Studies reveal contradictions in efforts to improve socioeconomic status

About Joe Rojas-Burke

Joe Rojas-Burke is AHCJ’s core topic leader on the social determinants of health, working to help journalists broaden the frame of health coverage to include factors such as education, income, neighborhood and social network. Send questions or suggestions to joe@healthjournalism.org or @rojasburke.

“You as a society have made a decision that child poverty is what you want. I can only assume that’s the case. Otherwise you would do what European countries are doing and use taxes and transfers to reduce child poverty.”  – Michael Marmot

Sir Michael Marmot isn’t the first to call out the United States for its exceptionally high rate of child poverty. About 45 percent of American kids are growing up in families that are poor or near poor (below 199 percent of the federal poverty level), up from 40 percent in 2006, according to a recent analysis.

This degree of social inequality helps explain why the health status of Americans is failing to keep up with progress in other wealthy nations. But how to make things better is not so clear. Two remarkable studies in the Journal of the American Medical Association this month highlight some of the paradoxes and hidden pitfalls inherent in efforts to boost the socioeconomic status of poor kids.

In the Moving to Opportunity study, a voucher program enabling low-income families to move out of impoverished neighborhoods resulted in some health gains for girls but made things substantially worse for boys.

The study enrolled 4,604 families in public or project-based assisted housing in high-poverty areas of Baltimore, Boston, Chicago, Los Angeles, and New York from 1994 to 1998. Researchers randomly assigned families to three groups. Some received vouchers to move to low-poverty neighborhoods, some received traditional vouchers enabling them to move but with no geographic restriction, and some received no change in the level of assistance. Researchers compared health outcomes 10 to 15 years later.

Girls in the traditional voucher group had decreased rates of major depression and conduct disorder, and girls in the low-poverty voucher group had no statistical differences, compared with those in the control group. Boys in the low-poverty voucher group had substantially increased rates of major depression, posttraumatic stress disorder, and conduct disorder compared with those in the control group. And boys in the traditional voucher group had an increased rate of post-traumatic stress disorder, the authors reported in JAMA’s March 5 issue.

The New Republic explored the reasons for the disparity between girls and boys with lead author Ronald Kessler, Ph.D., a professor of health care policy at Harvard Medical School:

Kessler points to various factors – community perception, interpersonal skills – as major points of influence: “We had an anthropologist working with us, and the anthropologist went and talked to and watched the kids in the old neighborhoods and the new neighborhoods, and their perception was that when the boys came into the new neighborhood they were coded as these juvenile delinquents,” says Kessler. “Whereas with the girls, it was exactly the opposite. They were embraced by the community – ‘you poor little disadvantaged thing, let me help you.’”

For Kessler, the lesson is that housing programs should be coordinated with carefully thought out social support “to make it so that people can thrive in better neighborhoods rather than drown.”

The same issue of JAMA included a study examining the surprising, apparent health benefit of tribal casinos for Native American children. The new study tracked changes in poverty and youth obesity over time in tribal communities that added or expanded casinos compared with those that did not. Tanya H. Lee, in Indian Country Today, gave a detailed explanation of the findings:

In school districts that encompassed tribal lands where a new casino had been built or an existing casino expanded between the years 2001 and 2012, the risk of being an overweight/obese AI/AN child dropped 0.19 percent per new slot machine. Since there were on average 13 new slots per capita, the total reduction in the risk of being overweight or obese averaged 2.47 percent. Each new slot represented a per capita increase in annual income of $541 and a decrease in the number of people living in poverty. For the average of 13 new slots per capita, this would mean a 7.8-percent reduction in the number of people living in poverty.

The study, because of its design, couldn’t establish cause and effect. And previous studies of the health impact of casinos have produced conflicting results. One, for instance, linked casinos to an increase in accidental deaths among adults and worsening obesity among low-income young adults. But it has been fairly well established that children in families with higher income are less likely to be overweight or obese.

Lead author Jessica Jones-Smith told Reuters Health, “We weren’t trying to weigh in on whether casinos should be held up as an example of economic development. Instead, we were trying to isolate the impact of economic resources on kids’ health.”

UCLA physician Neal Halfon, in a written commentary for JAMA, argued that the study highlights the need for our society to take steps to reduce income inequality:

An enormous loss of human potential results from unsafe, uncertain, stressful childhood environments that do not have the basic scaffolding that all children need to thrive. A casino in every neighborhood is not the answer, but increasing family income and removing other pressures that reduce the capacity of families to invest in their children should be part of the solution. While incremental improvements like expanding preschool and extending health insurance may help add new rungs to the existing ladder of social opportunity, the fact is that these ladders are broken, outdated, and designed for a different era and need to be redesigned and transformed from the bottom up.

Coverage of both papers was limited to brief, study-of-the-week news stories. But wouldn’t it be cool to dig deeper with, say, a narrative telling the stories of boys from a poor neighborhood attempting to adapt after moving to a “better” environment, or maybe comparing the health of tribal communities with and without casinos?

2 thoughts on “Studies reveal contradictions in efforts to improve socioeconomic status

  1. Robert C. Bowman, M.D.

    Designs for health spending in the United States can be tracked by the locations of physicians. About 1100 zip codes with 1% of the land area and 10% of the population have 45% of physicians resulting in multiple times more health spending per person. About 40,000 zip codes with 68% of the population have 30% of the physician workforce and the workforce is predominantly primary care and specialties involved in basic and lower paid services. These are zip codes with multiple times less health spending per person locally.

    The economic impact of medical education has been estimated by AAMC as 500 billion dollars. Half of this or 250 billion dollars can be tracked to 6 states and actually only a few counties or a few dozen zip codes in these states. Legislation to move graduate medical education to most states in need of physicians, to primary care, and to rural training has failed. (Chen, Phillips)

    Designs for training and payment result in the least pay for primary care and for basic services – about 70% of the workforce in locations in need of physicians. Designs for training and payment result in the most lines of revenue and the top reimbursement in each line for 1% of the land area in highest concentration zip codes that are clustered together for least access to care and also least economic impact for most Americans.

    Population based spending is distributed most equitably and includes Social Security, SNAP, payments in lieu of taxes, some education funding, and spending that supports family practice positions – the only population based types of MDs, DOs, NPs, or PAs. Designers and designs that curtail or terminate population based spending are defeating social determinants and will likely contribute to lesser income and lesser health.

    Multiple state and federal across the board cuts plus specific cuts to special programs will continue to devastate reservations, other rural counties with minority populations, as well as rural and urban locations with lowest concentrations of physicians.

  2. Pingback: Interventions might alleviate poverty’s impact on child health | Association of Health Care Journalists

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