Dissertation Title: “Essays on Health Policy: How Racism Impedes Progress”

Health policy and racism are extremely intertwined in American politics. Racism is not only a social ill, but also contributes to poor health outcomes for minorities. Major events like the COVID-19 pandemic, the Black Lives Matter movements after the death of George Floyd, and the January 6^th Capitol Riots further highlight the tension between health policy and equitable policies. This interdisciplinary dissertation aims to explore this relationship further within this context. It will use statistical methods, legal analysis, and survey methods to engage with these questions.

Paper 1: Lead Exposure Increases Risk of Death from COVID-19, Particularly in Counties with More Black Residents

Before the rollout of the COVID-19 vaccine, Black Americans were more likely to die from coronavirus infection than their white counterparts, despite being more likely to engage in preventive behaviors. Black Americans are also more likely to live in communities with high rates of lead exposure. At the extreme end of exposure, lead poisoning is associated with numerous health problems, including asthma, cardiovascular disease, kidney disease, and immunodeficiency. These comorbidities are, in turn, associated with greater risk of severe illness from COVID-19. We hypothesized that US counties with greater rates of lead exposure would have higher rates of COVID-19 mortality and that this effect would be especially pronounced in Black communities. Using county-level data on lead exposure and COVID-19 mortality from 1,320 counties in 26 states, we estimated the association between elevated blood lead levels among children and population-adjusted rates of death from COVID-19. We found that there is a positive, statistically significant correlation between elevated blood lead levels in children and COVID-19 mortality. A one-unit increase in the rate of confirmed EBLL among children is associated with a 0.7% (incidence rate ratio: 1.007) higher rate of mortality from COVID-19. We also found that increasing the proportion of a county’s white population is protective against COVID-19 mortality.

Paper 2: Public Health Neglect

Traditionally, scholars and law makers concerned with addressing inequity within health care systems and structures have focused on insurance reform, like what was pursued when the Affordable Care Act was passed. And yet, these same sets of scholars recognize that insurance reform is just one part of a multifaceted effort to address disparities within the United States healthcare system. Indeed, the gaps left by insurance reform scholarship were highlighted by the COVID-19 pandemic and the massive disparities in illness and death that existed between White and Black Americans as a result. Though lawmakers, scholars, and policymakers viewed increasing access to health care through insurance coverage as a victory, racially marginalized Americans still experienced the starkest disparities in COVID-19 exposure and mortality. This has left scholars and policymakers to answer why these disparities existed in an environment where there was supposed to be greater equity across demographic groups in their access to healthcare.

This Article contributes to these conversations. It addresses how communities that have consistently experienced de jure and de facto structural racism, decreased access to desirable social determinants of health, and compromised infrastructural integrity, are not as equipped to weather major health crises as communities that do not have these challenges. The impact of historically discriminatory policies on minority communities, set up them up for failure – especially within the context of public health. This Article argues that the disparities in health outcomes within the United States, at least in part, are attributable to public health neglect. Public health neglect refers to ignoring a community’s health needs, either passively or intentionally, with a consequence of reduced resilience in said community. Framing the current disparities under this new public health neglect theory provides an opportunity to better understand the impact of the COVID-19 pandemic on racially marginalized communities and where health law should shift its focus to in the future. Utilizing a case study and an original empirical study, the Article examines the relationship that structural racism has with social determinants of health, with a specific emphasis on infrastructure. To make progress on equity within the health care system, policymakers and scholars must reframe their thinking to consider the ways neglect has hindered effective public health policy within the United States.

Paper 3: Let’s Talk About Race: Racial Resentment and Health Policy in the 2020s

Racially coded language is a prevalent feature of American politics, and prior studies have shown it has a major impact on public opinion. It has been present in various aspects of social policy throughout American history. Prior studies have shown it affects vote choice, policy preferences, voter realignment, and perceptions of health policy in general. It also activates racial resentment. Researchers have argued that health policy is currently racialized. Though the general relationship that Americans have had with social policy is intertwined with race, health policy became especially racialized during the Obama Administration. Additionally, the United States’ history of racism and discrimination have inserted benefit disproportionality into health policy.

However, there are two gaps in the literature on the impact of racially coded language on health policy. First, there is a need for more literature evaluating racial resentment within the 2020s. The 2020s have brought unprecedented upheavals – the COVID-19 pandemic, the movement for Black Lives after the death of George Floyd, the January 6th Capitol Riots, and the banning of literature and curriculum on racial inequality. These upheavals were heavily racialized. Historically, some scholars have found that explicit racialized language did not resonate with Americans. However, given the racial strife of this era, it is worth reevaluating if these previous findings still hold in 2021. Second, there is a gap in the literature using original datasets to examine the impact of racially coded language and health policy. Much of the literature above relies on analysis done on polling surveys, such as the American National Election Study (ANES). Another portion of this literature has used observational data to develop new theories on the relationship between race and policy. This paper aims to explore these questions by utilizing an original survey that tests the impact of racialized language on health policy.