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The Impact of Urban Governance on Health Disparities and Local Health Expenditure



The Impact of Political Fragmentation on Health Disparities and Local Health Expenditure

By Yonsu Kim

Doctor of Philosophy in Planning, Policy, and Design

University of California, Irvine, 2016

Associate Professor Tim-Allen Bruckner, Chair

During the 1970s and1980s in the U.S., population movement, urban sprawl and governance reform led to a proliferation of local, autonomous jurisdictions. Previous literature examines how this creation of local governments, referred to as political fragmentation, contributes to public spending and social inequality. I build on this literature by examining three potential consequences of political fragmentation: increased health disparities, reduced public investments in health, and reductions in public economic efficiency. I ground these lines of inquiry from diverse fields including political science, urban planning, and public health.

In my first analytic chapter, I test the hypothesis that the mortality disparity between whites and African Americans varies positively with fragmentation. I retrieved mortality data from the multiple cause-of-death file and measured fragmentation among 226 U.S. counties (population size ≤ 200,000) over four distinct periods (1972-73, 1977-78, 1982-83, and 1987-88). Consistent with my hypothesis, I find a positive relation between political fragmentation and the African American / white difference in all-cause mortality.

Next, to explore a pathway through which fragmentation may increase to health disparities, I examined whether fragmentation corresponds with a reduction in public health expenditures. Consistent with this proposition, I find that fragmentation varies negatively with per capita health expenditure (coef: -0.03, p<0.01), and health expenditure as a proportion of total expenditure (coef: -0.0084, P<0.001). In my last analytic chapter, I test the Leviathan hypothesis that fragmented local governments act inefficiently and lead to unexpected rises in overall local expenditures. Counter to this hypothesis, results indicate that general purpose government fragmentation constraints per capita expenditure (coef: =-0.953, p<0.001).

Taken together, my results suggest that political fragmentation may exacerbate health inequalities by reducing the per capita public outlay for health spending among disadvantaged groups. However, my findings remain inconclusive regarding whether, and to what extent, political fragmentation promotes economic efficiency in public management of urban locales. I conclude with recommendations of future areas of research.

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