The Influence of Early-Life Health Conditions on Life Course Health.

We expand on previous studies investigating the links between early health and later health by examining four distinct dimensions of early-life health and multiple life course outcomes, including the age of onset of serious cardiovascular diseases (CVDs) and several job-related health outcomes. The four dimensions of childhood health are mental, physical, self-reported general health, and severe headaches or migraines. The data set we use includes men and women in 21 countries from the Survey of Health, Ageing and Retirement in Europe. We find that the different dimensions of childhood health have unique ties to later outcomes. For men, early mental health problems play a stronger role for life course job-related health outcomes, but early poor/fair general health is more strongly linked to the spike in onset of CVDs in their late 40s. For women, these links between childhood health dimensions and life course outcomes are similar but are less clear-cut than for men. The spike in onset of CVDs in women's late 40s is driven by those with severe headaches or migraines, while those with early poor/fair general health or mental health problems do worse as captured by job-related outcomes. We also delve into and control for possible mediating factors. Exploring the links between several dimensions of childhood health and multiple health-related life course outcomes will enable a better understanding of how health inequalities originate and are shaped over the course of people's lives.

Low household income and neurodevelopment from infancy through adolescence.

Despite advancements in the study of brain maturation at different developmental epochs, no work has linked the significant neural changes occurring just after birth to the subtler refinements in the brain occurring in childhood and adolescence. We aimed to provide a comprehensive picture regarding foundational neurodevelopment and examine systematic differences by family income. Using a nationally representative longitudinal sample of 486 infants, children, and adolescents (age 5 months to 20 years) from the NIH MRI Study of Normal Brain Development and leveraging advances in statistical modeling, we mapped developmental trajectories for the four major cortical lobes and constructed charts that show the statistical distribution of gray matter and reveal the considerable variability in regional volumes and structural change, even among healthy, typically developing children. Further, the data reveal that significant structural differences in gray matter development for children living in or near poverty, first detected during childhood (age 2.5-6.5 years), evolve throughout adolescence.

Maximizing research on the adverse effects of child poverty through consensus measures.

A variety of new research approaches are providing new ways to better understand the developmental mechanisms through which poverty affects children's development. However, studies of child poverty often characterize samples using different markers of poverty, making it difficult to contrast and reconcile findings across studies. Ideally, scientists can maximize the benefits of multiple disciplinary approaches if data from different kinds of studies can be directly compared and linked. Here, we suggest that individual studies can increase their potential usefulness by including a small set of common key variables to assess socioeconomic status and family income. These common variables can be used to (a) make direct comparisons between studies and (b) better enable diversity of subjects and aggregation of data regarding many facets of poverty that would be difficult within any single study. If kept brief, these items can be easily balanced with the need for investigators to creatively address the research questions in their specific study designs. To advance this goal, we identify a small set of brief, low-burden consensus measures that researchers could include in their studies to increase cross-study data compatibility. These US based measures can be adopted for global contexts.

How developmental neuroscience can help address the problem of child poverty.

Nearly 1 in 5 children in the United States lives in a household whose income is below the official federal poverty line, and more than 40% of children live in poor or near-poor households. Research on the effects of poverty on children's development has been a focus of study for many decades and is now increasing as we accumulate more evidence about the implications of poverty. The American Academy of Pediatrics recently added "Poverty and Child Health" to its Agenda for Children to recognize what has now been established as broad and enduring effects of poverty on child development. A recent addition to the field has been the application of neuroscience-based methods. Various techniques including neuroimaging, neuroendocrinology, cognitive psychophysiology, and epigenetics are beginning to document ways in which early experiences of living in poverty affect infant brain development. We discuss whether there are truly worthwhile reasons for adding neuroscience and related biological methods to study child poverty, and how might these perspectives help guide developmentally based and targeted interventions and policies for these children and their families.

Effect of the Affordable Care Act on Racial and Ethnic Disparities in Health Insurance Coverage.

OBJECTIVES: To document how health insurance coverage changed for White, Black, and Hispanic adults after the Affordable Care Act (ACA) went into effect. METHODS: We used data from the American Community Survey from 2008 to 2014 to examine changes in the percentage of nonelderly adults who were uninsured, covered by Medicaid, or covered by private health insurance. In addition to presenting overall trends by race/ethnicity, we stratified the analysis by income group and state Medicaid expansion status. RESULTS: In 2013, 40.5% of Hispanics and 25.8% of Blacks were uninsured, compared with 14.8% of Whites. We found a larger gap in private insurance, which was partially offset by higher rates of public coverage among Blacks and Hispanics. After the main ACA provisions went into effect in 2014, coverage disparities declined slightly as the percentage of adults who were uninsured decreased by 7.1 percentage points for Hispanics, 5.1 percentage points for Blacks, and 3 percentage points for Whites. Coverage gains were greater in states that expanded Medicaid programs. CONCLUSIONS: The ACA has reduced racial/ethnic disparities in coverage, although substantial disparities remain. Further increases in coverage will require Medicaid expansion by more states and improved program take-up in states that have already done so.

