State-Level Education Quality and Trajectories of Cognitive Function by Race and Educational Attainment.

Policy Points Education-cognition research overlooks the role of education quality in shaping cognitive function at midlife and older ages, even though quality may be more responsive to federal and state investment in public schooling than attainment. For older US adults who attended school during the early to mid-20th century, the quality of US education improved considerably as federal and state investment increased. Ensuring access to high-quality primary and secondary education may protect against poor cognitive function at midlife and older ages, particularly among Black Americans and persons who complete less education. It may also play an important role in reducing health inequities. CONTEXT: Although educational attainment is consistently associated with better cognitive function among older adults, we know little about how education quality is related to cognitive function. This is a key gap in the literature given that the quality of US education improved considerably during the early to mid-20th century as state and federal investment increased. We posit that growing up in states with higher-quality education systems may protect against poor cognitive function, particularly among Black adults and adults who completed fewer years of school. METHODS: We used prospective data on cognitive function from the Health and Retirement Study linked to historical data on state investment in public schools, restricting our sample to non-Hispanic White and Black adults born between 1914 and 1959 (19,096 White adults and 4,625 Black adults). Using race-stratified linear mixed models, we considered if state-level education quality was associated with level and decline in cognitive function and if these patterns differed by years of schooling and race. FINDINGS: Residing in states with higher-resourced education systems during childhood was associated with better cognitive function, particularly among those who completed less than 12 years of schooling, regardless of race. For White adults, higher-resourced state education systems were associated with higher scores of total cognitive function and episodic memory, but there were diminishing returns as resources increased to very high levels. For Black adults, the relationship between state education resources and cognitive function varied by age with positive associations in midlife and generally null or negative associations at the oldest ages. CONCLUSIONS: Federal and state investment in public schools may provide students with opportunities to develop important cognitive resources during schooling that translate into better cognitive function in later life, especially among marginalized populations.

A practical revealed preference model for separating preferences and availability effects in marriage formation.

Many demographic problems require models for partnership formation. We consider a model for matchings within a bipartite population where individuals have utility for people based on observed and unobserved characteristics. It represents both the availability of potential partners of different types and the preferences of individuals for such people. We develop an estimator for the preference parameters based on sample survey data on partnerships and population composition. We conduct simulation studies based on the Survey of Income and Program Participation showing that the estimator recovers preference parameters that are invariant under different population availabilities and has the correct confidence coverage.

State-level desegregation in the U.S. South and mid-life cognitive function among Black and White adults.

RATIONALE: Black adults experience worse cognitive function than their White peers. Although educational attainment is an important predictor of cognitive function, other aspects of education, including school desegregation, may also shape this relationship. For Black adults who grew up in the U.S. South in the 1950s-1970s, exposure to school desegregation may have altered life course pathways critical for later cognitive function. OBJECTIVE: We determined if state variation in exposure to school desegregation in the U.S. South was associated with cognitive function at mid-life, if the association varied by race, and if the association remained after adjustment for state-level education quality and respondents' educational attainment. METHODS: We linked historical data on state-level school desegregation to the Health and Retirement Study, a nationally representative sample of U.S. adults aged 50 and older. We restricted our sample to Black (n = 1443) and White (n = 1507) adults born between 1948 and 1963 who resided in the U.S. South during primary school. We assessed three cognition outcomes: total cognitive function, episodic memory, and mental status. We estimated race-stratified linear regression models with cluster adjustment and a final model using state fixed effects. RESULTS: Greater exposure to desegregated primary schooling was associated with higher cognitive function and episodic memory among Black but not White adults. Among Black adults, the association between school desegregation and cognitive function and episodic memory remained after adjustment for state-level education quality and educational attainment. CONCLUSIONS: Our findings suggest that state-level school desegregation efforts played a consequential role in shaping the cognitive function of Black adults who grew up in the U.S. South.

Out-of-Pocket Medical Expenditures in the Redesigned Current Population Survey: Evaluating Improvements to Data Processing.

