Economic Dislocation and Landscapes of Despair: Rural-Urban & Within-Rural Differences in Non-Hispanic White Premature Mortality Shannon M. Monnat Lerner Chair for Public Health Promotion and Associate Professor of Sociology Senior Research Associate, Center for Policy Research Maxwell School of Citizenship and Public Affairs Syracuse University March 21-22, 2018, Washington, DC Rural Policy Research Initiative Rural Poverty: Fifty Years after The People Left Behind Acknowledgements: USDA ERS Cooperative Agreement (58-6000-6-0028); Institute for New Economic Thinking (INO17-00003); SU Lerner Center for Public Health Promotion; USDA Agricultural Experiment Station Multistate Research Project: W4001: Social, Economic, and Environmental Causes and Consequences of Demographic Change in Rural America.

Objectives Track distribution of counties by rates of drug, alcohol, and suicide mortality (2000-2016) by rural-urban and poverty status. Analyze relationships between poverty and mortality by metro status. Data County Mortality Rates: National Center for Health Statistics restricted multiple cause of death mortality files, 2000-2016 (NH whites, age 25-64, counties w/NHW pop >2,000) County Economic and Demographic Measures: 2000 U.S. Census & 2011-15 American Community Survey

Mortality Rates, (NHW 25-64), 2000-2016 Rates are age-adjusted Drugs Alcohol Suicide 2000-02 2007-09 2014-16

Mortality Rates, (NHW 25-64), 2014-16 All-Cause Mortality Drugs Alcohol Suicide Rates are age-adjusted

Percentage of Counties with NHW (age 25-64) Mortality Rates >30, by Metro Status Rates in 2014-16 highest in urban fringe Increased most in urban fringe & medium/small metro Nonmetro Rates in 2014-16 highest in micro & rural Increased most in medium/small metro Rates in 2014-16 highest in micro & rural Increased most in medium/small metro

Relationship between Poverty and NHW (age 25-64) Mortality Rates Similar patterns when plotting NHW poverty in 2011-15 Rates are age-adjusted; analyses exclude counties with <2000 NHW pop; error bars represent 95% confidence intervals

Persistent vs. New Poverty (NHW 18-64) – based on 15%+ poverty rates Rates are age-adjusted; analyses exclude counties with <2000 NHW pop

Persistent Poverty vs. New Poverty and Mortality Rates are age-adjusted; analyses exclude counties with <2000 NHW pop; error bars represent 95% confidence intervals

Regression Results – NHW (age 25-64) Mortality Rates 2014-16 Persistent Poverty vs. Non-Poverty B (RSE) New Poverty vs. Non-Poverty Drug Mortality Rates, 2014-16 Model 1 5.13 (1.35) 2.40 (0.89) Model 2 Alcohol Mortality Rates, 2014-16 3.10 (0.84) 1.69 (0.57) Suicide Mortality Rates, 2014-16 4.14 (1.04) 1.16 (0.70) Model 1: spatial autoregressive model with state fixed effects & robust standard errors (RSE), model controls for metro status, 2000 % NH black, % Hispanic, % age 65+, % veterans, % vacant housing, % separated divorced, change in each measure (2000 to 2011-15), and population loss 2000 to 2011-15 Model 2: adds 2000 % unemployed/not in labor force, % age 25+ w/4-year college degree, and change in these two measures 2000 to 2011-15 Bolded values indicate statistical significance at p<.05; B=difference in #deaths per 100,000 population

Regression Results – NHW (age 25-64) Mortality Rates 2014-16 Persistent Poverty vs. Non-Poverty B (RSE) New Poverty vs. Non-Poverty Drug Mortality Rates, 2014-16 Model 1 5.13 (1.35) 2.40 (0.89) Model 2 2.99 (1.45) 1.65 (0.91) Alcohol Mortality Rates, 2014-16 3.10 (0.84) 1.69 (0.57) 1.86 (0.93) 1.40 (0.93) Suicide Mortality Rates, 2014-16 4.14 (1.04) 1.16 (0.70) 4.16 (1.15) 1.05 (0.73) Model 1: spatial autoregressive model with state fixed effects & robust standard errors (RSE), model controls for metro status, 2000 % NH black, % Hispanic, % age 65+, % veterans, % vacant housing, % separated divorced, change in each measure (2000 to 2011-15), and population loss 2000 to 2011-15 Model 2: adds 2000 % unemployed/not in labor force, % age 25+ w/4-year college degree, and change in these two measures 2000 to 2011-15 Bolded values indicate statistical significance at p<.05; B=difference in #deaths per 100,000 population

Regression Results – Change in NHW Mortality Rates, 2000-02 to 2014-16 Model 1: spatial autoregressive model with state fixed effects & robust SEs, controls for mortality rate in 2000-02, metro status, 2000 % NH black, % Hispanic, % age 65+, % veterans, % vacant housing, % separated divorced, change in each measure (2000 to 2011-15), and population loss 2000 to 2011-15; Model 2: adds 2000 % unemployed/not in labor force, % age 25+ w/4-year college degree, and change in these two measures 2000 to 2011-15 Persistent Poverty vs. Non-Poverty B (RSE) New Poverty vs. Non-Poverty Change in Drug Mortality Rates Model 1 4.55 (1.33) 1.61 (0.88) Model 2 2.61 (1.43) 0.90 (0.90) Change in Alcohol Mortality Rates 2.67 (0.84) 1.53 (0.57) 1.54 (0.93) 1.27 (0.59) Change in Suicide Mortality Rates 4.14 (1.04) 1.16 (0.70) 4.16 (1.15) 1.05 (0.73) Bolded values indicate statistical significance at p<.05; B=difference in #deaths per 100,000 population

Regression Results by Metro Status –NHW (age 25-64) Mortality Rates, 2014-16 Drugs: Higher in persistent poverty; not explained by employment/education composition Alcohol: Higher in new poverty; explained by employment/education Suicide: poverty not associated NONMETRO Drugs: Higher in both persistent and new poverty; explained by employment/education composition Alcohol: Higher in persistent; explained by employment/education Suicide: Higher in persistent; not explained by employment/education

Nonmetro NHW (age 25-64) Mortality Means by Region, 2014-16

Nonmetro NHW (age 25-64) Mortality Means by Region, 2014-16

Summary Drug epidemic not disproportionately rural: NHW (age 25-64) drug mortality rates higher in metro counties Largest increases since 2000 in urban fringe and medium/small metro. But, rural areas may have more challenges dealing with it. Heterogeneity: very high rates in some nonmetro counties (i.e., Appalachia, southwest), very low in others. Don’t forget about the other “deaths of despair”: Alcohol & suicide mortality rates higher in nonmetro counties; largest increases since 2000 in medium/small metro. Poverty more strongly associated with drug mortality rates than with alcohol and suicide mortality rates. Poverty (especially persistent poverty) more strongly associated with drug mortality in nonmetro than metro counties. Driven by counties in Midwest and South. May be function of employment and education composition.

Shannon Monnat smmonnat@maxwell.syr.edu Thank you. Shannon Monnat smmonnat@maxwell.syr.edu