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
Food Deserts and the Causes of Nutritional Inequality Hunt Allcott, Rebecca Diamond, Jean-Pierre Dubé, Jessie Handbury, Ilya Rahkovsky, Molly Schnell

Food Deserts and the Causes of Nutritional Inequality

Author: Hunt Allcott, Rebecca Diamond, Jean-Pierre Dubé, Jessie Handbury, Ilya Rahkovsky, Molly Schnell
Publisher: Quarterly Journal of Economics
Date: 05/2019

We study the causes of “nutritional inequality”: why the wealthy eat more healthfully than the poor in the United States. Exploiting supermarket entry and household moves to healthier neighborhoods, we reject that neighborhood environments contribute meaningfully to nutritional inequality. We then estimate a structural model of grocery demand, using a new instrument exploiting the combination of grocery retail chains’ differing presence across geographic markets with their differing comparative advantages across product groups. Counterfactual simulations show that exposing low-income households to the same products and prices available to high-income households reduces nutritional inequality by only about 10%, while the remaining 90% is driven by differences in demand. These findings counter the argument that policies to increase the supply of healthy groceries could play an important role in reducing nutritional inequality.

Local Food Prices, SNAP Purchasing Power, and Child Health Erin T. Bronchetti, Garret S. Christensen, Hilary W. Hoynes

Local Food Prices, SNAP Purchasing Power, and Child Health

Author: Erin T. Bronchetti, Garret S. Christensen, Hilary W. Hoynes
Publisher: NBER
Date: 06/2018

The Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) is one of the most important elements of the social safety net. Unlike most other safety net programs, SNAP varies little across states and over time, which creates challenges for quasi-experimental evaluation. Notably, SNAP benefits are fixed across 48 states; but local food prices vary, leading to geographic variation in the real value – or purchasing power – of SNAP benefits. In this study, we provide the first estimates that leverage variation in SNAP purchasing power across markets to examine effects of SNAP on child health. We link panel data on regional food prices to National Health Interview Survey data and use a fixed effects framework to estimate the relationship between local purchasing power of SNAP and children’s health and health care utilization. We find that lower SNAP purchasing power leads to lower utilization of preventive health care and more days of school missed due to illness. We find no effect on reported health status.

U.S. Employment and Opioids: Is There a Connection? Janet Currie, Jonas Y. Jin, Molly Schnell

U.S. Employment and Opioids: Is There a Connection?

Author: Janet Currie, Jonas Y. Jin, Molly Schnell
Publisher: NBER
Date: 03/2018

This paper uses quarterly county-level data to examine the relationship between opioid prescription rates and employment-to-population ratios from 2006–2014. We first estimate models of the effect of opioid prescription rates on employment-to-population ratios, instrumenting opioid prescriptions for younger ages using opioid prescriptions to the elderly. We also estimate models of the effect of employment-to-population ratios on opioid prescription rates using a shift-share instrument. We find that the estimated effect of opioids on employment-to-population ratios is positive but small for women, but there is no relationship for men. These findings suggest that although they are addictive and dangerous, opioids may allow some women to work who would otherwise leave the labor force. When we examine the effect of employment-to-population ratios on opioid prescriptions, our results are more ambiguous. Overall, our findings suggest that there is no simple causal relationship between economic conditions and the abuse of opioids. Therefore, while improving economic conditions in depressed areas is desirable for many reasons, it is unlikely to curb the opioid epidemic.

State of the Union 2018: Health Mark Duggan, Valerie Scimeca

State of the Union 2018: Health

Author: Mark Duggan, Valerie Scimeca
Publisher: Stanford Center on Poverty and Inequality
Date: 03/2018

The male-female life expectancy gap, which favors females, fell from 7.6 years in 1970 to 4.8 years in 2010, a reduction of more than one-third. Most of this convergence was caused by asubstantial decline from 1990 to 2000 in HIV-AIDS mortality and in the homicide rate. Because HIV-AIDS and homicide affect men more than women, a decline in these underlying rates had the effect of reducing the male-female life expectancy gap. Life expectancy has stagnated for the last several years for men and women, primarily due to increases in drug poisoning deaths and in the suicide rate. 

The Kids Are All Right Janet M. Currie

The Kids Are All Right

Author: Janet M. Currie
Publisher: Stanford Center on Poverty and Inequality
Date: 01/2018

In this article, we pose the following question: Has the overall set of changes to the safety net since PRWORA improved outcomes for children? To answer that question, we look at several measures of child well-being—mortality rates, teen pregnancy, drug use, and high school graduation rates—and find that across all these measures, poor children are much better off today.

health - CPI Affiliates

Jacob Hacker's picture Jacob Hacker Stanley B. Resor Professor of Political Science; Director of the 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; Director of Graduate Studies
University of Michigan
Shannon Monnat's picture Shannon Monnat Assistant Professor of Rural Sociology, Demography, and Sociology
Pennsylvania State University
Asad L. Asad Assistant Professor of Sociology
Stanford University

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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.