In this investigation, we examined the associations between state-level structural sexism—a multidimensional index of gender inequities across economic, political, and cultural domains of the gender system—and health care access and quality among women and men in the United States. We linked administrative data gauging state-level gender gaps in pay, employment, poverty, political representation, and policy protections to individual-level data on health care availability, affordability, and quality from the national Consumer Survey of Health Care Access (2014–2019; N = 24,250). Results show that higher state-level sexism is associated with greater inability to access needed health care and more barriers to affording care for women but not for men. Furthermore, contrary to our hypothesis, women residing in states with higher state-level sexism report better quality of care than women in states with lower levels of sexism. These findings implicate state-level sexism in perpetuating gender disparities in health care.
AtrashHani K.JohnsonKayAdamsMyronCorderoJosé F.HowseJennifer. 2006. “Preconception Care for Improving Perinatal Outcomes: The Time to Act.”Maternal and Child Health Journal10(1):3–11.
2.
AyresMelanie M.FriedmanCarly K.LeaperCampbell. 2009. “Individual and Situational Factors Related to Young Women’s Likelihood of Confronting Sexism in Their Everyday Lives.” Sex Roles61(7–8):449–60.
3.
AzamIrimMoyErnest. 2016. National Healthcare Quality and Disparities Report: Chartbook on Access to Health Care. Rockville, MD: Agency for Healthcare Research and Quality.
4.
BakkoMatthewKattariShanna K.2019. “Differential Access to Transgender Inclusive Insurance and Healthcare in the United States: Challenges to Health across the Life Course.” Journal of Aging and Social Policy33(1):67–81.
5.
BaumCharles L.RuhmChristopher J.2016. “The Effects of Paid Family Leave in California on Labor Market Outcomes.” Journal of Policy Analysis and Management35(2):333–56.
6.
BerkmanMichael B.O’ConnorRobert E.1993. “Do Women Legislators Matter?: Female Legislators and State Abortion Policy.” American Politics Research21(1):102–24.
7.
Bobbitt-ZeherDonna. 2011. “Gender Discrimination at Work: Connecting Gender Stereotypes, Institutional Policies, and Gender Composition of Workplace.” Gender & Society25(6):764–86.
8.
BolzendahlCatherineBrooksClem. 2007. “Women’s Political Representation and Welfare State Spending in 12 Capitalist Democracies.” Social Forces85(4):1509–34.
9.
BossonJennifer K.PinelElizabeth C.VandelloJoseph A.2010. “The Emotional Impact of Ambivalent Sexism: Forecasts Versus Real Experiences.” Sex Roles62(7–8):520–31.
10.
BrattonKathleen A.HaynieKerry L.1999. “Agenda Setting and Legislative Success in State Legislatures: The Effects of Gender and Race.” Journal of Politics61(3):658–79.
11.
CaseAnnePaxsonChristina. 2005. “Sex Differences in Morbidity and Mortality.” Demography42(2):189–214.
12.
ChapmanElizabeth N.KaatzAnnaCarnesMolly. 2013. “Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities.” Journal of General Internal Medicine28(11):1504–10.
13.
ChenYing YehSubramanianS. V.Acevedo-GarciaDolorosKawachiIchiro. 2005. “Women’s Status and Depressive Symptoms: A Multilevel Analysis.” Social Science and Medicine60(1):49–60.
14.
CreangaAndreea A.BergCynthia J.KoJean Y.FarrSherry L.TongVan T.BruceF. CarolCallaghanWilliam M.2014. “Maternal Mortality and Morbidity in the United States: Where Are We Now?”Journal of Women’s Health23(1):3–9.
15.
DanielHilaryEricksonShari M.BornsteinSue S.KaneGregory C.GantzerHeather E.HenryTracey L.LenchusJoshua D., et al2018. “Women’s Health Policy in the United States: An American College of Physicians Position Paper.” Annals of Internal Medicine168(12):874–75.
16.
DickmanSamuel L.HimmelsteinDavid U.WoolhandlerSteffie. 2017. “Inequality and the Health-Care System in the USA.” The Lancet389(10077):1431–41.
17.
DoranElizabeth L.BartelAnn P.RuhmChristopher J.WaldfogelJane. 2020. “California’s Paid Family Leave Law Improves Maternal Psychological Health.” Social Science & Medicine256:113003. doi:10.1016/j.socscimed.2020.113003.
