RESEARCH AND PRACTICE
State Constitutional Commitment to Health and Health Care and Population Health Outcomes: Evidence From Historical US Data Hiroaki Matsuura, ScD
In light of the current debate over the Affordable Care Act (Pub. L. No. 111---148), the right to health or one of its elements, the right to health care, is taking center stage in terms of resource allocation in US health politics. Although the term “right to health” appeared as early as 1796 in congressional debates over quarantine laws, the right to health and health care has played a fairly limited role in US health politics.1 In addition, the US judiciary has been reluctant to recognize this right and has never interpreted the Constitution as requiring the government to guarantee any protection of health care access or other health-related rights for US citizens.2,3 One reason for this lack of recognition is that the US Constitution does not include an explicit statement regarding health and health care or other socioeconomic rights, such as education, social welfare, or the environment. The US constitutional system has enjoyed a unique division of labor between federal and state constitutions regarding the provision of constitutional rights.4---6 State constitutions contain a number of socioeconomic rights for which there is no acknowledged national consensus and that are not included in the federal constitution. As of April 2014, 15 state constitutions specifically mention health and health care—either in the form of a programmatic statement, public concern, individual right, or government duty beyond the federal minimum, that is, no constitutional right. States have a long history of leadership regarding health policy in the United States. State constitutions may bind and restrict such state government initiatives to offer more equitable health care to their citizens. Although such state-level constitutional rights have also been poorly enforced through the judiciary in the United States, the presence of such rights may lead to a better health care system through legislative action.7
Objectives. I investigated whether the introduction of health and health care provisions in US state constitutions can make health systems more equitable and improve health outcomes by urging state policymakers and administrative agencies to uphold their human rights obligations at state level. Methods. I constructed a panel of infant mortality rates from 50 US states over the period 1929 through 2000 to examine their association with the timing and details of introducing a constitutional right to health and health care provisions. Results. The introduction of a stronger constitutional commitment that obligates state legislature to provide health care was associated with a subsequent reduction in the infant mortality rate of approximately 7.8%. The introduction of provisions explicitly targeting the poor was also associated with a reduction in the infant mortality rate of 6.5%. These health benefits are primarily evident in non-White populations. Conclusions. This empirical result supports Elizabeth Leonard’s view that although state constitutional rights have been poorly enforced through the judiciary, a constitutional expression of health care duties has fueled the political and social process, ultimately allowing states to identify the best way to address citizens’ health inequality concerns. (Am J Public Health. 2015;105:e48–e54. doi: 10.2105/AJPH.2014.302405)
I explored the link between the introduction into state constitutions of a commitment to health and health care and the trend of infant mortality rates, using historical panel data of the 50 US states for the period 1929 through 2000. I also conducted a robustness check by including early census estimates of infant mortality rate for the period 1850 through 1900, creating a sample of 150 years of historical data on these rates.
METHODS The main variable of interest was a dummy variable of constitutional provisions for health and health care, which was 1 if there are constitutional provisions for health and health care in state i at time t, and otherwise 0. Table 1 presents a list of the US states with constitutional provisions for health and health care. The level of commitment to this right varies across state constitutions. Statements of duty and entitlement reflect a greater constitutional
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commitment to health and health care than public concern or programmatic statements. Some constitutions specify types of services and target particular population groups rather than the general population. Four states’ constitutional provisions were introduced in the second half of the 19th century, giving these states a long tradition of constitutional entitlement to health care access. Three of these early constitutional provisions, however, primarily targeted the treatment of mental health rather than general disease or infirmity. Over the course of the 20th century, 11 other states added 1 or more provisions of health and health care to their constitutions. Constitutional provisions for health and health care have been proposed in only 4 other states (Massachusetts, Minnesota, Michigan, and Oregon), and those proposals failed to pass in the state legislature.8
Infant Mortality Rate The key outcome variable was the infant mortality rate over time in each of the 50
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census estimates of infant mortality rates and analyzed data from 1850 to 2000 to test the robustness of the study’s results. Although 1929 was the first year for which infant mortality rates were available for most states, the combination of 2 data sources allowed the extension of the sample to as early as 1850. The US Census provided information regarding births and deaths long before the country’s vital registration was established. To obtain the national data on births and deaths necessary to calculate infant mortality rate, the decennial censuses in the second half of the 19th century included questions concerning vital events, such as “born within the year” or “death under one year old if died within the year.” The methodology and data sources of these early estimates differ from the modern estimates used in the vital statistics system; thus, it is not sensible to pool these early estimates with the later vital statistical records in my main specification. I used these early estimates only for the robustness check.
TABLE 1—US States With Constitutional Provisions for Health and Health Care: 1929–2000 Specific Target Population (If Any) State
Effective Date
Level of Commitment
Indigent Access to Health Care
Mentally Ill
Public Health
Environment No
Indiana
1851
Duty
No
Yes
No
Mississippi
1869
Duty
Yes
Yes
No
No
Arkansas Wyoming
1874 1890
Duty Duty
No No
Yes No
No Yes
No No
New York
1938
Concern
Yes
No
Yes
No
Alabama
1946
Programmatic statement
No
No
No
No
Alaska
1959
Duty
No
No
Yes
No
Michigan
1963
Concern
No
No
Yes
No
Illinois
1970
Right
No
No
Yes
No
North Carolina
1970
Duty
Yes
No
No
No
South Carolina Montana
1971 1972
Concern Right
No No
No No
Yes No
Yes Yes
Missouri
1972
Concern
No
No
No
No
Louisiana
1974
Programmatic statement
No
No
Yes
No
Hawaii
1978
Duty
Yes
No
Yes
No
Note. This list of states with constitutional provision(s) for health and health care is primarily derived from Leonard.7 Art. IV §1 of the Indiana Constitution added because this provision is identical to Art. 19, §19 of the Arkansas Constitution. Statements of duty and entitlement in some state constitutional provisions reflect a greater constitutional commitment to health and health care than public concern or programmatic statements. Moreover, some constitutions specify types of services and target particular population groups such as those with mental health issues, those living in unhealthy environments, indigents who have limited access to health care services, and those in need of public health services, rather than the general population.
states. The infant mortality rate is an important measure of the well-being of infants, children, and pregnant women, and is directly influenced by inequality in access to medical care. The reported number of prenatal hospital visits has a substantial effect on the neonatal mortality rate.9 The medical treatment of newborns also has a substantial effect on the infant mortality rate among high-risk newborns.10 Moreover, infant deaths are likely to be affected by the medical treatment of the state of residence reported in vital statistics. Residential mobility across the state line during pregnancy and after childbirth is quite limited. A mother’s state of residence at the time of her infant’s birth is likely to be the same as at the time of her infant’s death. This rubric is useful for investigating the effect of constitutional rights on health outcomes. The current data on infant mortality rates come from Vital Statistics of the United States.11 In the primary analysis, I used panel data for the 50 states from 1929 to 2000, having nearly 3600 observations in the study sample.
Other State Constitutional Provisions
I selected this particular period of analysis for 2 reasons. First, infant mortality rates from the vital statistics system was available for most states only after 1928. Second, the control variables for most of these studies are not provided any earlier than this date. For example, state personal income data from the Bureau of Labor Statistics has been available only since 1928. There are also drawbacks in excluding infant mortality data prior to 1929. First, 4 states (Indiana, Mississippi, Arkansas, and Wyoming) adopted the constitutional right to health and health care prior to the period of analysis. Therefore, I would have been ignoring the within-state variation of these 4 states if I had used the data beginning in 1929. Second, there may be a potential omitted variable because the timing of the introduction of the right to health and health care into these 19th-century constitutions also correlated with other variables across time within the state. To tackle these potential drawbacks, I extended the study’s data set by including early
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The achievement of the right to health is closely related to and dependent on the realization of other socioeconomic rights, such as education, social welfare, and the environment. Moreover, many state governments have substantial budget constraints that are dictated by their constitutions; therefore, these rights must be financed through competing state budgets, as with health and health care. With respect to controlling for within-state time variation of other socioeconomic state constitutional provisions that may affect infant mortality rate, I constructed a dummy variable of the following: constitutional provisions for social welfare,12 constitutional provisions for the environment, constitutional duty to protect the environment,13,14 tax and expenditure limitations, and supermajority requirement.15 I did not include the constitutional right to education in the analysis because most of these provisions were adopted during the 18th and 19th centuries, which means that there was no within-country variation in the study’s sample period.16 I constructed all dummy variables in the same manner as the dummy variable of constitutional health and health care provisions.