Household surveys are an important source of information on medical spending and burden. We examine how recently implemented post-processing improvements to the Current Population Survey Annual Social and Economic Supplement (CPS ASEC) affected estimates of medical expenditures and medical burden. The revised data extraction and imputation procedures mark the second stage of the CPS ASEC redesign and the beginning of a new time series for studying household medical expenditures. Using data for the calendar year 2017, we find that median family medical expenditures are not statistically different from legacy methods; however, updated processing does significantly reduce the percentage of families estimated to have a high medical burden (medical expenses are at least 10% of family income). The updated processing system also changes the characteristics of families with high medical spending and is primarily driven by changes in imputation of health insurance and medical spending.

Data Processing Improvements for Estimates of Health Insurance Coverage in the Current Population Survey Annual Social and Economic Supplement.

Estimates of health insurance coverage in the United States rely on household-based surveys, and these surveys seek to improve data quality amid a changing health insurance landscape. We examine postcollection processing improvements to health insurance data in the Current Population Survey Annual Social and Economic Supplement (CPS ASEC), one of the leading sources of coverage estimates. The implementation of updated data extraction and imputation procedures in the CPS ASEC marks the second stage of a two-stage improvement and the beginning of a new time series for health insurance estimates. To evaluate these changes, we compared estimates from two files that introduce the updated processing system with two files that use the legacy system. We find that updates resulted in higher rates of health insurance coverage and lower rates of dual coverage, among other differences. These results indicate that the updated data processing improves coverage estimates and addresses previously noted limitations of the CPS ASEC.

Estimating Prevalence of Abortion Using List Experiments: Findings from a Survey of Women in Delaware and Maryland.

BACKGROUND: Widespread underreporting of abortion persists in survey data. The list experiment, a measurement tool designed to elicit truthful responses to sensitive questions, may alleviate underreporting. METHODS: Using The Statewide Survey of Women of Reproductive Age in Delaware and Maryland (n = 2,747), we estimate the prevalence of abortion in Maryland and Delaware using a double list experiment. RESULTS: We find 21% (95% confidence interval [CI]: 16.8%-25.3%) of respondents aged 18 to 44 ever had an abortion and we identify disparities in abortion prevalence by age, race, education, income, marital status, and insurance status. Respondents who were Black (37.0%; 95% CI: 27.1%-46.8%), had less than a college degree (24.8%; 95% CI: 18.3%-31.3%), were in a cohabiting relationship (39.0%; 95% CI: 29.1%-48.9%), were living in households with incomes less than $50,000 (28.6%; 95% CI: 19.7%-37.5%), and were currently covered by Medicaid (42.8%; 95% CI: 27.6%-58.0%) were more likely than their counterparts to have ever had an abortion. CONCLUSIONS: List experiments yield estimates of abortion substantially higher than those obtained from direct questions. Findings demonstrate external validity through consistency with estimates from administrative data sources and gold standard abortion provider survey data.

Deaths, Disparities, and Cumulative (Dis)Advantage: How Social Inequities Produce an Impairment Paradox in Later Life.

BACKGROUND: Research on health across the life course consistently documents widening racial and socioeconomic disparities from childhood through adulthood, followed by stabilization or convergence in later life. This pattern appears to contradict expectations set by cumulative (dis)advantage (CAD) theory. Informed by the punctuated equilibrium perspective, we examine the relationship between midlife health and subsequent health change and mortality and consider the impact of earlier socioeconomic exposures on observed disparities. METHODS: Using the Health and Retirement Study, we characterize the functional impairment histories of a nationally representative sample of 8464 older adults between 1994 and 2016. We employ nonparametric and discrete outcome multinomial logistic regression to examine the competing risks of mortality, health change, and attrition. RESULTS: Exposures to disadvantages are associated with poorer functional health in midlife and mortality. However, a higher number of functional limitations in midlife is negatively associated with the accumulation of subsequent limitations for White men and women and for Black women. The impact of educational attainment, occupation, wealth, and marriage on later-life health differs across race and gender groups. CONCLUSIONS: Observed stability or convergence in later-life functional health disparities is not a departure from the dynamics posited by CAD, but rather a result of the differential impact of racial and socioeconomic inequities on mortality and health at older ages. Higher exposure to disadvantages and a lower protective impact of advantageous exposures lead to higher mortality among Black Americans, a pattern which masks persistent health inequities later in life.

