“Healing Alone?”: Social Capital, Racial Diversity and Health Care Inequality in the American States

• DOI: 10.1177/1532673X17721195
• Published date: 01 November 2017
• Author: Ling Zhu
• Date: 01 November 2017
• Subject Matter: Articles

https://doi.org/10.1177/1532673X17721195

American Politics Research

2017, Vol. 45(6) 1059 –1087

© The Author(s) 2017

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DOI: 10.1177/1532673X17721195

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Article

“Healing Alone?”:

Social Capital, Racial

Diversity and Health

Care Inequality in the

American States

Ling Zhu1

Abstract

There is an influential tradition in political science that social capital,

defined as mutual trust and civic engagement, is linked to better substantive

outcomes for citizens in democracies. Recently, scholars who link social

capital to race and inequality have challenged this favorable picture of

social capital. This study draws from the scholarly discussion on how

social capital affects inequality in diverse societies. Focusing on the health

care domain, I use a new dynamic measure of social capital to evaluate the

“social capital thesis” and “racial diversity thesis” of inequality. Moreover,

I explore how these two political forces are intertwined with each other

in shaping the unequal health care access across American states. Key

empirical findings confirm that social capital and racial diversity are

counterbalancing forces shaping health care inequality. Despite it reduces

health care inequality, the impact of social capital is tempered with high

level of racial diversity.

Keywords

social capital, racial diversity, health care inequality

1University of Houston, Houston, TX, USA

Corresponding Author:

Ling Zhu, Department of Political Science, University of Houston, Philip G. Hoffman Hall 436,

Houston, TX 77204, USA.

Email: lzhu4@central.uh.edu

721195APRXXX10.1177/1532673X17721195American Politics ResearchZhu

research-article2017

1060 American Politics Research 45(6)

Of all the forms of inequality, injustice in health care is the most shocking and

inhumane.

—Martin Luther King, Jr.

A prominent feature of almost all industrialized democracies is the social

gradient in health (Marmot, 2003). Health inequality, defined as group differ-

ences in preventable health risks and access to health care, is a major form of

social inequality. Health inequality blights the lives of many people in both

developed and developing countries (Wilkinson & Pikett, 2009), impedes

democratization, and undermines democracy (Tilly, 2007). Nowhere in the

world places as much emphasis as the United States on improving health

through heavy investment in new medicines and health care technologies

(World Health Organization [WHO], 2010).1 The quality of health care facili-

ties, doctors, and medical technologies in the United States has been deemed

as one of the best in the world. Paradoxically, American citizens do not ben-

efit uniformly from the quality and availability of health care resources.

The American democracy also distinguishes itself from many other west-

ern countries by the evident social inequality in access to health care (Barr,

2007; Jacobs & Skocpol, 2007). As of 2011, about 16% Americans live with-

out any health care coverage. Although the overall uninsured rate has been

stabilized since 2011, stark gaps in access to health care exist across income

groups. In 2011, about 25% of people in households with income less than

US$25,000 had no health care coverage; only 7.8% of people in households

with income of US$75,000 or more were uninsured (DeNavas-Walt, Proctor,

& Smith, 2012). Inequality in access to health care, moreover, is deemed as

one major cause of delayed service utilization (Smedley, Stith, & Nelson,

2003) and disparity in health outcomes (LaVeist, 2005). Disparity in health

care coverage confronts the fundamental value of liberal democracy.

Political scientists have attributed the stark pattern of health care inequal-

ity to various political factors, such as a failure to adopt generous redistribu-

tive health care policies to help the poor (Gray, Lowery, Mo nogan, &

Godwin, 2010; Jacobs & Skocpol, 2007), the privatization of government

responsibilities in health care (Hacker, 2004; Soss, Hacker, & Mettler, 2007),

partisan politics that yield unequal representation (Bartels, 2008), and gov-

ernment inaction in face of market-based inequality and insecurity (Hacker,

2006). We now know much about how these complex political and institu-

tional factors weave the Gordian knot of health care inequality in the

American democracy. Nonetheless, we know far less about what are the

underlying forces that sustain the unequal system and distantiate the privi-

leged and the disadvantaged.