The Political Realignment of Health: How Partisan Power Shaped Infant Health in the United States, 1915-2017.

The US two-party system was transformed in the 1960s when the Democratic Party abandoned its Jim Crow protectionism to incorporate the policy agenda fostered by the civil rights movement, and the Republican Party redirected its platform toward socioeconomic and racial conservatism. The authors argue that the policy agendas promoted by the two parties through presidents and state legislatures codify a racially patterned access to resources and power detrimental to the health of all. To test the hypothesis that fluctuations in overall and race-specific infant mortality rates (IMRs) shift between the parties in power before and after the political realignment (PR), the authors apply panel data analysis methods to state-level data from the National Center for Health Statistics for the period 1915 through 2017. Net of trend, overall, and race-specific IMRs were not statistically different between presidential parties before the PR. This pattern, however, changed after the PR, with Republican administrations consistently underperforming Democratic ones. Net of trend, non-Southern state legislatures controlled by Republicans underperform Democratic ones in overall and racial IMRs in both periods.

Associations between breast cancer subtype and neighborhood socioeconomic and racial composition among Black and White women.

PURPOSE: Studies of Black-White differences in breast cancer subtype often emphasize potential ancestry-associated genetic or lifestyle risk factors without fully considering how the social or economic implications of race in the U.S. may influence risk. We assess whether neighborhood racial composition and/or socioeconomic status are associated with odds of triple-negative breast cancer (TNBC) diagnosis relative to the less-aggressive hormone receptor-positive/HER2-negative subtype (HR+ /HER-), and whether the observed relationships vary across women's race and age groups. METHODS: We use multilevel generalized estimating equation models to evaluate odds of TNBC vs. HR+ /HER2- subtypes in a population-based cohort of 7291 Black and 74,208 White women diagnosed with breast cancer from 2006 to 2014. Final models include both neighborhood-level variables, adjusting for individual demographics and tumor characteristics. RESULTS: Relative to the HR+ /HER- subtype, we found modestly lower odds of TNBC subtype among White women with higher neighborhood median household income (statistically significant within the 45-64 age group, OR = 0.981 per $10,000 increase). Among Black women, both higher neighborhood income and higher percentages of Black neighborhood residents were associated with lower odds of TNBC relative to HR+ /HER2-. The largest reduction was observed among Black women diagnosed at age ≥ 65 (OR = 0.938 per $10,000 increase; OR = 0.942 per 10% increase in Black residents). CONCLUSION: The relationships between neighborhood composition, neighborhood socioeconomic status, and odds of TNBC differ by race and age. Racially patterned social factors warrant further exploration in breast cancer subtype disparities research.

Trend Toward Older Maternal Age Contributed To Growing Racial Inequity In Very-Low-Birthweight Infants In The US.

In 2016 the Centers for Disease Control and Prevention reported that for the first time, US women in their thirties were bearing more children than those in their twenties. Analyzing US vital statistics data from the period 1989-2019, we simulated the effect that the distributional shift to older maternal ages at first birth had on health inequity between Black and White infants. Net of maternal socioeconomic indicators, this shift increased the relative odds that White women gave birth to very-low-birthweight (VLBW) infants by 10 percent, versus 19 percent for Black women, largely accounting for the rise in VLBW and the increase in racial inequity seen in the years analyzed. Reductions in infant mortality over the period were dampened by the maternal age shift, especially among Black babies, exacerbating Black-White inequity. Policy implications for promoting reproductive justice include universal tertiary care access, increasing the supply and distribution of maternity care providers, addressing the holistic needs of mothers throughout pregnancy and postpartum, and expanding family support policies. Conceptually, we recommend centering the realities of pregnancy and parenting from the perspective of the populations at highest risk-centering on the margins-and taking into account their implications for maternal weathering (accelerated deterioration due to disparate impacts of structural racism).

Partisan Control of U.S. State Governments: Politics as a Social Determinant of Infant Health.

