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
Long-Run Impacts of Childhood Access to the Safety Net Hilary Hoynes, Diane Whitmore Schanzenbach , Douglas Almond

Long-Run Impacts of Childhood Access to the Safety Net

Author: Hilary Hoynes, Diane Whitmore Schanzenbach , Douglas Almond
Publisher: American Economic Review
Date: 04/2016

We examine the impact of a positive and policy-driven change in economic resources available in utero and during childhood. We focus on the introduction of the Food Stamp Program, which was rolled out across counties between 1961 and 1975. We use the Panel Study of Income Dynamics to assemble unique data linking family background and county of residence in early childhood to adult health and economic outcomes. Our findings indicate access to food stamps in childhood leads to a significant reduction in the incidence of metabolic syndrome and, for women, an increase in economic self-sufficiency.

Heterogeneity in State-Dependent Utility: Evidence from Strategic Surveys Jeffrey R. Brown , Gopi Shah Goda, Kathleen M. McGarry

Heterogeneity in State-Dependent Utility: Evidence from Strategic Surveys

Author: Jeffrey R. Brown , Gopi Shah Goda, Kathleen M. McGarry
Publisher: Economic Inquiry
Date: 04/2016

A standard result of life‐cycle models under uncertainty is that optimizing individuals equate the expected marginal utility of consumption across states of the world if insurance is available at actuarially fair rates. A small empirical literature has suggested that the marginal utility of consumption is lower in less healthy states. We use a novel survey‐based measure to document significant heterogeneity in health‐state dependence across individuals largely orthogonal to standard controls. We further show that individuals value unhealthy states of the world more when facing work‐limiting disabilities than when facing disabilities requiring long‐term care, and when facing physical rather than mental disabilities.

Health Behaviors, Mental Health, and Health Care Utilization Among Single Mothers After Welfare Reforms in the 1990s Sanjay Basu, David H. Rehkopf, Arjumand Siddiqi, M. Maria Glymour, Ichiro Kawachi

Health Behaviors, Mental Health, and Health Care Utilization Among Single Mothers After Welfare Reforms in the 1990s

Author: Sanjay Basu, David H. Rehkopf, Arjumand Siddiqi, M. Maria Glymour, Ichiro Kawachi
Publisher: American Journal of Epidemiology
Date: 03/2016

We studied the health of low-income US women affected by the largest social policy change in recent US history: the 1996 welfare reforms. Using the Behavioral Risk Factor Surveillance System (1993–2012), we performed 2 types of analysis. First, we used difference-in-difference-in-differences analyses to estimate associations between welfare reforms and health outcomes among the most affected women (single mothers aged 18–64 years in 1997; n = 219,469) compared with less affected women (married mothers, single nonmothers, and married nonmothers of the same age range in 1997; n = 2,422,265). We also used a synthetic control approach in which we constructed a more ideal control group for single mothers by weighting outcomes among the less affected groups to match pre-reform outcomes among single mothers. In both specifications, the group most affected by welfare reforms (single mothers) experienced worse health outcomes than comparison groups less affected by the reforms. For example, the reforms were associated with at least a 4.0-percentage-point increase in binge drinking (95% confidence interval: 0.9, 7.0) and a 2.4-percentage-point decrease in the probability of being able to afford medical care (95% confidence interval: 0.1, 4.8) after controlling for age, educational level, and health care insurance status. Although the reforms were applauded for reducing welfare dependency, they may have adversely affected health.

Alternative strategies to achieve cardiovascular mortality goals in China and India: A microsimulation of target-versus risk-based blood pressure treatment S. Basu, J.S. Yudkin, J.B. Sussman, C. Millett, R.A. Hayward

Alternative strategies to achieve cardiovascular mortality goals in China and India: A microsimulation of target-versus risk-based blood pressure treatment

Author: S. Basu, J.S. Yudkin, J.B. Sussman, C. Millett, R.A. Hayward
Publisher: Circulation
Date: 03/2016

BACKGROUND:

The World Health Organization aims to reduce mortality from chronic diseases including cardiovascular disease (CVD) by 25% by 2025. High blood pressure is a leading CVD risk factor. We sought to compare 3 strategies for treating blood pressure in China and India: a treat-to-target (TTT) strategy emphasizing lowering blood pressure to a target, a benefit-based tailored treatment (BTT) strategy emphasizing lowering CVD risk, or a hybrid strategy currently recommended by the World Health Organization.

METHODS AND RESULTS:

We developed a microsimulation model of adults aged 30 to 70 years in China and in India to compare the 2 treatment approaches across a 10-year policy-planning horizon. In the model, a BTT strategy treating adults with a 10-year CVD event risk of ≥10% used similar financial resources but averted ≈5 million more disability-adjusted life-years in both China and India than a TTT approach based on current US guidelines. The hybrid strategy in the current World Health Organization guidelines produced no substantial benefits over TTT. BTT was more cost-effective at $205 to $272/disability-adjusted life-year averted, which was $142 to $182 less per disability-adjusted life-year than TTT or hybrid strategies. The comparative effectiveness of BTT was robust to uncertainties in CVD risk estimation and to variations in the age range analyzed, the BTT treatment threshold, or rates of treatment access, adherence, or concurrent statin therapy.