18.
DoyalLesley. 2000. “Gender Equity in Health: Debates and Dilemmas.” Social Science & Medicine51(6):931–39.
19.
ElliottMarc N.LehrmanWilliam G.BeckettMegan K.GoldsteinElizabethHambarsoomianKatrinGiordanoLaura A.2012. “Gender Differences in Patients’ Perceptions of Inpatient Care.” Health Services Research47(4):1482–501.
20.
FeaginJoeBennefieldZinobia. 2014. “Systemic Racism and U.S. Health Care.” Social Science & Medicine103:7–14.
21.
GaultBarbaraHartmannHeidiHegewischArianeMilliJessicaReichlinLindsey. 2014. Paid Parental Leave in the United States: What the Data Tell Us about Access, Usage, and Economic and Health Benefits. Washington, DC: Institute for Women’s Policy Research.
22.
Van WijkGijsbersCecileM. T.Van VlietKatja P.KolkAnnemarie M.1996. “Gender Perspectives and Quality of Care: Towards Appropriate and Adequate Health Care for Women.” Social Science & Medicine43(5):707–20.
23.
GlickPeterFiskeSusan T.1996. “The Ambivalent Sexism Inventory: Differentiating Hostile and Benevolent Sexism.” Journal of Personality and Social Psychology70(3):491–512.
24.
GoldenbergTamarReisnerSari L.HarperGary W.GamarelKristi E.StephensonRob. 2020. “State Policies and Healthcare Use among Transgender People in the U.S.” American Journal of Preventive Medicine59(2):247–59.
25.
GoodJessica J.WoodzickaJulie A.BourneKimberly A.Moss-RacusinCorinne A.2019. “The Decision to Act: Factors That Predict Women’s and Men’s Decisions to Confront Sexism.” Pp. 49–71 in Confronting Prejudice and Discrimination: The Science of Changing Minds and Behaviors, edited by MallettR. K.MonteithM. J.Cambridge: Academic Press.
26.
HallJudith A.RoterDebra L.1995. “Patient Gender and Communication with Physicians: Results of a Community-Based Study.” Women’s Health1(1):77–95.
27.
HambergKatarina. 2008. “Gender Bias in Medicine.” Women’s Health4(3):237–43.
28.
HarnoisCatherine E.BastosJoão L.2018. “Discrimination, Harassment, and Gendered Health Inequalities: Do Perceptions of Workplace Mistreatment Contribute to the Gender Gap in Self-Reported Health?”Journal of Health and Social Behavior59(2):283–99.
29.
HawkinsSummer SherburneGhianiMarcoHarperSamBaumChristopher F.KaufmanJay S.2020. “Impact of State-Level Changes on Maternal Mortality: A Population-Based, Quasi-experimental Study.” American Journal of Preventive Medicine58(2):165–74.
30.
HessCynthiaMilliJessicaHayesJeffHegewischArianeMayayevaYanaRománStephanieAndersonJulieAugeriJustine. 2015. The Status of Women in the States: 2015. Washington, DC: Institute for Women’s Policy Research.
31.
HomanPatricia. 2017. “Political Gender Inequality and Infant Mortality in the United States, 1990–2012.” Social Science & Medicine182:127–35.
32.
HomanPatricia. 2019. “Structural Sexism and Health in the United States: A New Perspective on Health Inequality and the Gender System.” American Sociological Review84(3):486–516.
33.
JesusTiago SilvaSilvaIsabel Lopes. 2016. “Toward an Evidence-Based Patient–Provider Communication in Rehabilitation: Linking Communication Elements to Better Rehabilitation Outcomes.” Clinical Rehabilitation30(4):315–28.
34.
JohnstonEmily M.StrahanAndrea E.JoskiPeterDunlopAnne L.AdamsE. Kathleen. 2018. “Impacts of the Affordable Care Act’s Medicaid Expansion on Women of Reproductive Age: Differences by Parental Status and State Policies.” Women’s Health Issues28(2):122–29.
35.
KaiserCheryl R.MillerCarol T.2001. “Stop Complaining! The Social Costs of Making Attributions to Discrimination.” Personality and Social Psychology Bulletin27(2):254–63.
