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What Accounts for Health Disparities - Stephen Klineberg, Ph.D.

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Stephen Klineberg, Ph.D., Professor/Co-Director Rice University's Kinder Institute for Urban Research, shared the impact demographics have on access to healthcare. Presentation was made at the …

Stephen Klineberg, Ph.D., Professor/Co-Director Rice University's Kinder Institute for Urban Research, shared the impact demographics have on access to healthcare. Presentation was made at the Designing Healthcare in Texas conference on June 4, 2014.

Published in: Healthcare, Technology, Education

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  • 1. The Changing Face of Houston and Texas: Healthcare Challenges Tracking the Economic and Demographic Transfor- mations through 33 Years of Houston Surveys. Dr. Stephen Klineberg Conference on “Designing Healthcare in Texas,” One Voice Texas, 4 June 2014.
  • 2. The Kinder Institute Houston Area Survey (1982-2014) More than three decades of systematic interviews with representative samples of Harris County residents, focused on three central issues: 2
  • 3. Supported by a grant from Houston Endowment Inc., three focused surveys were developed during 2011 through a series of meetings with local leaders and national experts in the arts, education, and community health. From November 2011 through July 2012, separate samples of 1,200 scien- tifically selected Harris County residents were interviewed in three successive surveys, with approximately 65% reached by landline and 35% by cell phone. Weights were assigned to the data to ensure that the final distributions are in close agreement with the actual Harris County distributions with respect to ethnicity, age, gender, education levels, and home ownership. The three printed reports on the most important findings from these separate surveys have now been released to the public and are available from the Kinder Institute web site (at: kinder.rice.edu/reports). The SHEA Surveys on Health, Education and the Arts (2012)
  • 4. Two contrasting economic eras Percent increase in before-tax income The 30 years after World War II (1949-1979) The past 30 years (1980-2011) 116% 100% 111% 114% 99% 86% -3% 2% 5% 15% 43% 63% -10% 50% 110% Bottom 20% Second 20% Middle 20% Fourth 20% Top 20% Top 5% 4 Source: U.S. Census Bureau, Current Population Survey, Annual Social And Economic Supplements. Mean Household Income Received By Each Fifth And The Top 5 Percent, Inflation Adjusted. © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research The 30 years after World War II were a period of broad-based prosperity. The past 30 years have been marked by growing income inequalities.
  • 5. The New Economy Percent rating job opportunities as “excellent” or “good” 0 10 20 30 40 50 60 70 80 90 100 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 Positive evaluations of job opportunities in the Houston area (1982-2014) 5 Source: Kinder Houston Area Survey (1982-2014) © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research 71% 36% 11% 42% 68% 43% 35% 66% 25% 41% 58% 60% 58% 48%
  • 6. The New Economy The official unemployment rates in Harris County (1982-2014) 6 Source: U.S. Department of Labor, Bureau of Labor Statistics. Unemployment rates are not seasonally adjusted. © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research 7.3 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 11.0 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 9.8 10.1 6.8 8.6 4.0 4.3 6.8 7.8 6.5 5.7
  • 7. The New Economy The prevalence of food insecurity (2014) 7 Source: Kinder Institute Houston Area Survey (2014) © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research “At any time in the past year, did you have a problem paying for the groceries to feed your household? Has that been a very serious problem for you, somewhat serious, not much of a problem, or not a problem during the past year?” 67 16 12 6 "Not a problem" "Not much of a problem" "Somewhat serious problem" "A very serious problem"
  • 8. The New Economy The importance of post-secondary education, in the total sample and by ethnicity (2013) 8 Source: Kinder Institute Houston Area Survey (2013) © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research 73 63 78 81 71 25 36 20 17 27 0 10 20 30 40 50 60 70 80 90 100 Total sample Anglos (N=331) Blacks (N=220) Hispanics (N=360) Asians (N=36) PERCENTOFRESPONDENTS An education beyond high school is necessary There are many ways to succeed with no more than high school "For a person to be successful in today's world, is it necessary to get an education beyond high school, or are there many ways to succeed with no more than a high school diploma?"