INTRODUCTION: State policies and programs affect population health; yet, little is known about the connections between health and the political institutions and actors that prescribe and execute those policies and programs. METHODS: The 2-way fixed-effects regression models were fitted to data from the National Center for Health Statistics, 1969-2014, to estimate logged infant mortality rate differentials between Republican- and non-Republican‒controlled state legislatures. These data were used in 2020 to hypothesize that net of trend, fluctuations in infant mortality rates-overall and by race-correlate with the party that controls state legislatures (the Lower House, the Upper House, and Congress). RESULTS: Findings show that state infant and postneonatal mortality rates are substantively higher under Republican-controlled state legislatures than under non-Republican‒controlled ones. The effect size is larger for postneonatal than for neonatal mortality. Findings suggest that effects may be greater for Black than for White infants, although the race-specific results are estimated imprecisely. The governor's party shows no substantive impacts on infant mortality rates net of party control of the Lower House. CONCLUSIONS: Findings support the proposition that the social determinants of health are constructed, at least in part, by the power vested in governments.

Excess black mortality in the United States and in selected black and white high-poverty areas, 1980-2000.

OBJECTIVES: Black working-aged residents of urban high-poverty areas suffered severe excess mortality in 1980 and 1990. Our goal in this study was to determine whether this trend persisted in 2000. METHODS: We analyzed death certificate and census data to estimate age-standardized all-cause and cause-specific mortality among 16- to 64-year-old Blacks and Whites nationwide and in selected urban and rural high-poverty areas. RESULTS: Urban men's mortality rate estimates peaked in 1990 and declined between 1990 and 2000 back to or below 1980 levels. Evidence of excess mortality declines among urban or rural women and among rural men was modest, with some increases. Between 1980 and 2000, there was little decline in chronic disease mortality among men and women in most areas, and in some instances there were increases. CONCLUSIONS: In 2000, despite improved economic conditions, working-age residents of the study areas still died disproportionately of early onset of chronic disease, suggesting an entrenched burden of disease and unmet health care needs. The lack of consistent improvement in death rates among working-age residents of high-poverty areas since 1980 necessitates reflection and concerted action given that sustainable progress has been elusive for this age group.

The globalization of postsecondary education: The role of international students in the US higher education system.

In the four decades since 1980, U.S. colleges and universities have seen the number of students from abroad quadruple. This rise in enrollment and degree attainment affects the global supply of highly educated workers, the flow of talent to the U.S. labor market, and the financing of U.S. higher education. Yet, the impacts are far from uniform, with significant differences evident by level of study and type of institution. The determinants of foreign flows to U.S. colleges and universities reflect both changes in student demand from abroad and the variation in market circumstances of colleges and universities, with visa policies serving a mediating role. The consequences of these market mechanisms impact global talent development, the resources of colleges and universities, and labor markets in the U.S. and countries sending students.

Coming up short: Comparing venous blood, dried blood spots & saliva samples for measuring telomere length in health equity research.

BACKGROUND: Telomere length (TL) in peripheral blood mononuclear cells (PBMC) from fresh venous blood is increasingly used to estimate molecular impacts of accumulated social adversity on population health. Sometimes, TL extracted from saliva or dried blood spots (DBS) are substituted as less invasive and more scalable specimen collection methods; yet, are they interchangeable with fresh blood? Studies find TL is correlated across tissues, but have not addressed the critical question for social epidemiological applications: Do different specimen types show the same association between TL and social constructs? METHODS: We integrate expertise in social epidemiology, molecular biology, and the statistical impact of measurement error on parameter estimates. Recruiting a diverse sample of 132 Metro-Detroit women, we measure TL for each woman from fresh blood PBMC, DBS, and saliva. Using regression methods, we estimate associations between social characteristics and TL, comparing estimates across specimen types for each woman. RESULTS: Associations between TL and social characteristics vary by specimen type collected from the same woman, sometimes qualitatively altering estimates of the magnitude or direction of a theorized relationship. Being Black is associated with shorter TL in PBMC, but longer TL in saliva or DBS. Education is positively associated with TL in fresh blood, but negatively associated with TL using DBS. CONCLUSION: Findings raise concerns about the use of TL measures derived from different tissues in social epidemiological research. Investigators need to consider the possibility that associations between social variables and TL may be systematically related to specimen type, rather than be valid indicators of socially-patterned biopsychosocial processes.

