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ABSTRACT OF THE DISSERTATIONThe Impact of Political Fragmentation on Health Disparities and Local Health ExpenditureBy Yonsu KimDoctor of Philosophy in Planning, Policy, and DesignUniversity of California, Irvine, 2016Associate Professor Tim-Allen Bruckner, Chair During the 1970s and1980s in the U.S., population movement, urban sprawl and governance reform led to a proliferation of local, autonomous jurisdictions. Previous literature examines how this creation of local governments, referred to as political fragmentation, contributes to public spending and social inequality. I build on this literature by examining three potential consequences of political fragmentation: increased health disparities, reduced public investments in health, and reductions in public economic efficiency. I ground these lines of inquiry from diverse fields including political science, urban planning, and public health. In my first analytic chapter, I test the hypothesis that the mortality disparity between whites and African Americans varies positively with fragmentation. I retrieved mortality data from the multiple cause-of-death file and measured fragmentation among 226 U.S. counties (population size ≤ 200,000) over four distinct periods (1972-73, 1977-78, 1982-83, and 1987-88). Consistent with my hypothesis, I find a positive relation between political fragmentation and the African American / white difference in all-cause mortality.Next, to explore a pathway through which fragmentation may increase to health disparities, I examined whether fragmentation corresponds with a reduction in public health expenditures. Consistent with this proposition, I find that fragmentation varies negatively with per capita health expenditure (coef: -0.03, p<0.01), and health expenditure as a proportion of total expenditure (coef: -0.0084, P<0.001). In my last analytic chapter, I test the Leviathan hypothesis that fragmented local governments act inefficiently and lead to unexpected rises in overall local expenditures. Counter to this hypothesis, results indicate that general purpose government fragmentation constraints per capita expenditure (coef: =-0.953, p<0.001).Taken together, my results suggest that political fragmentation may exacerbate health inequalities by reducing the per capita public outlay for health spending among disadvantaged groups. However, my findings remain inconclusive regarding whether, and to what extent, political fragmentation promotes economic efficiency in public management of urban locales. I conclude with recommendations of future areas of research.

ObjectiveDuring the 1970s and 1980s in the U.S., population movement, urban sprawl and urban governance reform led to a proliferation of local, autonomous jurisdictions. Prior literature examines how this creation of local governments, also referred to as political fragmentation, contributes to economic growth and social inequality. We examine the impact of political fragmentation on health equity by testing the hypothesis that the mortality disparity between whites and African-Americans varies positively with political fragmentation.MethodsWe retrieved mortality data from the multiple cause-of-death file and calculated total number of local governments per 1000 residents in a county to measure the degree of political fragmentation. We focused on 226 U.S. counties with population size greater than 200,000 and restricted the analysis to four distinct periods with overlapping government and mortality data (1972-73, 1977-78, 1982-83, and 1987-88). We applied generalized estimating equation methods that permit analysis of clustered data over time. Methods also controlled for the age structure of the population, reductions in mortality over time, and confounding by county-level sociodemographic variables.ResultsAdjusted coefficients of fragmentation are positive and statistically significant for both whites (coef: 2.60, SE: 0.60, p<0.001) and African-Americans (coef: 5.31, SE: 1.56, p<0.001). The two-fold larger positive coefficient for African-Americans than for whites indicates a greater racial disparity in mortality among more politically fragmented urban counties and/or time periods.ConclusionsFrom 1972 to 1988, political fragmentation in large urban counties moves positively with the racial/ethnic gap in mortality between whites and African-Americans. We discuss intervening mechanisms through which political fragmentation may disproportionately affect mortality among African-Americans.

Objective:During the 1970s and 1980s in the U.S., population movement, urban sprawl and urban governance reform led to a proliferation of local, autonomous jurisdictions. Prior literature examines how this creation of local governments, also referred to as political fragmentation, contributes to economic growth and social inequality. We examine the impact of political fragmentation on health equity by testing the hypothesis that the mortality disparity between whites and African-Americans varies positively with political fragmentation. Methods:We retrieved mortality data from the multiple cause-of-death file and calculated total number of local governments per 1000 residents in a county to measure the degree of political fragmentation. We focused on 226 U.S. counties with population size greater than 200,000 and restricted the analysis to four distinct periods with overlapping government and mortality data (1972-73, 1977-78, 1982-83, and 1987-88). We applied generalized estimating equation methods that permit analysis of clustered data over time. Methods also controlled for the age structure of the population, reductions in mortality over time, and confounding by county-level sociodemographic variables. Results:Adjusted coefficients of fragmentation are positive and statistically significant for both whites (coef: 2.60, SE: 0.60, p<0.001) and African-Americans (coef: 5.31, SE: 1.56, p<0.001). The two-fold larger positive coefficient for African-Americans than for whites indicates a greater racial disparity in mortality among more politically fragmented urban counties and/or time periods. Conclusions:From 1972 to 1988, political fragmentation in large urban counties moves positively with the racial/ethnic gap in mortality between whites and African-Americans. We discuss intervening mechanisms through which political fragmentation may disproportionately affect mortality among African-Americans.

During the 1970s and 1980s in the U.S., population movement, urban sprawl and urban governance reform led to a proliferation of local, autonomous jurisdictions. Prior literature examines how this creation of local governments, also referred to as political fragmentation, contributes to economic growth and social inequality. We examine the impact of political fragmentation on health equity by testing the hypothesis that the mortality disparity between whites and African-Americans varies positively with political fragmentation.We retrieved mortality data from the multiple cause-of-death file and calculated total number of local governments per 1000 residents in a county to measure the degree of political fragmentation. We focused on 226 U.S. counties with population size greater than 200,000 and restricted the analysis to four distinct periods with overlapping government and mortality data (1972-73, 1977-78, 1982-83, and 1987-88). We applied generalized estimating equation methods that permit analysis of clustered data over time. Methods also controlled for the age structure of the population, reductions in mortality over time, and confounding by county-level sociodemographic variables.Adjusted coefficients of fragmentation are positive and statistically significant for both whites (coef: 2.60, SE: 0.60, p<0.001) and African-Americans (coef: 5.31, SE: 1.56, p<0.001). The two-fold larger positive coefficient for African-Americans than for whites indicates a greater racial disparity in mortality among more politically fragmented urban counties and/or time periods.From 1972 to 1988, political fragmentation in large urban counties moves positively with the racial/ethnic gap in mortality between whites and African-Americans. We discuss intervening mechanisms through which political fragmentation may disproportionately affect mortality among African-Americans.

•We study political fragmentation in urban areas from 1972 to 1988.•We use local governments per 1000 persons as a fragmentation metric.•Our panel data and methods permit robust population health estimates.•Fragmented governance increases African-American more than white mortality.