Winning Proposal to the Pierce Scholar's Fund: 2010 Competition

Project Title: The Political Geography of U.S. Health Policy

Faculty Sponsor and PI: Jowei Chen

Ph.D. Student: Kate Bradley

Project Description

Why has the U.S. historically lagged behind other Western democracies in health care spending for the poor? The U.S. spends more on health per person than any other OECD nation, and makes higher per-capita public expenditures on health care than almost all other OECD nations, but this public spending is regressively distributed in comparison with other Western democracies. Our direct public health spending flows disproportionately to the elderly, and tax subsidies constitute an enormous public expenditure on those who can afford private health insurance. While the U.S. covers certain categories of the poor with Medicaid, the US is alone among Western industrialized countries in not providing universal coverage.

Previous scholars have offered several explanations for such "American exceptionalism" in low health spending for the poor. Under the conventional wisdom, the U.S. has lagged behind other OECD nations in most categories of poverty spending because of its cultural tradition of small government and because of institutional barriers such as federalism and the separation of powers. Health policy researchers have also explored such explanations as path dependence and the influence of existing health programs such as Medicare,iv the historical role of American "welfare capitalism," or private welfare structures, in dampening demand for public welfare, interest group influence, and the organization of medical care in the U.S.

In this project, we explore a unique geography-based explanation for the lack of political support for universal health coverage in the U.S. Through extensive spatial analysis of GIS data and analysis of geocoded public opinion survey data, we will demonstrate that the geographic distance of many poor, rural communities from specialized medical facilities contributes to relatively low levels of experience with the medical care delivery system, lower health literacy, and low demand for specialized health services. This, in turn, contributes to low electoral demand for federal health care spending, despite high uninsured rates and poor health outcomes among the rural poor. In addition, using congressional roll call votes, we will show that geographic distance to secondary and tertiary medical care is associated with low congressional support for public health financing. In other words, we expect to demonstrate that the residential geography of rural, medically vulnerable populations in the U.S. helps to account for the government’s relatively low spending on health care for the poor.

This project will be the first to show how voters’ local health-related surroundings shape their knowledge of and attitudes toward federal health care policy. Hence, the project contributes to broader theoretical debates in political science concerning political attitudes, electoral representation, distributive spending, and electoral geography. In addition, given that the poor in the U.S. are relatively less urbanized than in many of the developed countries with universal coverage,viii this research constitutes an important addition to the literature on American exceptionalism in health policy.

This research also speaks directly to the current legislative politics of health care reform. Paradoxically, the House Democrats’ health care reform bill was opposed last November by legislators from rural districts, despite the high uninsured rates and high unemployment among these rural populations; the 39 Democratic House members who voted against the health care bill serve disproportionately rural, poorer districts with less access to urban medical facilities. We explain this paradox by demonstrating that the votes of these rural legislators simply reflected their constituents’ low health literacy and their consequent lack of interest in health care reform.

To fully develop this project during the summer, we will collect and analyze data from three sources: 1) GIS data on medical facilities and hospital service areas (HSAs); 2) Geocoded survey responses on health and health policy-related issues from the American National Election Studies (ANES) and the General Social Survey (GSS); 3) U.S. Census demographic and socioeconomic data; and 4) Congressional roll call votes from health care-related bills.

We plan to present this project at the 2011 MPSA and APSA conferences. We are planning two papers from this research for peer-reviewed publication. We will submit one paper to a political science journal, while the second paper will target a health policy audience.