Trends in U.S. Population Health: The Central Role of Policies, Politics, and Profits

The urban-rural gap in older Americans' healthy life expectancy

PURPOSE

Estimate health-quality-adjusted life expectancy (QALE) for Americans nearing retirement age and assess rural-urban disparities in QALE.

METHODS

We used a dynamic microsimulation model based on Health and Retirement Study data to estimate the quantity and health quality of expected future life years for rural and urban Americans ages 59-60 in 2014-2020.

FINDINGS

Cohort life expectancy at age 60 (LE) for urban and rural men was 22.9 and 20.9, respectively; for urban and rural women, LE was 25.6 and 25.0, respectively. Adjusting future life years to quality-adjusted life years, QALE was 17.5 versus 15.7 for urban versus rural men, and 19.3 versus 18.7 for women. Compared to a cohort in 1994-2000, the urban-rural QALE gap in 2014-2020 grew substantially for men; changes for women were smaller. Average QALE masked heterogeneity by race/ethnicity, education, and Census region. Counterfactual scenarios suggested eliminating smoking and managing obesity and prevalent heart conditions would be particularly beneficial for increasing rural QALE and reducing the urban-rural gap.

CONCLUSIONS

Expected health quality, in addition to longevity, is an important factor when assessing rural disparities in older Americans' future life outcomes. Current chronic disease disparities are expected to translate to a widening urban-rural gap in QALE, particularly for men. Interventions earlier in life may be needed to fully address disparities in QALE at older ages.

Institutional Failures as Structural Determinants of Suicide: The Opioid Epidemic and the Great Recession in the United States

We investigate recent trends in U.S. suicide mortality using a "structural determinants of health" framework. We access restricted-use multiple cause of death files to track suicide rates among U.S. Black, White, American Indian/Alaska Native, and Latino/a men and women between 1990 and 2017. We examine suicide deaths separately by poisonings and nonpoisonings to illustrate that (1) women's suicide rates from poisonings track strongly with increases in prescription drug availability and (2) nonpoisoning suicide rates among all adult Americans track strongly with worsening economic conditions coinciding with the financial crash and Great Recession. These findings suggest that institutional failures elevated U.S. suicide risk between 1990 and 2017 by increasing access to more lethal means of self-harm and by increasing both exposure and vulnerability to economic downturns. Together, these results support calls to scale up to focus on the structural determinants of U.S. suicide.

Structural Sexism and Preventive Health Care Use in the United States

Preventive health care use can reduce the risk of disease, disability, and death. Thus, it is critical to understand factors that shape preventive care use. A growing body of research identifies structural sexism as a driver of population health, but it remains unknown if structural sexism is linked to preventive care use and, if so, whether the relationship differs for women and men. Gender performance and gendered power and resource allocation perspectives lead to competing hypotheses regarding these questions. This study explores the relationship between structural sexism and preventive care in gender-stratified, multilevel models that combine data from the Behavioral Risk Factor Surveillance System with state-level data (N = 425,454). We find that in states with more structural sexism, both men and women were less likely to seek preventive care. These findings support the gender performance hypothesis for men and the gendered power and resource allocation hypothesis for men and women.

An examination of sugar-sweetened beverage tax regulations in six jurisdictions: Applying a social justice perspective to beverage taxation and exemptions

Taxes, legislation and politics are social determinants of health, which can impact health through multiple pathways. The purpose of this study was to review regulations regarding sugar-sweetened beverage (SSB) taxation and describe taxation/exemption of various beverage categories. We reviewed SSB taxation regulations from Mexico, the United Kingdom, Berkeley, Philadelphia, San Francisco and South Africa. Supplementary government documents and academic publications were also reviewed to further discern beverage taxation/exemption and zero-rating. There were a number of beverage types that fell clearly into typically taxed or exempt/zero-rated categories across all six jurisdictions (e.g. pop/soda as taxed and water as zero-rated). Exemptions and ambiguities within the six regulations can generally be grouped as a lack of clarity regarding the meaning and use of milk; the meaning of 'medical purposes' and 'supplemental'; the point at which a beverage is prepared; the form of concentrate (i.e. liquid/frozen/powder) or medium used (e.g. water, coffee); and location of preparation or business size of retailer. SSB tax regulations are complex, unclear, vary across jurisdiction and leave several beverage types with added sugar exempt from taxation or at risk of a legal challenge. Lastly, tax exemptions generally reflect and perpetuate existing sociopolitical dynamics within the food system.

