesitant about taxing the major source of revenue in their economy, slave assets. This created a distinct political economy in the South characterized by low tax rates, limited public goods, and high levels of inequality. ⁷¹ In contrast, fiscal policy in the North supported a national bank, a more powerful federal government, and an industrial economy. ⁷²

During Reconstruction, newly elected Black politicians worked to transform the Southern economy by supporting taxes to provide public goods like education, infrastructure, railroads, and public assistance. The taxation and expanding role of government was met with organized, significant, and at times violent, backlash. The tax burden for these public goods fell on white landowners and white people who believed that these new programs would disproportionately benefit Black people. ⁷¹ The backlash against the provision of robust public goods and increased taxation hindered the transformation of fiscal policy in the South. Compared to other counties in the South, counties with more wealthy elite planters were comparatively less productive post‐Civil War because they had low levels of investment in public goods. ⁷⁰ All of this occurred at the same time other countries were discussing and beginning to implement their fiscal equalization programs, yet discussions and action in the United States were constrained by civil unrest and racial injustice. Historical attempts to equalize fiscal resources at the state level fell short because wealthier regions were reluctant to fund state sanctioned racial segregation and oppression. ⁶⁰

The South remains the poorest region in the country. ⁷³ Longstanding state‐level disparities in resources and the historical racism that undergirds them are especially consequential for Black people given that in 2019, 56% of the Black population lived in the South. ⁷⁴ Black people are disproportionately exposed to place‐based disparities as a consequence of simply living in states with less fiscal capacity and less robust economic and social resources that are important for health.

Regulatory Federalism Through Social Programs and Racial Inequity

In addition to differing fiscal capabilities and structures, states have significant autonomy in policymaking (i.e., regulatory federalism) resulting in high levels of geographic policy variation. ⁷⁵ , ⁷⁶ Like fiscal federalism, regulatory federalism also creates place‐based inequalities that adversely affect Black people and other people of color. Medicaid expansion under the Affordable Care Act (ACA) and welfare reform are salient examples of how regulatory federalism contributed to the production of racial inequity in health and health determinants.

The ACA originally intended to expand Medicaid access to all people with incomes 138% below the federal poverty level, however, that provision was struck down in a US Supreme Court ruling that gave states the legal authority to not expand their Medicaid programs. ⁷⁶ The majority of nonexpansion states are in the South and several of those states have large populations of people of color. ⁷⁷ Most studies have concluded that Medicaid expansion reduced but did not eliminate racial disparities in health care coverage. The continuing disparities in health care coverage have partially been attributed to the disproportionate number of uninsured people of color living in nonexpansion states. ⁷⁸

Welfare reform is another example of how regulatory federalism can breed racial inequality. Since 1935, the Aid to Families with Dependent Children (AFDC) provided cash assistance to families with children living in poverty. States had significant discretion in determining eligibility, and caseworkers often decided that families of color were not eligible to participate. ⁷⁹ , ⁸⁰ Due to rampant racial discrimination in program implementation, state authority over eligibility was reduced. However, in 1996, welfare was reformed, and the TANF program replaced AFDC. This change was accompanied by block grants to states from the federal government, mandatory work requirements for recipients, limits on cash assistance, and increased state authority over the program. ⁸¹ States were again able to determine eligibility, amount of cash assistance, time limits on program participation, and what additional services (e.g., childcare, job training, work supports) would be provided to help recipients meet their work requirements. The federalist structure means that there is not a single TANF program but 50 different programs with various levels of spending and supports. Predictably, these state TANF policy choices have contributed to racial inequity. ⁸²

States with higher proportions of Black residents have less generous benefits and more restrictive programs. ⁸³ The racial composition of TANF caseloads also influences state policy decisions. States with higher proportions of Black TANF recipients have comparatively less generous programs with stricter time limits and family caps (i.e., denying aid for additional children). The decentralization of policy through federalism provides an avenue for states to produce and reify racial inequity. ⁸⁴ While both federal and state governments have created racist policies, federal intervention has typically been required to address state‐level racially discriminatory policies. ⁸⁵

The Convergence of Federalism, Policy Feedback Effects, Structural Racism to Produce Racial Health Inequities

As a responsive structure, federalism interacts with racism to shape state‐level policy decisions and produce racial health inequities. Mississippi's response to the COVID‐19 pandemic is emblematic of how federalism and the dynamic nature of structural racism and public policy converged to produce racial health inequities. Racial disparities in COVID‐19 morbidity, mortality, and vaccination rates are pronounced in Mississippi. ⁸⁶ The majority Black population of the Mississippi Delta was especially vulnerable to the health and economic effects of COVID‐19 due to state policy choices available because of federalism and a history grounded in the economics and politics of slavery.

Mississippi has not expanded their Medicaid program under the ACA and has one of the most restrictive Medicaid income eligibility limits in the country. ⁸⁷ The state also has a higher‐than‐average uninsured rate, and some of the poorest health outcomes in the nation. Within the state, Black Mississippians have a comparatively higher prevalence of chronic disease morbidity and mortality and the highest rate of uninsured. ⁸⁸ Even though they opted not to expand their Medicaid program, Mississippi has a pending Section 1115 waiver to require Medicaid enrollees to work or to engage in work‐related activities at least 20 hours a week to receive health coverage. ⁸⁹ Black and rural Medicaid recipients would be most affected by the proposed work requirement. ⁹⁰

In addition to limited health care access, the state operates under the federal minimum wage of $7.25 and has the highest proportion of Supplemental Nutrition Assistance Program (SNAP) enrollees of any state. ⁹¹ As of December 2021, Mississippi also had one of the lowest labor force participation rates in the nation at 55.2% compared to the US average of 62.2%. ⁹² Some Mississippians have noted that increasing access to health care coverage may be an important mechanism for increasing the low labor force participation rate. ⁹³ Multiple studies have found increased labor force participation after receiving coverage through Medicaid expansion. ⁹⁴

Chronic underinvestment and decreasing federal funding for public health is well‐documented. ⁹⁵ As federal funding for public health has decreased, there has been an increased reliance on state and local funds, ⁹⁶ but increasing funding is more difficult for states like Mississippi with limited fiscal capacity. The Mississippi Department of Health has cited greater demand for public services due to high poverty and unemployment and limited state dollars due to a poor local tax base as major external factors affecting their ability to conduct their work. ⁸⁸

The combination of these policies created an ideal environment for the production of racial health inequities—limited access to health care, difficulty earning a living wage, the inability to build wealth, and less political power to make the needed changes. The current political environment in Mississippi is shaped by both past and the present attitudes and beliefs. Southern whites that currently reside in areas where slaveholding was more prevalent, like the Mississippi Delta, are more politically conservative and less likely to support redistributive social policies, particularly policies that are perceived to be helpful to Black people or be race‐related. ⁹⁷ Research has also found that states with larger Black populations and higher levels of racial resentment were less likely and more resistant to Medicaid expansion. In the Mississippi Delta, all of this is compounded by state legislators from that region being less influential in decision‐making at the state level as well. ²⁹ While this is just one example, research on the health effects of structural racism must contend with all of the complexities and nuances present in the Mississippi Delta.

Conclusion

Research on the health effects of structural racism must be interdisciplinary and grounded in history. The lack of historical context and analysis is a major critique of the racial health disparities literature. ⁹⁸ , ⁹⁹ However, the dynamism of structural racism and public policy can only be understood and dissected through a historical lens. Racism and the resultant racial health inequities are deeply entrenched in American society. The elimination of racial inequities requires a clear understanding of the dynamic processes and systems that has produced and perpetuates them.