Structural Classism and Health in the United States

• In Event: Fundamental Cause Theory at 30: Rethinking Health Inequities

Abstract

Fundamental Cause Theory (FCT) posits that health disparities by socioeconomic status (SES) persist because the higher SES group has access to flexible resources that they use to maintain their health. While this explains why higher-SES groups always have better health relative to lower-SES groups, it does not address why the health advantage may be larger in some places and at some time points than others. Meanwhile, recent literature on social determinants of health has turned to state-level structural determinants to explain downstream health outcomes and differences in the size of health disparities across states. Social class is one axis that has not yet been measured this way, despite its strong relationship to health. In this paper, we develop the concept of structural classism and construct a quantitative index that captures the domains of policies, labor force, economic inequality, and politics. We then link this index to individual self-rated health to understand how state-level structural classism shapes population health. We argue that structural classism affects health by first stratifying the population into social classes and then modifying individuals’ ability to use health-promoting resources to achieve good health based on their social class. In multilevel logistic regression models with data from the Behavioral Risk Factor Surveillance System in 2023 (N=392,581), we find that structural classism was associated with poor health for individuals with less than a college education (OR=0.97, 95%CI 0.94, 0.99) as well as individuals who graduated college (OR=0.94, 95%CI 0.90, 0.98). These results support the universal harm hypothesis, suggesting that structural classism harms overall population health.

Authors

• Emily Dore, Harvard TH Chan School of Public Health

• Patricia Homan, Florida State University

• Megan M. Reynolds, University of Utah