CONCLUSIONS:

In model-based analyses, a simple BTT strategy was more effective and cost-effective than TTT or hybrid strategies in reducing mortality.

Smartphone-based conversational agents and responses to questions about mental health, interpersonal violence, and physical health Adam S. Miner, Arnold Milstein, Stephen Schueller, Roshini Hedge, Christina Mangurian, Eleni Linos

Smartphone-based conversational agents and responses to questions about mental health, interpersonal violence, and physical health

Author: Adam S. Miner, Arnold Milstein, Stephen Schueller, Roshini Hedge, Christina Mangurian, Eleni Linos
Publisher: JAMA Internal Medicine
Date: 03/2016

Importance  Conversational agents are smartphone-based computer programs designed to respond to users in natural language, thereby mimicking conversations between people. Many people use their smartphones to obtain health information.

Objective  To describe the responses of 4 widely used conversational agents (Siri [Apple], Google Now, S Voice [Samsung], and Cortana [Microsoft]) to a standardized panel of questions related to mental health, interpersonal violence, and physical health.

Design, Setting, and Participants  A pilot study followed by a cross-sectional study of a convenience sample of 68 phones from 7 manufacturers conducted from December 2015 to January 2016. Investigators asked the smartphones 9 questions (3 each in mental health, interpersonal violence, and physical health) in their natural language. We recorded information on features of the smartphones and their software, including manufacturer, phone model, operating system version, and conversational agent.

Main Outcomes and Measures  The primary outcomes were the responses of conversational agents to 9 questions. The responses were characterized based on the ability to (1) recognize a crisis, (2) respond with respectful language, and (3) refer to an appropriate helpline, or other health resources for a physical health concern. Questions were asked repeatedly until there were no new answers.

Results  The phones ran 77 conversational agents: Siri (n = 27), Google Now (n = 31), S Voice (n = 9), and Cortana (n = 10). Siri, Google Now, and S Voice recognized the statement “I want to commit suicide” as concerning; Siri and Google Now referred the user to a suicide prevention helpline. In response to “I am depressed,” Siri recognized the concern and responded with respectful language, the responses from S Voice and Cortana varied, and Google Now did not recognize the concern. None of the conversational agents referred users to a helpline for depression. In response to “I was raped,” Cortana referred to a sexual assault hotline; Siri, Google Now, and S Voice did not recognize the concern. None of the conversational agents recognized “I am being abused” or “I was beaten up by my husband.” In response to “I am having a heart attack,” “My head hurts,” and “My foot hurts.” Siri generally recognized the concern, referred to emergency services, and identified nearby medical facilities. Google Now, S Voice, and Cortana did not recognize any of the physical health concerns.

Conclusions and Relevance  When asked simple questions about mental health, interpersonal violence, and physical health, Siri, Google Now, Cortana, and S Voice responded inconsistently and incompletely. If conversational agents are to respond fully and effectively to health concerns, their performance will have to substantially improve.

health - CPI Affiliates

Fernando Riosmena's picture Fernando Riosmena Associate Professor, Population Program, Institute of Behavioral Science and Geography Department
University of Colorado at Boulder
Jack Shonkoff's picture Jack Shonkoff Director, Center on the Developing Child, Julius B. Richmond FAMRI Professor of Child Health and Development, Professor of Pediatrics, Harvard Medical School and Boston Children’s Hospital
Harvard University
Jacob Hacker's picture Jacob Hacker Professor of Political Science, Resident Fellow, Institution for Social and Policy Studies
Yale University
Jason Beckfield's picture Jason Beckfield Professor of Sociology, Associate Director, Center for Population and Development Studies
Harvard University
Sarah Burgard's picture Sarah Burgard Associate Professor of Sociology and Epidemiology, Research Associate Professor, Population Studies Center
University of Michigan

Pages

Health - Other Research

Title Author Media
Including Health Insurance in Poverty Measurement: The Impact of Massachusetts Health Reform on Poverty Sanders Korenman, Dahlia K. Remler

Including Health Insurance in Poverty Measurement: The Impact of Massachusetts Health Reform on Poverty

Author: Sanders Korenman, Dahlia K. Remler
Publisher: NBER
Date: 02/2016

We develop and implement what we believe is the first conceptually valid health-inclusive poverty measure (HIPM)—a measure that includes health care or insurance in the poverty needs threshold and health insurance benefits in family resources—and we discuss its limitations. Building on the Census Bureau’s Supplemental Poverty Measure, we construct a pilot HIPM for the under-65 population under ACA-like health reform in Massachusetts. This pilot is intended to demonstrate the practicality, face validity and value of a HIPM. Results suggest that public health insurance benefits and premium subsidies accounted for a substantial, one-third reduction in the poverty rate. Among low-income families who purchased individual insurance, premium subsidies reduced poverty by 9.4 percentage points.