Is fair representation good for children? effects of electoral partisan bias in state legislatures on policies affecting children's health and well-being

Increasing evidence suggests that state policies impact constituents' health, but political determinants of health and health inequities remain understudied. Using state and year fixed-effects models, we determined the extent to which changes in electoral partisan bias in lower chambers of U.S. state legislatures (i.e., discrepancy between statewide vote share and seat share) were followed by changes in five state policies affecting children and families (1980-2019) and a composite of safety net programs (1999-2018). We examined effects on each policy and whether the effect was modified when bias was accompanied by unified party control. Next, we determined whether the effect differed depending on which party it favored. Less bias resulted only in higher AFDC/TANF benefits. Both pro-Democratic and pro-Republican bias was followed by decreased AFDC/TANF benefits and increased Medicaid benefits. AFDC/TANF recipients, unemployment benefits, minimum wage, and pre-K-12 education spending increased following pro-Democratic bias and decreased following pro-Republican bias. Estimated effects on the composite measure of safety net policies were all close to null. Some effects were modulated by unified party control. Results demonstrate that increasing fairness in elections is not a panacea by itself for increasing generosity of programs affecting children's well-being. Indeed, bias can be somewhat beneficial for the expansiveness of some policies. Furthermore, with the exception of unemployment benefits and AFDC/TANF recipients, Democrats have not been using the additional power that comes with electoral bias to spend more on major programs that benefit children. Finally, after decades in which electoral bias was in Democrats' favor, bias has started to shift toward Republicans in the last decade. This trend forecasts more cuts in almost all the policies in this study, especially education and AFDC/TANF recipients. There is a need for more research and advocacy emphasis on the political determinants of social determinants of health, especially at the state level.

Anticipatory stress, state policy contexts, and mental health during the COVID-19 pandemic

Substantial economic disruptions during the COVID-19 pandemic upended daily life and contributed to a widespread symptom of psychological distress during this period. Disruptions also led to more concerns about future stressful events related to financial hardship, or economic-related anticipatory stress, with the potential to undermine mental health. Although prior research provides ample evidence that state policies can impact mental and physical health, it has not considered how state policy contexts reduce adverse psychological outcomes stemming from economic-related anticipatory stress. The present study uses national survey data from the Census Bureau's Household Pulse Survey (April 2020-October 2020) to examine the extent to which state policy contexts moderate the association between economic-related anticipatory stress and depression/anxiety. We find that states with stronger social safety nets weakened the impact of anticipatory stress on depression/anxiety. This finding held for different types of anticipated economic hardships (i.e., reduced income, difficulty paying rent, difficulty affording food), as well as for policies that existed prior to COVID-19 and policies enacted in response to COVID-19. Findings provide strong evidence that state policies may buffer against poor mental outcomes for people who even anticipate facing economic uncertainty during the COVID-19 pandemic. We provide insight into how state policy contexts can shape individual experiences in ways that impact the mental health outcomes of the United States population.

Dynamic Changes in the Association Between Education and Health in the United States

Policy Points We reviewed some of the recent advances in education and health, arguing that attention to social contextual factors and the dynamics of social and institutional change provide critical insights into the ways in which the association is embedded in institutional contexts. Based on our findings, we believe incorporating this perspective is fundamentally important to ameliorate current negative trends and inequality in Americans' health and longevity.

Socioeconomic Positions and Midlife Health Trajectories in a Changing Social Context: Evidence from China, 1991-2006

Cumulative (dis)advantage theory posits that socioeconomic disparities in health may increase with age. This study examines individuals' midlife health trajectories, taking account of how their life courses are embedded within changing social contexts. Using the China Health and Nutrition Survey (1991-2006), it examines the health gap between Chinese rural peasants and urban nonpeasants in three adjacent time periods, during which a rapid process of social change increased the inequalities between rural and urban areas. Findings show that the health gap increases more rapidly in the more recent time periods, with higher levels of inequality, indicating that health inequalities between the two groups are contingent upon the social contexts in which individuals' lives unfold. To better understand the differences observed over these time periods, further analysis will examine the roles of two structural factors: income inequality and differential access to medical care.

Political Economy of the COVID-19 Pandemic: How State Policies Shape County-Level Disparities in COVID-19 Deaths

The authors examine how two state-level coronavirus disease 2019 (COVID-19) policy indices (one capturing economic support and one capturing stringency measures such as stay-at-home orders) were associated with county-level COVID-19 mortality from April through December 2020 and whether the policies were more beneficial for certain counties. Using multilevel negative binominal regression models, the authors found that high scores on both policy indices were associated with lower county-level COVID-19 mortality. However, the policies appeared to be most beneficial for counties with fewer physicians and larger shares of older adults, low-educated residents, and Trump voters. They appeared to be less effective in counties with larger shares of non-Hispanic Black and Hispanic residents. These findings underscore the importance of examining how state and local factors jointly shape COVID-19 mortality and indicate that the unequal benefits of pandemic policies may have contributed to county-level disparities in COVID-19 mortality.

