Health Disparities

  • Sanjay Basu
  • Mark Cullen
  • Jeremy Freese
  • David Rehkopf

Leaders: Sanjay Basu, Mark Cullen, Jeremy Freese, David Rehkopf 

The affiliates within the Health Disparities RG are using new computer modeling and statistical techniques to examine how poverty affects the health of children and adults and how some anti-poverty programs are reducing those effects. Here’s a sampling of our projects. 

Income, geography, and life expectancy: Using deidentified tax data and Social Security Administration death records, Raj Chetty and his coauthors have shown that the richest 1 percent live 14.6 years longer, on average, than the poorest 1 percent. Although poor people typically have much shorter lives, Chetty also shows that the extent of this disadvantage depends on the place of residence, thus suggesting that there may be opportunities for policy to reduce the gap in life expectancy.

Infant health and poverty: Which poor neighborhoods are associated with very low birth weights? By identifying neighborhoods that are yielding very low birth weights, we can start to target home visiting and related programs.

Biological mechanisms of disadvantage: We all know that poverty “gets under the skin” and creates lasting disadvantage. Is this because children exposed to poverty-induced stress experience epigenetic changes? We’re going to know very soon.

Income and the developing brain: The prevailing view is that poverty is especially likely to shape children’s early development because of the high plasticity and rapid growth of the brain during the first three years of life. It’s high time for a rigorous study of how income affects the brain function and development of infants and toddlers. 

Health - CPI Research

Title Author Media
The Effects of the Affordable Care Act on Health Insurance Coverage and Labor Market Outcomes Mark Duggan, Gopi Shah Goda, Emilie Jackson

The Effects of the Affordable Care Act on Health Insurance Coverage and Labor Market Outcomes

Author: Mark Duggan, Gopi Shah Goda, Emilie Jackson
Publisher: NBER
Date: 07/2017

The Affordable Care Act (ACA) includes several provisions designed to expand insurance coverage that also alter the tie between employment and health insurance. In this paper, we exploit variation across geographic areas in the potential impact of the ACA to estimate its effect on health insurance coverage and labor market outcomes in the first two years after the implementation of its main features. Our measures of potential ACA impact come from pre-existing population shares of uninsured individuals within income groups that were targeted by Medicaid expansions and federal subsidies for private health insurance, interacted with each state’s Medicaid expansion status. Our findings indicate that the majority of the increase in health insurance coverage since 2013 is due to the ACA and that areas in which the potential Medicaid and exchange enrollments were higher saw substantially larger increases in coverage. While labor market outcomes in the aggregate were not significantly affected, our results indicate that labor force participation reductions in areas with higher potential exchange enrollment were offset by increases in labor force participation in areas with higher potential Medicaid enrollment

State of the Union 2017: Health Rucker C. Johnson

State of the Union 2017: Health

Author: Rucker C. Johnson
Publisher: Stanford Center on Poverty and Inequality
Date: 06/2017

Racial and ethnic minorities experience higher-than-average rates of illness, have higher age-specific death rates throughout the life course, and are more likely to suffer from early onset of illnesses and more severe diseases than whites. In this article, I examine these and other differences in health outcomes for whites and blacks in the United States and show that black-white health disparities are large and appear to widen over the life cycle. I also discuss several policy changes that served to narrow racial health disparities in the past and consider how future policies might help ameliorate racial inequities in health.

The Effects of Job Insecurity on Health Care Utilization: Findings from a Panel of U.S. Workers Rita Hamad , Sepideh Modrek, Mark R. Cullen

The Effects of Job Insecurity on Health Care Utilization: Findings from a Panel of U.S. Workers

Author: Rita Hamad , Sepideh Modrek, Mark R. Cullen
Publisher: Health Services Research
Date: 06/2016

Objective

To examine the impacts of job insecurity during the recession of 2007–2009 on health care utilization among a panel of U.S. employees.

Data Sources/Study Setting

Linked administrative and claims datasets on a panel of continuously employed, continuously insured individuals at a large multisite manufacturing firm that experienced widespread layoffs (N = 9,486).

Study Design

We employed segmented regressions to examine temporal discontinuities in utilization during 2006–2012. To assess the effects of job insecurity, we compared individuals at high- and low-layoff plants. Because the dataset includes multiple observations for each individual, we included individual-level fixed effects.