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Other Socioeconomic Control Variables For other control variables, the model for this study included only major determinants of infant mortality not on the pathway from the constitutional right to health and health care to infant mortality. Thus, I did not include more proximal causes of infant mortality than the constitutional right to health and health care, including all of the economic, political, and social activities inspired by this constitutional right. The 3 socioeconomic control variables included log state personal income per capita (CPI adjusted 1982---1984 = 100), average number of years of schooling, and log state population density. Turner et al. constructed real state-per-worker output estimates every 10 years for the period 1850 through 1910 and combined them with annual data from the Bureau of Labor Statistics for the period 1929 through 2000.17---20 Again, the methodology and data source of these estimates differ from those of modern estimates; therefore, it was not sensible to pool these early income estimates with the later census estimates for the main result. Turner et al. also constructed data on the average number of years of schooling from 1840 to 2000 by using a perpetual inventory method.17 Finally, I calculated state population density as the total population divided by the land area of the state by the US Census. For the measure of political variables, I expanded on the data set provided by Besley et al.,21 which includes political competition, the average proportion of Democratic seats in the upper and lower houses, and a dummy variable of the state governor’s party affiliation. Using additional data from Dubin22 and Dal Bó et al.,23 I expanded on the data set of political competition and the average proportion of the Democratic vote as early as 1850. Because data from earlier years were available, I calculated the political competition variable for this study exclusively from a political party’s share of the state legislature rather than from a wide variety of statewide election statistics used by Begley et al.21,24 The decision not to use Besley et al.’s original data on political competition did not affect the study’s results for the period 1929 through 2000. I also added a dummy variable of the governor’s party affiliation as early as 1850, using the National Governors Association’s Web page.25
RESULTS Figure 1 shows that there has been substantial progress in the introduction of health, social welfare, and environmental provisions, as well as restrictions and limitations on state government expenditures into state constitutions. Appendix A (available as a supplement to this article at httrp://www.ajph.org) summarizes all of the constitutional socioeconomic rights as well as restrictions and limitations on state expenditures referenced in this article. Figure 2 shows the continued decline in infant mortality among both White and non-White populations. The gap in mortality between White and non-White infants has narrowed over time, but the ratio of non-White to White infant mortality rates has increased during the same period, indicating that racial health inequalities are still a major national concern. Table 2 presents summary statistics of all the data used in the analysis, showing the mean and the standard deviation of the dependent and independent variables. I employed difference-in-difference methods to estimate the relation between the log infant mortality rate and the introduction of state constitutional provisions for health and health
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care over time at the state level. My panel data model included state and year fixed effects as well as state-specific linear and quadratic trends. These capture unobserved variables that are fixed for each state over time and nationwide changes that affect all states at the same time, as well as each state’s trend of child mortality decline. The most basic identification is as follows: Yi;t ¼ ai þ d t þ
50 X
ui TRENDt
i¼1
ð1Þ
þ
50 X
-i TRENDt2
i¼1
þc1 CON PROVi;t þbXi;t þ gi;t Y is the natural log of the infant mortality rate (the number of infant deaths per 1000 live births), which varies by state i and time t. a and d are the state and year fixed effects. TRENDs are state-specific trends. X is a vector of controls, including a dummy variable of constitutional provision of social welfare, a dummy variable of constitutional provision of the environment, a dummy variable of constitutional duty to protect the environment, a dummy
FIGURE 1—Substantial progress in the introduction of health and health care, social welfare, and environmental provisions as well as restrictions and limitations on state government expenditures into state constitutions: United States, 1929–2000.
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FIGURE 2—Substantial decline in the infant mortality rate in White and non-White populations: United States, 1929–2000.
variable of tax and expenditure limitations, a dummy variable of the supermajority requirement, log per capita state income, log average years of schooling, log population density, political competitiveness, a dummy variable for Democratic governor, and the composition of state legislatures. I also replicated the results of equation (1) with each law indicator variable split to reflect heterogeneous treatments of each law with different levels of constitutional commitment. I distinguish statements of duty and entitlement from concern and programmatic statements in that the former language clearly imposes an unqualified duty on the state to meet the health needs of the state population. Yi;t ¼ ai þ rt þ
50 X
ui TRENDt
i¼1
ð2Þ
þ
50 X
-i TRENDt2 þc1 DUTYi:;t
i¼1
þc2 RIGHTi;t þ c3 CONCERNi;t þc4 PROGRAMMEi;t þ bXi;t þgi;t Some constitutions specify types of services and target particular population groups rather than the general population. Following
Leonard,7 I focused on the following 3 types of services and target populations: environment, indigents, and public health. I included a dummy variable of constitutional health provisions targeting only the mental health population in the robustness check, which included early census estimates of infant mortality because all 3 states with mental health provisions—Indiana (1856), Arkansas (1874), and Mississippi (1869)—adopted them prior to 1929. Yi;t ¼ai þ rt þ
50 X
ui TRENDt
i¼1
ð3Þ
þ
50 X
-i TRENDt2 þc1 INDIGi:;t
i¼1
þc2 ENVi;t þ c3 PUBHELi;t þc4 NOTARGET þðc5 MENTALi;t Þ þ bXi;t þ gi;t Table 3 presents the results of the multivariate analysis of infant mortality rates. Columns 1 through 3 show the results of estimating Equations 1 through 3, using infant mortality data from 1929 to 2000. I calculated standard errors (in parentheses), clustering observations by state.26 I did not find a significant association between the introduction of
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health and health care provisions in general and infant mortality rates in column 1. However, state duty statements and specific targeting of the indigent population were significantly associated with a reduction in the infant mortality rate in columns 2 and 3. The results indicate that state constitutional recognition of the duty to provide health care is associated with a reduction in the infant mortality rate of 7.8%. The study also indicates that the explicit constitutional recognition of health for the poor is associated with a reduction in the infant mortality rate of 6.5%. An increase in income has modest impact on infant mortality, demonstrating that economic growth failed to trickle down to the poorest during this period and inequality in access to medical care is a much more crucial factor for infant survival (Table A of Appendix A). Between 1929 and 2000, the average state experienced an 89.9% decline in its infant mortality rate. The estimated effects are still a small fraction of the infant mortality decline that occurred in this period, reflecting that the within-state, overtime variation in non---health policy factors explains much of the variation in infant mortality rate in this period. The second set of columns (4---6) show the results from the same equations as in the first 3 columns, but include log per capita state government expenditure on health and hospitals, adjusted by consumer price index in the specification. I obtained the data on state government expenditure on health and hospitals from the Census of Governments and the Annual Survey of Governments.27,28 The data set is available for the period 1942 through 2000. (Data for the years 1942 through 1950 were produced during the even years.) In theory, the constitutional right to health and health care may cause more public health and hospital spending. Controlling for public health spending could cause one to underestimate the effect of the constitutional right to health and health care. On the other hand, if the cause of the infant mortality improvement is government spending not induced by the constitutional right, then the effect in the first 3 columns is overestimated. The inclusion of per capita state government expenditure on health and hospitals does not substantially change the magnitude and significance of the estimates. This infers that the allocation of government health
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TABLE 2—Summary Statistics of Data Used in the Analysis of State Constitutional Provisions for Health and Health Care: United States 1929–2000, Mean (SD) or No.
1850–2000, Mean (SD) or No.
