Structural Responses to Structural Inequities: Evaluating the Potential of Earned Income Tax Credit (EITC) Policies as Tools for Addressing Social Inequities in Mental Distress

Abstract

Unjust systems of social hierarchy such as racism, sexism, and classism are pervasive in the United States today. They shape the opportunities, resources, and health of all members of society and contribute to substantial social inequities in health and economic wellbeing. As economic inequality and mental distress have concurrently worsened over recent decades and economic resources are an important determinant of mental health, there is reason to worry that these trends will have contributed to widening social inequities as well. However, the existing literature on this topic is inconsistent; varying depending on the time-period, measurement scale, level of social granularity, and social groups considered. This dissertation addresses these limitations by using repeated cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS) to quantify trends in the prevalence of frequent mental distress (FMD) and social inequities in FMD between 1993 and 2019 for populations defined individually and intersectionally by sex, race, ethnicity, educational attainment, and household poverty status. In doing so, we find that the prevalence of FMD has increased substantially over recent decades across the social spectrum; that social inequities in FMD have mostly widened over time in absolute terms while narrowing relatively; that those in poverty and low-socioeconomic status (SES) non-Hispanic white women in particular have seen the greatest increases in FMD and widening of social inequities in FMD over time; and that there are important within-group differences in FMD that would not have been identified if focusing on broad social groups alone. As systems of social hierarchy and the social inequities they create are caused and upheld by structural factors (e.g., the ways our political and economic systems are organized, the policies we have adopted, and the built and social environment those policies have created), it is equally important that we identify how social policy has shaped social inequities in health over time and where social policy can be reformed to foster social equity instead of inequity. In this context, means-tested cash transfer policies such as the Earned Income Tax Credit (EITC) may be effective in mitigating rising mental distress and widening social inequities in mental distress. EITC policies in particular are some of the largest cash transfer programs in the US and have been shown to improve the economic wellbeing of recipients and reduce mental distress and disproportionately benefit socially disadvantaged groups. Practically, they have also been enacted (and so could be reformed) at state and federal levels and have already been expanded several times since their introduction in the 1970s. For these reasons, this dissertation conducts two studies examining the relationship between EITC policies, economic wellbeing, FMD prevalence, and social inequities in each outcome. First, we use 2000-2019 BRFSS data to examine how refundable State EITC policies have been associated with longitudinal trends in FMD prevalence and social inequities in FMD between 2000 and 2019 for populations defined individually by sex, race and ethnicity, and household poverty status. In doing so, we find that states which historically offered a refundable State EITC policy saw smaller increases in FMD prevalence over time, comparatively narrowing sex- and poverty-based inequities in FMD, and contemporaneously lower FMD prevalence overall. However, our findings also suggest that State EITC policies have been associated with widening racial inequities in FMD over time for those non-Hispanic Black or Native American or Alaska Native (NAAN). In our second study, we use respondent information from the 2019 BRFSS and policy information from the University of Kentucky Center for Poverty Research (UKCPR) National Welfare Database to simulate how several Federal and State EITC reforms may have impacted national EITC expenditures, EITC recipiency rates, typical EITC credit eligibilities, and FMD prevalence in 2019 had they been implemented for the overall population as well as for groups defined individually by sex, race, ethnicity, educational attainment, and household poverty status. We find that these reforms could lift hundreds of thousands out of poverty and increase EITC benefits for millions more, while in most cases disproportionately benefiting socially disadvantaged groups. However, some of these reforms could also widen socioeconomic inequities and none of the reforms we considered would be expected to meaningfully affect FMD prevalence.