The Robert Wood Johnson Foundation’s Commission to Build a Healthier America has just released a report that reveals the degree to which a child’s health is determined by the hand he draws when he is born.
The report, which is titled “America’s Health Starts With Healthy Children: How Do States Compare?” confirms what we have written in other Health Beat posts.
While having or not having health insurance is important, poverty will have an even greater influence on an individual’s health. As Commission Co-Chair and former Congressional Budget Office director Alice M. Rivlin puts it, “This report shows us just how much a child’s health is shaped by the environment in which he or she lives.”
Moreover, the report reveals that it is not only the poor who are molded by their environment. “In nearly every state, children in middle-income families also experience shortfalls in health when compared with those in higher income families. And these differences in children’s health by income can be seen across racial or ethnic groups” says the report, which is based on research done at the University of California at San Francisco’s Center on Social Disparities in Health. Ultimately, this study highlights “the unrealized health potential possible if all children had the same opportunities for health as those in the best-off families.”
“Most of our efforts to improve health have focused on improving quality, access to and affordability of care. While these are important, support for better health that is associated with resources and community matters as well,” says Commission Co-Chair Mark McClellan. “As a nation, we clearly need to do better…a large body of research shows that the causes [of poor health among children] are complex,” the report observes, “and that medical care interventions are important but not sufficient.”
To illustrate “the magnitude of the link between education and health” the Commission also is releasing a new online tool that lets viewers see the connection first hand, says Dr Steven Woolf, a professor of Family Medicine at Virginia Commonwealth who was involved in developing the tool. (Readers who want to check the relationship between education and premature deaths in their state or country will find the tool here).
How the Study Measures Income and Education
Taking family size into account, family income is categorized by
comparing it to Federal Poverty Level (FPL), which has been defined as
the amount of income that will provide a bare minimum of food,
clothing, transportation, shelter and other necessities. In 2006, the
U.S. FPL was $16,079 for a family of three and $20,614 for a family of
four. Children were considered to be poor if they lived in households
below the FPL, “near poor” if they lived in homes that fell somewhere
between the FPL and twice the FPL (for a family of three that would be
somewhere between $16,079 and roughly $32,000) “middle income” if they
lived in households with income somewhere between twice and three times
the FPL (or between $32,000 and $48,000), and “higher income” if they
lived households earning four times the FPL or more ( over roughly
$64,000 for a family of three, $80,000 for a family of four.)
To measure education while examining children’s general health, the
report looks at the highest level attained by any person in the
household using four categories (less than high-school graduate,
high-school graduate, some college, and college graduate).
As the chart below shows, in the U.S. 18 percent of children live in
households that are “poor’ and another 19 percent in households that
are “near poor.” Thirty-two percent are in middle-class homes, and just
28 percent live in “higher income” homes. Only 9 percent are growing
up in households where no adult has completed high school, 24 percent
live in families where at least one adult is a high school graduate, 32
percent in homes where one adult has some college, and 35 percent in
homes where at least one person is a college graduate.
Just How Much Difference Does Income and Education Make?
In the United States, 16 percent of children ages 17 and younger are in
less than optimal health—a rate that varies widely across states from a
high of 22.8 percent in Texas to a low of 6.9 percent in Vermont.
(Assessment of a child’s health is based on parents’ reports;
researchers ranked a child’s health as “less than optimal” when parents
described it as “poor,” “fair” or “good”—but not “very good” or
“excellent.” )
But within states, health varies dramatically by income. In Texas, for
example, “44 percent of children in poor families are in less than
optimal health compared with 6.7 percent of children in higher income
families. Texas has the largest income gap in children’s health status
among all states.”
The picture in New Hampshire is very different. There, “13 percent of
poor children are in less than optimal health compared with 6.4 percent
of children in higher-income families.” When compared to other states,
New Hampshire has the smallest income gap in children’s general health.
Nationwide, as the chart below shows, children in poor, near-poor or
middle-income families were 4.7, 2.8 and 1.5 times as likely as more
affluent children to be in “less than optimal health.”
Education also matters. Compared with children living with someone who
has completed some college, children in households without a
high-school graduate were more than four times as likely—and those in
households with a high-school graduate twice as likely—to be in
suboptimal health. Race also counts, with white children faring better
than Hispanic or African-American children.
Ultimately, “there are a variety of intermingled factors that explain
the better health status of advantaged people” Woolf explains. “A lot
of it has to do with neighborhood, environmental and social support
systems. It’s a complicated, inter-related mix. We view education and
income as proxies for that package.”
Within each racial or ethnic group, income makes all the difference.
Among non-Hispanic whites, for example, children in poor, near-poor or
middle-income households were 3.5 2.1 and 1.4 times as likely to be in
poor health than children in wealthier families.
Finally, as one would expect, adult “behaviors” influence childrens’
health. At every income level, children living in households where no
one exercise regularly or someone smokes are more likely to be in
poorer health than children in families with healthier behaviors.