Total
26.55 (19.08)
31.26 (27.66)
White Others
23.98 (17.85) 43.86 (37.95)
Variable Infant mortality rate, deaths/1000 live births
Constitutional socioeconomic rights provisions Constitutional provision(s) for health and
0.19 (0.39)
0.18 (0.38)
Programmatic statement dummy
0.02 (0.15)
0.02 (0.14)
Public concern dummy
0.04 (0.20)
0.04 (0.20)
Individual right dummy State duty dummy
0.02 (0.13) 0.11 (0.31)
0.01 (0.12) 0.10 (0.30)
0.02 (0.12)
0.01 (0.12)
health care dummy Level of commitment
Target population Mental health dummy
0.06 (0.23)
Healthy environment dummy Public health dummy
0.09 (0.28)
0.08 (0.27)
Indigent access to health care dummy
0.03 (0.18)
0.03 (0.18)
No specific targeting population dummy
0.02 (0.15)
0.02 (0.14)
Constitutional provision(s) for social welfare dummy
0.39 (0.49)
0.37 (0.48)
Constitutional duty to protect social welfare
0.06 (0.23)
provision(s) dummy Constitutional provision(s) for environment
0.21 (0.41)
0.20 (0.40)
0.10 (0.30)
0.09 (0.29)
dummy Constitutional duty to protect environment provision(s) dummy Constitutional limitation on state expenditures Constitutional tax and expenditure limitation(s) 0.08 (0.27)
0.07 (0.26)
dummy Supermajority requirement dummy
0.07 (0.26)
0.07 (0.25)
10.29 (0.47)
10.21 (0.56)
Control variables Log per capita state personal income (CPI adjusted, 1982–1984 = 100) Log population density
3.88 (1.45)
3.79 (1.53)
10.52 (1.97) –0.22 (0.16)
10.04 (2.66) –0.22 (0.16)
0.58 (0.26)
0.58 (0.26)
Democratic governor dummy
0.58 (0.49)
0.58 (0.49)
Log per capita state health and hospital expenditure
1.98 (0.20)
Average years of schooling Political Competitiveness Average proportion of Democratic seats in the house and senate
(CPI adjusted, 1982–1984 = 100) Observations
3600
3900
Note. CPI = consumer price index. The data of log per capita state government expenditure on health and hospitals are available for the period 1942 through 2000. The data are available for every 2 years from 1942 to 1950. The sample size was 2730.
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care spending, rather than an absolute amount of spending induced by the constitutional right, might be important for reducing infant mortality rate. The next 3 columns (7---9) check the robustness of the study’s main result in the first 3 columns by including all early census estimates of infant mortality from 1850 to 1900. The inclusion of a statement of a duty to provide health care is associated with a reduction in the infant mortality rate of 20.7% (P < .05), and the explicit constitutional recognition of health for the poor with a rate reduction of 20.2% (P < .01). The final 6 columns investigate the heterogeneity of association by racial groups. The “difference-in-difference-in-difference” estimation strategy exploits the fact that the effect of the right to health and health care is larger among the non-White population than the White population. However, these 2 groups are still similarly affected by other time-varying state-specific factors that influence infant mortality rates. Inclusion of race · state fixed effects in the regressions eliminates the bias in the cross-sectional estimates attributable to timeinvariant omitted factors that vary across race in each state. I found an association between the constitutional duty to provide health care and the infant mortality rate among the nonWhite population, but not the White population. I also found that the association between the explicit constitutional recognition of health for the poor is associated with a reduction in the infant mortality rate among the non-White population, but not the White population. This finding indicates that the constitutional right to health and health care protects the health of minorities rather than that of the general population. Thus, the introduction of a stronger constitutional commitment to health and health care reduces the racial gap in infant mortality. The explicit constitutional recognition of a healthy environment is also associated with a reduction in infant mortality among nonWhite populations, but the magnitude is too small for detection of an effect in the general population. In Appendix B (available as a supplement to this article at http://www.ajph.org), I also report the result of a falsification test. Following Bertrand, Duflo, and Mullainathan,26 I first randomly generated dates of the adoption of
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0.0086 (0.0561)
Individual right statement dummy
0.99
R2
2.06
–0.2020** (0.0711)
0.0203 (0.0265)
–0.0011 (0.0600)
9
3.34 0.99
3296 0.986
0.986
2544
5.31 0.986
2544 0.985
0.985
3494
2.57 0.985
3494 0.947
6502
–0.0561 (0.0417)
10: Non-White
0.947
6502
2.96
0.0244 (0.0317) –0.0041 (0.0534)
0.0106 (0.0441) –0.1880** (0.0556)
0.947
6502
6.17
–0.0551 (0.0727)
–0.2330** (0.0440)
0.0323 (0.0361)
–0.0290 (0.0283)
11: White
–0.0124 (0.0651)
0.0093 (0.0319)
10: White
–0.0083 (0.0472)
–0.0585** (0.0187)
12: Non-White
Main Specification by Race, Estimate (SE)
–0.0816 (0.0774)
11: Non-White
–0.0187 (0.0267)
–0.0385 (0.0637)
0.0016 (0.0360)
0.0607 (0.0599)
12: White
Note. All SEs are clustered at the state level. Tables A through C of Appendix A provide full regression results. In Columns 1 through 9, the data are constructed by years · states. In Columns 1 through 3, I used the data for the 50 states from 1929 to 2000. In Columns 4 through 6, because of the availability of government expenditure data, I used the data for the 50 states from 1942 to 2000 (every 2 years from 1942 to 1950). In Columns 7 through 9, I used the data for the 50 states from 1850 to 2000 (every 10 years from 1850 to 1900). All 9 regressions include year fixed effects, state fixed effects, state-specific time trends and their square terms, a dummy variable of constitutional provision of social welfare, a dummy variable of constitutional provision of environment, a dummy variable of constitutional duty to protect environment, a dummy variable of tax and expenditure limitations, a dummy variable of the supermajority requirement, log per capita state income, log average years of schooling, log population density, political competitiveness, a dummy variable for Democratic governor, and the composition of state legislatures. In addition, the specifications in columns 4 through 6 include log per capita state government expenditure on health and hospitals and the specifications in columns 7 through 9 include a dummy variable of constitutional duty to protect social welfare. In columns 10 through 12, the data are constructed by years · states · races (White and non-White populations). I used the data for the 50 states · 2 races from 1929 to 2000. All 3 regressions include year fixed effects, state · race fixed effects, state · race specific time trends and their square terms, a dummy variable of constitutional provision of social welfare, a dummy variable of constitutional provision of environment, a dummy variable of constitutional duty to protect environment, a dummy variable of tax and expenditure limitations, a dummy variable of the supermajority requirement, log per capita state income, log average years of schooling, log population density, political competitiveness, a dummy variable for Democratic governor, and the composition of state legislatures. There are 2 columns for each regression result (10 through 12). One is for White population; the other is for non-white population. a Joint F test for all constitutional provisions for health and health care variables. *P < .05; **P < .01.
0.99
3.1
3296
3296
Fa
Observations
Model statistics
0.0119 (0.0669)
–0.0597** (0.0147)
0.0307 (0.0275)
3494
By targeting populations –0.0116 (0.0548)
–0.2070* (0.0947)
–0.0240 (0.0575)
–0.0028 (0.0412)
0.0337 (0.0201)
8
0.0278 (0.0324)
1.95
–0.0340 (0.0354)
7
Including Earlier Census Estimates, Estimate (SE)
By level of commitment
6
–0.3710 (0.278)
2544
–0.0810* (0.0344)
–0.0335 (0.0497)
0.0293 (0.0390)
0.0245 (0.0406)
5
No specific population dummy
0.0313 (0.0287)
–0.0075 (0.0246)
4
With Per Capita Government Expenditure on Health and Hospitals, Estimate (SE)
Mental health population dummy
–0.0647** (0.0188)
0.0014 (0.0352)
Public health dummy
Indigent access to health care dummy
0.0062 (0.0610)
3
Healthy environment dummy
–0.0775** (0.0233)
–0.0117 (0.0506)
Public concern statement dummy
State duty statement dummy
0.0087 (0.0170)
Programmatic statement dummy
health care
2
Main Specification, Estimate (SE)
Constitutional provisions for health and –0.0150 (0.0256)
1
TABLE 3—Multivariate Analysis of Infant Mortality Rates Used in Study of State Constitutional Provisions for Health and Health Care: United States
placebo constitutional right to health and health care, which I then randomly assigned to states. I then estimated Equations 2 and 3 and repeated this process 1000 times. The falsification test shows that the results shown in Table 3 are unlikely to stem from pure coincidence or to capture random trends in infant mortality, thus confirming the results.
