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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