Principal Findings

We found discontinuous increases in outpatient (3.5 visits/month/10,000 individuals, p = .002) and emergency (0.4 visits/month/10,000 individuals, p = .05) utilization in the panel of all employees. Compared with individuals at low-layoff plants, individuals at high-layoff plants decreased outpatient utilization (−4.0 visits/month/10,000 individuals, p = .008), suggesting foregone preventive care, with a marginally significant increase in emergency utilization (0.4 visits/month/10,000 individuals, p = .08).

Conclusions

These results suggest changes in health care utilization and potentially adverse impacts on employee health in response to job insecurity during the latest recession. This study contributes to our understanding of the impacts of economic crises on the health of the U.S. working population.

Beyond Income: What Else Predicts Very Low Food Security Among Children? Patricia M. Anderson, Kristin F. Butcher, Hilary W. Hoynes, Diane Whitmore Schanzenbach

Beyond Income: What Else Predicts Very Low Food Security Among Children?

Author: Patricia M. Anderson, Kristin F. Butcher, Hilary W. Hoynes, Diane Whitmore Schanzenbach
Publisher: Southern Economic Journal
Date: 06/2016

We examine characteristics and correlates of households in the United States that are most likely to have children at risk of inadequate nutrition – those that report very low food security (VLFS) among their children. Using 11 years of the Current Population Survey, plus data from the National Health and Nutrition Examination Survey and American Time Use Survey, we describe these households in great detail with the goal of trying to understand how these households differ from households without such severe food insecurity. While household income certainly plays an important role in determining VLFS among children, we find that even after flexibly controlling for income-to-poverty rates some household characteristics and patterns of program participation have important additional explanatory power. Finally, our examination of the NHANES and ATUS data suggests an important role for both mental and physical health in determining the food security status of children.

Family Ruptures, Stress, and the Mental Health of the Next Generation Petra Persson, Maya Rossin-Slater

Family Ruptures, Stress, and the Mental Health of the Next Generation

Author: Petra Persson, Maya Rossin-Slater
Publisher: NBER
Date: 05/2016

This paper studies how in utero exposure to maternal stress from family ruptures affects later mental health. We find that prenatal exposure to the death of a maternal relative increases take-up of ADHD medications during childhood and anti-anxiety and depression medications in adulthood. Further, family ruptures during pregnancy depress birth outcomes and raise the risk of perinatal complications necessitating hospitalization. Our results suggest large welfare gains from preventing fetal stress from family ruptures and possibly from economically induced stressors such as unemployment. They further suggest that greater stress exposure among the poor may partially explain the intergenerational persistence of poverty.

health - CPI Affiliates

David Rehkopf's picture David Rehkopf Health Disparities Research Group Leader, Assistant Professor of Medicine
Stanford University
Jeremy Freese's picture Jeremy Freese Health Disparities Research Group Leader, Professor of Sociology
Stanford University
Mark Cullen's picture Mark Cullen Health Disparities Research Group Leader, Director of Stanford Center for Population Health Sciences, Professor of Medicine
Stanford University
Sanjay Basu's picture Sanjay Basu Health Disparities Research Group Leader, Assistant Professor of Medicine
Stanford University
Fernando Riosmena's picture Fernando Riosmena Associate Professor, Population Program, Institute of Behavioral Science and Geography Department
University of Colorado at Boulder

Pages

Health - Other Research

Title Author Media
Desire for and to Avoid Pregnancy During the Transition to Adulthood Abigail Weitzman, Jennifer S. Barber, Yasamin Kusunoki, Paula England

Desire for and to Avoid Pregnancy During the Transition to Adulthood

Author: Abigail Weitzman, Jennifer S. Barber, Yasamin Kusunoki, Paula England
Publisher: Journal of Marriage and Family
Date: 08/2017

Unintended pregnancies disproportionately occur among teenage women, yet little is known about the determinants of pregnancy desire among this group. The authors use a comprehensive baseline survey and data on pregnancy desires to investigate which unmarried 18- to 20-year-old women want a pregnancy, want to avoid pregnancy, and report consistent pregnancy desire and disinclination. Variables that positively predict pregnancy desire generally negatively predict desire to avoid pregnancy. Although most young women have no desire and strong disinclination in most weeks, childhood public assistance is a strong predictor of wanting pregnancy and not wanting to avoid it. Comparing nested models suggests that the effects of childhood disadvantage operate through social environments where early pregnancy is less stigmatized. Young women in serious relationships, who are depressed, and who are not pursuing postsecondary education have more desire for pregnancy and less disinclination, but little of childhood disadvantage is mediated by these factors.