DISCUSSION
These findings suggest that the introduction of a stronger constitutional commitment to health and health care has a robust effect on subsequent reductions in infant mortality rates. However, without truly exogenous variation in state constitutional differences, the concern remains that this effect represents omitted political and social variables. The mechanisms through which the right to health and health care works to affect population health are also not addressed by this investigation. However, based on the regression results including log per capita state government expenditure on health and hospitals, I infer that the allocation of government health care spending, rather than an absolute amount of spending induced by the constitutional right to health and health care, might be important for reducing the infant mortality rate. Future research must address the consequences for policy change and distribution of resources induced by the state constitutional right. My finding of a relatively large reduction in infant mortality rates among the non-White population may reflect the fact that the constitutional commitment to health and health care not only influences political and legal processes but also promotes social preference over the provision of indigent health care. In political philosophy, the democratic process is regarded not only as a system that aggregates individual preferences but also as a process of collective reasoning to include additional information, perspectives, and voices into the public debate.29,30 After the introduction of a constitutional right to health and health care, improvements in infant mortality rates may be caused by a social commitment to the right to health and health care through public discussion, social monitoring, investigative reporting, and social work, rather than to the state government’s constitutional commitment to the
RESEARCH AND PRACTICE
right.31 My estimates of the infant mortality rate include these social commitment effects. The empirical results of the regression analysis in the current study support Leonard’s view that, although state-level constitutional rights have been poorly enforced through the judiciary throughout US history, the constitutional expression of health care rights and duties fuels the political and social process, ultimately allowing states to determine the best way to address their citizens’ health inequality concerns.7 Despite the lack of constitutional commitment at the federal level, residents in some states have enjoyed a constitutional protection of health and health care for a much longer period than any other global population. The long-standing discussions about the right to health and its implementation in these states may fuel the recognition of the right to health throughout the United States, providing case studies of the effective implementation of this right at the national level. The results presented here contribute to a growing body of literature that associates the right to health with population health outcomes. Further research should aim to determine the circumstances within which such constitutional rights are most effective at reducing health inequality between and within different racial groups. j
About the Author Hiroaki Matsuura is with the School of Interdisciplinary Area Studies, University of Oxford, Oxford, UK. Correspondence should be sent to Hiroaki Matsuura, ScD, University of Oxford, 27 Winchester Road, Oxford UK OX2 6NA (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted October 17, 2014.
Acknowledgments I thank David Canning, Katherine Baicker, Gunther Fink, Amartya Sen, and Stephen Marks at Harvard University and Anup Malani at the University of Chicago.
Human Participant Protection
3. Hershkoff H. Positive rights and state constitutions: the limits of federal rationality review. Harv Law Rev. 1999;112(6):1131---1196. 4. Calabresi SG. A government of limited and enumerated powers: in defense of United States v Lopez. Mich Law Rev. 1995;94(3):752---831. 5. Stewart RB. Federalism and rights. Georgia Law Rev. 1984---1985;19(4):917---980. 6. Lutz DS. The United States Constitution as an incomplete text. Ann Am Acad Pol Soc Sci. 1988;496(1):23-- 32. 7. Leonard EW. State constitutionalism and the right to health care. Univ Pa J Const Law. 2010;12(5):1235---1406. 8. Rüeg K. Embedding the human right to health care in US state constitutions: a progress review and lessons for advocates. Human Right to Health Program, Working Paper 2009. Available at: http://www.nesri.org/ resources/embedding-the-human-right-to-health-care-inus-state-constitutions-a-progress-review-and-lessons-foradvocates. Accessed June 21, 2014. 9. Harris JE. Prenatal medical care and infant mortality. In: Fuchs V, ed. Economic Aspects of Health. Chicago, IL: University of Chicago Press; 1982:15---52. 10. Almond D, Doyle JJ, Kowalski AE, Williams H. Estimating marginal returns to medical care: evidence from at-risk newborns. Q J Econ. 2010;125(2):591---634. 11. National Center for Health Statistics. Vital Statistics of the United States, 1929---2000. Available at: http://www. cdc.gov/nchs/products/vsus.htm. Accessed June 21, 2014.
23. Dal Bó E, Dal Bó P, Snyder J. Political dynasties. Rev Econ Stud. 2009;76(1):115---142. 24. Ansolabehere S, Snyder JM Jr. The incumbency advantage in US elections: an analysis of state and federal offices, 1942---2000. Election Law J. 2002;1(3):315--338. 25. National Governors Association Web site. Available at: http://www.nga.org. Accessed June 21, 2014. 26. Bertrand M, Duflo E, Mullainathan S. How much should we trust differences-in-differences estimates? Q J Econ. 2004;119(1):249---275. 27. US Census Bureau. Census of governments: finance. Available at: http://www.census.gov/govs/cog. Accessed June 21, 2014. 28. US Census Bureau. Annual survey of state government finances. Available at: https://www.census.gov/ econ/overview/go1500.html. Accessed June 21, 2014. 29. Sen A. Human rights and the limits of law. Cardozo Law Rev. 2005;27:2913---2927. 30. Sen A. The Idea of Justice. Cambridge, MA: Belknap Press of Harvard University Press; 2009. 31. Sen A. Why and how is health a human right? Lancet. 2008;372(9655):2010---2010.
12. Rava WC. State constitutional protections for the poor. Temple Law Rev. 1998;71(3):543---578. 13. Cusack ME. Judicial interpretation of state constitutional rights to a healthful environment. Boston Coll Environ Aff Law Rev. 1993;20(173):175---176. 14. Adams B, Garner A, Gunson B, Andrea H, Holje M. Environmental and natural resources provisions in state constitutions. J Land Resources Environ Law. 2002;22: 73---270. 15. Knight B, Levinson A. Fiscal institutions in US states. In: Strauch R, von Hagen J, eds. Institutions, Politics, and Fiscal Policy. Dordrecht, Netherlands: Kluwer; 2000: 167---187. 16. Eastman JC. Adequacy and the rights revolution: reinterpreting the education clauses in state constitutions. In: West M, Peterson P, eds. The Legal Pursuit of Educational Adequacy. Washington, DC: Brookings Institution Press; 2006:55---76. 17. Turner C, Tamura R, Mulholland S, Baier S. Education and income of the states of the United States: 1840---2000. J Econ Growth. 2007;12(2):101---158. 18. Easterlin R. Regional growth of output: long term tendencies, 1880---1950. In: Kuznets S, Miller AR, eds. Population and Redistribution and Economic Growth, United States, 1870---1950, V2: Analyses of Economic Change. Philadelphia, PA: American Philosophical Society; 1960.
References
19. Easterlin R. Interregional differences in per capita output, population and total output, 1840---1950. In: Parker W, ed. Trends in the American Economy in the Nineteenth Century. Princeton, NJ: Princeton University Press; 1960:73---140.
1. Visscher MB. Humanistic Perspectives in Medical Ethics. Buffalo, NY: Prometheus Books; 1972.
20. Statistical Abstracts of the United States. Washington, DC: US Census Bureau; 1929---2002.
2. Hall MA, Ellman IM, Orentlicher D. Health Care Law and Ethics in a Nutshell. 3rd ed. St Paul, MN: West Academic Publishing; 2011.
