Source: Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion. Paper 2 (Policy and Practice).Available at: http://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf (Accessed 10.19.2012).
Gis conf. 2013 differential effects of the great recession
Differential Effects of The Great Recession onMinority Populations: Preliminary FindingsSamuel D. Towne Jr. MPH, CPHJanice C. Probst, PhDZhimin Chen, MSDepartment of Health Services Policy and ManagementArnold School of Public HealthFebruary 2013
Presenter Disclosures Samuel D. Towne, MPH, CPH The following personal financial relationshipswith commercial interests relevant to thispresentation existed during the past 12months:No relationships to disclose
Great RecessionThe United States (US) Bureau of Labor Statisticsdescribes an economic recession as:“A general slowdown in economic activity, adownturn in the business cycle, a reduction inthe amount of goods and serviced produced andsold” (US Bureau of Labor Statistics, p1, 2012a) December of 2007 and June of 2009 (USBureau of Labor Statistics (a), 2012).
State Policy Considerations As of July 2012, at least 13 states wereplanning to cut Medicaid in an attempt tobalance their budgets (Galewitz, 2012); (KaiserHealth News, 2012).
Medicaid Expansion Medicaid expansion: Broadening eligibility to include individualsnot previously eligible Associated with decreases in mortality ratesfor individuals in states that expandedeligibility (Sommers, 2012)
Medicaid Expansion New Medicaid enrollees under Section 1115Medicaid Waivers:Eligibility based on income category (%FPL) CharacteristicsOlder, minorities & those in poorer health thanthe general population (Sommers, 2012); (Natoli,2011)
Medicaid Expansion Section 1115 Expansion Enrollment,representing 37% of all Medicaid-coveredadults (Borck et al., 2012); (The MedicaidAnalytic Extract 2008 Chartbook AppendixTables For Chapter 7, p. 107, 2012)
Income Inequality Gini coefficients can be defined as:‘half of the arithmetic average of the absolutedifferences between all pairs of incomes in apopulation, the total then being normalized onmean income’ (Subramanian & Kawachi, p78,2004)
Patient Protection and Affordable Care Act(ACA) -2010Access (32 million newly covered) Medicaid ExpansionIndividuals < 133% Federal Poverty Level(FPL) Tax CreditsFamilies < 400% FPLGoal: Offset premiums & cost of insurancegained through State HI Exchanges
Race-Based Disparities -Education In 2009, White adults had the highest level ofeducation, with 90% having “at least a highschool education” (Ryan & Siebens, p. 5, 2012)Ryan CL, Siebens J (2012).
Race-Based Disparities -Employment American Indian and Alaska Native individualshad the “lowest labor force participationrates” (59.2%) of any race and ethnicity groupin 2011 Black individuals had the second lowest “laborforce participation rates” (61.4%) in 2011Source: (US Department of Labor and the US Bureau of LaborStatistics, p. 1, 2012)
Race-Based Disparities -Employment Hispanic workers were more likely to loseemployment-based health insurance coveragethan both Black and White individuals(Fronstin, 2012).
People without Health Insurance by Race and Ethnicity Group,2003 – 201115.80%21.00%17.20%32.40%0.00%5.00%10.00%15.00%20.00%25.00%30.00%35.00%40.00%200320042005200620072008200920102011WhiteBlackAsianHispanic of anyrace
Research Purpose Measure:Access & Utilization of Healthcare & HealthChanges across time (2003-2010) for racial ðnic groups Identify Whether:Income InequalityMedicaid coverage policies affected individualsunevenly
Study Design & Population Cross-Sectional Samples, 2003-2010 Multi-level Models (Individuals nested withinStates) PopulationNon-institutionalized working-aged adults byrace/ethnicity DataBRFSS, ARF, Census
Conceptual Framework for Action on the SocialDeterminants of Health
• Public Policy• Medicaid Generosity (k)• Socioeconomic Position, SocialClass, Gender, Ethnicity, Education, Occupation, Income• Sex (i)• Income-level (i)• Race & Ethnic category (i)• Education-level (i)• Employment Status (i)• Insurance Coverage (i)• Age (i)StructuralDeterminants
