Communities of color and poor neighborhoods are disproportionately exposed to more air pollution—a pattern known as environmental injustices. Environmental injustices increase susceptibility to negative health outcomes among residents in affected communities. The structural mechanisms distributing environmental injustices in the USA are understudied. Bridging the literatures on the social determinants of health and environmental justice highlights the importance of the environmental conditions for health inequalities and sheds light on the institutional mechanisms driving environmental health inequalities. Employing a critical quantitative methods approach, we use data from an innovative state racism index to argue that systematic racialized inequalities in areas from housing to employment increase outdoor airborne environmental health risks in neighborhoods. Results of a multilevel analysis in over 65,000 census tracts demonstrate that tracts in states with higher levels of state-level Black–white gaps report greater environmental health risk exposure to outdoor air pollution. The state racism index explains four-to-ten percent of county- and state-level variation in carcinogenic risk and noncarcinogenic respiratory system risks from outdoor air toxics. The findings suggest that the disproportional exposure across communities is tied to systematic inequalities in environmental regulation and other structural elements such as housing and incarceration. Structural racism is an environmental justice issue.