'Double jeopardy' measure suggests blacks and hispanics face more severe disparities than previously indicated.

Eliminating disparities in health and health care is a long-standing objective of the US government. Racial and ethnic differences in insurance coverage pose a major obstacle to achieving this objective. With important coverage provisions of the Affordable Care Act beginning to take effect, we propose a new way of conceptualizing and quantifying the racial and ethnic disadvantages of uninsurance over the course of a lifetime. Using a life expectancy approach, we estimate the number of years whites, blacks, and Hispanics can expect to live in insurance "double jeopardy": being uninsured while also in lesser health and, therefore, at higher risk of needing medical care. Our measures indicate that compared to whites, Hispanics and blacks are more likely not only to be uninsured at any point throughout most of their lives, but also to spend more years uninsured and spend more of these uninsured years at high risk of needing medical care. These life expectancy measures--designed for ease of use by policy makers, researchers, and the general public--have the potential to reframe the discussion of disparities and monitor progress toward their elimination.

Explaining Late Life Urban vs. Rural Health Discrepancies in Beijing.

Social characteristics that differ by place of residence are consequential for health. To study implications of this among older adults in rural vs. urban China, this study employs data from the Beijing municipality, a region that has witnessed growth and gaps in development. Life and active life expectancy is assessed using a multistate life table technique that estimates hazard rates and subsequent expected years in various health states. Hazards are estimated for a model that adjusts regional differences for age and sex and for a series of other models including additional covariates. Results indicate urban residents have an advantage. Specific factors show socio-economic status and access to health service account for a large part, social support and health behaviors for little, while disease is a suppressor.

A multi-level analysis of urban/rural and socioeconomic differences in functional health status transition among older Chinese.

The main purpose of the study is to assess urban versus rural differences in functional status transitions among older Chinese, aged 55+, and to examine how individual and community level socioeconomic indicators alter the rural/urban effects and themselves influence transitions. The study uses a hierarchical linear modeling approach that considers individual responses to be embedded within communities. Data come from the 2004 and 2006 rounds of the Chinese Health and Nutrition Survey. The study considers the functional transitions of 2944 individuals living across 209 communities in nine Chinese provinces. Functioning is measured at baseline as being able or not being able to conduct all of the following: walking, standing, climbing stairs, lifting, kneeling. Outcomes include having or not having a functional limitation, measured the same way, dying, or not responding. Outcomes are modeled adjusted for baseline functional status. Findings indicate urbanites have substantial advantages. They are less likely to have a limitation at follow-up and less likely to die over the study period. Some of this is explained by socioeconomic indicators measured at two levels. Cross-level interactions suggest education and having insurance operate differently in urban and rural areas. Community-level indicators are somewhat less predictive, and much of the urban advantage is unexplained. In conclusion, the study suggests differences in the influences of socioeconomic indicators in China versus what has been found in the past, and that place of residence in China is a particularly robust predictor of functional health transitions.

Unhealthy and uninsured: exploring racial differences in health and health insurance coverage using a life table approach.

Millions of people in the United States do not have health insurance, and wide racial and ethnic disparities exist in coverage. Current research provides a limited description of this problem, focusing on the number or proportion of individuals without insurance at a single time point or for a short period. Moreover, the literature provides no sense of the joint risk of being uninsured and in need of medical care. In this article, we use a life table approach to calculate health- and insurance-specific life expectancies for whites and blacks, thereby providing estimates of the duration of exposure to different insurance and health states over a typical lifetime. We find that, on average, Americans can expect to spend well over a decade without health insurance during a typical lifetime and that 40% of these years are spent in less-healthy categories. Findings also reveal a significant racial gap: despite their shorter overall life expectancy, blacks have a longer uninsured life expectancy than whites, and this racial gap consists entirely of less-healthy years. Racial disparities in insurance coverage are thus likely more severe than indicated by previous research.

[Effects and trends of stroke and life expectancy among older adults--from 1990s to 2000s].

OBJECTIVE: To explore the experience of stroke influencing the life expectancy (LE), active life expectancy (ALE), inactive life expectancy (IALE), and the trend of life expectancy among older adults, from 1990s to 2000s in Beijing, China. METHODS: A representative sample of 3257 elderly people living in urban or rural communities in Beijing were followed up from 1990 until 2004. Their health and survival status had been surveyed every 3-5 years. Activity Daily Living (ADL) scale, recommended by WHO was used to evaluate the physical function capability of the elderly. SAS was used to estimate LE, ALE and IALE for both periods of 1992-1997 and 2000-2004 by age and by areas of residency (rural or urban). RESULTS: LE and ALE were shorter, and IALE was longer, among the elderly with stroke than those without stroke at all age groups. Functional status at baseline was also a very important factor in determining ALE and IALE. For those active at baseline, ALE in the elderly with stroke was shorter than those without. There were no differences found in IALE between those with or without stroke, but ALE was longer than IALE. For the elderly with stroke and inactive at baseline, their IALE were longer than ALE and their ALE were at low levels in all age groups. Among those with stroke and living in urban, their LE and ALE were longer than those living in the rural area. When comparing with the period of 1992-1997, both LE and ALE increased during the period of 2000-2004 in all the elderly groups, both in urban and rural areas. The largest increment occurred among those with stroke who originated in an inactive state. CONCLUSION: Stroke reduced both quality and quantity of life of the elderly. The reductions of LE and ALE were greater among the elderly with stroke in rural than in urban areas. Both LE and ALE increased from 1992-1997 to 2000-2004 among the elderly with stroke in both urban and rural areas.

