Slide 1 of 31 Income Inequality and Health in Washington State Donald L. Patrick, Jesse J. Plascak, Shirley A.A. Beresford University of Washington Autumn Quarterly Meeting Biobehavioral Cancer Prevention and Training Program October 31 st, 2014 ** Funded in part by National Cancer Institute Biobehavioral Cancer Prevention and Control Training Grant (R25CA092408) and P50CA148143
Slide 2 of 31 Outline 1. Background 2. Gini Index and top 1% 3. Associations between SES Inequality and health 4. Conclusions
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Slide 4 of 31 Why the interest in income inequality? Thomas Piketty and Capital in the 21 st Century Public increasingly concerned about wealth gap Public confidence in economy waning, ego opportunity viewed as finite or zero sum game The extent of and continuing increase in inequality in the United States greatly concerns me...i think it is appropriate to ask if this trend is compatible with values rooted in our nation's history, among them the high value Americans have traditionally placed on equality of opportunity Janet Yellen, Federal Reserve Chairwoman
Slide 5 of 20 Is income inequality bad for population health?
Slide 6 of 31 Previous Literature Higher income inequality associated with all cause mortality, self rated health, depressive symptoms, hypertension, smoking, BMI, disability status Sensitive to geographic scale and lag effects Strongest evidence of association at state level Evidence of 15+ year time lag
Slide 7 of 31 A Theory of SES, SES Inequality and Health Health 100 90 80 70 60 50 40 30 20 10 0 0 20 40 60 80 100 Income ($1,000) If $10,000 is transferred from individual with income=$80,000 and health=95 to individual with income=$20,000 and health=50, Population health gain of 15 (health income=$70,000+ health income=$30,000; (94+66) (95+50)=15) Adapted from Subramanian and Kawachi, Epidemiol Rev 2004
Slide 8 of 31 Theory of SES, SES Inequality and Health Socioeconomic Inequality Individual socioeconomic status Health
Slide 9 of 31 Measuring Income Inequality and Health Jesse Plascak
Slide 10 of 31 Gini Index and the Lorenz Curve The average of the absolute differences between all pairs of scores, divided by twice the mean Gini = A/(A+B) Cumulative % of Income 100 90 80 70 60 50 40 30 20 10 A B 0 0 10 20 30 40 50 60 70 80 90 100 Cumulative % of Individuals Top 1%
Slide 11 of 31 Gini Index Shortcomings Viable data U.S. Census: household, gross income (but has whole distribution) IRS: left truncated of (but IRS can account for redistributive tax systems [net income]) More sensitive to change in middle incomes Non decomposable inequality in every subgroup does not necessarily lead to Gini
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Slide 14 of 31 Trends in Income Inequality and Health Shirley Beresford
50 45 Income Inequality (Top 1%) in the U.S., Washington, North Dakota, Alaska, New York, and Delaware, 1916 2012 Slide 15 of 31 % OF PRE TAX INCOME HELD BY TOP 1% 40 35 30 25 20 15 10 5 0 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 YEAR U.S. WA ND (Lowest) AK (2nd lowest) NY (2nd highest) DE (Highest)
LOG INFANT MORTALITY RATE (PER 1,000) 80 Slide 16 of 31 Top 1% and Infant Mortality Rate by Race, 1916 2010, United States 20 18 16 14 12 10 8 6 4 2 % OF PRE TAX INCOME HELD BY TOP 1% 4 0 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 YEAR Infant Mortality Rate All Races Infant Mortality Rate non White Top 1% Infant Mortality Rate White Infant Mortality Rate Black
INFANT MORTALITY EVENT RATE RATIO 2.7 2.6 2.5 2.4 2.3 2.2 2.1 2.0 1.9 1.8 Slide 17 of 20 Gini index and Infant Mortality Rate Ratio Disparity by Race, 1968 2010, United States 0.45 0.43 0.41 0.39 0.37 0.35 GINI INDEX 1.7 0.33 1940 1950 1960 1970 1980 1990 2000 2010 2020 YEAR Rate Ratio Black vs White Rate Ratio non White vs White Gini
GINI INDEX OF PRE TAX INCOME 0.65 0.60 0.55 0.50 0.45 0.40 0.35 0.30 0.25 0.20 0.15 0.10 0.05 Income Inequality 1916 2012, Pre tax Washington State Slide 18 of 31 30 25 20 15 10 5 % OF PRE TAX INCOME HELD BY TOP 1% 0.00 0 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 YEAR Gini % of Income Held by Top 1%
