Officer-Involved Killings of Unarmed Black People and Racial Disparities in Sleep Health.

Importance: Racial disparities in sleep health may mediate the broader health outcomes of structural racism. Objective: To assess changes in sleep duration in the Black population after officer-involved killings of unarmed Black people, a cardinal manifestation of structural racism. Design, Setting, and Participants: Two distinct difference-in-differences analyses examined the changes in sleep duration for the US non-Hispanic Black (hereafter, Black) population before vs after exposure to officer-involved killings of unarmed Black people, using data from adult respondents in the US Behavioral Risk Factor Surveillance Survey (BRFSS; 2013, 2014, 2016, and 2018) and the American Time Use Survey (ATUS; 2013-2019) with data on officer-involved killings from the Mapping Police Violence database. Data analyses were conducted between September 24, 2021, and September 12, 2023. Exposures: Occurrence of any police killing of an unarmed Black person in the state, county, or commuting zone of the survey respondent's residence in each of the four 90-day periods prior to interview, or occurence of a highly public, nationally prominent police killing of an unarmed Black person anywhere in the US during the 90 days prior to interview. Main Outcomes and Measures: Self-reported total sleep duration (hours), short sleep (<7 hours), and very short sleep (<6 hours). Results: Data from 181 865 Black and 1 799 757 White respondents in the BRFSS and 9858 Black and 46 532 White respondents in the ATUS were analyzed. In the larger BRFSS, the majority of Black respondents were between the ages of 35 and 64 (99 014 [weighted 51.4%]), women (115 731 [weighted 54.1%]), and college educated (100 434 [weighted 52.3%]). Black respondents in the BRFSS reported short sleep duration at a rate of 45.9%, while White respondents reported it at a rate of 32.6%; for very short sleep, the corresponding values were 18.4% vs 10.4%, respectively. Statistically significant increases in the probability of short sleep and very short sleep were found among Black respondents when officers killed an unarmed Black person in their state of residence during the first two 90-day periods prior to interview. Magnitudes were larger in models using exposure to a nationally prominent police killing occurring anywhere in the US. Estimates were equivalent to 7% to 16% of the sample disparity between Black and White individuals in short sleep and 13% to 30% of the disparity in very short sleep. Conclusions and Relevance: Sleep health among Black adults worsened after exposure to officer-involved killings of unarmed Black individuals. These empirical findings underscore the role of structural racism in shaping racial disparities in sleep health outcomes.

Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion.

Importance: The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known. Objective: To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations. Design, Setting, and Participants: Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys. Exposure: Time-varying state-level adoption of Medicaid expansion. Main Outcomes and Measures: Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits. Results: The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (ß coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion. Conclusion and Relevance: Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.

Wealth Redistribution to Extend Longevity in the US.

Importance: The US is unique among wealthy countries in its degree of wealth inequality and its poor health outcomes. Wealth is known to be positively associated with longevity, but little is known about whether wealth redistribution might extend longevity. Objective: To examine the association between wealth and longevity and estimate the changes in longevity that could occur with simulated wealth distributions that were perfectly equal, similar to that observed in Japan (among the most equitable of Organisation for Economic Co-operation and Development [OECD] countries), generated by minimum inheritance proposals, and produced by baby bonds proposals. Design, Setting, and Participants: This longitudinal cohort study analyzed the association between wealth and survival among participants in the Health and Retirement Study (1992-2018), a nationally representative panel study of middle-aged and older (≥50 years) community-dwelling, noninstitutionalized US adults. The data analysis was performed between November 15, 2022, and September 24, 2023. Exposure: Household wealth on study entry, calculated as the sum of all assets minus the value of debts and classified into deciles. Main Outcomes and Measures: Weibull survival models were used to estimate the association between per-person wealth decile and survival, adjusting for age, sex, marital status, household size, and race and ethnicity. Changes in longevity that might occur under alternative wealth distributions were then estimated. Results: The sample included 35 164 participants (mean [SE] age at study entry, 59.1 [0.1] years; 50.1% female and 49.9% male [weighted]). The hazard of death generally decreased with increasing wealth, wherein participants in the highest wealth decile had a hazard ratio of 0.59 for death (95% CI, 0.53-0.66) compared with those in the lowest decile, corresponding to a 13.5-year difference in survival. A simulated wealth distribution of perfect equality would increase populationwide median longevity by 2.2 years (95% CI, 2.2-2.3 years), fully closing the mortality gap between the US and the OECD average. A simulated minimum inheritance proposal would increase populationwide median longevity by 1.7 years; a simulated wealth distribution similar to Japan's would increase populationwide median longevity by 1.2 years; and a simulated baby bonds proposal would increase populationwide median longevity by 1.0 year. Conclusions and Relevance: These findings suggest that wealth inequality in the US is associated with significant inequities in survival. Wealth redistribution policies may substantially reduce those inequities and increase population longevity.

