Dissertation Title:  "Pressing Challenges in U.S. Health Policy: Polarization, Gun Violence, And Discrimination"

In this dissertation, I examine three pressing challenges in health policy in the United States: political polarization, gun violence, and racial discrimination. All three jeopardize public health and risk exacerbating health inequities. Political polarization, especially as it pertains to vaccine uptake, threatens the nation’s ability to protect population health and, in the case of COVID-19, prevent surges in hospitalizations that overwhelm our healthcare system. However, it remains unclear whether polarization is an endemic feature of public health emergencies or whether high levels of polarization during the pandemic represent a departure from the norm.

In Chapter 1, I assess how polarization during COVID-19 compares to past disease outbreaks in the U.S. I conducted a systematic review of survey data from the Roper Center polling database and estimated the association between polarization and COVID vs. non-COVID disease outbreaks using random-effects meta-analyses and mixed-effects meta-regressions. In total, 131 polls spanning 11 outbreaks over nearly 70 years met inclusion criteria. Results show that political polarization is 5-7 times greater than past public health emergencies for which data is available when it comes to concern about infection and vaccine intention, respectively. After controlling for variations in question wording, response options, sampling and weighting techniques, and survey mode, I find that COVID-19 is associated with 10-16 more percentage-points of polarization than historical trends. In sum, polarization, as it pertains to concern about infection and vaccine intention, is far greater during COVID-19 than any other disease outbreak in modern American history for which we have public opinion data.

Gun violence cuts short the lives of nearly 40,000 Americans each year and is a leading cause of death for many demographic groups. Firearm homicides, in particular, disproportionately harm Black Americans. Emerging research suggests firearm deregulation policies like Stand Your Ground may increase rates of violent, premature death. In Chapter 2, I examine the association between a common firearm deregulation policy called permitless carry and firearm mortality in the U.S. Permitless carry laws remove the need for a permit or license for adults to carry a loaded concealed handgun in public, thereby removing administrative barriers, fees, and basic firearm safety training. However, as the law’s popularity has grown, the scientific literature has not kept pace. Using an interrupted time series design, I analyze detailed mortality files from the Centers for Disease Control and Prevention to examine changes in firearm deaths before and after the law’s enactment. Six states that adopted the law between January 1, 2015 and December 31, 2017, excluding states with unusual statutory language and those that passed other gun laws at the same time, comprise my treated group: Idaho, Kansas, Maine, New Hampshire, North Dakota, and West Virginia. I find that enactment of permitless carry is associated with an immediate and sustained increase in population-weighted average monthly rates of firearm homicides, firearm accidents, and firearm deaths of undetermined intent. I find no significant changes in firearm suicide, however, the law is also associated with increases in firearm deaths among young adults ages 20-34 and increases in the growth rate of firearm deaths among older adults ages 55 and above.

Finally, racial discrimination, a pervasive and pernicious problem in American life, threatens the foundations of democracy and our purported values as a nation, and contributes to worse mental and physical health outcomes among victims. However, experiences of racial discrimination among Asian Americans remains understudied, especially as it pertains to subgroups like East Asians, Southeast Asians, and South Asians. In Chapter 3, I use a nationally-representative, probability-based telephone survey of 500 Asian American adults and 902 White adults conducted from January to April 2017 to examine experiences of racial discrimination among Asian Americans across institutional and interpersonal settings. I find that Asians in the United States experience discrimination interpersonally and across many institutional settings, including housing, employment, and health care. I also find that South Asians may be especially vulnerable to forms of institutional discrimination and microaggressions. These results illustrate a need for greater investigation into the unique experiences of Asian subgroups. Given the dramatic rise in discrimination and violence against Asian Americans during the coronavirus pandemic, these findings also underscore the need for greater protections for groups at higher risk of discrimination, within health care and beyond.