Income and Education Are Bigger Determinants of Health Than Insurance, Report Shows
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This story originally appeared on Health Beat.
The Robert Wood Johnson Foundation's Commission to Build a Healthier America has just released a report that reveals the degree to which a child's health is determined by the hand he or she draws at birth.
While having or not having health insurance is important, poverty will have an even greater influence on an individual's health. As Commission Co-Chair and former Congressional Budget Office director Alice M. Rivlin puts it, "This report shows us just how much a child's health is shaped by the environment in which he or she lives."
Moreover, the report reveals that it is not only the poor who are molded by their environment. "In nearly every state, children in middle-income families also experience shortfalls in health when compared with those in higher income families. And these differences in children's health by income can be seen across racial or ethnic groups" says the report, which is based on research done at the University of California at San Francisco's Center on Social Disparities in Health. Ultimately, this study highlights "the unrealized health potential possible if all children had the same opportunities for health as those in the best-off families."
"Most of our efforts to improve health have focused on improving quality, access to and affordability of care. While these are important, support for better health that is associated with resources and community matters as well," says Commission Co-Chair Mark McClellan. "As a nation, we clearly need to do better...a large body of research shows that the causes [of poor health among children] are complex," the report observes, "and that medical care interventions are important but not sufficient."
To illustrate "the magnitude of the link between education and health" the Commission also is releasing a new online tool that lets viewers see the connection first hand, says Dr Steven Woolf, a professor of Family Medicine at Virginia Commonwealth who was involved in developing the tool. (Readers who want to check the relationship between education and premature deaths in their state or country will find the tool here).
How the Study Measures Income and Education
Taking family size into account, family income is categorized by comparing it to Federal Poverty Level (FPL), which has been defined as the amount of income that will provide a bare minimum of food, clothing, transportation, shelter and other necessities. In 2006, the U.S. FPL was $16,079 for a family of three and $20,614 for a family of four. Children were considered to be poor if they lived in households below the FPL, "near poor" if they lived in homes that fell somewhere between the FPL and twice the FPL (for a family of three that would be somewhere between $16,079 and roughly $32,000) "middle income" if they lived in households with income somewhere between twice and three times the FPL (or between $32,000 and $48,000), and "higher income" if they lived households earning four times the FPL or more ( over roughly $64,000 for a family of three, $80,000 for a family of four.)
To measure education while examining children's general health, the report looks at the highest level attained by any person in the household using four categories (less than high-school graduate, high-school graduate, some college, and college graduate).
In the U.S. 18 percent of children live in households that are "poor' and another 19 percent in households that are "near poor." Thirty-two percent are in middle-class homes, and just 28 percent live in "higher income" homes. Only 9 percent are growing up in households where no adult has completed high school, 24 percent live in families where at least one adult is a high school graduate, 32 percent in homes where one adult has some college, and 35 percent in homes where at least one person is a college graduate.
Just How Much Difference Do Income and Education Make?
In the United States, 16 percent of children ages 17 and younger are in less than optimal health -- a rate that varies widely across states from a high of 22.8 percent in Texas to a low of 6.9 percent in Vermont. (Assessment of a child's health is based on parents' reports; researchers ranked a child's health as "less than optimal" when parents described it as "poor," "fair" or "good" -- but not "very good" or "excellent." )
But within states, health varies dramatically by income. In Texas, for example, "44 percent of children in poor families are in less than optimal health compared with 6.7 percent of children in higher income families. Texas has the largest income gap in children's health status among all states."
The picture in New Hampshire is very different. There, "13 percent of poor children are in less than optimal health compared with 6.4 percent of children in higher-income families." When compared to other states, New Hampshire has the smallest income gap in children's general health.
Nationwide, as the chart below shows, children in poor, near-poor or middle-income families were 4.7, 2.8 and 1.5 times as likely as more affluent children to be in "less than optimal health."
Education also matters. Compared with children living with someone who has completed some college, children in households without a high-school graduate were more than four times as likely -- and those in households with a high-school graduate twice as likely -- to be in suboptimal health. Race also counts, with white children faring better than Hispanic or African-American children.
Ultimately, "there are a variety of intermingled factors that explain the better health status of advantaged people" Woolf explains. "A lot of it has to do with neighborhood, environmental and social support systems. It's a complicated, inter-related mix. We view education and income as proxies for that package."
Within each racial or ethnic group, income makes all the difference. Among non-Hispanic whites, for example, children in poor, near-poor or middle-income households were 3.5 2.1 and 1.4 times as likely to be in poor health than children in wealthier families.
Finally, as one would expect, adult "behaviors" influence children's health. At every income level, children living in households where no one exercise regularly or someone smokes are more likely to be in poorer health than children in families with healthier behaviors.
