UCLA

This dissertation examines the differential impact of voter suppression on life expectancy, gestational age, and birth weight by race-ethnicity. Voter suppression, though not typically studied by public health researchers, is a critical part of understanding how racial disparities in health are created, maintained, and even exacerbated. Voting is a civil right, and consequently, it is connected to many aspects of everyday life, especially the social determinants of health. Through its ability to concentrate power and resources, as suggested by Fundamental Cause Theory, voter suppression may impact health. Further, voter suppression and the logics that support it are grounded in the ideology of White Supremacy. While some may argue that the goal of voter suppression is to prevent voter fraud, the outcome is to disenfranchise certain groups of people, often defined by race. As such, in Aim 1, I first conduct a county-level analysis to investigate whether inequality in voting for Blacks compared to Whites is associated with four social determinants: segregation, income inequality, child poverty, and air pollution. Next, I test the relationships among voter suppression, county social determinants, and life expectancy, investigating whether social determinants mediate or moderate the impact of voting inequality on health. Data include Robert Wood Johnson Foundation County Health Rankings 2019 and Cooperative Congressional Election Survey (CCES) Data from 2008, 2012, and 2016 aggregated to the county-level are used (N=841 counties). I found that voting inequality is associated, at the county-level, with lower air pollution, higher segregation, and higher income inequality. Further, the strength of the association on social determinants varies with the level of voting inequality (none, low, high). Low voting inequality was a significant predictor of higher White life expectancy, but not significantly associated with Black life expectancy, in bivariate models and as covariates were added, but this relationship was attenuated once social determinants were added to the model. While mediation results were not significant, I did observe a significant interaction effect between segregation and voting inequality in bivariate analyses and one of marginal significance when all covariates were added in predicting Black life expectancy. This relationship is complex: when low and no voting inequality interact with segregation, lower life expectancy is predicted, but when high voting inequality interacts with segregation, we observe a protective effect through which higher levels of segregation are associated with higher life expectancy. In Aim 2, the items from the CCES were used to approximate county-level voter suppression. National Center for Health Statistics Birth Cohort (NCHS) Data was matched to the CCES using county identification codes. Using this multilevel data set, the impact of county-level voter suppression on two birth outcomes, gestational age and birthweight, were tested separately for three Presidential Elections (2008, 2012, and 2016). Voter suppression items included the proportion who had to wait 30 minutes or more to vote, proportion who were unable to vote in general and proportion unable to vote due to reasons such as long lines, loss of absentee ballot, etc. A second set of state-level analyses was conducted which tested the association of state voter identification requirements with birth outcomes. Results for voter suppression items were mixed, with some significant positive and negative associations, as well as many nonsignificant findings. However, when moderation by mother’s race was tested, a clear pattern emerged. While not all results were significant, the majority of significant interaction terms suggest that voter suppression has a disparate, negative impact upon birth outcomes for Black infants compared to White infants. Lastly, Aim 3 investigated the impact of the Shelby County v. Holder Supreme Court decision which invalidated Section 5 of the Voting Rights Act, thus removing voting protections in counties with a history of discrimination at the polls. These counties had been required to seek “preclearance” from the Department of Justice for any changes made to their electoral policies. To test the association between this policy decision and birth outcomes, using NCHS data from 2012-2013 and 2016-2017, a difference in differences approach was used to compare infant outcomes in preclearance counties and non-preclearance counties before and after the policy decision. While the policy decision was not significantly associated with birth outcomes once covariates were added in final models, moderation by mother’s race was tested. For gestational age, the difference in difference in differences estimate was significant and associated with higher gestational age for Black infants in counties previously covered by preclearance. Together, the results suggest that to understand the associations of voter suppression on birth outcomes, once must utilize a race conscious approach. To ignore the roles of race and racism in the pathways connecting voter suppression and health would yield an incomplete picture. Thus, voter suppression may be an important piece in understanding the persistence of racial disparities in birth outcomes and moving towards racial equity.