Associations Between Use of Paid Help and Care Experiences Among Medicare-Medicaid Enrolled Older Adults With and Without Dementia

OBJECTIVES

Community-living older Medicare and Medicaid enrollees ("dual-enrollees") have high care needs and commonly receive paid and unpaid long-term services and supports (LTSS) to help with routine activities. Little is known about whether receiving paid help or individuals' state and neighborhood environmental context ("LTSS environment") relates to dual-enrollees' care experiences.

METHODS

We examine a sample of n = 979 community-dwelling dual-enrollees with disabilities from 2011 to 2015 National Health and Aging Trends Study, linked to measures of neighborhood disadvantage and state Medicaid home and community-based services (HCBS) generosity. Logistic regression models stratified by dementia status assess associations between paid help and: (a) adverse consequences due to unmet care needs, and (b) participation restrictions in valued activities, among dual-enrollees with and without dementia, adjusting for individual and LTSS environmental characteristics.

RESULTS

Use of paid help was greater for those with (versus without) dementia (46.9% vs. 37.8%). Neighborhood disadvantage was associated with greater use of paid help among dual-enrollees living with dementia. High state Medicaid HCBS generosity was associated with the use of paid help, regardless of dementia status. Dual-enrollees with dementia receiving paid help had higher odds of experiencing adverse consequences due to unmet need (adjusted odds ratio = 2.05; 95% confidence interval 1.16-3.61; p = .02)-no significant associations were observed for participation restrictions. Use of paid help and LTSS environment were not significantly associated with care experiences for dual-enrollees without dementia.

DISCUSSION

Findings highlight the complexities of caring for dual-enrollees, particularly those with dementia, and emphasize the need to strengthen the delivery of paid care with considerations for the LTSS environment.

Enhancing the Utility of the Health and Retirement Study (HRS) to Identify Drivers of Rising Mortality Rates in the United States

A recent report from the National Academies of Sciences, Engineering, and Medicine (NASEM) highlights rising rates of working-age mortality in the United States, portending troubling population health trends for this group as they age. The Health and Retirement Study (HRS) is an invaluable resource for researchers studying health and aging dynamics among Americans ages 50 and above and has strong potential to be used by researchers to provide insights about the drivers of rising U.S. mortality rates. This paper assesses the strengths and limitations of HRS data for identifying drivers of rising mortality rates in the U.S. and provides recommendations to enhance the utility of the HRS in this regard. Among our many recommendations, we encourage the HRS to prioritize the following: link cause of death information to respondents; reduce the age of eligibility for inclusion in the sample; increase the rural sample size; enhance the existing HRS Contextual Data Resource by incorporating longitudinal measures of structural determinants of health; develop additional data linkages to capture residential settings and characteristics across the life course; and add measures that capture drug use, gun ownership, and social media use.

State Immigration Policy Contexts and Racialized Legal Status Disparities in Health Care Utilization Among U.S. Agricultural Workers

Research links restrictive immigration policies to immigrant health and health care outcomes. Yet most studies in this area focus on the impact of single policies in particular years, with few assessing how broader state-level immigration policy contexts affect groups by nativity, race/ethnicity, and legal status. Linking data from the National Agricultural Workers Survey (2005-2012) with information on state immigration policies, we use an intersectional approach to examine the links between policy contexts and health care utilization by nativity, race/ethnicity, and legal status. We also assess the associations between two specific types of state immigration policies-those governing immigrant access to Medicaid and driver's licenses-and health care utilization disparities. We find that state-level immigration policy contexts are associated with health care utilization among U.S.-born and naturalized U.S. citizen non-White Latinx agricultural workers, who report lower levels of health care utilization and greater barriers to care-seeking in more restrictive policy contexts. By contrast, we find little evidence that state policies shaped health care utilization among undocumented workers. These findings advance understanding of the impact of "policies of exclusion" on the lives of marginalized groups and underscore the importance of racialized legal status in considering the links between sociopolitical contexts and health and health care disparities.

Neighborhood cohesion and psychological distress across race and sexual orientation

Introduction

Method

Result

Conclusion

•

Lesbian, gay, and bisexual (LGB) people are more likely to meet the criteria for psychological distress than non-LGB people.

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Neighborhood cohesion (NC) has differing impact on psychological distress by race and sexual orientation.

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NC provides greater protection against moderate distress for non-LGB groups and severe psychological distress for LGB groups.