Earnings of US Physicians With and Without Disabilities.

This cross-sectional study uses American Community Survey data to assess disability earnings gaps for physicians between 2005 and 2019.

Public Views on Medicaid Work Requirements and Mandatory Premiums in Kentucky.

Importance: Federal and state policymakers continue to pursue work requirements and premiums as conditions of Medicaid participation. Opinion polling should distinguish between general policy preferences and specific views on quotas, penalties, and other elements. Objective: To identify views of adults in Kentucky regarding the design of Medicaid work requirements and premiums. Design, Setting, and Participant: A cross-sectional survey was conducted via telephone and the internet from June 27 through July 11, 2019, of 1203 Kentucky residents 9 months before the state intended to implement Medicaid work requirements and mandatory premiums. Statistical analysis was performed from October 2019 to August 2023. Main Outcomes and Measures: Agreement, disagreement, or neutral views on policy components were the main outcomes. Recruitment for the survey used statewide random-digit dialing and an internet panel to recruit residents aged 18 years or older. Findings were weighted to reflect state demographics. Of 39 110 landlines called, 209 reached an eligible person (of whom 150 participated), 8654 were of unknown eligibility, and 30 247 were ineligible. Of 55 305 cell phone lines called, 617 reached an eligible person (of whom 451 participated), 29 951 were of unknown eligibility, and 24 737 were ineligible. Internet recruitment (602 participants) used a panel of adult Kentucky residents maintained by an external data collector. Results: Percentages were weighted to resemble the adult population of Kentucky residents. Of the participants in the study, 52% (95% CI, 48%-55%) were women, 80% (95% CI, 77%-82%) were younger than 65 years, 41% (95% CI, 38%-45%) were enrolled in Medicaid, 36% (95% CI, 32%-39%) were Republican voters, 32% (95% CI, 29%-36%) were Democratic voters, 14% (95% CI, 11%-16%) were members of racial and ethnic minority groups (including but not limited to American Indian or Alaska Native, Asian, Black, Hispanic or Latinx, and Native Hawaiian or Pacific Islander), and 48% (95% CI, 44%-52%) were employed. Most participants supported work requirements generally (69% [95% CI, 66%-72%]) but did not support terminating benefits due to noncompliance (43% [95% CI, 39%-46%]) or requiring quotas of 20 or more hours per week (34% [95% CI, 31%-38%]). Support for monthly premiums (34% [95% CI, 31%-38%]) and exclusion penalties for premium nonpayment (22% [95% CI, 19%-25%]) was limited. Medicaid enrollees were significantly less supportive of these policies than nonenrollees. For instance, regarding work requirements, agreement was lower (64% [95% CI, 59%-69%] vs 72% [95% CI, 68%-77%]) and disagreement higher (26% [95% CI, 21%-31%] vs 20% [95% CI, 16%-24%]) among current Medicaid enrollees compared with nonenrollees (P = .04). Among Medicaid enrollees, some beliefs about work requirements varied significantly by employment status but not by political affiliation. Among nonenrollees, beliefs about work requirements, premiums, and Medicaid varied significantly by political affiliation but not by employment. Conclusions and Relevance: This study suggests that even when public constituencies express general support for Medicaid work requirements or premiums, they may oppose central design features, such as quotas and termination of benefits. Program participants may also hold significantly different beliefs than nonparticipants, which should be understood before policies are changed.

The Effect Of Labor Unions On Nursing Home Compliance With OSHA's Workplace Injury And Illness Reporting Requirement.