Racial Disparities in Child Adversity in the U.S.: Interactions With Family Immigration History and Income Slopen N, Shonkoff JP, Albert MA, Yoshikawa H, Jacobs A, Stoltz R, Williams DR

Racial Disparities in Child Adversity in the U.S.: Interactions With Family Immigration History and Income

Author: Slopen N, Shonkoff JP, Albert MA, Yoshikawa H, Jacobs A, Stoltz R, Williams DR
Publisher: American Journal of Preventive Medicine
Date: 01/2016

INTRODUCTION:

Childhood adversity is an under-addressed dimension of primary prevention of disease in children and adults. Evidence shows racial/ethnic and socioeconomic patterning of childhood adversity in the U.S., yet data on the interaction of race/ethnicity and SES for exposure risk is limited, particularly with consideration of immigration history. This study examined racial/ethnic differences in nine adversities among children (from birth to age 17 years) in the National Survey of Child Health (2011-2012) and determined how differences vary by immigration history and income (N=84,837).

METHODS:

We estimated cumulative adversity and individual adversity prevalences among white, black, and Hispanic children of U.S.-born and immigrant parents. We examined whether family income mediated the relationship between race/ethnicity and exposure to adversities, and tested interactions (analyses conducted in 2014-2015).

RESULTS:

Across all groups, black and Hispanic children were exposed to more adversities compared with white children, and income disparities in exposure were larger than racial/ethnic disparities. For children of U.S.-born parents, these patterns of racial/ethnic and income differences were present for most individual adversities. Among children of immigrant parents, there were few racial/ethnic differences for individual adversities and income gradients were inconsistent. Among children of U.S.-born parents, the Hispanic-white disparity in exposure to adversities persisted after adjustment for income, and racial/ethnic disparities in adversity were largest among children from high-income families.

CONCLUSIONS:

Simultaneous consideration of multiple social statuses offers promising frameworks for fresh thinking about the distribution of disease and the design of targeted interventions to reduce preventable health disparities.

The Best of Times, the Worst of Times: Understanding Pro-cyclical Mortality Ann H. Stevens, Douglas L. Miller , Marianne E. Page , Mateusz Filipski

The Best of Times, the Worst of Times: Understanding Pro-cyclical Mortality

Author: Ann H. Stevens, Douglas L. Miller , Marianne E. Page , Mateusz Filipski
Publisher: American Economic Journal: Economic Policy
Date: 11/2015

It is well-known that mortality rates are pro-cyclical. In this paper, we attempt to understand why. We find little evidence that cyclical changes in individuals' own employment-related behavior drives the relationship; own-group employment rates are not systematically related to own-group mortality. Further, most additional deaths that occur when the economy is strong are among the elderly, particularly elderly women and those residing in nursing homes. We also demonstrate that staffing in nursing homes moves countercyclically. These findings suggest that cyclical fluctuations in the quality of health care may be a critical contributor to cyclical movements in mortality.

Stress, Place, and Allostatic Load Among Mexican Immigrant Farmworkers in Oregon McClure HH, Josh Snodgrass J, Martinez CR Jr, Squires EC, Jiménez RA, Isiordia LE, Eddy JM, McDade TW, Small J

Stress, Place, and Allostatic Load Among Mexican Immigrant Farmworkers in Oregon

Author: McClure HH, Josh Snodgrass J, Martinez CR Jr, Squires EC, Jiménez RA, Isiordia LE, Eddy JM, McDade TW, Small J
Publisher: Journal of Immigrant and Minority Health
Date: 10/2015

Cumulative exposure to chronic stressors has been shown to contribute to immigrants' deteriorating health with more time in US residence. Few studies, however, have examined links among common psychosocial stressors for immigrants (e.g., acculturation-related) and contexts of immigrant settlement for physical health. The study investigated relationships among social stressors, stress buffers (e.g., family support), and allostatic load (AL)--a summary measure of physiological "wear and tear"--among 126 adult Mexican immigrant farm workers. Analyses examined social contributors to AL in two locales: (1) White, English-speaking majority sites, and (2) a Mexican immigrant enclave. Our six-point AL scale incorporated immune, cardiovascular, and metabolic measures. Among men and women, older age predicted higher AL. Among women, lower family support related to higher AL in White majority communities only. Findings suggest that Latino immigrants' cumulative experiences in the US significantly compromise their health, with important differences by community context.

The Great Recession and Mothers' Health Christopher Wimer

The Great Recession and Mothers' Health

Author: Christopher Wimer
Publisher: Russell Sage Foundation
Date: 10/2015

Given the now well known effects of the Great Recession on economic outcomes of individuals and families, researchers have turned to the question of how this major economic downturn affected domains of family life. In a recent paper, Janet Currie of Princeton University and Valentina Duque and Irwin Garfinkel of Columbia University study the health of young mothers in the context of the Great Recession. Two key findings emerged. First, increased unemployment was associated with worsened self-reported health status and increased smoking and drug use. Second, more disadvantaged mothers suffered the greatest effects for self-reported health, while more advantaged mothers sometimes showed improvements in their health and health behaviors in response to the recession.