Poverty and Health Jennifer Madans, Kimberly Lochner, and Diane Makuc National Center for Health Statistics Centers for Disease Control and Prevention.

Poverty and Health

Jennifer Madans, Kimberly Lochner,

and Diane Makuc

National Center for Health Statistics

Centers for Disease Control and Prevention

March 8, 2005

Overview

• NCHS interest in the definition of poverty– HP 2010 context

• The poverty/health connection– What influences health – Why poverty/income are related to health?

• Mechanisms and reverse causation

– Selection of health indicators

Overview (con’t)

• How NCHS collects information on income/poverty

• Selected health indicators by poverty status

• Discussion of data issues/limitations

• Recap of why NCHS is interested in poverty and how it is defined

Why is NCHS Interested in Poverty?

• Healthy People 2010 goal

– Eliminate health disparities among Americans• Gender• Race/Ethnicity• Education• Income• Disability• Geographic location• Sexual orientation

Focus on Health

Education

Income

Early life experiences

Environment/Living conditions

Human biology/genetics

Health behaviors

Health insurance/Health care

Psychological/Psychosocial

Healthstatus

Focus on Health

Education

Income

Early life experiences

Environment/Living conditions

Human biology/genetics

Health behaviors

Health insurance/Health care

Psychological/Psychosocial

Healthstatus

Focus on Health

Education

Income

Early life experiences

Environment/Living conditions

Human biology/genetics

Health behaviors

Health insurance/Health care

Psychological/Psychosocial

Healthstatus

Selection of Health Indicators

• National Health and Nutrition Examination Surveys (1971-74, 1976-80, 1988-94, 1999-2002)– Measured health outcomes

• National Health Interview Survey (1984-2002)– Self-reported health outcomes – Health care utilization

• Criteria for selection– Consistent data over long period of time– Range of indicators– Income data available

Collection of Income in NHANES and NHIS

• Individual earnings (NHIS)

• Family income sources

• Total family income amount– Follow-up questions ask income category for

non-respondents– Unknown income imputed in 1990-2003 NHIS– Non-response lower in NHANES

• Program participation

Health Indicators

• Measured health indicators– Hypertension– Serum cholesterol– Obesity– Untreated dental caries– Blood lead levels

• Self reported health indicators– Activity limitation– Self-rated health status– Health care utilization

Life Expectancy at Birth and at 65 Years of Age by Sex

0

20

40

60

80

100

1901 1910 1920 1930 1940 1950 1960 1970 1980 1990 2001

Life Expectancy at birth

Life expectancy at 65 years

Year

Males

Females

Females

Males

Life

exp

ect

an

cy in

ye

ars

Life Expectancy Among the Poor?

0

20

40

60

80

100

1901 1910 1920 1930 1940 1950 1960 1970 1980 1990 2001

Yea

rs X

Infant Mortality Rates by Years of Maternal Education

0

2

4

6

8

10

12

14

16

18

20

13+ years

<12 years

12 years

1984 1986 1988 1990 20021998199619941992

Note: Rates are for infants of mothers aged 20 years and over.Data Source: National Vital Statistics System: Linked Birth/Infant Death Data Set

2000

Year

100

1000

1994 1995 1996 1997 1998 1999 2000 2001 2002

13+ years

<12 years

12 years

Year

Data Source: National Vital Statistics System

Chronic Disease Death Rates Among Adults 25-64 Years by Education

Year

Data Source: National Vital Statistics System

1

10

100

1000

1994 1995 1996 1997 1998 1999 2000 2001 2002

13+ years

<12 years

12 years

Communicable Disease Death Rates Among Adults 25-64 Years by Education

Hypertension Among Adults 20-74 Years by Percent of Poverty Threshold

Data Source: National Health and Nutrition Examination Survey

0

10

20

30

40

50

60

Per

cent

1971-74 1976-80 1988-94

1999-02

Year

<100

100-<200

200+

Men

1971-74 1976-80 1988-94 1999-02

Women

100-<200<100

200+

Year

Elevated Serum Cholesterol Among Adults 20-74 Years by Percent of Poverty Threshold