All US nursing homes are required to report workplace injury and illness data to the Occupational Safety And Health Administration (OSHA). Nevertheless, the compliance rate for US nursing homes during the period 2016-21 was only 40 percent. We examined whether unionization increases the probability that nursing homes will comply with that requirement. Using a difference-in-differences design and proprietary data on union status from the Service Employees International Union for all forty-eight continental US states from the period 2016-21, we found that two years after unionization, nursing homes were 31.1 percentage points more likely than nonunion nursing homes to report workplace injury and illness data to OSHA. Data on injuries occurring in specific workplaces play a central role in injury prevention. Further unionization could help improve workplace safety in nursing homes, a sector with one of the highest occupational injury and illness rates in the US.

Using measures of race to make clinical predictions: Decision making, patient health, and fairness.

The use of race measures in clinical prediction models is contentious. We seek to inform the discourse by evaluating the inclusion of race in probabilistic predictions of illness that support clinical decision making. Adopting a static utilitarian framework to formalize social welfare, we show that patients of all races benefit when clinical decisions are jointly guided by patient race and other observable covariates. Similar conclusions emerge when the model is extended to a two-period setting where prevention activities target systemic drivers of disease. We also discuss non-utilitarian concepts that have been proposed to guide allocation of health care resources.

Continuous Eligibility And Coverage Policies Expanded Children's Medicaid Enrollment.

We examined children's Medicaid participation during 2019-21 and found that as of March 2021, states newly adopting continuous Medicaid coverage for children during the COVID-19 pandemic experienced a 4.62 percent relative increase in children's Medicaid participation compared to states with previous continuous eligibility policies.

Potential gaps in income support policies for those in poor health: The case of the earned income tax credit-A cross sectional analysis.

Background: The federal Earned Income Tax Credit (EITC) is the primary income support program for low-income workers in the U.S., but its design may hinder its effectiveness when poor health limits, but does not preclude, work. Methods: Cross-sectional analysis of nationally-representative U.S. Census Current Population Survey (CPS) data covering 2019. Working-age adults eligible to receive federal EITC were included in this study. Poor health, as indicated by self-report of at least one problem with hearing, vision, cognitive function, mobility, dressing and bathing, or independence, was the exposure. The main outcome was federal EITC benefit category, categorized as no benefit, phase-in (income too low for the maximum benefit), plateau (maximum benefit), phase-out (income above threshold for maximum benefit), or earnings too high to receive any benefit. We estimated EITC benefit category probabilities by health status using multinomial logistic regression. We further examined whether other government benefits provided additional income support to those in poor health. Results: 41,659 participants (representing 87.1 million individuals) were included. 2,724 participants (representing 5.6 million individuals) reported poor health. In analyses standardized over age, gender, race, and ethnicity, those in poor health, compared with those not in poor health, were more likely to be in the no benefit (2.40% vs. 0.30%, risk difference 2.10 percentage points [95%CI 1.75 to 2.46 percentage points]), and phase-in (9.28% vs. 2.74%, risk difference 6.54 percentage points [95%CI 5.82 to 7.26 percentage points]) categories. Differences in resources by health status persisted even after accounting for other government benefits. Conclusions: EITC program design creates an important gap in income support for those for whom poor health limits work, which is not closed by other programs. Filling this gap is an important public health goal.

Inequities in Time Spent Coordinating Care for Children and Youth With Special Health Care Needs.

OBJECTIVE: In the United States, caregivers of children and youth with special health care needs (CYSHCN) must navigate complex, inefficient health care and insurance systems to access medical care. We assessed for sociodemographic inequities in time spent coordinating care for CYSHCN and examined the association between time spent coordinating care and forgone medical care. METHODS: This cross-sectional study used data from the 2018-2020 National Survey of Children's Health, which included 102,740 children across all 50 states. We described the time spent coordinating care for children with less complex special health care needs (SHCN) (managed through medications) and more complex SHCN (resulting in functional limitations or requiring specialized therapies). We examined race-, ethnicity-, income-, and insurance-based differences in time spent coordinating care among CYSHCN and used multivariable logistic regression to examine the association between time spent coordinating care and forgone medical care. RESULTS: Over 40% of caregivers of children with more complex SHCN reported spending time coordinating their children's care each week. CYSHCN whose caregivers spent ≥ 5 h/wk on care coordination were disproportionately Hispanic, low-income, and publicly insured or uninsured. Increased time spent coordinating care was associated with an increasing probability of forgone medical care: 6.7% for children whose caregivers spent no weekly time coordinating care versus 9.4% for< 1 hour; 11.4% for 1 to 4 hours; and 15.8% for ≥ 5 hours. CONCLUSIONS: Reducing time spent coordinating care and providing additional support to low-income and minoritized caregivers may be beneficial for pediatric payers, policymakers, and health systems aiming to promote equitable access to health care for CYSHCN.