Gender Differences in Functional Health and Mortality Among the Chinese Elderly: Testing an Exposure Versus Vulnerability Hypothesis.

In this study, the authors focused on older adults in Beijing with three objectives: to examine gender differences in functional health and mortality at the end of a five-year study period, controlling for initial functional health; to determine the extent to which these differences were a function of exposure versus vulnerability to risk factors; and to analyze the relative importance of social, economic, and psychological risk factors in explaining gender differences. The results show that women were more likely to survive and to be functionally dependent at follow-up compared with men among those functionally independent at baseline. No significant differences among those who were initially dependent were apparent. Differential vulnerability to risk factors, more so than exposure, explained the variation in health outcomes across gender. Smoking, a lack of formal education, a lack of health insurance, a low sense of control, stressful events, and rural living played large roles in explaining the differences.

Effects and trends of stroke and life expectancy among older adults-from 1990s to 2000s / 中华流行病学杂志

Objective To explore the experience of stroke influencing the lire expectancy(LE),active life expectancy(ALE),inactive life expectancy(IALE),and the trend of 1ife expectancy among older adults,from 1990s to 2000s in Beijing,China.Methods A representative sample of 3257 elderly people living in urban or rural communities in Beijing were followed up from 1990 until 2004.Their health and survival status had been surveyed every 3-5 years.Activity Daily Living(ADL)scale,recommended bv WHO was used to evaluate the physical function capability of the elderly.SAS was used to estimate LE,ALE and IALE for both periods of 1992-1997 and 2000-2004 by age and by areas of residency(rural or urban).Results LE and ALE were shorter.and IALE was longer,among the elderly with stroke than those without stroke at all age groups.Functional Status at baseline was also a very important factor in determining ALE and IALE.For those active at baseline,ALE in the elderly with stroke was shorter than those without.There were no difiererlces found in IALE between those with or without stroke.but ALE was longer than LALE.For the elderly with stroke and inactive at baseline.their IALE were longer than ALE and their ALE were at low levels in all age groups.Among those with stroke and living in urban,their LE and ALE were longer than those living in the rural area.When comparing with the period of 1992-1997.botll LE and ALE increased during the period of 2000-2004 in all the elderly groups,both in urban and rural areas.The largest increment occurred among those with stroke who originated in an inactive state.Conclusion Stroke reduced both quality and quantity of life of the elderly.The reductions of LE and ALE were greater among the elderly with stroke in rural than in urban areas.Both LE and ALE increased from 1992-1997 to 2000-2004 among the elderly with stroke in both urban and rural areas.

An examination of urban versus rural mortality in China using community and individual data.

OBJECTIVE: Urban/rural residence is a critical health determinant and one researchers have historically found to distinguish health experiences. In this study, we investigated variations in older adult mortality across urban and rural areas of China and assessed mechanisms driving an urban advantage through a series of socioeconomic and health service covariates measured at individual and community levels. METHODS: We employed 15 years of mortality data from the China Health and Nutrition Survey. We calculated average annual age-specific death rates and used combinations of covariates to examine Cox proportional hazards models. We employed the 2000 Chinese Census and the 2002 Demographic Yearbook descriptively to assess reliability and provide an alternative source for mortality variation. RESULT: Hazard ratios and standardized death rates showed rural mortality to be about 30% higher than urban mortality. Cadre status, amenities within the community, and average wage within the community are important determinants of mortality, and adjusting for these covariates reduced the urban advantage. DISCUSSION: There is great differentiation in economic and social life between urban and rural China, and this appears to be negatively influencing survival chances of older adults in rural areas. The policy implications are fairly clear: Investment in rural China is needed to reduce health inequalities.

Education, gender, and functional transitions among Indonesian elderly.

Consistent and robust associations between education and health have been found for older adults in developed countries, with effects generally being stronger for men than for women. Tests of the association in developing countries are still limited, existing results are inconsistent, and variations by gender have not been examined. Using two waves of data (1993 and 1997) from the Indonesian Family Life Survey, this analysis examines the association between education and functional transitions over a 4-year period and investigates gender differences in the association. A review of past evidence leads us to speculate that the association may be weaker among Indonesian elderly than among elderly in developed countries, particularly for women. This is because the elderly in Indonesia have substantially lower levels of education, lower returns on education from the labor market, and weaker linkages between education and factors that are considered to more directly influence health, including health-related behaviors and receipt of social support. Our results indicate that associations between education and functional transition depend upon gender and functional status at the beginning of the study period. Specifically, education is significantly associated with functional outcome for men who were functionally healthy at baseline, but not for women or those who were functionally limited. The conclusion speculates on the possible mechanisms behind these diverse findings.