  • 9. The New Economy
  • 10. The New Economy10 The number of documented U.S. immigrants, by decade (1820-2010) From 1492 to 1965, 82% of all immigrants coming to America came from Europe. After reform in 1965, 88% of all the new immigrants have been non-Europeans. Source: U.S. Department of Homeland Security. Office of Immigration Statistics. © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research 0.1 8.8 0.5 10.5 0 2 4 6 8 10 12 1820s 1830s 1840s 1850s 1860s 1870s 1880s 1890s 1900s 1910s 1920s 1930s 1940s 1950s 1960s 1970s 1980s 1990s 2000s 1924 “National Origins Quota Act” 1965 “Hart-Celler Act” Millions of immigrants
  • 11. The New Economy11 San DiegoLos Angeles New York City San Francisco Miami Chicago Houston Major U.S. immigrant cities (2010) Washington D.C. Atlanta Dallas Boston
  • 12. The New Economy12 Anglos Blacks Latinos Asians Anglos Blacks Latinos Asians Asians Anglos Blacks Latinos Anglos Blacks Latinos Asians Anglos Blacks Latinos Asians 0 1 2 3 4 PopulationinMillions 15.5% 9.9% 20.1% 69.2% 0.8% 1,741,912 1960 1970 19801990 2000 2010 The demographic transformations of Harris County Anglos Blacks Latinos Asians 2,818,199 22.7% 19.1% 54.0% 4.1% 6.7% 32.9% 18.2% 42.1% 3,400,578 7.7% 18.4% 40.8% 33.0% 4,092,459 19.7% 62.7% 2.1% 15.5% 2,409,5471,243,258 6.0% 19.8% 73.9% 0.3% Source: U.S. Census. Classifications based on Texas State Data Center Conventions. © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research
  • 13. The New Economy13 Anglos Blacks Latinos Asians Anglos Blacks Latinos Asians Anglos Blacks Latinos Asians Anglos Blacks Latinos Asians 0 300,000 600,000 15.5 The demographic changes in Fort Bend County and Montgomery County 53.8% 20.3% 19.5% 6.5% 1990 46.2% 19.6% 21.1% 13.1% 36.2% 21.1% 23.7% 19.0% Anglos Blacks Latinos Asians 2000 2010 199020002010 87.5% 4.2% 7.3% 1.0% 225,421 354,452 585,375 182,201 293,768 455,746 Fort Bend County Montgomery County 71.2% 4.1% 20.8% 4.0% 81.4% 3.4% 12.6% 2.5% Source: U.S. Census. Classifications based on Texas State Data Center Conventions. © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research
  • 14. The New Economy14 Harris County total population Anglo majority Black majority Latino majority No majority 14 Color represents demographic group being a majority in that census tract. Source: Outreach Strategists, LLC © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research 1980
  • 15. The New Economy15 Harris County total population 15 Color represents demographic group being a majority in that census tract. Source: Outreach Strategists, LLC © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research Anglo majority Black majority Latino majority No majority 1990
  • 16. The New Economy16 Harris County total population 16 Color represents demographic group being a majority in that census tract. Source: Outreach Strategists, LLC © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research Anglo majority Black majority Latino majority No majority 2000
  • 17. The New Economy17 Harris County total population 17 Color represents demographic group being a majority in that census tract. Source: Outreach Strategists, LLC © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research Anglo majority Black majority Latino majority No majority 2010
  • 18. The New Economy18 Percent of the population by age group and ethnicity in Harris County in 2012 Source: U.S. Census Bureau. 2008-2012 ACS 5-year estimates © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research18 21 22 24 25 25 29 28 31 41 50 54 61 79 78 76 75 75 71 72 69 59 50 46 39 Non-Hispanic Whites All others
  • 19. The New Economy19 Percent of the population by age group and ethnicity in Texas in 2012 Source: U.S. Census Bureau. 2008-2012 ACS 5-year estimates © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research19 32 33 35 37 39 40 40 43 53 60 65 7068 67 65 63 61 60 60 57 47 40 35 30 Non-Hispanic Whites All others
  • 20. The New Economy20 Percent of the population by age group and ethnicity in the United States in 2012 Source: U.S. Census Bureau. 2008-2012 ACS 5-year estimates © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research20 51 53 55 56 57 58 58 61 69 75 78 82 49 47 45 44 43 42 42 39 31 25 22 18 Non-Hispanic Whites All others
  • 21. The New Economy21 Percent of the population by age group and ethnicity in the United States in 2050 Source: U.S. Census Bureau. 2012 National Population Projections, Alternative Net International Migration Series (Constant Series). © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research 36 38 39 41 42 43 44 46 50 53 56 6464 62 61 59 58 57 56 54 50 47 44 36 Non-Hispanic Whites All others
  • 22. The New Economy Self-rated health status in Harris County 19 25 38 13 6 20 26 32 16 5 0 5 10 15 20 25 30 35 40 Excellent Very good Good Fair Poor PERCENTOFRESPONDENTS The 2012 HAHS 2001-2013 KIHAS, combined “In general, would you say that your overall state of physical health these days is excellent, very good, good, fair, or poor?”