Health, Economic Resources and the Work Decisions of Older Men.

We specify a dynamic programming model that addresses the interplay among health, financial resources, and the labor market behavior of men late in their working lives. We model health as a latent variable, for which self reported disability status is an indicator, and allow self-reported disability to be endogenous to labor market behavior. We use panel data from the Health and Retirement Study. While we find large impacts of health on behavior, they are substantially smaller than in models that treat self-reports as exogenous. We also simulate the impacts of several potential reforms to the Social Security program.

A PASSAGE TO AMERICA: UNIVERSITY FUNDING AND INTERNATIONAL STUDENTS.

The number of international undergraduate students at U.S. public research universities increased dramatically over the last two decades, alongside concurrent reductions in state support for universities. We show that these trends are closely connected as public research universities relied on foreign students to cushion the effects of falling appropriations. The growing capacity in emerging economies to pay for a U.S. education provided opportunities for universities to recover revenues from full-fare paying foreign students. Between 1996-2012, we estimate that a 10 percent reduction in state appropriations led to an increase in foreign enrollment of 16 percent at public research universities.

Weathering, Drugs, and Whack-a-Mole: Fundamental and Proximate Causes of Widening Educational Inequity in U.S. Life Expectancy by Sex and Race, 1990-2015.

Discussion of growing inequity in U.S. life expectancy increasingly focuses on the popularized narrative that it is driven by a surge of "deaths of despair." Does this narrative fit the empirical evidence? Using census and Vital Statistics data, we apply life-table methods to calculate cause-specific years of life lost between ages 25 and 84 by sex and educational rank for non-Hispanic blacks and whites in 1990 and 2015. Drug overdoses do contribute importantly to widening inequity for whites, especially men, but trivially for blacks. The contribution of suicide to growing inequity is unremarkable. Cardiovascular disease, non-lung cancers, and other internal causes are key to explaining growing life expectancy inequity. Results underline the speculative nature of attempts to attribute trends in life-expectancy inequity to an epidemic of despair. They call for continued investigation of the possible weathering effects of tenacious high-effort coping with chronic stressors on the health of marginalized populations.

Black-white differences in age trajectories of hypertension prevalence among adult women and men, 1999-2002.

OBJECTIVES: To describe age patterns of hypertension prevalence in young through middle-aged adults and to test the hypothesis that hypertension prevalence rises more rapidly with age among Blacks than Whites in the United States. DESIGN, SETTING, AND PARTICIPANTS: Using multiple logistics regression, we predicted probability of being hypertensive for participants ages 15-65 years in the National Health and Nutrition Examination Survey (NHANES) IV, 1999-2002. We estimated age-specific Black-to-White odds ratios of hypertension overall, by sex, and adjusted for body mass index (BMI) and poverty income ratio. We also followed NHANES cohorts to test whether differential age patterns of hypertension prevalence by race or gender represented cohort effects. MAIN OUTCOME MEASURE: Hypertension: systolic blood pressure > or = 140 mm Hg, diastolic blood pressure > or = 90 mm Hg, or current antihypertensive medication use. RESULTS: Black/White odds of hypertension increased from 1.71 to 3.12 between ages 15 and 65. Odds for women increased faster, from 2.11 to 4.04. By age 40, Black women had the highest hypertension rates and steepest age-gradient of race/sex groups. Adjustment for poverty income ratio did not affect results. Adjustment for BMI reduced Black women's hypertension risk somewhat but not men's. Cohort analysis confirmed a more rapid increase in hypertension prevalence among Blacks and women. CONCLUSIONS: Hypertension screening of Blacks should begin at young ages. Early diagnosis and vigilant management are critical to addressing racial and sex differences and their effect on cardiovascular disease, life expectancy, and maternal and infant health. Psychosocial stressors merit consideration as candidates for primary prevention. Addressing fundamental causes is needed. Understanding the growing age-gradient increase among US Black women is pressing.

