Equity in Healthcare: Exploring the Viability of Reparations as a Means to Address Racial Health Inequities, Invest in the Community, and Bestow Reconciliation for African Americans

Author

• Alesia A. Smith, Clemson UniversityFollow

Date of Award

8-2026

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Policy Studies

Committee Chair/Advisor

Kenneth Robinson, Ph.D

Committee Member

Rachel Mayo, Ph.D

Committee Member

Bruce Ransom, Ph.D

Committee Member

Natallia Sianko, Ph.D

Abstract

Racial health inequities remain among the most persistent forms of health disparity in the United States, despite decades of policy efforts to eliminate them. African Americans, in particular, continue to experience disproportionately poor health outcomes rooted in generations of institutional racism and in inequities in the social determinants of health, income, wealth, education, housing, and access to care, disparities that the COVID-19 pandemic further exposed and intensified. These enduring, structurally produced harms strengthen the case for reparative investment as a potential intervention.

The purpose of this qualitative study was to examine whether reparations, framed as a community-based investment in health, could serve as an effective and equitable strategy for reducing racial health inequities among African Americans. Specifically, the study explored how a housing-based reparations model influenced the social, political, and cultural mechanisms that drive racial disparities in health. The overarching research question was: How does a housing-based reparations model impact the social, political, and cultural mechanisms that drive racial health inequities? Three sub-questions examined how elected and public officials, health administrator and African American community members described reparations, understood the program's origins and adoption, and assessed its implementation, sustainability, and perceived effects on community well-being.

A single case study design was employed, drawing on semi-structured interviews and document analysis. The study was guided by two frameworks: the Multiple Streams Framework, which explains how a policy problem, available solutions, and political conditions converge to move an issue onto the government agenda, and the Community Capital Framework, which clarifies which community assets a reparative investment actually repairs. There were 13 participants that included, African American community members, elected and local officials, and a health administrator in Evanston, Illinois. Completed interviews lasted 20 to 60 minutes.

Five themes emerged: equity as a consequence of housing policy; reparations framed as local restorative policy; political opportunity structures that enabled adoption; fiscal design as a determinant of scope and sustainability; and tension between symbolic reparations and material redistribution. Findings indicated that the program transferred housing wealth toward geographically concentrated determinants of poor health, including substandard housing, food deserts, and diminished tree canopy. The harm proved remediable through public acknowledgment, documented institutional authorship, and the legal durability to sustain payments. Naming the initiative "reparations" converted advocacy into policy, restored community pride, and loosened constraints tied to the legacy of disadvantage.

The study concluded that housing-based reparations represent a foundational but insufficient step toward health equity. Evanston's program was designed to register its impact primarily through housing and financial gains, on the assumption that such gains would eventually yield longer, healthier lives; yet participants expressed uncertainty about the pathway linking reparations to health outcomes, an ambiguity that likely reflects gaps in how officials themselves understand that mechanism. Even so, participants identified concrete, near-term levers embedded in the program's design, home ownership, access to fresh food, and community gardens, each closely tied to community health and each offering a plausible, testable mechanism for future evaluation. Additional research is needed to determine whether, and how, reparations can reduce racial health inequities.

Recommended Citation

Smith, Alesia A., "Equity in Healthcare: Exploring the Viability of Reparations as a Means to Address Racial Health Inequities, Invest in the Community, and Bestow Reconciliation for African Americans" (2026). All Dissertations. 4310.
https://open.clemson.edu/all_dissertations/4310