The Effects of the Affordable Care Act Adult Dependent Coverage Expansion on Mental Health.

BACKGROUND: In September 2010, the Affordable Care Act increased the availability of private health insurance for young adult dependents in the United States and prohibited coverage exclusions for their pre-existing conditions. The coverage expansion improved young adults' financial protection from medical expenses and increased their mental health care use. These short-term effects signal the possibility of accompanying changes in mental health through one or more mechanisms: treatment-induced symptom relief or improved function; improved well-being and/or reduced anxiety as financial security increases; or declines in self-reported mental health if treatment results in the discovery of illnesses. AIMS: In this study, we estimate the effects of this insurance coverage expansion on young adults' mental health outcomes one year after its implementation. METHODS: We use a difference-in-differences (DD) framework to estimate the effects of the ACA young adult dependent coverage on mental health outcomes for adults ages 23-25 relative to adults ages 27-29 from 2007-2011. Outcome measures include a global measure of self-rated mental health, the SF-12 mental component summary (MCS), the PHQ-2 screen for depression, and the Kessler index for non-specific psychological distress. RESULTS: The overall pattern of findings suggests that both age groups experienced modest improvements in a range of outcomes that captured both positive and negative mental health following the 2010 implementation of the coverage expansion. The notable exception to this pattern is a 1.4 point relative increase in the SF-12 MCS score among young adults alone, a measure that captures emotional well-being, mental health symptoms (positive and negative), and social role functioning. DISCUSSION: This study provides the first estimates of a broad range of mental health outcomes that may be responsive to changes in mental health care use and/or the increased financial security that insurance confers. For the population as a whole, there were few short-term changes in young adults' mental health outcome relative to older adults. However, the relative increase in the SF-12 score among young adults, while small, is likely meaningful at a population level given the observed effect sizes for this measure obtained in clinical trials. IMPLICATIONS: The vast majority of mental illnesses emerge before individuals reach age 24. Public policy designed to expand health insurance coverage to this population has the potential to influence mental health in a relatively short time frame.

Association of Child Poverty, Brain Development, and Academic Achievement.

IMPORTANCE: Children living in poverty generally perform poorly in school, with markedly lower standardized test scores and lower educational attainment. The longer children live in poverty, the greater their academic deficits. These patterns persist to adulthood, contributing to lifetime-reduced occupational attainment. OBJECTIVE: To determine whether atypical patterns of structural brain development mediate the relationship between household poverty and impaired academic performance. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal cohort study analyzing 823 magnetic resonance imaging scans of 389 typically developing children and adolescents aged 4 to 22 years from the National Institutes of Health Magnetic Resonance Imaging Study of Normal Brain Development with complete sociodemographic and neuroimaging data. Data collection began in November 2001 and ended in August 2007. Participants were screened for a variety of factors suspected to adversely affect brain development, recruited at 6 data collection sites across the United States, assessed at baseline, and followed up at 24-month intervals for a total of 3 periods. Each study center used community-based sampling to reflect regional and overall US demographics of income, race, and ethnicity based on the US Department of Housing and Urban Development definitions of area income. One-quarter of sample households reported the total family income below 200% of the federal poverty level. Repeated observations were available for 301 participants. EXPOSURE: Household poverty measured by family income and adjusted for family size as a percentage of the federal poverty level. MAIN OUTCOMES AND MEASURES: Children's scores on cognitive and academic achievement assessments and brain tissue, including gray matter of the total brain, frontal lobe, temporal lobe, and hippocampus. RESULTS: Poverty is tied to structural differences in several areas of the brain associated with school readiness skills, with the largest influence observed among children from the poorest households. Regional gray matter volumes of children below 1.5 times the federal poverty level were 3 to 4 percentage points below the developmental norm (P < .05). A larger gap of 8 to 10 percentage points was observed for children below the federal poverty level (P < .05). These developmental differences had consequences for children's academic achievement. On average, children from low-income households scored 4 to 7 points lower on standardized tests (P < .05). As much as 20% of the gap in test scores could be explained by maturational lags in the frontal and temporal lobes. CONCLUSIONS AND RELEVANCE: The influence of poverty on children's learning and achievement is mediated by structural brain development. To avoid long-term costs of impaired academic functioning, households below 150% of the federal poverty level should be targeted for additional resources aimed at remediating early childhood environments.