21. Besley T, Persson T, Sturm DM. Political competition, policy and growth: theory and evidence from the US. Rev Econ Stud. 2010;77(4):1329---1352.
No protocol approval was necessary because no human participation was involved in this study.
22. Dubin MJ. United States Congressional Elections, 1788---1997: The Official Results of the Elections of the 1st Through 105th Congresses. Jefferson, NC: McFarland; 1998.
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American Journal of Public Health | Supplement 3, 2015, Vol 105, No. S3
State Constitutional Commitment to Health and Health Care and Population Health Outcomes: Evidence From Historical US Data Hiroaki Matsuura, ScD
In light of the current debate over the Affordable Care Act (Pub. L. No. 111---148), the right to health or one of its elements, the right to health care, is taking center stage in terms of resource allocation in US health politics. Although the term “right to health” appeared as early as 1796 in congressional debates over quarantine laws, the right to health and health care has played a fairly limited role in US health politics.1 In addition, the US judiciary has been reluctant to recognize this right and has never interpreted the Constitution as requiring the government to guarantee any protection of health care access or other health-related rights for US citizens.2,3 One reason for this lack of recognition is that the US Constitution does not include an explicit statement regarding health and health care or other socioeconomic rights, such as education, social welfare, or the environment. The US constitutional system has enjoyed a unique division of labor between federal and state constitutions regarding the provision of constitutional rights.4---6 State constitutions contain a number of socioeconomic rights for which there is no acknowledged national consensus and that are not included in the federal constitution. As of April 2014, 15 state constitutions specifically mention health and health care—either in the form of a programmatic statement, public concern, individual right, or government duty beyond the federal minimum, that is, no constitutional right. States have a long history of leadership regarding health policy in the United States. State constitutions may bind and restrict such state government initiatives to offer more equitable health care to their citizens. Although such state-level constitutional rights have also been poorly enforced through the judiciary in the United States, the presence of such rights may lead to a better health care system through legislative action.7
Objectives. I investigated whether the introduction of health and health care provisions in US state constitutions can make health systems more equitable and improve health outcomes by urging state policymakers and administrative agencies to uphold their human rights obligations at state level. Methods. I constructed a panel of infant mortality rates from 50 US states over the period 1929 through 2000 to examine their association with the timing and details of introducing a constitutional right to health and health care provisions. Results. The introduction of a stronger constitutional commitment that obligates state legislature to provide health care was associated with a subsequent reduction in the infant mortality rate of approximately 7.8%. The introduction of provisions explicitly targeting the poor was also associated with a reduction in the infant mortality rate of 6.5%. These health benefits are primarily evident in non-White populations. Conclusions. This empirical result supports Elizabeth Leonard’s view that although state constitutional rights have been poorly enforced through the judiciary, a constitutional expression of health care duties has fueled the political and social process, ultimately allowing states to identify the best way to address citizens’ health inequality concerns. (Am J Public Health. 2015;105:e48–e54. doi: 10.2105/AJPH.2014.302405)
I explored the link between the introduction into state constitutions of a commitment to health and health care and the trend of infant mortality rates, using historical panel data of the 50 US states for the period 1929 through 2000. I also conducted a robustness check by including early census estimates of infant mortality rate for the period 1850 through 1900, creating a sample of 150 years of historical data on these rates.
METHODS The main variable of interest was a dummy variable of constitutional provisions for health and health care, which was 1 if there are constitutional provisions for health and health care in state i at time t, and otherwise 0. Table 1 presents a list of the US states with constitutional provisions for health and health care. The level of commitment to this right varies across state constitutions. Statements of duty and entitlement reflect a greater constitutional
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commitment to health and health care than public concern or programmatic statements. Some constitutions specify types of services and target particular population groups rather than the general population. Four states’ constitutional provisions were introduced in the second half of the 19th century, giving these states a long tradition of constitutional entitlement to health care access. Three of these early constitutional provisions, however, primarily targeted the treatment of mental health rather than general disease or infirmity. Over the course of the 20th century, 11 other states added 1 or more provisions of health and health care to their constitutions. Constitutional provisions for health and health care have been proposed in only 4 other states (Massachusetts, Minnesota, Michigan, and Oregon), and those proposals failed to pass in the state legislature.8
Infant Mortality Rate The key outcome variable was the infant mortality rate over time in each of the 50
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census estimates of infant mortality rates and analyzed data from 1850 to 2000 to test the robustness of the study’s results. Although 1929 was the first year for which infant mortality rates were available for most states, the combination of 2 data sources allowed the extension of the sample to as early as 1850. The US Census provided information regarding births and deaths long before the country’s vital registration was established. To obtain the national data on births and deaths necessary to calculate infant mortality rate, the decennial censuses in the second half of the 19th century included questions concerning vital events, such as “born within the year” or “death under one year old if died within the year.” The methodology and data sources of these early estimates differ from the modern estimates used in the vital statistics system; thus, it is not sensible to pool these early estimates with the later vital statistical records in my main specification. I used these early estimates only for the robustness check.
TABLE 1—US States With Constitutional Provisions for Health and Health Care: 1929–2000 Specific Target Population (If Any) State
Effective Date
Level of Commitment
Indigent Access to Health Care
Mentally Ill
Public Health
Environment No
Indiana
1851
Duty
No
Yes
No
Mississippi
1869
Duty
Yes
Yes
No
No
Arkansas Wyoming
1874 1890
Duty Duty
No No
Yes No
No Yes
No No
New York
1938
Concern
Yes
No
Yes
No
Alabama
1946
Programmatic statement
No
No
No
No
Alaska
1959
Duty
No
No
Yes
No
Michigan
1963
Concern
No
No
Yes
No
Illinois
1970
Right
No
No
Yes
No
North Carolina
1970
Duty
Yes
No
No
No
South Carolina Montana
1971 1972
Concern Right
No No
No No
Yes No
Yes Yes
Missouri
1972
Concern
No
No
No
No
Louisiana
1974
Programmatic statement
No
No
Yes
No
Hawaii
1978
Duty
Yes
No
Yes
No
Note. This list of states with constitutional provision(s) for health and health care is primarily derived from Leonard.7 Art. IV §1 of the Indiana Constitution added because this provision is identical to Art. 19, §19 of the Arkansas Constitution. Statements of duty and entitlement in some state constitutional provisions reflect a greater constitutional commitment to health and health care than public concern or programmatic statements. Moreover, some constitutions specify types of services and target particular population groups such as those with mental health issues, those living in unhealthy environments, indigents who have limited access to health care services, and those in need of public health services, rather than the general population.
states. The infant mortality rate is an important measure of the well-being of infants, children, and pregnant women, and is directly influenced by inequality in access to medical care. The reported number of prenatal hospital visits has a substantial effect on the neonatal mortality rate.9 The medical treatment of newborns also has a substantial effect on the infant mortality rate among high-risk newborns.10 Moreover, infant deaths are likely to be affected by the medical treatment of the state of residence reported in vital statistics. Residential mobility across the state line during pregnancy and after childbirth is quite limited. A mother’s state of residence at the time of her infant’s birth is likely to be the same as at the time of her infant’s death. This rubric is useful for investigating the effect of constitutional rights on health outcomes. The current data on infant mortality rates come from Vital Statistics of the United States.11 In the primary analysis, I used panel data for the 50 states from 1929 to 2000, having nearly 3600 observations in the study sample.