  • 23. The New Economy The structural correlates of self-rated health: The additional importance of health insurance Independent Variable Respondents who said that their “overall state of health these days” was only “fair” or “poor.” Model 1 (KHAS 2001-2013) Model 2 (KHAS 2001-2012) B SE OR B SE OR Sociodemographics Age +.022**** .002 1.022 +.025**** .002 1.025 Female -.043 .064 .958 -.060 .072 .942 Ethnicitya Non-Hispanic Whites (Anglos) -.406**** .072 .666 -.363**** .080 .695 Measures of Socioeconomic Status Incomeb $35,501 – 50,000 -.459**** .096 .632 -.381**** .108 .683 $50,001 – 75,000 -.631**** .095 .532 -.529**** .107 .589 More than $75,000 -.951**** .093 .387 -.771**** .104 .463 Educationc High School Diploma -.165 .104 .848 -.053 .122 .948 Some College -.337*** .103 .714 -.214* .121 .807 College Degree -.838**** .113 .432 -.743**** .132 .476 Health Insurance ----- ----- ----- -.463**** .093 .630 N 6,972 5,435 aThere were no meaningful differences in self-rated health status between blacks, U.S.-born Latinos, and Latino immigrants . Blacks and Latinos make up the reference group. The few Asians and “others” were removed from this analysis. bReference group: Less than $35,501. cReference group: Less than high school. *p < .10, **p < .05, ***p < .01. ****p < .001 (two-tailed tests). Source: KHAS (2001-2013)
  • 24. The New Economy Respondents’ ratings of the quality of health care available to them, by insurance coverage (HAHS) 31 10 40 28 18 21 12 41 0 5 10 15 20 25 30 35 40 45 Yes, Insured No, Not insured PERCENTOFRESPONDENTS "Are you currently covered by any type of health insurance or health care plan?" "Excellent" "Good" "Fair" "Poor"
  • 25. The New Economy Self-reported health status by proximity to the ten Harris County ZIP codes on the APWL (KIHAS) 38 57 50 37 25 31 25 19 19 0 10 20 30 40 50 60 70 APWL ZIP codes and surrounding areas Inside the 610 Loop Outside the 610 Loop PERCENTOFRESPONDENTS "Excellent" or "Very Good" "Good" "Fair" or "Poor"
  • 26. The New Economy The effects of living in or near the APWL ZIP codes on self-reported health, controlling for the structural variables and for insurance coverage (KIHAS) Independent Variable Self-Reported “Fair” or “Poor” Health Coefficient Standard Error Odds Ratio (OR) 1-OR (A) Socioeconomic Status (1) Educationa High School Diploma -.110 .126 .896 -.104 Some College -.261* .126 .770 -.230 College Degree -.781*** .139 .458 -.542 (2) Incomeb $35,501 to $50,000 -.449*** .112 .638 -.362 $50,001 to $75,000 -.522*** .109 .593 -.407 More than $75,000 -.776*** .106 .460 -.540 (B) Demographic Characteristics (3) Ethnicityc Black +.423*** .095 1.526 +.526 Latino +.195* .100 1.216 +.216 Asian +.038 .281 1.039 +.039 (4) Age +.023*** .002 1.023 +.023 (5) Female -.101 .073 .904 -.096 (C) Having Health Insuranced -.460*** .096 .631 -.369 (D) Living in or near APWL ZIP Codese +.248** .090 1.281 +.281 ----------------------- Constant -.457*** .144 .633 -.367 N 5,275 a Reference group: Less than high school. b Reference group: Less than $35,000. c Reference group: Anglos. d The question about health insurance coverage was included in the 2001, 2003-2012 surveys. Reference group: Living in areas other than APWL ZIP codes or its surrounding ZIP codes. *p < .05, **p < .01. ***p < .001 (two-tailed tests).