Family poverty affects the rate of human infant brain growth.

Living in poverty places children at very high risk for problems across a variety of domains, including schooling, behavioral regulation, and health. Aspects of cognitive functioning, such as information processing, may underlie these kinds of problems. How might poverty affect the brain functions underlying these cognitive processes? Here, we address this question by observing and analyzing repeated measures of brain development of young children between five months and four years of age from economically diverse backgrounds (n = 77). In doing so, we have the opportunity to observe changes in brain growth as children begin to experience the effects of poverty. These children underwent MRI scanning, with subjects completing between 1 and 7 scans longitudinally. Two hundred and three MRI scans were divided into different tissue types using a novel image processing algorithm specifically designed to analyze brain data from young infants. Total gray, white, and cerebral (summation of total gray and white matter) volumes were examined along with volumes of the frontal, parietal, temporal, and occipital lobes. Infants from low-income families had lower volumes of gray matter, tissue critical for processing of information and execution of actions. These differences were found for both the frontal and parietal lobes. No differences were detected in white matter, temporal lobe volumes, or occipital lobe volumes. In addition, differences in brain growth were found to vary with socioeconomic status (SES), with children from lower-income households having slower trajectories of growth during infancy and early childhood. Volumetric differences were associated with the emergence of disruptive behavioral problems.

The effects of teenage fatherhood on young adult outcomes.

This paper uses national longitudinal data and several new empirical strategies to examine the consequences of teenage fatherhood. The key contribution is to compare economic outcomes of young fathers to young men whose partners experienced a miscarriage rather than a live birth. The results suggest that teenage fatherhood decreases years of schooling and the likelihood of receiving a high school diploma and increases general educational development receipt. Teenage fatherhood also appears to increase early marriage and cohabitation, and has mixed short-term effects on several labor market outcomes.

The effect of patient reminders and gas station gift cards on patient adherence to testing guidelines for diabetes.

OBJECTIVE: Analysis of the effectiveness of a small financial incentive and a written reminder to encourage test taking among persons with diabetes who have missed glycosylated hemoglobin (HbAlc) and low-density lipoprotein cholesterol (LDL-C) screenings. RESEARCH DESIGN AND METHODS: The analysis uses data from the University of Wisconsin Medical Foundation medical records of persons diagnosed with diabetes who had not received an HbA1c screening or had not received an LDL-C screening over the previous year (prior to October 2005). This study uses a quasi-experimental design comparing 464 diabetic patients (cases) who received a letter reminder of screening and financial incentive for undergoing screening, and 693 controls who did not receive a letter or financial incentive. The treated patients (464) all were seen in 1 of 4 clinics while those not treated used different clinics within the same system of care. Propensity scores served as the matching procedure using the following covariates: age, gender, ethnicity, marital status, number of HbA1c tests and number of LDL-C tests in the year prior to pilot program, mean HbA1c levels in the year prior to the pilot program (when available), census income data, and a comorbidity measure. RESULTS: During the 2 years following the pilot program, on average the target or "treated" population received significantly more screenings--3.34-compared to 2.69 screenings for the matched comparison group, and a far smaller proportion of the target population had no screening at all. CONCLUSIONS: The results provide evidence that a small financial incentive coupled with a written reminder work to increase test taking (especially the HbA1c screening) and suggest greater control of HbA1c levels among persons who had previously missed screenings.

Association between income and the hippocampus.

Facets of the post-natal environment including the type and complexity of environmental stimuli, the quality of parenting behaviors, and the amount and type of stress experienced by a child affects brain and behavioral functioning. Poverty is a type of pervasive experience that is likely to influence biobehavioral processes because children developing in such environments often encounter high levels of stress and reduced environmental stimulation. This study explores the association between socioeconomic status and the hippocampus, a brain region involved in learning and memory that is known to be affected by stress. We employ a voxel-based morphometry analytic framework with region of interest drawing for structural brain images acquired from participants across the socioeconomic spectrum (n = 317). Children from lower income backgrounds had lower hippocampal gray matter density, a measure of volume. This finding is discussed in terms of disparities in education and health that are observed across the socioeconomic spectrum.

Government mandates and employer-sponsored health insurance: who is still not covered?

We characterize employer-sponsored health insurance offering strategies in light of benefit non-discrimination and minimum wage regulation when workers have heterogeneous earnings and partially unobservable demand for (and cost of) insurance. We then empirically examine how earnings and expected medical expenses are associated with low wage workers' ability to obtain insurance before and after enactment of federal benefit non-discrimination rules. We find no evidence that the non-discrimination rules helped low wage workers (especially those with high own or children's expected medical expenses) to obtain insurance.