Other State Constitutional Provisions
I selected this particular period of analysis for 2 reasons. First, infant mortality rates from the vital statistics system was available for most states only after 1928. Second, the control variables for most of these studies are not provided any earlier than this date. For example, state personal income data from the Bureau of Labor Statistics has been available only since 1928. There are also drawbacks in excluding infant mortality data prior to 1929. First, 4 states (Indiana, Mississippi, Arkansas, and Wyoming) adopted the constitutional right to health and health care prior to the period of analysis. Therefore, I would have been ignoring the within-state variation of these 4 states if I had used the data beginning in 1929. Second, there may be a potential omitted variable because the timing of the introduction of the right to health and health care into these 19th-century constitutions also correlated with other variables across time within the state. To tackle these potential drawbacks, I extended the study’s data set by including early
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The achievement of the right to health is closely related to and dependent on the realization of other socioeconomic rights, such as education, social welfare, and the environment. Moreover, many state governments have substantial budget constraints that are dictated by their constitutions; therefore, these rights must be financed through competing state budgets, as with health and health care. With respect to controlling for within-state time variation of other socioeconomic state constitutional provisions that may affect infant mortality rate, I constructed a dummy variable of the following: constitutional provisions for social welfare,12 constitutional provisions for the environment, constitutional duty to protect the environment,13,14 tax and expenditure limitations, and supermajority requirement.15 I did not include the constitutional right to education in the analysis because most of these provisions were adopted during the 18th and 19th centuries, which means that there was no within-country variation in the study’s sample period.16 I constructed all dummy variables in the same manner as the dummy variable of constitutional health and health care provisions.
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Other Socioeconomic Control Variables For other control variables, the model for this study included only major determinants of infant mortality not on the pathway from the constitutional right to health and health care to infant mortality. Thus, I did not include more proximal causes of infant mortality than the constitutional right to health and health care, including all of the economic, political, and social activities inspired by this constitutional right. The 3 socioeconomic control variables included log state personal income per capita (CPI adjusted 1982---1984 = 100), average number of years of schooling, and log state population density. Turner et al. constructed real state-per-worker output estimates every 10 years for the period 1850 through 1910 and combined them with annual data from the Bureau of Labor Statistics for the period 1929 through 2000.17---20 Again, the methodology and data source of these estimates differ from those of modern estimates; therefore, it was not sensible to pool these early income estimates with the later census estimates for the main result. Turner et al. also constructed data on the average number of years of schooling from 1840 to 2000 by using a perpetual inventory method.17 Finally, I calculated state population density as the total population divided by the land area of the state by the US Census. For the measure of political variables, I expanded on the data set provided by Besley et al.,21 which includes political competition, the average proportion of Democratic seats in the upper and lower houses, and a dummy variable of the state governor’s party affiliation. Using additional data from Dubin22 and Dal Bó et al.,23 I expanded on the data set of political competition and the average proportion of the Democratic vote as early as 1850. Because data from earlier years were available, I calculated the political competition variable for this study exclusively from a political party’s share of the state legislature rather than from a wide variety of statewide election statistics used by Begley et al.21,24 The decision not to use Besley et al.’s original data on political competition did not affect the study’s results for the period 1929 through 2000. I also added a dummy variable of the governor’s party affiliation as early as 1850, using the National Governors Association’s Web page.25
RESULTS Figure 1 shows that there has been substantial progress in the introduction of health, social welfare, and environmental provisions, as well as restrictions and limitations on state government expenditures into state constitutions. Appendix A (available as a supplement to this article at httrp://www.ajph.org) summarizes all of the constitutional socioeconomic rights as well as restrictions and limitations on state expenditures referenced in this article. Figure 2 shows the continued decline in infant mortality among both White and non-White populations. The gap in mortality between White and non-White infants has narrowed over time, but the ratio of non-White to White infant mortality rates has increased during the same period, indicating that racial health inequalities are still a major national concern. Table 2 presents summary statistics of all the data used in the analysis, showing the mean and the standard deviation of the dependent and independent variables. I employed difference-in-difference methods to estimate the relation between the log infant mortality rate and the introduction of state constitutional provisions for health and health
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care over time at the state level. My panel data model included state and year fixed effects as well as state-specific linear and quadratic trends. These capture unobserved variables that are fixed for each state over time and nationwide changes that affect all states at the same time, as well as each state’s trend of child mortality decline. The most basic identification is as follows: Yi;t ¼ ai þ d t þ
50 X
ui TRENDt
i¼1
ð1Þ
þ
50 X
-i TRENDt2
i¼1
þc1 CON PROVi;t þbXi;t þ gi;t Y is the natural log of the infant mortality rate (the number of infant deaths per 1000 live births), which varies by state i and time t. a and d are the state and year fixed effects. TRENDs are state-specific trends. X is a vector of controls, including a dummy variable of constitutional provision of social welfare, a dummy variable of constitutional provision of the environment, a dummy variable of constitutional duty to protect the environment, a dummy
FIGURE 1—Substantial progress in the introduction of health and health care, social welfare, and environmental provisions as well as restrictions and limitations on state government expenditures into state constitutions: United States, 1929–2000.
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FIGURE 2—Substantial decline in the infant mortality rate in White and non-White populations: United States, 1929–2000.
variable of tax and expenditure limitations, a dummy variable of the supermajority requirement, log per capita state income, log average years of schooling, log population density, political competitiveness, a dummy variable for Democratic governor, and the composition of state legislatures. I also replicated the results of equation (1) with each law indicator variable split to reflect heterogeneous treatments of each law with different levels of constitutional commitment. I distinguish statements of duty and entitlement from concern and programmatic statements in that the former language clearly imposes an unqualified duty on the state to meet the health needs of the state population. Yi;t ¼ ai þ rt þ
50 X
ui TRENDt
i¼1
ð2Þ
þ
50 X
-i TRENDt2 þc1 DUTYi:;t
i¼1
þc2 RIGHTi;t þ c3 CONCERNi;t þc4 PROGRAMMEi;t þ bXi;t þgi;t Some constitutions specify types of services and target particular population groups rather than the general population. Following
Leonard,7 I focused on the following 3 types of services and target populations: environment, indigents, and public health. I included a dummy variable of constitutional health provisions targeting only the mental health population in the robustness check, which included early census estimates of infant mortality because all 3 states with mental health provisions—Indiana (1856), Arkansas (1874), and Mississippi (1869)—adopted them prior to 1929. Yi;t ¼ai þ rt þ
50 X
ui TRENDt
i¼1
ð3Þ
þ
50 X
-i TRENDt2 þc1 INDIGi:;t
i¼1
þc2 ENVi;t þ c3 PUBHELi;t þc4 NOTARGET þðc5 MENTALi;t Þ þ bXi;t þ gi;t Table 3 presents the results of the multivariate analysis of infant mortality rates. Columns 1 through 3 show the results of estimating Equations 1 through 3, using infant mortality data from 1929 to 2000. I calculated standard errors (in parentheses), clustering observations by state.26 I did not find a significant association between the introduction of
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health and health care provisions in general and infant mortality rates in column 1. However, state duty statements and specific targeting of the indigent population were significantly associated with a reduction in the infant mortality rate in columns 2 and 3. The results indicate that state constitutional recognition of the duty to provide health care is associated with a reduction in the infant mortality rate of 7.8%. The study also indicates that the explicit constitutional recognition of health for the poor is associated with a reduction in the infant mortality rate of 6.5%. An increase in income has modest impact on infant mortality, demonstrating that economic growth failed to trickle down to the poorest during this period and inequality in access to medical care is a much more crucial factor for infant survival (Table A of Appendix A). Between 1929 and 2000, the average state experienced an 89.9% decline in its infant mortality rate. The estimated effects are still a small fraction of the infant mortality decline that occurred in this period, reflecting that the within-state, overtime variation in non---health policy factors explains much of the variation in infant mortality rate in this period. The second set of columns (4---6) show the results from the same equations as in the first 3 columns, but include log per capita state government expenditure on health and hospitals, adjusted by consumer price index in the specification. I obtained the data on state government expenditure on health and hospitals from the Census of Governments and the Annual Survey of Governments.27,28 The data set is available for the period 1942 through 2000. (Data for the years 1942 through 1950 were produced during the even years.) In theory, the constitutional right to health and health care may cause more public health and hospital spending. Controlling for public health spending could cause one to underestimate the effect of the constitutional right to health and health care. On the other hand, if the cause of the infant mortality improvement is government spending not induced by the constitutional right, then the effect in the first 3 columns is overestimated. The inclusion of per capita state government expenditure on health and hospitals does not substantially change the magnitude and significance of the estimates. This infers that the allocation of government health
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TABLE 2—Summary Statistics of Data Used in the Analysis of State Constitutional Provisions for Health and Health Care: United States 1929–2000, Mean (SD) or No.
