Social inequalities in health : an institutional perspective

Since the mid-20th century, U.S. healthcare policies have required working-age adults to access health insurance through labor market, marriage, and family institutions. These policy arrangements helped employed, married, and parenting adults gain coverage through the benefits derived from their institutional attachments, but offered unemployed, unmarried, and childless adults little protection against the risk of being uninsured. As the pathways expected to provide access to health insurance are themselves highly stratified, coverage was systematically lower for certain segments of the population, including: men, people of color, and adults with low levels of formal schooling. Recent changes to U.S. healthcare policy prompted by the passage of the Patient Protection and Affordable Care Act (ACA), however, provide adults with a new pathway for obtaining health insurance decoupled from their labor market, marriage, and family attachments. By introducing a new route for adults to obtain health insurance outside of stratifying institutions, the ACA provides a history opportunity to consider the institutional determinants of health and draws attention to the centrality of institutions for our knowledge of health inequalities. I therefore leverage the timing of the ACA’s implementation as a “natural experiment” to investigate how institutions affect health. In three substantive chapters, I use data from the National Survey on Drug Use and Health (NSDUH) to explore the extent to which institutions generate inequalities in outcomes related to health insurance, health care, and health status. Results from these studies show that the ACA produced a number of desirable outcomes in just the first three years following implementation of its key provisions. First, the ACA helped close longtime gaps in health insurance coverage across gender, race and ethnicity, and education. Second, previously uninsured adults experienced substantial improvements in health care and health status. Third, the ACA exhibited large and profound benefits for low-income men with a history of incarceration. Together, these results demonstrate how the ACA raised the floor of health by improving a variety of outcomes for the population’s most disadvantaged groups. In the context of a dramatic and precarious shift in the U.S. healthcare system, this dissertation also has significant methodological and policy relevance.