Yet, as the chart below reveals income is far more important than the
example set by the parent. Even if adults exhibit healthy behaviors,
33 percent of children in poor husbands are in less than optimal
health. By contrast, in affluent households, only 10 percent of
children are in poor health if parents smoke and don’t
exercise—compared to 5.4 percent if adults adopt healthy lifestyles.
Why are Income and Education So Important?
“Educated parents may have a better understanding of health-related
behaviors,” the report explains, “along with resources to make
healthier choices.” Knowledge alone is not enough. Resources are
essential. While a parent my understand that it is important for her
child to exercise, if she lives in a tiny apartment in a neighborhood
where there are no safe playgrounds—and where the public school offers
phys ed only once a week, there is little that she can do. She cannot
afford to send her child to camp in the summer. She cannot afford to
join the YMCA.
Better-educated parents are “better able to obtain higher-paying jobs,
providing the income to afford better housing, better “neighborhoods
and a healthy diet,” the report points out. (See the chart in this HealthBeat post, showing that the most nutritious foods are, indeed, significantly more expensive than other foods).
In addition, the report observes, “community influences such as
safety, school quality, presence of favorable role models and
availability of healthful foods and recreational opportunities affect
children’s health. Racial or ethnic group matters in part because it
continues to influence educational and employment opportunities. In
addition, discrimination and its legacy in residential segregation mean
that black and Hispanic families more often live in substandard housing
and unsafe or deteriorating neighborhood conditions compared with
whites with similar incomes and education.”
At the same time, the report acknowledges that “medical care is
important for children’s health.” For example, “timely immunizations
and regular treatment for conditions like asthma can make a big
difference in overall well-being. Genetic predisposition to certain
diseases also influences children’s health. But many experts have
concluded that medical care and genes actually play a relatively minor
role compared with the influence of the physical and social conditions
in which children grow up.
Finally higher income also means less stress—not only for families but
for children. And we know that chronic stress leads to disease.
What Can We Do?
The commission plans to make recommendations in April. In the meantime, I have a few suggestions.
- We should explore ways to provide jobs that pay a living wage to
less-educated workers. For example, in these tough economic times, the
government might invest in rebuilding our infrastructure—an investment
that also would create jobs. - Investments in safe playgrounds and subsidies for green-markets
that locate in poor neighborhoods could help improve quality of
life—and the health of children - Low-income and middle-income children a;sp need also
scholarships to help them go to college. In recent years, federal
funding has favored financing loans that only more affluent families
can afford; at the same time scholarship programs for low-income and
median-income children have been cut. This trend should be reversed. - Finally, we should find new ways to lift the quality of public
education for low-income students. Richard Kahlenberg, a colleague at
The Century Foundation, has written extensively about innovative
programs doing just that.
As Kahlenberg points out in Part IV of a report titled
“Fixing No Child Left Behind”: “A wide body of research has found
that concentrations of poverty create enormous difficulties for
schools.” It is very hard to try to “fix” schools located in a
ghetto—just as it is difficult to improve the health of children living
there. There are too many factors working against the schools. This is
why, rather than pouring money into failing schools in poor
neighborhoods, some educators recommend taking the children out of the
ghetto and bussing them to suburban schools.
Kahlenberg reports impressive results: studies show that when
“low-income fourth-grade American students” are “given a chance to
attend more- affluent schools” they score almost two years ahead of
low-income students stuck in high-poverty schools on National
Assessment of Educational Progress math tests…Likewise, data from the
2006 Program for International Student Assessment (PISA) for
fifteen-year-olds in science showed a “clear advantage in attending a
school whose students are, on average from more advantaged
socio-economic backgrounds.”
The advantages are clear. Middle-class schools provide not only more
financial resources on average, but also a more positive peer
environment, better teachers, and more actively involved parents
A forthcoming Century Foundation study by Amy Stuart Wells of Teachers
College, Columbia University, and Jennifer Jellison Holme of the
University of Texas at Austin looks at eight highly successful
inter-district programs—in Boston, St. Louis, Hartford, Milwaukee,
Rochester, Indianapolis, Minneapolis, and East Palo Alto. Researchers
have found that “after an initial adjustment period, students generally
see large test score achievement gains in suburban schools. In St.
Louis, transfer students not only scored higher, they also were twice
as likely to go on to two-year or four-year colleges than graduates of
the schools they left behind.
These programs work in part because students tend to model themselves
on each other. When you put a small group of low-income students into a
middle-class classroom, the low-income students are less likely to talk
while the teacher is talking, and more likely to do their homework.
Children do not like to be “different.”
Kahlenberg explains that “one the key reasons for the political success
of these programs is the financial incentives provided to middle-class
receiving districts.” Granted, “there was strong political resistance
to many of these programs initially,” but “ over time suburban
legislators have often come to support continuation of the programs
…And new suburban districts have asked to be added to programs in
Boston, Minneapolis, and Rochester. The authors attribute the
political success of the programs not only to the financial incentives,
but also to salutary effects that the programs themselves have on the
racial attitudes of students and parents in the suburbs over time.”
These are just a few suggestions. I look forward to the Commission’s spring report.