Racial health inequities are well-documented and pervasive in the United States, but there is still resistance to naming structural racism—and the resultant public policies— as the root cause of those inequities.¹ Although structural racism has the most profound effect on population health, the health effects of it are understudied,^2,3 and divorced from politics and policy.⁴ Structural racism has previously been conceptualized and has largely focused on the criminal legal system, racial residential segregation, health care, and environmental justice.^2,3,5,6 With a few exceptions, most of the empirical research in this area has operationalized structural racism using measures of racial residential segregation and redlining with less attention to other manifestations.^7-8 However, research is underway to create indices that better reflect the multidimensional nature of structural racism.^9-11 As the discourse around and measurement of structural racism continues to develop, the dynamism of both structural racism and public policy should be considered.

Structural racism is dynamic in that is composed of multiple reinforcing systems that allow its continuation even in the absence of individual actions,¹² and its manifestations change over time.¹³ Those systems are embedded and integrated into a federalist system of policymaking where responsibilities and relationships between federal, state, and local governments are constantly shifting. Public policies enacted within this federalist structure also affect future politics and policy development.¹⁴ Furthermore, the United States “has been pervasively constituted by systems of racial hierarchy since its inception.”^15(p75) It is imperative that scholarship on the health effects of structural racism account for the dynamic nature of public policy and racism, racism as a foundational aspect of public policymaking, and the federalist nature of governance in the United States.

Structural and policy changes are required to eliminate racial health inequities and improve overall population health. Michener notes that “the distance between policy intentions and policy outcomes cannot be bridged without attending to the constraints of profoundly racialized social, economic, and political systems.”¹⁶ Bridging the distance between policy intentions and realized health equity will require interdisciplinary approaches and understanding invisible rules and processes.¹⁷ The current paper integrates scholarship from the fields of law, political science, public finance, and public health to elucidate how structural racism produces racial health inequities. As this paper is bringing together ideas from multiple disciplines, I would like to clarify the use of inequality and inequity throughout the paper. Health literature makes a clear distinction between inequality and inequity, and these terms are not interchangeable.¹⁸ Other disciplines do not have this same distinction and typically use the term inequality. I will use inequity and inequities to refer to differences in health that are unfair, avoidable, and unjust.¹⁹ Outside of health, I will use the term inequality to be consistent with the literature I am referencing. The goals of this paper are to 1) describe how the dynamic nature of both structural racism and public policy produces and perpetuates racial health inequities, 2) discuss how federalism contributes to racial inequity in health and the determinants of health, and 3) use the COVID-19 pandemic as an example of how all these factors converge. These concepts can help inform our approach to identifying and measuring structural racism, understanding the role of politics in the production racial health inequities, and informing the development of policies that move us toward health equity.

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