Maternal upward socioeconomic mobility and black-white disparities in infant birthweight.

OBJECTIVES: We estimate the extent to which upward socioeconomic mobility limits the probability that Black and White women who spent their childhoods in or near poverty will give birth to a low-birthweight baby. METHODS: Data from the National Longitudinal Survey of Youth 1979 and the 1970 US Census were used to complete a series of logistic regression models. We restricted multivariate analyses to female survey respondents who, at 14 years of age, were living in households in which the income-to-needs ratio did not exceed 200% of poverty. RESULTS: For White women, the probability of giving birth to a low-birthweight baby decreases by 48% for every 1 unit increase in the natural logarithm of adult family income, once the effects of all other covariates are taken into account. For Black women, the relation between adult family income and the probability of low birthweight is also negative; however, this association fails to reach statistical significance. CONCLUSIONS: Upward socioeconomic mobility contributes to improved birth outcomes among infants born to White women who were poor as children, but the same does not hold true for their Black counterparts.

Educational gradients in five Asian immigrant populations: Do country of origin, duration and generational status moderate the education-health relationship?

Education usually shows a relationship with self-rated health such that those with highest education have the best health and those with lowest education have the worst health. We examine these educational gradients among Asian immigrants and whether they differ by country of origin, duration in the United States, and generational status. Migration theories suggest that recent immigrants from poorer countries should show a weaker relationship between education and health than US-born Whites. Acculturation theory further suggests that differences in gradients across country of origin should diminish for longer-term immigrants and the US-born and that these groups should display gradients similar to US-born Whites. We use the March Current Population Survey (2000 - 2010) to examine educational gradients in self-rated health among recent immigrants (≤ 15 years duration), longer-term immigrants (> 15 years duration), and second generation US-born Asians from China (n = 4473), India (n = 4,307), the Philippines (n = 5746), South Korea (n = 2760), and Japan (n = 1265). We find weak or non-significant educational gradients among recent Asian immigrants across the five countries of origin. There is no indication that longer-term immigrants display significant differences across educational status. Only second generation Chinese and Filipinos show significant differences by educational status. Overall, Asians show an attenuated relationship between education and self-rated health compared to US-Whites that persists over duration in the US and generational status. Our findings show shortcomings in migration and acculturation theories to explain these gradient patterns. Future research could use binational data or explore psychosocial factors to identify potential suppressors of educational gradients.

Recruitment of Foreigners in the Market for Computer Scientists in the United States.

We present and calibrate a dynamic model that characterizes the labor market for computer scientists. In our model, firms can recruit computer scientists from recently graduated college students, from STEM workers working in other occupations or from a pool of foreign talent. Counterfactual simulations suggest that wages for computer scientists would have been 2.8-3.8% higher, and the number of Americans employed as computers scientists would have been 7.0-13.6% higher in 2004 if firms could not hire more foreigners than they could in 1994. In contrast, total CS employment would have been 3.8-9.0% lower, and consequently output smaller.

Black lives matter: Differential mortality and the racial composition of the U.S. electorate, 1970-2004.