Beyond question wording: How survey design and administration shape estimates of disability.

BACKGROUND: Between 2008 and 2014, annual estimates of disability prevalence among U.S. adults varied somewhat across federal surveys that use a standardized measure of disability, but trends over-time were relatively stable and consistent. In 2014, however, estimates of disability from the Survey of Income and Program Participation (SIPP) increased markedly relative to previous years and were much higher than disability estimates from other federal surveys. OBJECTIVE: To examine why disability prevalence among adults aged 40 and older substantially increased in the first wave of the 2014 SIPP Panel. METHODS: We consider three factors that may have contributed to the rise in disability: data processing, context effects linked to question order, and sampling. To do so, we compare estimates with and without survey weights and imputed data, analyze supplemental disability-related data collected among SIPP participants, and employ decomposition analysis to assess what proportion of the increase in disability can be attributed to changes in sample composition. RESULTS: We find evidence that differences in sample composition contributed to the observed rise in disability prevalence in SIPP between 2011 and 2014. There is less evidence that weighting and imputation or context effects played a role. CONCLUSIONS: Previous studies emphasize differences in operationalization and conceptualization of disability as the major factor driving discrepancies in disability estimates. This study suggests that other factors related to survey design and administration may influence disability measurement. Such aspects of surveys, like question order and sampling, may be difficult to standardize, leading to meaningful cross-survey differences in disability estimates.

Economic Inequality and Divergence in Family Formation in sub-Saharan Africa.

Economic inequality has been rising in many sub-Saharan African countries alongside rapid changes to union and family formation. In high-income countries marked by rising inequality, union and family formation practices have diverged across socioeconomic statuses, with intergenerational social and health consequences for the disadvantaged. In this study, we address whether there is also evidence of demographic divergence in low-income settings. Specifically, we model the age at first marriage and first birth by socioeconomic status groups for women born between 1960-1989 using Demographic and Health Survey data from twelve sub-Saharan African countries where economic inequality levels are relatively high or rising. We argue that economic and socio-cultural factors may both serve to increasingly delay marriage and childbearing for the elite as compared to others in the context of rising inequality. We find emerging social stratification in marriage and childbearing, and demonstrate that this demographic divergence is driven by the elites who are increasingly marrying and having children at later ages, with near stagnation in the age at first marriage and birth among the remaining majority. We urge further research at the intersection of socioeconomic and demographic inequality to inform necessary policy levers and curtail negative social and health consequences.

Improvements in Uninsurance Estimates for Fully Imputed Cases in the Current Population Survey Annual Social and Economic Supplement.

In 2019, the Current Population Survey Annual Social and Economic Supplement introduced updates to data processing, including to the imputation of health insurance for cases with no reported health insurance information. This article examines the impact on health insurance estimates of modernized imputation procedures that were part of a redesign of the Current Population Survey Annual Social and Economic Supplement. We use descriptive analysis and multinomial logistic regression to examine whether imputation biases estimates of health insurance coverage using data from the 2017 Current Population Survey Annual Social and Economic Supplement, which used legacy methods, and the 2017 Current Population Survey Annual Social and Economic Supplement Research File, which debuted the processing redesign. We find that cases with all of their health insurance information imputed using legacy methods were more likely to be uninsured or to be covered by multiple insurance types after adjusting for factors associated with having missing data. With the processing updates, fully imputed cases do not differ from other cases in their likelihood of being uninsured, having private coverage, having public coverage, or in having private and public coverage. Processing updates in the Current Population Survey Annual Social and Economic Supplement improved data quality by increasing the percent of people with any health insurance coverage and decreasing the percent of people with multiple types of coverage, especially among fully imputed cases.