Access to health care: does neighborhood residential instability matter?.

Many Americans do not have access to adequate medical care. Previous research on this problem focuses primarily on individual-level determinants of access such as income and insurance coverage. The role of community-level factors in helping or hindering individuals in obtaining needed medical care, however, has not received much attention. We address this gap in the literature by investigating the association between neighborhood residential instability and access to health care. Using individual-level data from the 2000 Medical Expenditure Panel Survey and block-group level data from the 2000 decennial census, we find that individuals who live in neighborhoods with high residential turnover have worse health care access than residents of other neighborhoods. This association persists even when the prevalence of poverty, the supply of health care, and a variety of individual characteristics are held constant. We offer explanations for these findings and suggest directions for future research.

Socioeconomic status differentials in life and active life expectancy among older adults in Beijing.

PURPOSE: The study compares life and active life expectancy estimates across indicators of socioeconomic status (SES) for a cohort of older adults in the Beijing municipality. Our aim is to determine if associations found are consistent across indicators and with those typically observed in the Western industrialized countries. METHOD: A multistate life table method is used to estimate expected years of total and active life, defined as life spent without limitation in functions necessary for performing daily tasks. RESULTS: We find that men of higher status experience advantages with respect to life and active life expectancies. Among women, only active life expectancy is significantly higher for those of higher status, but the difference by income is not statistically significant. With respect to the proportion of life spent in an active state, both men and women of higher status benefit in comparison to their lower status counterparts. Finally, we find that disparities by SES generally increase with age. CONCLUSIONS: Despite several inconsistencies across SES indicators by gender, findings generally confirm inequalities within a society that is organized very differently socially, economically, and politically from the West.

Neighborhood socioeconomic disadvantage and access to health care.

Most research on access to health care focuses on individual-level determinants such as income and insurance coverage. The role of community-level factors in helping or hindering individuals in obtaining needed care, however, has not received much attention. We address this gap in the literature by examining how neighborhood socioeconomic disadvantage is associated with access to health care. We find that living in disadvantaged neighborhoods reduces the likelihood of having a usual source of care and of obtaining recommended preventive services, while it increases the likelihood of having unmet medical need. These associations are not explained by the supply of health care providers. Furthermore, though controlling for individual-level characteristics reduces the association between neighborhood disadvantage and access to health care, a significant association remains. This suggests that when individuals who are disadvantaged are concentrated into specific areas, disadvantage becomes an "emergent characteristic " of those areas that predicts the ability of residents to obtain health care.

[Study on the active life expectancy of the elderly and its longitudinal transition in Beijing].

OBJECTIVE: Focus on the Active Life Expectancy (ALE) of elderly in Beijing and the transition in recent years. METHODS: A representative sample of 3257 elderly people who lived in the urban, suburban and rural communities in Beijing that had been followed up for 12 years. Their health and survival status had been surveyed every 2-3 years. Activity Daily Living scale (ADL), recommended by WHO was used to evaluate the physical function capability of the elderly. IMaCH 0.8 was used to estimate life expectancy (LE) and active life expectancy (ALE) for both periods while age, sex and rural/urban residence areas were adjusted. RESULTS: Longitudinally, data showed that the main characters remained unchange throughout the two periods including 1) LE, ALE, ALE/LE of elderly living in urban area were higher than those living in rural area; 2) LE seemed longer in women than men, but ALE/LE was less in women. The transition between two period showed that 1) LE increased modestly in all groups but less prominent in urban residents and in females; 2) ALE was not significantly changed in the rural elderly but declined markedly in women living in the urban area; 3) ALE/LE of the elderly declined in all groups, especially in urban and oldest old groups. CONCLUSION: In Beijing, elderly AL-E did not increase in parallel with the increase of LE while ALE/LE of the elderly declined significantly in recent years. In order to improve quality of life of the elderly and to increase their ALE, emphasis should be given to prevention of cardiovascular, cerebrovascular and other chronic diseases while reducing the occurrence of physical disability and strengthening on rehabilitation would be the basic health care measures.

Health insurance and family structure: the case of adolescents in skipped-generation families.

Since 1970, both the number and proportion of children being parented by a grandparent without the help of a parent has increased substantially. The increase in skipped-generation households has generated much concern from policy makers because such households are, on average, disadvantaged compared with most other household types. One important challenge facing grandparents with parenting responsibilities is securing health insurance for their dependent grandchildren. In this study, the authors investigate the extent to which grandparents raising their grandchildren were able to secure health insurance for their dependent grandchildren. They find that adolescents living in skipped-generation families in 1995 were more often uninsured, more often publicly insured, and less often privately insured compared with adolescents in other family types. Even after controlling for income, work status, and education, adolescents in skipped-generation families were still more likely to have public insurance and less likely to have private insurance compared with other adolescents.