• Material Circumstances• Median Income (j)• Income Inequality (Gini) (j)• Rurality(j)• Poverty Rate (j)• Unemployment Rate (j)• Behavioral & Biological factors• Disability (i)• Diabetes Status (i)IntermediaryDeterminants
• Self-reported Health Status• General Health Status• Poor Physical Health Days• Poor Mental Health Days• Access to Care• Cost-related Forgone MedicalCareImpact onEquity inHealth &Well-being
References U.S. Bureau of Labor Statistics. The Recession of 2007-2009. BLS Spotlighton Statistics. 2012 Feb: 1-18. Available at:http://www.bls.gov/spotlight/2012/recession/pdf/recession_bls_spotlight.pdf (Accessed December 16, 2012). Galewitz P, Fleming M. (2012). 13 states cut Medicaid to balance budgets.Kaiser Health News. July 24. Available at:http://www.kaiserhealthnews.org/Stories/2012/July/25/medicaid-cuts.aspx Kaiser Health News. (2012). States cutting Medicaid. July 24, Available at:http://www.kaiserhealthnews.org/Stories/2012/July/25/Medicaid-Cuts-Chart.aspx Sommers BD, Baicker K, Epstein AM. Mortality and Access to Care amongAdults after State Medicaid Expansions. N Engl J Med. 2012 Jul 25. [Epubahead of print]
References Natoli C, Cheh V, Verghese S (2011). Who will enroll in medicaid in 2014?Lessons from Section 1115 Medicaid Waivers. Mathematica PolicyResearch. Brief 1. May The Medicaid Analytic Extract (Max) 2008 Chartbook Appendix Tables ForChapter 7. Waiver Enrollment And Utilization. Table A7.1 Section 1115Waiver Enrollment In 2008. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/MAX_Chartbooks.html (AccessedJanuary 29, 2013). Current Population Reports: Educational Attainment in the United States:2009: Population Characteristics. February 2012. Available at:http://www.census.gov/prod/2012pubs/p20-566.pdf (Accessed December16, 2012). US Department of Labor and the US Bureau of Labor Statistics. Labor ForceCharacteristics by Race and Ethnicity, 2007. Report 1005. September 2008.Available at: http://www.bls.gov/cps/cpsrace2007.pdf (AccessedDecember 16, 2012).
References DeNavas-Walt C, Proctor BD, Mills RJ. U.S. Census Bureau, Current PopulationReports, P60-226, Income, Poverty, and Health Insurance Coverage in the UnitedStates: 2003, U.S. Government Printing Office, Washington, DC, 2004. Availableat: http://www.census.gov/prod/2004pubs/p60-226.pdf (Accessed December16, 2012). DeNavas-Walt C, Proctor BD, Lee CH. U.S. Census Bureau, Current PopulationReports, P60-231, Income, Poverty, and Health Insurance Coverage in the UnitedStates: 2005, U.S. Government Printing Office, Washington, DC, 2006. Available at:http://www.census.gov/prod/2006pubs/p60-231.pdf (Accessed December16, 2012). DeNavas-Walt C, Proctor BD, Smith JC. U.S. Census Bureau, Current PopulationReports, P60-235, Income, Poverty, and Health Insurance Coverage in the UnitedStates: 2007, U.S. Government Printing Office, Washington, DC, 2008. Available at:http://www.census.gov/prod/2008pubs/p60-235.pdf (Accessed December16, 2012).
References DeNavas-Walt C, Proctor BD, Smith JC. U.S. Census Bureau, Current PopulationReports, P60-238, Income, Poverty, and Health Insurance Coverage in the UnitedStates: 2009, U.S. Government Printing Office, Washington, DC, 2010. Availableat: http://www.census.gov/prod/2010pubs/p60-238.pdf (Accessed December16, 2012). DeNavas-Walt C, Proctor BD, Smith JC. U.S. Census Bureau, Current PopulationReports, P60-239, Income, Poverty, and Health Insurance Coverage in the UnitedStates: 2010, U.S. Government Printing Office, Washington, DC, 2011. Availableat: http://www.census.gov/prod/2011pubs/p60-239.pdf (Accessed December16, 2012). DeNavas-Walt C, Proctor BD, Smith JC. U.S. Census Bureau, Current PopulationReports, P60-243, Income, Poverty, and Health Insurance Coverage in the UnitedStates: 2011, U.S. Government Printing Office, Washington, DC, 2012. Available at:http://www.census.gov/prod/2012pubs/p60-243.pdf (Accessed December16, 2012).
References Fronstin P. The impact of the recession on employment-basedhealth coverage. EBRI Issue Brief. 2010 May;(342):1-22. Subramanian SV, Kawachi I. (2004). Income inequality andhealth: what we have learned so far? Epidemiol Rev. 26(1):78-91 doi: 10.1093/epirev/mxh003