Gradual Change, Homeostasis, and Punctuated Equilibrium: Reconsidering Patterns of Health in Later Life.

Longitudinal methods aggregate individual health histories to produce inferences about aging populations, but to what extent do these summaries reflect the experiences of older adults? We describe the assumption of gradual change built into several influential statistical models and draw on widely used, nationally representative survey data to empirically compare the conclusions drawn from mixed-regression methods (growth curve models and latent class growth analysis) designed to capture trajectories with key descriptive statistics and methods (multistate life tables and sequence analysis) that depict discrete states and transitions. We show that individual-level data record stasis irregularly punctuated by relatively sudden change in health status or mortality. Although change is prevalent in the sample, for individuals it occurs rarely, at irregular times and intervals, and in a nonlinear and multidirectional fashion. We conclude by discussing the implications of this punctuated equilibrium pattern for understanding health changes in individuals and the dynamics of inequality in aging populations.

Robust Respondents and Lost Limitations: The Implications of Nonrandom Missingness for the Estimation of Health Trajectories.

OBJECTIVE: We offer a strategy for quantifying the impact of mortality and attrition on inferences from later-life health trajectory models. METHOD: Using latent class growth analysis (LCGA), we identify functional limitation trajectory classes in the Health and Retirement Study. We compare results from complete case and full information maximum likelihood (FIML) analyses, and demonstrate a method for producing upper- and lower-bound estimates of the impact of attrition on results. RESULTS: LCGA inferences vary substantially depending on the handling of missing data. For older adults who die during the follow-up period, the widely used FIML approach may underestimate functional limitations by up to 20%. DISCUSSION: The most commonly used approaches to handling missing data likely underestimate the extent of poor health in aging populations. Although there is no single solution for nonrandom missingness, we show that bounding estimates can help analysts to better characterize patterns of health in later life.

Attention-deficit/hyperactivity disorder severity, diagnosis, & later academic achievement in a national sample.

Although 11% (6.4 million) American children are diagnosed with attention deficit/hyperactivity disorder (ADHD), the role of ADHD severity in shaping the association between ADHD diagnosis and academic achievement is not understood. Using a nationally-representative sample of 7830 U.S. kindergartners from the Early Childhood Longitudinal Study-Kindergarten Cohort, we use regression and propensity score matching to compare diagnosed (N = 350) and undiagnosed children who are cognitively, behaviorally, and demographically similar. Diagnosed children with less severe ADHD-related behaviors on average scored lower in reading (-0.30 SD) and math (-0.22 SD) than their undiagnosed peers - a difference two times larger than that between diagnosed and undiagnosed children with more severe ADHD-related behaviors. Pharmacological treatment did not attenuate most of this "diagnostic labeling effect" among children with less severe ADHD-related behaviors. Negative factors associated with an ADHD diagnosis may outweigh potential benefits for achievement among children with less severe ADHD-related behaviors, even those receiving treatment.

Cost-Effectiveness of Injectable Extended-Release Naltrexone Compared With Methadone Maintenance and Buprenorphine Maintenance Treatment for Opioid Dependence.

BACKGROUND: The aim of this study was to estimate the cost-effectiveness of injectable extended-release naltrexone (XR-NTX) compared with methadone maintenance and buprenorphine maintenance treatment (MMT and BMT, respectively) for adult males enrolled in treatment for opioid dependence in the United States from the perspective of state-level addiction treatment payers. METHODS: A Markov model with daily time cycles was used to estimate the incremental cost per opioid-free day in a simulated cohort of adult males aged 18-65 over a 6-month period from the state health program perspective. RESULTS: XR-NTX is predicted to be more effective and more costly than methadone or buprenorphine in our target population, with an incremental cost per opioid-free day gained relative to the next-most effective treatment (MMT) of $72. The cost-effectiveness of XR-NTX relative to MMT was driven by its effectiveness in deterring opioid use while receiving treatment. CONCLUSIONS: XR-NTX is a cost-effective medication for treating opioid dependence if state addiction treatment payers are willing to pay at least $72 per opioid-free day.