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 Health status

Focus on Health Education Income Early life experiences Environment/ Living conditions Human biology/ genetics Health behaviors Health insurance/ Health care Psychological/ Psychosocial Health status

Focus on Health Education Income Early life experiences Environment/ Living conditions Human biology/ genetics Health behaviors Health insurance/ Health care Psychological/ Psychosocial Health status

Selection of Health Indicators National Health and Nutrition Examination Surveys ( , , , ) –Measured health outcomes National Health Interview Survey ( ) –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 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 Life Expectancy at birth Life expectancy at 65 years Year Males Females Males Life expectancy in years

Life Expectancy Among the Poor? X

Infant Mortality Rates by Years of Maternal Education 13+ years <12 years 12 years 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

13+ years <12 years 12 years Year Data Source: National Vital Statistics System Chronic Disease Death Rates Among Adults Years by Education

Year Data Source: National Vital Statistics System 13+ years <12 years 12 years Communicable Disease Death Rates Among Adults Years by Education

Hypertension Among Adults Years by Percent of Poverty Threshold Data Source: National Health and Nutrition Examination Survey Year < < Men Women 100-<200 < Year

Elevated Serum Cholesterol Among Adults Years by Percent of Poverty Threshold Data Source: National Health and Nutrition Examination Survey Year < < Men Women 100-<200 < Year

Obesity Among Adults Years by Percent of Poverty Threshold Data Source: National Health and Nutrition Examination Survey Year < < Men Women 100-<200 < Year

Data Source: National Health and Nutrition Examination Survey < < Year Ages 6-11 years Ages years < <200 Year Overweight Among Children by Percent of Poverty Threshold

Year Untreated Dental Caries by Percent of Poverty Threshold Data Source: National Health and Nutrition Examination Survey <100% 100-<200% 200+% Ages 6-17 years < < Year Ages years

Elevated Blood Lead Levels Among Children 1-5 Years by Percent of Poverty Threshold < < 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 Year Ages 5-17 years Year < < Ages years

ADL Limitation for Medicare Beneficiaries 65 and Older by Percent of Poverty Threshold < < Year Data Source: Medicare Current Beneficiary Survey

Year <200 < Ages 65 years and over Year Ages years <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 Year

Percent of Persons Without a Health Care Visit in the Past 2 Years by Percent of Poverty Threshold Data Source: National Health Interview Survey Year Ages years 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