Association Between Racial Wealth Inequities and Racial Disparities in Longevity Among US Adults and Role of Reparations Payments, 1992 to 2018.

Importance: In the US, Black individuals die younger than White individuals and have less household wealth, a legacy of slavery, ongoing discrimination, and discriminatory public policies. The role of wealth inequality in mediating racial health inequities is unclear. Objective: To assess the contribution of wealth inequities to the longevity gap that exists between Black and White individuals in the US and to model the potential effects of reparations payments on this gap. Design, Setting, and Participants: This cohort study analyzed the association between wealth and survival among participants in the Health and Retirement Study, a nationally representative panel study of community-dwelling noninstitutionalized US adults 50 years or older that assessed data collected from April 1992 to July 2019. Participants included 7339 non-Hispanic Black (hereinafter Black) and 26 162 non-Hispanic White (hereinafter White) respondents. Data were analyzed from January 1 to September 17, 2022. Exposures: Household wealth, the sum of all assets (including real estate, vehicles, and investments), minus the value of debts. Main Outcomes and Measures: The primary outcome was all-cause mortality by the end of survey follow-up in 2018. Using parametric survival models, the associations among household wealth, race, and survival were evaluated, adjusting for age, sex, number of household members, and marital status. Additional models controlled for educational level and income. The survival effects of eliminating the current mean wealth gap with reparations payments ($828 055 per household) were simulated. Results: Of the 33 501 individuals in the sample, a weighted 50.1% were women, and weighted mean (SD) age at study entry was 59.3 (11.1) years. Black participants' median life expectancy was 77.5 (95% CI, 77.0-78.2) years, 4 years shorter than the median life expectancy for White participants (81.5 [95% CI, 81.2-81.8] years). Adjusting for demographic variables, Black participants had a hazard ratio for death of 1.26 (95% CI, 1.18-1.34) compared with White participants. After adjusting for differences in wealth, survival did not differ significantly by race (hazard ratio, 1.00 [95% CI, 0.92-1.08]). In simulations, reparations to close the mean racial wealth gap were associated with reductions in the longevity gap by 65.0% to 102.5%. Conclusions and Relevance: The findings of this cohort study suggest that differences in wealth are associated with the longevity gap that exists between Black and White individuals in the US. Reparations payments to eliminate the racial wealth gap might substantially narrow racial inequities in mortality.

Changes in economic outcomes before and after rural hospital closures in the United States: A difference-in-differences study.

OBJECTIVE: The objective of this study is to assess changes in local economic outcomes before and after rural hospital closures. DATA SOURCES: Rural hospital closures from January 1, 2005, to December 31, 2018, were obtained from the Sheps Center for Health Services Research. Economic outcomes from this same period were obtained from the Bureau of Labor Statistics, Bureau of Economic Analysis, Quarterly Workforce Indicators, U.S. Federal Reserve Economic Data, RAND Corporation state statistics database, U.S. Social Security Administration, and U.S. Census Bureau. DESIGN: Difference-in-differences study of 2094 rural counties. DATA COLLECTION/EXTRACTION: The primary exposure was county-level rural hospital closures. The primary outcomes were county-level unemployment rates; employment-population ratios; labor force participation-population ratios; per capita income; total jobs; health care sector jobs; disability program participation-population ratios; percent of the population with subprime credit scores; total filings for bankruptcies per 1000 population; and population size. PRINCIPAL FINDINGS: A total of 104 rural counties experienced a hospital closure, compared to 1990 rural counties that did not. Rural hospital closures were associated with significant reductions in health care sector employment (-13.8%; 95% CI: -22%, -5.6%; p < 0.001), but not with changes in any other economic measure. For unemployment rates, employment-population ratios, per capita income, disability program participation-population ratios, and total jobs, we found evidence of adverse trends preceding hospital closures. Findings were robust to adjusting for county-specific time trends, specifying exposure at the commuting zone-level, and using alternate definitions of rurality to define sample counties. CONCLUSION: With the exception of a decline in jobs within the health care sector, there was no association between rural hospital closures and county-level economic outcomes. Instead, economic conditions were already declining in counties experiencing closures compared to those that did not.

