'The Very Structure of Opportunities Has Collapsed': How Taxation Policies Enhance, Decay, and Otherwise Affect the Distribution of Health & Health Services in the United States

Author

Valerie Pacino, University of Nebraska Medical CenterFollow

ORCID ID

0000-0001-6109-0677

Graduation Date

Spring 5-6-2023

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Programs

Health Services Research, Administration, and Policy

First Advisor

Hongmei Wang, Ph.D.

Second Advisor

Hyo Jung Tak, Ph.D.

Third Advisor

David Palm, Ph.D.

Fourth Advisor

Melissa Tibbits, Ph.D.

Abstract

Taxation is a function of government that patterns our lives socially, economically, and politically, but it remains understudied in public health. This dissertation examines three different elements of tax policy in the United States. First, a systematic review assesses the effects of in-work tax credits on child health outcomes and suggests they improve some infant and child health outcomes, particularly overall health, low birthweight, gestational age, and abuse and neglect. It concludes with suggestions to improve both the study of and structure of tax credits. Next, an interrupted time series analysis tracks ten years of community benefits spending by nonprofit hospitals and finds Medicaid expansion is associated with significant and substantial decreases in spending allocated toward financial aid at cost (“charity care”) but no increases in spending allocated toward population health activities. These findings raise policy questions about the justification of nonprofit hospitals’ tax-exempt status. Finally, a multilevel random-effects analysis of state tax code progressivity finds odds of premature death above median are significantly lower in counties in the states with the most progressive tax systems compared to counties in the states with the most regressive tax systems – as much as 78% lower. Taken together, we begin to see the ways in which tax policies meaningfully shape the macroeconomic, social, and political contexts that contribute to the way health and health inequities are distributed in a society. We end by suggesting that the complexity and administrative burden of tax policy itself could be a tax, one placed on those least able to afford it. Public health researchers should rigorously and robustly consider these and other under-studied tax policies and their ramifications for population health. Public health practitioners and policymakers should advocate for more progressive tax systems and policies as a strategy for improving health outcomes and health equity among their constituencies.

Comments

2023 Copyright, the authors

Recommended Citation

Pacino, Valerie, "'The Very Structure of Opportunities Has Collapsed': How Taxation Policies Enhance, Decay, and Otherwise Affect the Distribution of Health & Health Services in the United States" (2023). Theses & Dissertations. 733.
https://digitalcommons.unmc.edu/etd/733