70 Top 1% and Infant Mortality Rate 1916 2012, Washington State Slide 19 of 31 30 INFANT MORTALITY RATE (PER 1,000) 60 50 40 30 20 10 25 20 15 10 5 % OF PRE TAX INCOME HELD BY TOP 1% 0 0 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 YEAR Infant Mortality Rate (per 1,000) Top 1%
70 Gini Index and Infant Mortality Rate 1916 2012, Washington State Slide 20 of 31 0.65 INFANT MORTALITY RATE (PER 1,000) 60 50 40 30 20 10 0.60 0.55 0.50 0.45 0.40 0.35 GINI INDEX 0 0.30 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 YEAR Infant Mortality Rate (per 1,000) Gini
100 Slide 21 of 31 Gini Index and Infant Mortality Rate (Log) by Race, 1916 2012, Washington State 0.65 LOG INFANT MORTALITY RATE (PER 1,000) 10 0.60 0.55 0.50 0.45 0.40 0.35 GINI INDEX 1 0.30 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 YEAR Infant Mortality Rate All Race Infant Mortality Rate Black Infant Mortality Rate American Indian Infant Mortality Rate White Infant Mortality Rate Asian Gini
15.0 14.5 Gini index and % Poor/Fair Health, Washington State Slide 22 of 31 0.50 0.48 0.46 % POOR/FAIR HEALTH 14.0 13.5 13.0 12.5 12.0 1999 2009 YEAR % Poor/Fair Health Gini 0.44 0.42 0.40 0.38 0.36 0.34 0.32 0.30 GINI INDEX
Slide 23 of 31 % < 100% FPL by County, 2007 2011
Slide 24 of 31 County Level Washington State Health Disparity Indicators by SES % Poor/Fair Health (N=39) Low Birth Weight (<2500 g) (N=36) Teenage Birth Rate (N=39) Corr Coefficient Corr Coefficient Corr Coefficient (P value) (P value) (P value) % < 100% FPL 0.38 (0.015) 0.29 (0.082) 0.38 (0.017) Median Household Income 0.45 (0.004) 0.10 (0.567) 0.27 (0.101) % < High School Diploma 0.74 (<.001) 0.48 (0.003) 0.93 (<.001)
Slide 25 of 31 Associations with Poor/Fair Health, Household Income Washington State, 2001 2010 < $15,000 1.00 OR (95% CI) P value $15,000 $25,000 0.58 (0.54 0.63) < 0.001 $25,001 $35,000 0.31 (0.29 0.34) < 0.001 $35,001 $50,000 0.22 (0.20 0.24) < 0.001 $50,000 0.11 (0.11 0.12) < 0.001
Slide 26 of 31 Associations with Poor/Fair Health, Washington State, 2001 2010 OR (95% CI) P value Education Attainment < High School Diploma 1.00 High School Diploma 0.42 (0.37 0.43) < 0.001 Some College / 0.30 (0.27 0.32) < 0.001 Associate s Degree Bachelor s Degree 0.14 (0.13 0.15) < 0.001
Slide 27 of 31 Conclusions and Discussion Donald Patrick
Slide 28 of 31 Conclusions Internationally, higher income inequality higher infant mortality In the US, income inequality has steadily risen over the last 40 years In the US, income inequality is not consistently associated with infant mortality disparities by race in different time epochs In WASHINGTON STATE, income inequality not consistently associated health indicators in multilevel analyses HOWEVER< lower SES indicators (poverty, median income, and education) are associated with poor/fair health at both a county and individual level Multilevel studies of income inequality are difficult or impractical yet Income inequality is important to our notions of equity and justice
Slide 29 of 31 Policy Implications Interventions at policy and individual level may be best directed toward reducing poverty and increasing education for all Distributive Justness: John Rawls Each person as an equal right to the most extensive basic liberty compatible with a similar liberty for others Social and economic inequalities are to be arranged so they are to the greatest benefit to the least advantaged members of society
Slide 30 of 31 Data Sources Internal Revenue Service household income inequality by year Mark Frank of Sam Houston State University (State data) Immanuel Saez of University of California, Berkeley (U.S. data) U.S. Census Bureau American Community Survey County level % < 100% federal poverty level, median household income, % < high school diploma, income Gini 2007 2011 Behavioral Risk Factor Surveillance System Individual level % poor/fair health, household income, education attainment, age, sex 2001 2010 National Center for Health Statistics Infant mortality rate by race and year (U.S.) Low birth rate, teenage birth rate 2005 2011 (Washington State) Washington State Department of Health, Center for Health Statistics Infant mortality rate by race and year The World Bank (international data) Infant mortality and income Gini
Thank you! Slide 31 of 31