36.
KawachiIchiroKennedyBruce P.GuptaVanitaProthrow-StithDeborah. 1999. “Women’s Status and the Health of Women and Men: A View from the States.” Social Science & Medicine48(1):21–32.
37.
KentJennifer A.PatelVinishaVarelaNatalie A.2012. “Gender Disparities in Health Care.” Mount Sinai Journal of Medicine79(5):555–59.
38.
KoganRichardKatchHannahRosenbaumDorothyRiceDouglasRomigKathleenFloydIfeParrottSharon. 2019. Cuts to Low-Income Assistance Programs in President Trump’s 2020 Budget Are Wide-Ranging. Washington, DC: Center on Budget and Policy Priorities.
39.
KriegerNancy. 2001. “Theories for Social Epidemiology in the 21st Century: An Ecosocial Perspective.” International Journal of Epidemiology30(4):668–77.
40.
KriegerNancy. 2020. “Measures of Racism, Sexism, Heterosexism, and Gender Binarism for Health Equity Research: From Structural Injustice to Embodied Harm—An Ecosocial Analysis.” Annual Review of Public Health41:37–62.
41.
LavelleBridgetSmockPamela J.2012. “Divorce and Women’s Risk of Health Insurance Loss.” Journal of Health and Social Behavior53(4):413–31.
42.
LawrenceHal C.NessDebra L.2017. “Planned Parenthood Provides Essential Services That Improve Women’s Health.” Annals of Internal Medicine166(6):443–44.
43.
LeeBethany C.ModrekSepidehWhiteJustin S.BatraAkanshaCollinDaniel F.HamadRita. 2020. “The Effect of California’s Paid Family Leave Policy on Parent Health: A Quasi-experimental Study.” Social Science & Medicine251:112915. doi:10.1016/j.socscimed.2020.112915.
44.
LeveilleSuzanne G.PenninxBrenda W. J. H.MelzerDavidIzmirlianGrantGuralnikJack M.2000. “Sex Differences in the Prevalence of Mobility Disability in Old Age: The Dynamics of Incidence, Recovery, and Mortality.” The Journal of Gerontology, Series B: Psychological Sciences and Social Sciences55(I):41–50.
45.
LongSharon K.StockleyKarenShulmanShanna. 2011. “Have Gender Gaps in Insurance Coverage and Access to Care Narrowed under Health Reform? Findings from Massachusetts.” American Economic Review101(3):640–44.
MargerisonClaire E.MacCallumColleen L.ChenJiajiaZamani-HankYasameanKaestnerRobert. 2020. “Impacts of Medicaid Expansion on Health among Women of Reproductive Age.” American Journal of Preventive Medicine58(1):1–11.
48.
McKernanSigne-MaryRatcliffeCaroline. 2018. Policy Efforts to Reduce Material Hardship for Low-Income Families. Washington, DC: Urban Institute.
49.
MolixLisa. 2014. “Sex Differences in Cardiovascular Health: Does Sexism Influence Women’s Health?”American Journal of the Medical Sciences348(2):153–55.
50.
MontezJennifer KarasZajacovaAnnaHaywardMark D.2016. “Explaining Inequalities in Women’s Mortality between U.S. States.” SSM - Population Health2:561–71.
51.
MossNancy E.2002. “Gender Equity and Socioeconomic Inequality: A Framework for the Patterning of Women’s Health.” Social Science & Medicine54(5):649–61.
52.
NgJudy H.KaftarianShakeh J.TilsonWilma M.GorrellPaulChenXiuhuaChesleyFrancis D.ScholleSarah Hudson. 2010. “Self-Reported Delays in Receipt of Health Care among Women with Diabetes and Cardiovascular Conditions.” Women’s Health Issues20(5):316–22.
53.
Nolen-HoeksemaSusan. 2001. “Gender Differences in Depression.” Current Directions in Psychological Science10(5):173–76.
54.
OwensGary M.2008. “Gender Differences in Health Care Expenditures, Resource Utilization, and Quality of Care.” Journal of Managed Care Pharmacy14(3):2–6.
55.
PabayoRomanCookDaniel M.HarlingGuyGunawanAnastasiaRosenquistNatalie A.MuennigPeter. 2019. “State-Level Income Inequality and Mortality among Infants Born in the United States 2007–2010: A Cohort Study.” BMC Public Health19(1):1–9.
