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Social stratification and the healthcare safety net


Social inequalities can produce disparities in healthcare access and quality. This dissertation explores relationships between two social stratification processes- community residential segregation and social capital- on the supply of U.S. urban safety net providers.

The first paper, "Community residential segregation and the local supply of Federally Qualified Health Centers," used data from the Area Resource File and the U.S. Census to examine growth in FQHCs in urban counties from 2000 to 2007. Residential segregation by poverty and race/ethnicity were measured using the dissimilarity index. Logistic and negative binomial regression models were used for dichotomous and count outcomes, respectively. Residential segregation measures were associated with both county FQHC supply at baseline and the addition of new FQHCs over time. Residential segregation may produce geographic segregation of health services, such that FQHCs may be required to fill the gaps arising from provider maldistribution.

The second paper, "Residential segregation and the survival of U.S. urban public hospitals," used data from the American Hospital Association Annual Survey from 1987 to 2007. Cox proportional hazards models were used to estimate competing risks of hospital closure versus privatization. Poverty rates, intermediate poverty segregation, a low proportion of black residents, and low black residential segregation were associated with closure. Poverty associations suggest that areas with a high need for safety net services may be at risk to lose them, but segregated black communities may successfully advocate for maintenance of public hospitals. In contrast, Hispanic residential segregation was associated with privatization. Areas with segregated Hispanic communities may be less inclined to support public provision of services and have reduced opposition to privatization.

The third paper analyzed the same sample of urban public hospitals in relation to measures of community social capital. Voting rates were associated with closure, whereas bridging social capital among elites was associated with privatization. The findings suggest that social capital among privileged groups bears more influence on public hospital outcomes than vertical connections between the disadvantaged and those in power.

Taken together, the three papers suggest that social determinants may dictate both the need and societal response for the safety net.

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