Mechanisms of the Social Production of Population Health Inequality in the United States

Abstract

This dissertation consists of three chapters examining the mechanisms generating health inequality and the potential of social policy to intervene on these mechanisms. In the first chapter I examine the impact of eviction on infant health outcomes. Using data from the state of Georgia from 2000-2016 I find that evictions during pregnancy are associated with significant decrements in infant health, including a decrease in infant birth weight and gestational age and an increase in the probability of being born low birth weight or premature. Eviction actions during pregnancy are associated with adverse birth outcomes which have been shown to have lifelong and multigenerational consequences. Assuring housing, social, and medical assistance to pregnant women at risk for eviction may improve infant health. In the second chapter I examine the inclusion of stigmatizing language in the electronic health record (EHR). Using the free-text of hospital admissions notes I examine whether the prevalence of stigmatizing language in the EHR varies with patient or provider demographic characteristics. I find that 2.5% of all admission notes contained stigmatizing language and that notes about non-Hispanic Black (vs. non-Hispanic White) patients had a greater probability of containing stigmatizing language. Stigmatizing language can alienate patients, alter treatment plans, and transmit biases between providers. Improved conscientiousness and training around avoiding stigmatizing language in medical notes may be beneficial to improving health equity. In the final chapter, I assess the impact of the Affordable Care Act (ACA)-facilitated expansion in Medicaid eligibility on rates of food insecurity. Using data on adult respondents to the Food Security Supplement to the Current Population Survey in U.S. states for the years 2010-2013 and 2015-2016, I compare trends in very low food security (VLFS) among low-income childless adults in states that did and did not expand Medicaid in 2014 under the ACA. In difference-in-difference analysis, Medicaid expansion was associated with a significant adjusted 2.2 percentage point decline in rates of VLFS, equivalent to a 12.5% relative reduction. The improvement in food security after the ACA's health insurance expansion suggests that health insurance provision has spillover effects that reduce other dimensions of poverty.