Excess mortality in marginalized populations could be both a cause and an effect of political processes. We estimate the impact of mortality differentials between blacks and whites from 1970 to 2004 on the racial composition of the electorate in the US general election of 2004 and in close statewide elections during the study period. We analyze 73 million US deaths from the Multiple Cause of Death files to calculate: (1) Total excess deaths among blacks between 1970 and 2004, (2) total hypothetical survivors to 2004, (3) the probability that survivors would have turned out to vote in 2004, (4) total black votes lost in 2004, and (5) total black votes lost by each presidential candidate. We estimate 2.7 million excess black deaths between 1970 and 2004. Of those, 1.9 million would have survived until 2004, of which over 1.7 million would have been of voting-age. We estimate that 1 million black votes were lost in 2004; of these, 900,000 votes were lost by the defeated Democratic presidential nominee. We find that many close state-level elections over the study period would likely have had different outcomes if voting age blacks had the mortality profiles of whites. US black voting rights are also eroded through felony disenfranchisement laws and other measures that dampen the voice of the US black electorate. Systematic disenfranchisement by population group yields an electorate that is unrepresentative of the full interests of the citizenry and affects the chance that elected officials have mandates to eliminate health inequality.

Measuring Recent Apparent Declines In Longevity: The Role Of Increasing Educational Attainment.

Independent researchers have reported an alarming decline in life expectancy after 1990 among US non-Hispanic whites with less than a high school education. However, US educational attainment rose dramatically during the twentieth century; thus, focusing on changes in mortality rates of those not completing high school means looking at a different, shrinking, and increasingly vulnerable segment of the population in each year. We analyzed US data to examine the robustness of earlier findings categorizing education in terms of relative rank in the overall distribution of each birth cohort, instead of by credentials such as high school graduation. Estimating trends in mortality for the bottom quartile, we found little evidence that survival probabilities declined dramatically. We conclude that widely publicized estimates of worsening mortality rates among non-Hispanic whites with low socioeconomic position are highly sensitive to how educational attainment is classified. However, non-Hispanic whites with low socioeconomic position, especially women, are not sharing in improving life expectancy, and disparities between US blacks and whites are entrenched. Findings underscore the urgency of an agenda to equitably disseminate new medical technologies and to deepen knowledge of social determinants of health and how that knowledge can be applied, to promote the objective of achieving population health equity.

Cohort and duration patterns among Asian immigrants: comparing trends in obesity and self-rated health.

Many studies, but not all, suggest that immigrant health worsens with duration of residence in the United States. Cohort effects may explain the inconsistent findings; not only are cohort effects confounded with duration, but the timing of entry into the United States may also create qualitatively different migration experiences. The present study tests for duration and cohort patterns among Asian immigrants to the United States across six year-of-entry cohorts (pre-1980, 1981-85, 1986-90, 1991-95, 1996-2000, 2001-05). Data come from the Asian American sample (n = 44,002) of the 1994-2009 waves of the National Health Interview Survey. The data show cohort differences for self-rated health, such that more recent cohorts showed improved baseline health compared to older cohorts. After accounting for cohorts, there was no significant change in self-rated health by duration of residence. Older cohorts actually showed improving self-rated health with longer duration. Obesity showed the opposite pattern; there were no differences across cohorts, but duration in the United States correlated with higher obesity. These results imply that immigrant health is not simply an issue of duration and adaptation; instead, they underscore the utility of considering cohorts as broader contexts of migration. Collectively, the results encourage future research that more carefully examines the etiological mechanisms that drive immigrant health.

Reconciling findings on the employment effect of disability insurance.

Over the last 25 years, the Social Security Disability Insurance Program (DI) has grown dramatically. During the same period, employment rates for men with work limitations showed substantial declines in both absolute and relative terms. While the timing of these trends suggests that the expansion of DI was a major contributor to employment decline among this group, raising questions about the targeting of disability benefits, studies using denied applicants suggest a more modest role of the DI expansion. To reconcile these findings, we decompose total employment changes into population and employment changes for three categories: DI beneficiaries, denied applicants, and non-applicants. Our results show that during the early 1990s, the growth in DI can fully explain the employment decline for men only under an extreme assumption about the employment potential of beneficiaries. For the period after the mid-1990s, we find little role for the DI program in explaining the continuing employment decline for men with work limitations.