By Mary Caffrey
The numbers didn’t lie, but they were hard to explain: black children are twice as likely as others to develop asthma.
There was evidence that low birth weight was a culprit, but could “being black” be a risk factor in asthma, as some believed?
Two scholars from Princeton University have concluded that it’s not race, but living conditions, that accounts for the disparity. The data are compelling, alright: they show the effects of ongoing segregation, which trap African American children in poor neighborhoods, surrounded by pollution.
Janet M. Currie, PhD, professor of economics and public affairs at Princeton, and Diane Alexander, PhD, of the Federal Reserve Bank of Chicago, made this finding after examining New Jersey health data for low birth weight children of all races living in zip codes where more than half the population was African American.
Within these neighborhoods, the racial disparities vanished: all low birthweight children had a higher risk of asthma.
Children with a low birth weight may be premature, which increases the risk for lung problems. The trigger for asthma comes from things found in aging neighborhoods with older housing: mold, rodent infestation, or air pollution. Being around people who smoke also causes asthma, even if a baby’s mother does not smoke. According to CDC, black men have much higher smoking rates (20%) than the overall population (15%), and the authors find that black women are more likely to smoke during pregnancy than white women.
New Jersey’s industrial history means many black residents live near pollution sources or close to highways that produce harmful soot. Housing in these areas is, on average, 7 years older than housing elsewhere. Currie said these conditions can cause women to have low birth weight babies in the first place.
“The United States continues to be highly racially segregated,” Currie said in a statement, “with African-American neighborhoods suffering higher poverty, lower average educational attainments, higher unemployment, higher exposure to pollution, and other ills.”
The authors state, “Our results suggest that the racial gap in asthma rates arises for three reasons: because African-American children are more likely to be low birth weight, because they are more likely to come from families with other characteristics that are associated with poorer health (such as maternal smoking and poverty), and because of where they live.”
African Americans of all ages tend to have poorer health than whites, and neighborhood divides may play a part. New Jersey, in fact, has spent decades trying to comply with a series of 1980s court rulings that called for creating more affordable housing in the suburbs, but those battles are still being fought.
The findings have widespread policy implications, if it means that investments in better housing could cut Medicaid costs over a child’s lifetime. A 2016 report from Express Scripts finds that Medicaid is the largest payer for asthma-related hospitalizations among children and adults, and asthma medications are in the top 3 spending classes, per member per month, at $62.73.
There has been some progress to improve the health of poor children in urban housing. In 2014, a study by CDC found that ending smoking in public housing would save $497 million a year, including $310 million in medical costs. In response, in November 2016, the Obama administration imposed a rule to ban smoking in all public housing.
The study covered New Jersey health data for children born from 2006 to 2010 and records from emergency department visits from 2006 to 2012, which let the researchers see which children were treated for asthma. The zip codes that included areas that were more than 50% African American covered 63% of all African American children born in New Jersey, as well as 16% children of other races.
Currie’s and Alexander’s article appears as a working paper in the National Bureau of Economic Research and will be published in the Journal of Health Economics.
By Kristian Foden-Vencil
When a receptionist hands out a form to fill out at a doctor’s office, the questions are usually about medical issues: What’s the visit for? Are you allergic to anything? Up to date on vaccines?
But some health organizations are now asking much more general questions: Do you have trouble paying your bills? Do you feel safe at home? Do you have enough to eat? Research shows these factors can be as important to health as exercise habits or whether you get enough sleep.
Some doctors even think someone’s ZIP code is as important to their health as their genetic code.
That’s why Shannon McGrath was asked to fill in a “life situation form” this spring when she turned up for her first obstetrics appointment at Kaiser Permanente in Portland, Ore. She was 36 weeks pregnant.
“When I got pregnant, I was homeless,” she says. “I didn’t have a lot of structure. And so it was hard to make an appointment. I had struggles with child care for my other kids, transportation, financial struggles.”
The form asked about her rent, her debts, her child care situation and other social factors. On the strength of her answers, Kaiser Permanente assigned her what is called a “patient navigator.”
“She automatically set up my next few appointments and then set up the rides for them, because that was my No. 1 struggle,” McGrath says. “She assured me that child care wouldn’t be an issue and that it would be OK if they came. So I brought the kids and everything was easy, just like she said it would be.”
McGrath’s navigator helped her get in touch with local nonprofits that helped her with rent, a phone and essentials for the baby — such as diapers and bottles — all in the hope that making her life easier might keep her healthier and, in turn, keep Kaiser’s medical costs lower.
McGrath says her patient navigator, Angelette Hamilton, was a bureaucratic ninja, removing paperwork obstacles that kept her from taking care of herself and her family.
Patient navigators have been around for a while. What is new is the form that McGrath filled out and how hospitals are using the socioeconomic and other data the forms glean to serve patients. The details now go into a patient’s file, which means providers such as Dr. Sarah Lamberthave more information at a glance.
“I find it incredibly helpful because it can be very hard to find out,” says Lambert, who is McGrath’s OB-GYN and works at Kaiser Permanente Northwest. “Having it coded right there — we have this problem list that jumps up — really can give you a much better understanding as to what the patient’s going through.”
Federal officials introduced new medical codes for the social determinants of health a few years ago, says Cara James, director of the Office of Minority Health at the Centers for Medicare and Medicaid Services.
“More providers are beginning to recognize the impact that the social determinants have on their patients,” she says.
Nicole Friedman, a regional manager at Kaiser Permanente Northwest, agrees. But she goes one step further.
She hopes giving doctors more information about the home life of each patient will push health care in a new direction — away from more high-priced treatments and toward providing the basics.
“My personal belief is that putting more money into health care is a moral sin,” she says. “We need to take money out of health care and put it into other social inputs like housing and food and transportation.”
Linking health organizations like Kaiser with nonprofit social services such as the Oregon Food Bank will help governments and medical providers see where their money can make the biggest difference, Friedman says.
For example, spending more on affordable housing for homeless people can also have health benefits, in turn saving the government money down the line.
Friedman says that when Kaiser started addressing people’s social needs, one study found a 40 percent reduction in emergency room use.
McGrath was initially skeptical when doctors offered to help her with things like rent and transportation.
“I didn’t want someone to see my situation and have it raise alarms,” she says.
But ultimately she was glad to have shared that information.
“I’m able to look at life and not feel overwhelmed or burdened,” she says, “or like I’ve got the whole world on my shoulders.
This story is part of NPR’s reporting partnership with Oregon Public Broadcasting and Kaiser Health News, which is an independent journalism organization and not affiliated with Kaiser Permanente.
Data reveals that homeownership does not protect low-income homeowners from experiencing severe housing cost burdens. Homeowners are less likely to be low-income than renters. But with equally low incomes, renters and homeowners suffer from similar severe housing cost burdens. Extremely low-income and very-low income homeowners are just as vulnerable to severe cost burdens as renters at the same income level. And while the cost burden looks similar for renters and homeowners at these income levels, the household composition does not. Severely burdened homeowners tend to be elderly, while severely burdened renters tend to have young families.
While renters experience the bulk of severe housing cost burdens, the data from How Housing Matters shows us that low-income homeowners, a predominantly elderly group, share some of these struggles. Since the households of very low-income renters and homeowners differ, policy solutions to address their challenges must as well.