  • 27. The New Economy The perceived determinants of a person’s health, average ratings (HAHS) 8.6 8.3 7.35 7.26 7.23 6.93 6.16 0 1 2 3 4 5 6 7 8 9 10 11 Diet and Physical Activity Amount of Stress Amount of Social Support Air and Water Pollution Level of Income Genetic Makeup Racial Discrimination EFFECTONHEALTH(SCALEFROM1TO10) “How much do you think a person's health is determined by each of these factors? Using a scale from 1 to 10, where 1 means it has 'very little effect' and 10 means it has a 'very strong effect,' how important is each of the following?”
  • 28. The New Economy The availability of health-promoting resources compared to their usage by the general public Source: SHEA Health Survey (2012) 56 14 83 44 58 30 44 24 0 10 20 30 40 50 60 70 80 90 Easy access to public transit in neighborhood Used transit at least once in past month Park or play area within a mile of home Visited park at least once in past month Hike and bike trail within a mile of home Visited trail at least once in past month workplace wellness program offered Used wellness program at least once in the past month PERCENTOFRESPONDENTS
  • 29. Hiking, boating, birding Arts, culture, sports Air and water quality Green spaces, trees Urban centers BayousTransportation
  • 30. Quality of Place Houston’s urban sprawl 2.1 million 600 sq. mi. Chicago 2.7 million 228 sq. mi. Baltimore 0.6 million 81 sq. mi. 30 Source: U.S. Census Bureau © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research Detroit 0.7 million 139 sq. mi. Philadelphia 1.5 million 134 sq. mi.
  • 31. Quality of Place The nine-county Houston metropolitan area 5.8 million 9,434 sq. mi. New Jersey 8.8 million 8,729 sq. mi. 31 Source: U.S. Census Bureau © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research Massachusetts 6.6 million 10,550 sq. mi.
  • 32. Quality of Place The divided preference for car-centered vs. transit-oriented developments (2009-2014) 32 Source: Kinder Institute Houston Area Survey (2009-2014) © Dr. Stephen L. Klineberg and the Kinder Institute for Urban Research 52 47 58 39 47 5050 50 47 51 44 51 47 51 51 47 46 49 0 10 20 30 40 50 60 70 A single-family residential area An area with a mix of developments A single-family home with need to drive everywhere A smaller, more urbanized home within walking distance Spending more to expand existing highways Spending more to improve rail and buses 2009, 2011, 2013 2010, 2012, 2014 2010, 2012, 2014
  • 33. Quality of Place 1978 © Alex
  • 34. Quality of Place 2011 © Alex
  • 35. Houston needs to develop into a truly successful multiethnic society, one with equality of opportunity for all communities, where all are encouraged to participate as full partners in shaping the region’s future. Today’s pro-growth agenda The Houston region needs to nurture a far more educated workforce and develop the research centers that will fuel the new economy. The Houston region needs to grow into a much more appealing urban destination, while accommodating an expected 3.5 million additional residents in the next 20 years.
  • 36. kinder.rice.edu kinder@rice.edu 713-348-4132 @RiceKinderInst /InstituteForUrbanResearch