1. Poverty and Health Jennifer Madans, Kimberly Lochner, and Diane Makuc National Center for Health Statistics Centers for Disease Control and Prevention March 8, 2005

2. 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

3. 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

4. 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

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

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

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

8. 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

9. 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

10. 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

11. Life Expectancy at Birth and at 65 Years of Age by Sex 1901 1910 1920 19301940 19501960 1970 1980 1990 2001 Life Expectancy at birth Life expectancy at 65 years Year Males Females Males Life expectancy in years

12. Life Expectancy Among the Poor? X

13. Infant Mortality Rates by Years of Maternal Education 13+ years <12 years 12 years 1984 1986 1988 1990 2002 1998 19961994 1992 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

14. 13+ years <12 years 12 years Year Data Source: National Vital Statistics System Chronic Disease Death Rates Among Adults 25-64 Years by Education

15. Year Data Source: National Vital Statistics System 13+ years <12 years 12 years Communicable Disease Death Rates Among Adults 25-64 Years by Education

16. Hypertension Among Adults 20-74 Years by Percent of Poverty Threshold Data Source: National Health and Nutrition Examination Survey 1971-74 1976-801988-941999-02 Year <100 100-<200 200+ Men 1971-741976-80 1988-94 1999-02 Women 100-<200 <100 200+ Year

17. Elevated Serum Cholesterol Among Adults 20-74 Years by Percent of Poverty Threshold Data Source: National Health and Nutrition Examination Survey 1971-74 1976-801988-941999-02 Year <100 100-<200 200+ Men 1971-741976-80 1988-94 1999-02 Women 100-<200 <100 200+ Year

18. Obesity Among Adults 20-74 Years by Percent of Poverty Threshold Data Source: National Health and Nutrition Examination Survey 1971-74 1976-801988-941999-02 Year <100 100-<200 200+ Men 1971-741976-80 1988-94 1999-02 Women 100-<200 <100 200+ Year

19. Data Source: National Health and Nutrition Examination Survey 1971-741976-80 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 Children by Percent of Poverty Threshold

20. Year Untreated Dental Caries by Percent of Poverty Threshold Data Source: National Health and Nutrition Examination Survey 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

21. Elevated Blood Lead Levels Among Children 1-5 Years by Percent of Poverty Threshold 1976-80 1988-94 1999-02 <100 100-<200 200+ Year Data Source: National Health and Nutrition Examination Survey

22. Percent of Persons with Activity Limitation by Percent of Poverty Threshold Data Source: National Health Interview Survey 1984 1986 1988 1990 1992 1994 1996 19982000 2002 Year Ages 5-17 years Year <100 100 - <200 200+ 1984 19861988199019921994 1996 20022000 1998 Ages 18-64 years

23. ADL Limitation for Medicare Beneficiaries 65 and Older by Percent of Poverty Threshold 1992 1999 1993 1994 1995 1996 1997 1998 2000 2001 <100 100-<200 200+ Year Data Source: Medicare Current Beneficiary Survey

24. 19821984 1986 1988 19901992 1994 19961998 2000 2002 Year 100 - <200 <100 200+ Ages 65 years and over 1982 1984 1986 1988 19901992 19941996 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

25. 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 1982 19841986 1988 1990 1992 1994 1996 1998 2000 2002

26. Percent of Persons Without a Health Care Visit in the Past 2 Years by Percent of Poverty Threshold Data Source: National Health Interview Survey 1982 1984 1986 1988 1990 1992 19941996 19982000 2002 Year Ages 18-64 years 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 Year Ages 65 years and over

27. Summary Improvements in health for everyone –Exceptions, obesity and overweight Generally worse health outcomes for poor people –Notable exceptions, especially among men

28. 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

29. 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

30. 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