56.
ParkSoon Seok. 2017. “Gendered Representation and Critical Mass: Women’s Legislative Representation and Social Spending in 22 OECD Countries.” Sociological Perspectives60(6):1097–114.
57.
PatchiasElizabeth M.WaxmanJudy. 2007. Women and Health Coverage: The Affordability Gap. New York, NY: The Commonwealth Fund.
58.
PattonDanaFordingRichard C.2020. “The Effect of Women’s Descriptive Representation on Premature Mortality.” Social Forces99(2):820–46.
59.
PenchanskyRoyThomasJ. William. 1981. “The Concept of Access: Definition and Relationship to Consumer Satisfaction.” Medical Care19(2):127–40.
60.
ReingoldRebecca B.GostinLawrence O.2019. “State Abortion Restrictions and the New Supreme Court: Women’s Access to Reproductive Health Services.” Journal of the American Medical Association322(1):21–22.
61.
RidgewayCecilia L.CorrellShelley J.2004. “Unpacking the Gender System: A Theoretical Perspective on Gender Beliefs and Social Relations.” Gender & Society18(4):510–31.
62.
RismanBarbara J.2004. “Gender as a Social Construct: Theory Wrestling with Activism.” Gender & Society18(4):429–50.
63.
RuggieroKaren M.TaylorDonald M.1995. “Coping with Discrimination: How Disadvantaged Group Members Perceive the Discrimination That Confronts Them.” Journal of Personality and Social Psychology68(5):826–38.
64.
RuggieroKaren M.TaylorDonald M.1997. “Why Minority Group Members Perceive or Do Not Perceive the Discrimination That Confronts Them: The Role of Self-Esteem and Perceived Control.” Journal of Personality and Social Psychology72(2):373–89.
65.
RustgiSheila D.DotyMichelle M.CollinsSara R.2009. Women at Risk: Why Many Women Are Forgoing Needed Health Care. New York, NY: The Commonwealth Fund.
66.
SechristGretchen B.DelmarCourtney. 2009. “When Do Men and Women Make Attributions to Gender Discrimination? The Role of Discrimination Source.” Sex Roles 61(9–10):607–20.
67.
SivaramanJosie J.RanapurwalaShabbar I.MoraccoKathryn E.MarshallStephen W.2019. “Association of State Firearm Legislation with Female Intimate Partner Homicide.” American Journal of Preventive Medicine56(1):125–33.
68.
StevensonAmanda J.Flores-VazquezImelda M.AllgeyerRichard L.SchenkkanPetePotterJoseph E.2016. “Effect of Removal of Planned Parenthood from the Texas Women’s Health Program.” New England Journal of Medicine374(9):853–60.
69.
StimpsonJim P.PintorJessie KemmickWilsonFernando A.2019. “Association of Medicaid Expansion with Health Insurance Coverage by Marital Status and Sex.” PLOS ONE14(10):e0223556. doi:10.1371/journal.pone.0223556.
70.
StreetRichard L.MakoulGregoryAroraNeeraj K.EpsteinRonald M.2009. “How Does Communication Heal? Pathways Linking Clinician–Patient Communication to Health Outcomes.” Patient Education and Counseling74(3):295–301.
71.
U.S. Bureau of Labor Statistics. 2019. “Highlights of Women’s Earnings in 2018.” BLS Reports 1083(November):1–113.
72.
von HippelPaul T.2007. “Regression with Missing Ys: An Improved Strategy for Analyzing Multiply Imputed Data.” Sociological Methodology37(1):83–117.
73.
VowlesKevin E.ThompsonMiles. 2012. “The Patient–Provider Relationship in Chronic Pain.” Current Pain and Headache Reports16(2):133–38.
74.
WisdomJennifer P.BerlinMichelleLapidusJodi A.2005. “Relating Health Policy to Women’s Health Outcomes.” Social Science & Medicine61(8):1776–84.
75.
YearbyRuqaiijah. 2018. “Racial Disparities in Health Status and Access to Healthcare: The Continuation of Inequality in the United States Due to Structural Racism.” American Journal of Economics and Sociology77(3–4):1113–52.
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