Data Source: National Health and Nutrition Examination Survey

0

10

20

30

40

50

60

Per

cent

1971-74 1976-80 1988-94

1999-02

Year

<100100-<200

200+

Men

1971-74 1976-80 1988-94 1999-02

Women

100-<200<100

200+

Year

Obesity Among Adults 20-74 Years by Percent of Poverty Threshold

Data Source: National Health and Nutrition Examination Survey

0

10

20

30

40

50

60

Per

cent

1971-74 1976-80 1988-94

1999-02

Year

<100100-<200

200+

Men

1971-74 1976-80 1988-94 1999-02

Women

100-<200

<100

200+

Year

Data Source: National Health and Nutrition Examination Survey

0

5

10

15

20

25

30

Per

cent

1971-74 1976-80 1988-94

1999-02

<100

100-<200

200+

Year

Ages 6-11 years

1971-74 1976-80 1988-94 1999-02

Ages 12-19 years

<100

200+

100-<200

Year

Overweight Among Childrenby Percent of Poverty Threshold

Year

Untreated Dental Caries by Percent of Poverty Threshold

Data Source: National Health and Nutrition Examination Survey

0

10

20

30

40

50

60

70

80

Per

cent

1971-74 1988-94

1999-02

<100%

100-<200%200+%

Ages 6-17 years

1971-74 1988-94

1999-02

<100

100-<200

200+

Year

Ages 18-64 years

Elevated Blood Lead Levels Among Children 1-5 Years by Percent of Poverty Threshold

0

10

20

30

40

50

60

70

80

90

100

Per

cent

1976-80 1988-94

1999-02

<100

100-<200

200+

Year

Data Source: National Health and Nutrition Examination Survey

Percent of Persons with Activity Limitation by Percent of Poverty Threshold

Data Source: National Health Interview Survey

0

10

20

30

40

50

60

Perc

ent

<100

100 - <200

200+

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Year

Ages 5-17 years

Year

<100

100 - <200

200+

1984 1986 1988 1990 1992 1994 1996 200220001998

Ages 18-64 years

ADL Limitation for Medicare Beneficiaries 65 and Older by Percent of Poverty Threshold

0

10

20

30

40

50

60

Per

cent

1992 19991993 1994 1995 1996 1997 1998 2000 2001

<100

100-<200

200+

Year

Data Source: Medicare Current Beneficiary Survey

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Year

100 - <200

<100

200+

Ages 65 years and over

0

10

20

30

40

50

60

Perc

ent

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Year

Ages 18-64 years

100 - <200

<100

200+

Percent of Persons in Fair/Poor Health by Percent of Poverty Threshold

Data Source: National Health Interview Survey

Percent of Children Under 18 Years Without a Health Care Visit in the Past Year by Percent of Poverty Threshold

Data Source: National Health Interview Survey

0

5

10

15

20

25

30

35

40P

erc

ent

<100

100 - <200

200+

Year

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Percent of Persons Without a Health Care Visit in the Past 2 Years by Percent of Poverty Threshold

Data Source: National Health Interview Survey

0

5

10

15

20

25

30

35

40

Perc

ent

<100

100 - <200

200+

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Year

Ages 18-64 years<100

100 - <200

200+

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Year

Ages 65 years and over

Summary

• Improvements in health for everyone– Exceptions, obesity and overweight

• Generally worse health outcomes for poor people– Notable exceptions, especially among men

Data Issues

• Surveys cover civilian, non-institutionalized population

• Insufficient numbers for reliable estimates for detailed subcategories

• Income difficult to collect

• Responses to health questions (particularly subjective health measures) influenced by income level

Data Issues (cont)

• When does income matter for health– Cross-sectional measurement of income may

underestimate the effect of income on health– Income changes over lifetime may have

stronger impact than income level on health

Conclusion: NCHS’s Focus

• Need valid poverty measure that can be easily collected

• Purpose as a classification variable to monitor health disparities

• Increased reliance on data linkage to augment surveys and research