1850–2000, Mean (SD) or No.
Total
26.55 (19.08)
31.26 (27.66)
White Others
23.98 (17.85) 43.86 (37.95)
Variable Infant mortality rate, deaths/1000 live births
Constitutional socioeconomic rights provisions Constitutional provision(s) for health and
0.19 (0.39)
0.18 (0.38)
Programmatic statement dummy
0.02 (0.15)
0.02 (0.14)
Public concern dummy
0.04 (0.20)
0.04 (0.20)
Individual right dummy State duty dummy
0.02 (0.13) 0.11 (0.31)
0.01 (0.12) 0.10 (0.30)
0.02 (0.12)
0.01 (0.12)
health care dummy Level of commitment
Target population Mental health dummy
0.06 (0.23)
Healthy environment dummy Public health dummy
0.09 (0.28)
0.08 (0.27)
Indigent access to health care dummy
0.03 (0.18)
0.03 (0.18)
No specific targeting population dummy
0.02 (0.15)
0.02 (0.14)
Constitutional provision(s) for social welfare dummy
0.39 (0.49)
0.37 (0.48)
Constitutional duty to protect social welfare
0.06 (0.23)
provision(s) dummy Constitutional provision(s) for environment
0.21 (0.41)
0.20 (0.40)
0.10 (0.30)
0.09 (0.29)
dummy Constitutional duty to protect environment provision(s) dummy Constitutional limitation on state expenditures Constitutional tax and expenditure limitation(s) 0.08 (0.27)
0.07 (0.26)
dummy Supermajority requirement dummy
0.07 (0.26)
0.07 (0.25)
10.29 (0.47)
10.21 (0.56)
Control variables Log per capita state personal income (CPI adjusted, 1982–1984 = 100) Log population density
3.88 (1.45)
3.79 (1.53)
10.52 (1.97) –0.22 (0.16)
10.04 (2.66) –0.22 (0.16)
0.58 (0.26)
0.58 (0.26)
Democratic governor dummy
0.58 (0.49)
0.58 (0.49)
Log per capita state health and hospital expenditure
1.98 (0.20)
Average years of schooling Political Competitiveness Average proportion of Democratic seats in the house and senate
(CPI adjusted, 1982–1984 = 100) Observations
3600
3900
Note. CPI = consumer price index. The data of log per capita state government expenditure on health and hospitals are available for the period 1942 through 2000. The data are available for every 2 years from 1942 to 1950. The sample size was 2730.
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care spending, rather than an absolute amount of spending induced by the constitutional right, might be important for reducing infant mortality rate. The next 3 columns (7---9) check the robustness of the study’s main result in the first 3 columns by including all early census estimates of infant mortality from 1850 to 1900. The inclusion of a statement of a duty to provide health care is associated with a reduction in the infant mortality rate of 20.7% (P < .05), and the explicit constitutional recognition of health for the poor with a rate reduction of 20.2% (P < .01). The final 6 columns investigate the heterogeneity of association by racial groups. The “difference-in-difference-in-difference” estimation strategy exploits the fact that the effect of the right to health and health care is larger among the non-White population than the White population. However, these 2 groups are still similarly affected by other time-varying state-specific factors that influence infant mortality rates. Inclusion of race · state fixed effects in the regressions eliminates the bias in the cross-sectional estimates attributable to timeinvariant omitted factors that vary across race in each state. I found an association between the constitutional duty to provide health care and the infant mortality rate among the nonWhite population, but not the White population. I also found that the association between the explicit constitutional recognition of health for the poor is associated with a reduction in the infant mortality rate among the non-White population, but not the White population. This finding indicates that the constitutional right to health and health care protects the health of minorities rather than that of the general population. Thus, the introduction of a stronger constitutional commitment to health and health care reduces the racial gap in infant mortality. The explicit constitutional recognition of a healthy environment is also associated with a reduction in infant mortality among nonWhite populations, but the magnitude is too small for detection of an effect in the general population. In Appendix B (available as a supplement to this article at http://www.ajph.org), I also report the result of a falsification test. Following Bertrand, Duflo, and Mullainathan,26 I first randomly generated dates of the adoption of
American Journal of Public Health | Supplement 3, 2015, Vol 105, No. S3
0.0086 (0.0561)
Individual right statement dummy
0.99
R2
2.06
–0.2020** (0.0711)
0.0203 (0.0265)
–0.0011 (0.0600)
9
3.34 0.99
3296 0.986
0.986
2544
5.31 0.986
2544 0.985
0.985
3494
2.57 0.985
3494 0.947
6502
–0.0561 (0.0417)
10: Non-White
0.947
6502
2.96
0.0244 (0.0317) –0.0041 (0.0534)
0.0106 (0.0441) –0.1880** (0.0556)
0.947
6502
6.17
–0.0551 (0.0727)
–0.2330** (0.0440)
0.0323 (0.0361)
–0.0290 (0.0283)
11: White
–0.0124 (0.0651)
0.0093 (0.0319)
10: White
–0.0083 (0.0472)
–0.0585** (0.0187)
12: Non-White
Main Specification by Race, Estimate (SE)
–0.0816 (0.0774)
11: Non-White
–0.0187 (0.0267)
–0.0385 (0.0637)
0.0016 (0.0360)
0.0607 (0.0599)
12: White
Note. All SEs are clustered at the state level. Tables A through C of Appendix A provide full regression results. In Columns 1 through 9, the data are constructed by years · states. In Columns 1 through 3, I used the data for the 50 states from 1929 to 2000. In Columns 4 through 6, because of the availability of government expenditure data, I used the data for the 50 states from 1942 to 2000 (every 2 years from 1942 to 1950). In Columns 7 through 9, I used the data for the 50 states from 1850 to 2000 (every 10 years from 1850 to 1900). All 9 regressions include year fixed effects, state fixed effects, state-specific time trends and their square terms, a dummy variable of constitutional provision of social welfare, a dummy variable of constitutional provision of environment, a dummy variable of constitutional duty to protect environment, a dummy variable of tax and expenditure limitations, a dummy variable of the supermajority requirement, log per capita state income, log average years of schooling, log population density, political competitiveness, a dummy variable for Democratic governor, and the composition of state legislatures. In addition, the specifications in columns 4 through 6 include log per capita state government expenditure on health and hospitals and the specifications in columns 7 through 9 include a dummy variable of constitutional duty to protect social welfare. In columns 10 through 12, the data are constructed by years · states · races (White and non-White populations). I used the data for the 50 states · 2 races from 1929 to 2000. All 3 regressions include year fixed effects, state · race fixed effects, state · race specific time trends and their square terms, a dummy variable of constitutional provision of social welfare, a dummy variable of constitutional provision of environment, a dummy variable of constitutional duty to protect environment, a dummy variable of tax and expenditure limitations, a dummy variable of the supermajority requirement, log per capita state income, log average years of schooling, log population density, political competitiveness, a dummy variable for Democratic governor, and the composition of state legislatures. There are 2 columns for each regression result (10 through 12). One is for White population; the other is for non-white population. a Joint F test for all constitutional provisions for health and health care variables. *P < .05; **P < .01.