Subsidizing Health Insurance for Low-Income Adults: Evidence from Massachusetts Amy Finkelstein, Nathaniel Hendren, Mark Shepard

Subsidizing Health Insurance for Low-Income Adults: Evidence from Massachusetts

Author: Amy Finkelstein, Nathaniel Hendren, Mark Shepard
Publisher: NBER
Date: 08/2017

How much are low-income individuals willing to pay for health insurance, and what are the implications for insurance markets? Using administrative data from Massachusetts’ subsidized insurance exchange, we exploit discontinuities in the subsidy schedule to estimate willingness to pay and costs of insurance among low-income adults. As subsidies decline, insurance take-up falls rapidly, dropping about 25% for each $40 increase in monthly enrollee premiums. Marginal enrollees tend to be lower-cost, consistent with adverse selection into insurance. But across the entire distribution we can observe – approximately the bottom 70% of the willingness to pay distribution – enrollee willingness to pay is always less than half of own expected costs. As a result, we estimate that take-up will be highly incomplete even with generous subsidies: if enrollee premiums were 25% of insurers’ average costs, at most half of potential enrollees would buy insurance; even premiums subsidized to 10% of average costs would still leave at least 20% uninsured. We suggest an important role for uncompensated care for the uninsured in explaining these findings and explore normative implications.

Addressing the Opioid Epidemic: Is There a Role for Physician Education? Molly Schnell, Janet Currie

Addressing the Opioid Epidemic: Is There a Role for Physician Education?

Author: Molly Schnell, Janet Currie
Publisher: NBER
Date: 08/2017

Using data on all opioid prescriptions written by physicians from 2006 to 2014, we uncover a striking relationship between opioid prescribing and medical school rank. Even within the same specialty and county of practice, physicians who completed their initial training at top medical schools write significantly fewer opioid prescriptions annually than physicians from lower ranked schools. Additional evidence suggests that some of this gradient represents a causal effect of education rather than patient selection across physicians or physician selection across medical schools. Altering physician education may therefore be a useful policy tool in fighting the current epidemic.

 

Is It Who You Are or Where You Live? Residential Segregation and Racial Gaps in Childhood Asthma Diane Alexander, Janet Currie

Is It Who You Are or Where You Live? Residential Segregation and Racial Gaps in Childhood Asthma

Author: Diane Alexander, Janet Currie
Publisher: NBER
Date: 07/2017

Higher asthma rates are one of the more obvious ways that health inequalities between African American and other children are manifested beginning in early childhood. In 2010, black asthma rates were double non-black rates. Some but not all of this difference can be explained by factors such as a higher incidence of low birth weight (LBW) among blacks; however, even conditional on LBW, blacks have a higher incidence of asthma than others. Using a unique data set based on the health records of all children born in New Jersey between 2006 and 2010, we show that when we split the data by whether or not children live in a “black” zip code, this racial difference in the incidence of asthma among LBW children entirely disappears. All LBW children in these zip codes, regardless of race, have a higher incidence of asthma. Our results point to the importance of residential segregation and neighborhoods in explaining persistent racial health disparities.

 

An Analysis of the Memphis Nurse-Family Partnership Program James J. Heckman, Margaret L. Holland, Kevin K. Makino, Rodrigo Pinto, Maria Rosales-Rueda

An Analysis of the Memphis Nurse-Family Partnership Program

Author: James J. Heckman, Margaret L. Holland, Kevin K. Makino, Rodrigo Pinto, Maria Rosales-Rueda
Publisher: NBER
Date: 07/2017

This paper evaluates a randomized controlled trial of the Nurse-Family Partnership (NFP) program conducted in Memphis, TN in 1990. NFP offers home visits conducted by nurses for disadvantaged first-time mothers during pregnancy and early childhood. We test NFP treatment effects using permutation-based inference that accounts for the NFP randomization protocol. Our methodology is valid for small samples and corrects for multiple-hypothesis testing. We also analyze the underlying mechanisms generating these treatment effects. We decompose NFP treatment effects into components associated with the intervention-enhanced parenting and early childhood skills. The NFP improves home investments, parenting attitudes and mental health for mothers of infants at age 2. At age 6, the NFP boosts cognitive skills for both genders and socio-emotional skills for females. These treatment effects are explained by program-induced improvements in maternal traits and early-life family investments. At age 12, the treatment effects for males (but not for females) persist in the form of enhanced achievement test scores. Treatment effects are largely explained by enhanced cognitive skills at age 6. Our evidence of pronounced gender differences in response to early childhood interventions contributes to a growing literature on this topic.