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
COVID-19 Is Also a Reallocation Shock Jose Maria Barrero, Nicholas Bloom, Steven J. Davis

COVID-19 Is Also a Reallocation Shock

Author: Jose Maria Barrero, Nicholas Bloom, Steven J. Davis
Publisher: National Bureau of Economic Research
Date: 05/2020

Drawing on firm-level expectations at a one-year forecast horizon in the Survey of Business Uncertainty (SBU), we construct novel, forward-looking reallocation measures for jobs and sales. These measures rise sharply after February 2020, reaching rates in April that are 2.4 (3.9) times the pre-COVID average for jobs (sales). We also draw on special questions in the April SBU to quantify the near-term impact of the COVID-19 shock on business staffing. We find 3 new hires for every 10 layoffs caused by the shock and estimate that 42 percent of recent layoffs will result in permanent job loss. Our survey evidence aligns well with anecdotal evidence of large pandemic-induced demand increases at some firms, with contemporaneous evidence on gross business formation, and with a sharp pandemic-induced rise in equity return dispersion across firms. After developing the evidence, we consider implications of our evidence for the economic outlook and for policy responses to the pandemic. Unemployment benefit levels that exceed worker earnings, policies that subsidize employee retention, occupational licensing restrictions, and regulatory barriers to business formation will impede reallocation responses to the COVID-19 shock.

Using Disasters to Estimate the Impact of Uncertainty Scott R. Baker, Nicholas Bloom, Stephen J. Terry

Using Disasters to Estimate the Impact of Uncertainty

Author: Scott R. Baker, Nicholas Bloom, Stephen J. Terry
Publisher: National Bureau of Economic Research
Date: 05/2020

Uncertainty rises in recessions and falls in booms. But what is the causal relationship? We construct cross-country panel data on stock market levels and volatility and use natural disasters, terrorist attacks, and political shocks as instruments in regressions and VAR estimations. We find that increased volatility robustly lowers growth. We also structurally estimate a heterogeneous firms business cycle model with uncertainty and disasters and use this to analyze our empirical results. Finally, using our VAR results we estimate COVID-19 will reduce US GDP by 9% in 2020 based on the initial stock market returns and volatility response.

Disability Insurance: Error Rates and Gender Differences Hamish Low, Luigi Pistaferri

Disability Insurance: Error Rates and Gender Differences

Author: Hamish Low, Luigi Pistaferri
Publisher: National Bureau of Economic Research
Date: 11/2019

We show the extent of errors made in the award of disability insurance using matched survey-administrative data. False rejections (Type I errors) are widespread, and there are large gender differences in these type I error rates. Women with a severe, work-limiting, permanent impairment are 20 percentage points more likely to be rejected than men, controlling for the type of health condition, occupation, and a host of demographic characteristics. We investigate whether these gender differences in Type I errors are due to women being in better health than men, to women having lower pain thresholds, or to women applying more readily for disability insurance. None of these explanations are consistent with the data. We use evidence from disability vignettes to suggest that there are different acceptance thresholds for men and women. The differences by gender arise because women are more likely to be assessed as being able to find other work than observationally equivalent men. Despite this, after rejection, women with a self-reported work limitation do not return to work, compared to rejected women without a work limitation.

Ethics of Inclusion: Cultivate Trust in Precision Medicine Lee, Sandra Soo-Jin, Fullerton, Stephanie M., Saperstein, Aliya, Shim, Janet K.

Ethics of Inclusion: Cultivate Trust in Precision Medicine

Author: Lee, Sandra Soo-Jin, Fullerton, Stephanie M., Saperstein, Aliya, Shim, Janet K.
Publisher: Science
Date: 06/2019

Precision medicine is at a crossroads. Progress toward its central goal, to address persistent health inequities, will depend on enrolling populations in research that have been historically underrepresented, thus eliminating longstanding exclusions from such research (1). Yet the history of ethical violations related to protocols for inclusion in biomedical research, as well as the continued misuse of research results (such as white nationalists looking to genetic ancestry to support claims of racial superiority), continue to engender mistrust among these populations (2). For precision medicine research (PMR) to achieve its goal, all people must believe that there is value in providing information about themselves and their families, and that their participation will translate into equitable distribution of benefits. This requires an ethics of inclusion that considers what constitutes inclusive practices in PMR, what goals and values are being furthered through efforts to enhance diversity, and who participates in adjudicating these questions. The early stages of PMR offer a critical window in which to intervene before research practices and their consequences become locked in (3).

State of the Union 2019: Health Mark Duggan, Jackie Li

State of the Union 2019: Health

Author: Mark Duggan, Jackie Li
Publisher: Stanford Center on Poverty and Inequality
Date: 06/2019
  • Millennials benefited from the expansion of health insurance coverage under the Affordable Care Act. The share of adults in their 20s without health insurance fell by more than half from 2009 to 2017. 
  • This expansion led to a reduction in racial and ethnic inequalities in health insurance coverage. 
  • Due primarily to increasing suicides and drug overdoses, mortality rates increased dramatically among young adults from 2008 to 2016. Because the increase was more rapid among non-Hispanic whites than non-Hispanic blacks, racial inequality in mortality rates declined.