0.99
3.1
3296
3296
Fa
Observations
Model statistics
0.0119 (0.0669)
–0.0597** (0.0147)
0.0307 (0.0275)
3494
By targeting populations –0.0116 (0.0548)
–0.2070* (0.0947)
–0.0240 (0.0575)
–0.0028 (0.0412)
0.0337 (0.0201)
8
0.0278 (0.0324)
1.95
–0.0340 (0.0354)
7
Including Earlier Census Estimates, Estimate (SE)
By level of commitment
6
–0.3710 (0.278)
2544
–0.0810* (0.0344)
–0.0335 (0.0497)
0.0293 (0.0390)
0.0245 (0.0406)
5
No specific population dummy
0.0313 (0.0287)
–0.0075 (0.0246)
4
With Per Capita Government Expenditure on Health and Hospitals, Estimate (SE)
Mental health population dummy
–0.0647** (0.0188)
0.0014 (0.0352)
Public health dummy
Indigent access to health care dummy
0.0062 (0.0610)
3
Healthy environment dummy
–0.0775** (0.0233)
–0.0117 (0.0506)
Public concern statement dummy
State duty statement dummy
0.0087 (0.0170)
Programmatic statement dummy
health care
2
Main Specification, Estimate (SE)
Constitutional provisions for health and –0.0150 (0.0256)
1
TABLE 3—Multivariate Analysis of Infant Mortality Rates Used in Study of State Constitutional Provisions for Health and Health Care: United States
placebo constitutional right to health and health care, which I then randomly assigned to states. I then estimated Equations 2 and 3 and repeated this process 1000 times. The falsification test shows that the results shown in Table 3 are unlikely to stem from pure coincidence or to capture random trends in infant mortality, thus confirming the results.
DISCUSSION
These findings suggest that the introduction of a stronger constitutional commitment to health and health care has a robust effect on subsequent reductions in infant mortality rates. However, without truly exogenous variation in state constitutional differences, the concern remains that this effect represents omitted political and social variables. The mechanisms through which the right to health and health care works to affect population health are also not addressed by this investigation. However, based on the regression results including log per capita state government expenditure on health and hospitals, I infer that the allocation of government health care spending, rather than an absolute amount of spending induced by the constitutional right to health and health care, might be important for reducing the infant mortality rate. Future research must address the consequences for policy change and distribution of resources induced by the state constitutional right. My finding of a relatively large reduction in infant mortality rates among the non-White population may reflect the fact that the constitutional commitment to health and health care not only influences political and legal processes but also promotes social preference over the provision of indigent health care. In political philosophy, the democratic process is regarded not only as a system that aggregates individual preferences but also as a process of collective reasoning to include additional information, perspectives, and voices into the public debate.29,30 After the introduction of a constitutional right to health and health care, improvements in infant mortality rates may be caused by a social commitment to the right to health and health care through public discussion, social monitoring, investigative reporting, and social work, rather than to the state government’s constitutional commitment to the
RESEARCH AND PRACTICE
right.31 My estimates of the infant mortality rate include these social commitment effects. The empirical results of the regression analysis in the current study support Leonard’s view that, although state-level constitutional rights have been poorly enforced through the judiciary throughout US history, the constitutional expression of health care rights and duties fuels the political and social process, ultimately allowing states to determine the best way to address their citizens’ health inequality concerns.7 Despite the lack of constitutional commitment at the federal level, residents in some states have enjoyed a constitutional protection of health and health care for a much longer period than any other global population. The long-standing discussions about the right to health and its implementation in these states may fuel the recognition of the right to health throughout the United States, providing case studies of the effective implementation of this right at the national level. The results presented here contribute to a growing body of literature that associates the right to health with population health outcomes. Further research should aim to determine the circumstances within which such constitutional rights are most effective at reducing health inequality between and within different racial groups. j
About the Author Hiroaki Matsuura is with the School of Interdisciplinary Area Studies, University of Oxford, Oxford, UK. Correspondence should be sent to Hiroaki Matsuura, ScD, University of Oxford, 27 Winchester Road, Oxford UK OX2 6NA (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted October 17, 2014.
Acknowledgments I thank David Canning, Katherine Baicker, Gunther Fink, Amartya Sen, and Stephen Marks at Harvard University and Anup Malani at the University of Chicago.
Human Participant Protection
3. Hershkoff H. Positive rights and state constitutions: the limits of federal rationality review. Harv Law Rev. 1999;112(6):1131---1196. 4. Calabresi SG. A government of limited and enumerated powers: in defense of United States v Lopez. Mich Law Rev. 1995;94(3):752---831. 5. Stewart RB. Federalism and rights. Georgia Law Rev. 1984---1985;19(4):917---980. 6. Lutz DS. The United States Constitution as an incomplete text. Ann Am Acad Pol Soc Sci. 1988;496(1):23-- 32. 7. Leonard EW. State constitutionalism and the right to health care. Univ Pa J Const Law. 2010;12(5):1235---1406. 8. Rüeg K. Embedding the human right to health care in US state constitutions: a progress review and lessons for advocates. Human Right to Health Program, Working Paper 2009. Available at: http://www.nesri.org/ resources/embedding-the-human-right-to-health-care-inus-state-constitutions-a-progress-review-and-lessons-foradvocates. Accessed June 21, 2014. 9. Harris JE. Prenatal medical care and infant mortality. In: Fuchs V, ed. Economic Aspects of Health. Chicago, IL: University of Chicago Press; 1982:15---52. 10. Almond D, Doyle JJ, Kowalski AE, Williams H. Estimating marginal returns to medical care: evidence from at-risk newborns. Q J Econ. 2010;125(2):591---634. 11. National Center for Health Statistics. Vital Statistics of the United States, 1929---2000. Available at: http://www. cdc.gov/nchs/products/vsus.htm. Accessed June 21, 2014.
23. Dal Bó E, Dal Bó P, Snyder J. Political dynasties. Rev Econ Stud. 2009;76(1):115---142. 24. Ansolabehere S, Snyder JM Jr. The incumbency advantage in US elections: an analysis of state and federal offices, 1942---2000. Election Law J. 2002;1(3):315--338. 25. National Governors Association Web site. Available at: http://www.nga.org. Accessed June 21, 2014. 26. Bertrand M, Duflo E, Mullainathan S. How much should we trust differences-in-differences estimates? Q J Econ. 2004;119(1):249---275. 27. US Census Bureau. Census of governments: finance. Available at: http://www.census.gov/govs/cog. Accessed June 21, 2014. 28. US Census Bureau. Annual survey of state government finances. Available at: https://www.census.gov/ econ/overview/go1500.html. Accessed June 21, 2014. 29. Sen A. Human rights and the limits of law. Cardozo Law Rev. 2005;27:2913---2927. 30. Sen A. The Idea of Justice. Cambridge, MA: Belknap Press of Harvard University Press; 2009. 31. Sen A. Why and how is health a human right? Lancet. 2008;372(9655):2010---2010.
12. Rava WC. State constitutional protections for the poor. Temple Law Rev. 1998;71(3):543---578. 13. Cusack ME. Judicial interpretation of state constitutional rights to a healthful environment. Boston Coll Environ Aff Law Rev. 1993;20(173):175---176. 14. Adams B, Garner A, Gunson B, Andrea H, Holje M. Environmental and natural resources provisions in state constitutions. J Land Resources Environ Law. 2002;22: 73---270. 15. Knight B, Levinson A. Fiscal institutions in US states. In: Strauch R, von Hagen J, eds. Institutions, Politics, and Fiscal Policy. Dordrecht, Netherlands: Kluwer; 2000: 167---187. 16. Eastman JC. Adequacy and the rights revolution: reinterpreting the education clauses in state constitutions. In: West M, Peterson P, eds. The Legal Pursuit of Educational Adequacy. Washington, DC: Brookings Institution Press; 2006:55---76. 17. Turner C, Tamura R, Mulholland S, Baier S. Education and income of the states of the United States: 1840---2000. J Econ Growth. 2007;12(2):101---158. 18. Easterlin R. Regional growth of output: long term tendencies, 1880---1950. In: Kuznets S, Miller AR, eds. Population and Redistribution and Economic Growth, United States, 1870---1950, V2: Analyses of Economic Change. Philadelphia, PA: American Philosophical Society; 1960.
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No protocol approval was necessary because no human participation was involved in this study.
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