Yet, as the chart below reveals income is far more important than the example set by the parent. Even if adults exhibit healthy behaviors, 33 percent of children in poor husbands are in less than optimal health. By contrast, in affluent households, only 10 percent of children are in poor health if parents smoke and don't exercise -- compared to 5.4 percent if adults adopt healthy lifestyles.
Why are Income and Education So Important?
"Educated parents may have a better understanding of health-related behaviors," the report explains, "along with resources to make healthier choices." Knowledge alone is not enough. Resources are essential. While a parent my understand that it is important for her child to exercise, if she lives in a tiny apartment in a neighborhood where there are no safe playgrounds -- and where the public school offers phys ed only once a week, there is little that she can do. She cannot afford to send her child to camp in the summer. She cannot afford to join the YMCA.
Better-educated parents are "better able to obtain higher-paying jobs, providing the income to afford better housing, better "neighborhoods and a healthy diet," the report points out. (See the chart in this HealthBeat post, showing that the most nutritious foods are, indeed, significantly more expensive than other foods).
In addition, the report observes, "community influences such as safety, school quality, presence of favorable role models and availability of healthful foods and recreational opportunities affect children's health. Racial or ethnic group matters in part because it continues to influence educational and employment opportunities. In addition, discrimination and its legacy in residential segregation mean that black and Hispanic families more often live in substandard housing and unsafe or deteriorating neighborhood conditions compared with whites with similar incomes and education."
At the same time, the report acknowledges that "medical care is important for children's health." For example, "timely immunizations and regular treatment for conditions like asthma can make a big difference in overall well-being. Genetic predisposition to certain diseases also influences children's health. But many experts have concluded that medical care and genes actually play a relatively minor role compared with the influence of the physical and social conditions in which children grow up.
Finally higher income also means less stress -- not only for families but for children. And we know that chronic stress leads to disease.
What Can We Do?
The commission plans to make recommendations in April. In the meantime, I have a few suggestions.
- We should explore ways to provide jobs that pay a living wage to less-educated workers. For example, in these tough economic times, the government might invest in rebuilding our infrastructure -- an investment that also would create jobs.
- Investments in safe playgrounds and subsidies for green-markets that locate in poor neighborhoods could help improve quality of life -- and the health of children
- Low-income and middle-income children a;sp need also scholarships to help them go to college. In recent years, federal funding has favored financing loans that only more affluent families can afford; at the same time scholarship programs for low-income and median-income children have been cut. This trend should be reversed.
- Finally, we should find new ways to lift the quality of public education for low-income students. Richard Kahlenberg, a colleague at The Century Foundation, has written extensively about innovative programs doing just that.
As Kahlenberg points out in Part IV of a report titled "Fixing No Child Left Behind": "A wide body of research has found that concentrations of poverty create enormous difficulties for schools." It is very hard to try to "fix" schools located in a ghetto -- just as it is difficult to improve the health of children living there. There are too many factors working against the schools. This is why, rather than pouring money into failing schools in poor neighborhoods, some educators recommend taking the children out of the ghetto and bussing them to suburban schools.
Kahlenberg reports impressive results: studies show that when "low-income fourth-grade American students" are "given a chance to attend more- affluent schools" they score almost two years ahead of low-income students stuck in high-poverty schools on National Assessment of Educational Progress math tests...Likewise, data from the 2006 Program for International Student Assessment (PISA) for fifteen-year-olds in science showed a "clear advantage in attending a school whose students are, on average from more advantaged socio-economic backgrounds."
The advantages are clear. Middle-class schools provide not only more financial resources on average, but also a more positive peer environment, better teachers, and more actively involved parents
A forthcoming Century Foundation study by Amy Stuart Wells of Teachers College, Columbia University, and Jennifer Jellison Holme of the University of Texas at Austin looks at eight highly successful inter-district programs -- in Boston, St. Louis, Hartford, Milwaukee, Rochester, Indianapolis, Minneapolis, and East Palo Alto. Researchers have found that "after an initial adjustment period, students generally see large test score achievement gains in suburban schools. In St. Louis, transfer students not only scored higher, they also were twice as likely to go on to two-year or four-year colleges than graduates of the schools they left behind.
These programs work in part because students tend to model themselves on each other. When you put a small group of low-income students into a middle-class classroom, the low-income students are less likely to talk while the teacher is talking, and more likely to do their homework. Children do not like to be "different."
Kahlenberg explains that "one the key reasons for the political success of these programs is the financial incentives provided to middle-class receiving districts." Granted, "there was strong political resistance to many of these programs initially," but " over time suburban legislators have often come to support continuation of the programs ...And new suburban districts have asked to be added to programs in Boston, Minneapolis, and Rochester. The authors attribute the political success of the programs not only to the financial incentives, but also to salutary effects that the programs themselves have on the racial attitudes of students and parents in the suburbs over time."
These are just a few suggestions. I look forward to the Commission's spring report.