Resident Mortality And Worker Infection Rates From COVID-19 Lower In Union Than Nonunion US Nursing Homes, 2020-21.

Since the start of the COVID-19 pandemic, nursing home residents have accounted for roughly one of every six COVID-19 deaths in the United States. Nursing homes have also been very dangerous places for workers, with more than one million nursing home workers testing positive for COVID-19 as of April 2022. Labor unions may play an important role in improving workplace safety, with potential benefits for both nursing home workers and residents. We examined whether unions for nursing home staff were associated with lower resident COVID-19 mortality rates and worker COVID-19 infection rates compared with rates in nonunion nursing homes, using proprietary data on nursing home-level union status from the Service Employees International Union for all forty-eight continental US states from June 8, 2020, through March 21, 2021. Using negative binomial regression and adjusting for potential confounders, we found that unions were associated with 10.8 percent lower resident COVID-19 mortality rates, as well as 6.8 percent lower worker COVID-19 infection rates. Substantive results were similar, although sometimes smaller and less precisely estimated, in sensitivity analyses.

Death by Robots? Automation and Working-Age Mortality in the United States.

The decline of manufacturing employment is frequently invoked as a key cause of worsening U.S. population health trends, including rising mortality due to "deaths of despair." Increasing automation-the use of industrial robots to perform tasks previously done by human workers-is one structural force driving the decline of manufacturing jobs and wages. In this study, we examine the impact of automation on age- and sex-specific mortality. Using exogenous variation in automation to support causal inference, we find that increases in automation over the period 1993-2007 led to substantive increases in all-cause mortality for both men and women aged 45-54. Disaggregating by cause, we find evidence that automation is associated with increases in drug overdose deaths, suicide, homicide, and cardiovascular mortality, although patterns differ by age and sex. We further examine heterogeneity in effects by safety net program generosity, labor market policies, and the supply of prescription opioids.

Early life adversity, biological adaptation, and human capital: evidence from an interrupted malaria control program in Zambia.

Growing evidence from evolutionary biology demonstrates how early life shocks trigger physiological changes designed to be adaptive in challenging environments. We examine the implications of one type of physiological adaptation - immunity formation - for human capital accumulation. Using variation in early life malaria risk generated by an interrupted disease control program in Zambia, we show that exposure to infectious diseases during the first two years of life can reduce the harmful effects of malaria exposure on cognitive development during the preschool years. These findings suggest a non-linear and trajectory-dependent relationship between early life adversity and human capital formation.

Poverty-related bandwidth constraints reduce the value of consumption.

Poverty confers many costs on individuals, primarily through direct material deprivation. We hypothesize that these costs may be understated: poverty may also reduce human welfare by decreasing the experiential value of what little the poor are able to consume via reduced bandwidth (cognitive resources)-exerting a de facto "tax" on the value of consumption. We test this hypothesis using a randomized controlled trial in which we experimentally simulate key aspects of poverty that impair bandwidth via methods commonly used in laboratory studies (e.g., memorizing sequences) and via introducing stressors commonly associated with life in poverty (e.g., thinking about financial security and experiencing thirst). Participants then engaged in consumption activities and were asked to rate their enjoyment of these activities. Consistent with our hypothesis, the randomly assigned treatments designed to reduce bandwidth significantly and meaningfully reduced ratings of the consumption activities, with the strongest effects on the consumption of food. Our results shed additional light on how the consequences of poverty on human welfare may compound and motivate future work on the full scope of returns to poverty alleviation efforts.