health - CPI Affiliates

David Rehkopf's picture David Rehkopf Health Disparities Research Group Leader; Associate Professor of Medicine; Associate Professor (By courtesy), Health Research & Policy
Stanford University
Jeremy Freese's picture Jeremy Freese Health Disparities Research Group Leader, Professor of Sociology
Stanford University
Mark Cullen's picture Mark Cullen Senior Associate Dean for Research, Stanford University School of Medicine; Health Disparities Research Group Leader, Director of Stanford Center for Population Health Sciences
Stanford University
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

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Health - Other Research

Title Author Media
The Opioid Epidemic Was Not Caused by Economic Distress But by Factors that Could be More Rapidly Addressed Janet Currie, Hannes Schwandt

The Opioid Epidemic Was Not Caused by Economic Distress But by Factors that Could be More Rapidly Addressed

Author: Janet Currie, Hannes Schwandt
Publisher: National Bureau of Economic Research
Date: 08/2020

Without the opioid epidemic, American life expectancy would not have declined prior to 2020. In turn, the epidemic was sparked by the development and marketing of a new generation of prescription opioids and provider behavior is still helping to drive it. There is little relationship between the opioid crisis and contemporaneous measures of labor market opportunity. Cohorts and areas that experienced poor labor market conditions do show lagged increases in opioid mortality, but the effect is modest relative to the scale of the epidemic. Instead, we argue that there are specific policies and features of the U.S. health care market that led to the current crisis. It will not be possible to quickly reverse depressed economic conditions, but it is possible to implement policies that would reduce the number of new opioid addicts and save the lives of many of those who are already addicted.

XX>XY?: The Changing Female Advantage in Life Expectancy Claudia Goldin, Adriana Lleras-Muney

XX>XY?: The Changing Female Advantage in Life Expectancy

Author: Claudia Goldin, Adriana Lleras-Muney
Publisher: NBER
Date: 06/2018

Females live longer than males in most parts of the world today. Among OECD nations in recent years, the difference in life expectancy at birth is around four to six years (seven in Japan). But have women always lived so much longer than men? The answer is that they have not. We ask when and why the female advantage emerged. We show that reductions in maternal mortality and fertility are not the reasons. Rather, we argue that the sharp reduction in infectious disease in the early twentieth century played a role. The primary reason is that those who survive most infectious diseases carry a health burden that affects organs, such as the heart, as well as impacting general well-being. We use new data from Massachusetts containing information on causes of death from 1887 to show that infectious diseases disproportionately affected females between the ages of 5 and 25. Increased longevity of women, therefore, occurred as the burden of infectious disease fell for all. Our explanation does not tell us why women live longer than men, but it does help understand the timing of the increase.

Tracking Health Inequalities from High School to Midlife Jamie M. Carroll, Chandra Muller, Eric Grodsky, John Robert Warren

Tracking Health Inequalities from High School to Midlife

Author: Jamie M. Carroll, Chandra Muller, Eric Grodsky, John Robert Warren
Publisher: Social Forces
Date: 12/2017

Educational gradients in health status, morbidity, and mortality are well established, but which aspects of schooling produce those gradients is only partially understood. We draw on newly available data from the midlife follow-up of the High School and Beyond sophomore cohort to analyze the relationship between students’ level of coursework in high school and their long-term health outcomes. We additionally evaluate the mediating roles of skill development, postsecondary attendance and degree attainment, and occupational characteristics. We find that students who took a medium- to high-level course of study in high school have better self-reported health and physical functioning in midlife, even net of family background, adolescent health, baseline skills, and school characteristics. The association partially operates through pathways into postsecondary education. Our findings have implications for both educational policy and research on the educational gradient in health.

Exploding Asthma and ADHD Caseloads: The Role of Medicaid Managed Care Anna Chorniy, Janet Currie, Lyudmyla Sonchak

Exploding Asthma and ADHD Caseloads: The Role of Medicaid Managed Care

Author: Anna Chorniy, Janet Currie, Lyudmyla Sonchak
Publisher: NBER
Date: 10/2017

In the U.S., nearly 11% of school-age children have been diagnosed with ADHD, and approximately 10% of children suffer from asthma. In the last decade, the number of children diagnosed with these conditions has inexplicably been on the rise. This paper proposes a novel explanation of this trend. First, the increase is concentrated in the Medicaid caseload nationwide. Second, nearly 80% of states transitioned their Medicaid programs from fee-for-service (FFS) reimbursement to managed care (MMC) by 2016. Using Medicaid claims from South Carolina, we show that this change contributed to the increase in asthma and ADHD caseloads. Empirically, we rely on exogenous variation in MMC enrollment due a change in the “default” Medicaid plan from FFS or MMC, and an increase in the availability of MMC. We find that the transition from FFS to MMC explains most of the rise in the number of Medicaid children being treated for ADHD and asthma. These results can be explained by the incentives created by the risk adjustment and quality control systems in MMC.

The Non-Market Benefits of Education and Ability James J. Heckman, John Eric Humphries, Gregory Veramendi

The Non-Market Benefits of Education and Ability

Author: James J. Heckman, John Eric Humphries, Gregory Veramendi
Publisher: NBER
Date: 10/2017

This paper analyzes the non-market benefits of education and ability. Using a dynamic model of educational choice we estimate returns to education that account for selection bias and sorting on gains. We investigate a range of non-market outcomes including incarceration, mental health, voter participation, trust, and participation in welfare. We find distinct patterns of returns that depend on the levels of schooling and ability. Unlike the monetary benefits of education, the benefits to education for many non-market outcomes are greater for low-ability persons. College graduation decreases welfare use, lowers depression, and raises self-esteem more for less-able individuals.