1. Are Local Health Department Expenditures Related to Racial Disparities in Mortality? David Grembowski Douglas Conrad Betty Bekemeier William Kreuter University of Washington Funded by the Robert Wood Johnson Foundation & Changes in Health Care Financing and Organization

2. Healthy People 2010 Goal 1: Increase quality and years of healthy life Goal 2: Eliminate health disparities Gender, race/ethnicity, education/income, disability, rural/urban, sexual orientation

3. Population Health Paradox Population health has increased in many developed countries Disparities in population health have increased in many developed countries

4. Absolute Change vs. Relative Disparity in Infant Mortality by Racial/Ethnic Group 2002-Absolute 19502004Change Black 44 1430 White 27 621 B/W Rate Ratio * 1.632.33.70 bigger gap * 1950 Black/White Rate Ratio = 44/27 = 1.63 Infant mortality rate: rate of deaths in children less than 1 year old per 1,000 live births Health, United States, 2007

5. Absolute Change vs. Relative Disparity in All-Cause, Age-Adjusted Mortality by Racial/Ethnic Group Absolute 19502004Change Black1,7221,027695 White1,411 786625 B/W Rate Ratio * 1.22 1.31.09 bigger gap * Black-White rate ratio in 1950 is 1,722/1,411 = 1.22 Rates are per 100,000 population Health, United States, 2007

6. Race & Gender Health, United States

7. Determinants of Population Health & Health Disparities Physical & Social Environment Behavior Human Biology Population Health & Disparities Medical Care

8. Determinants of Population Health & Health Disparities Physical & Social Environment Behavior Human Biology Population Health & Disparities Medical Care Public Health

9. Health Policy To reduce racial/ethnic disparities in mortality, How much of society’s resources should be invested in local public health systems vs. other determinants of population health and health disparities? What is the evidence that local public health funding reduces racial/ethnic disparities in mortality?

10. Can Local Public Health Reduce Racial/Ethnic Disparities?  Yes!  Population-based interventions that influence everyone have the potential to reduce health disparities Water fluoridation reduces disparities in oral health Raising the health of the worst off fastest  No!  Policies to improve overall population health may increase disparities because people with more resources are more likely to take advantage of them  Goal of improving population health may conflict with goal of reducing health disparities Link & Phelan 2005; Mechanic 2002

11. Few Studies  Medical Care 10% increase in medical expenditures per capita associated with 1-2% reduction in mortality rates (Hadley, 1982) Public Health 10% increase in local health department spending per capita associated with 1-7% decline in mortality rates (Mays & Smith 2007) In 1907-1910, 1 standard deviation increase in city health expenditures associated with decline in infant mortality from 14.9 to 11.5 deaths per 100 children under age 1 (Costa & Kahn 2006)

12. What Matters for Policy? For local health departments (LHDs): Is it the amount of LHD spending per capita - or - Is it the share of total public revenue in a local area that goes to a LHD that matters in reducing racial/ethnic disparities in mortality rates?

13. Methods Time-Trend Ecologic Study Design Test whether 1990-1997 changes in LHD funding are associated with 1990-1997 changes in Black/White mortality rates

14. Data Sources LHD expenditures: 1990 & 1997 National Profiles of Local Health Departments from the National Association of County and City Health Officials (NACCHO) 1990 & 1997 Black and White mortality rates from the CDC Compressed Mortality File 1989-91 & 1996-98 Black and White infant mortality rates

15. Data Sources U.S. Census of Government Organizations U.S. Population Census, 1990 county Area Resource File (Bureau of the Health Professions), county Medicare county expenditures per capita (Centers for Medicare and Medicaid Services) Rural/urban county commuting codes (Department of Agriculture)

16. Number of Local Areas Population: 3,256 LHDs in 1990 (NACCHO) 857 local areas with Black & White all-cause mortality rates 562 local areas (66%) have 1990 & 1997 Profile Surveys 187 local areas with Black & White infant mortality rates in 1989-1991 & 1996-98 133 local areas (71%) have 1990 & 1997 Profile Surveys

17. All-Cause, Age-Adjusted Mortality Variables Absolute change for each race Change = (1997MR - 1990MR) Males & Females Males Females Change in Black/White Rate Ratio Change = (1997 B/W Ratio - 1990 B/W Ratio)

18. Policy Variables Change in LHD Expenditures per capita Change = (1997 LHD$ - 1990 LHD$) Change in percentage share of total local public revenue going to LHD Percentage = LHD expenditures/(total revenue from county govt + cities & towns + school districts + special districts) Change = (1997% - 1990%)

19. Local Area Control Variables Social EnvironmentArea Characteristics Female Rural/Urban Education Home value Income Rent amount Income inequality White collar occupation Unemployment Medical Care Household size Medicare expenditures Single female household Percent Black Health Care System Foreign residents Hospital beds English speaking Physicians Veterans Drive to work People in mental institutions People in correctional institutions

20. Data Analysis Descriptive statistics General Estimating Equations (GEE) 40 binary (0,1) State variables to control for State-level influences on local areas Standard errors adjusted for clustering of local areas by Federal Region Test for 2-way causation between LHD funding and mortality

21. Results LHD Funding (Medians) 1997-1990 19901997 Change LHD expenditures $22 * $30 $7 per capita % share of public0.99% 1.17% 0.17 revenue to LHD * Adjusted 1997 dollars

22. Average Mortality Rates 1997-1990 19901997 Change Black Mortality Total1,2351,152 -83 Female 969 932 -37 Male1,6461,479 -167 White Mortality Total 956 914 -41 Female 754 743 -11 Male1,2441,150 -94 ___________________________________________________________________________________ Rates are per 100,000 population

23. Absolute Change in Black Mortality Rates (1997 – 1990)

24. Mortality Rates & 1990 + 1997 Profile Surveys Areas Areas withwithout ProfileProfile SurveysSurveys Both YrsBoth Yrsp-value 1997-1990 Change Black mortality -83-34.004 White mortality -41-40.868 Black infant mortality -3.0-1.8.070 White infant mortality -1.5-1.2.060 ___________________________________________________________________________________

25. 1997 - 1990 Absolute Change in Black Mortality Rates 1997-1990 change in LHD expenditures per capita are not associated with 1997-1990 change in Black total mortality, Black female mortality and Black male mortality

26. Change in LHD Share of Public Revenue & Change in Mortality Rates A 1-percent increase in share of public revenue to LHD associated with small declines in Black and White mortality rates: Avg Change 1997-1990 MortalityDecline Black Total Mortality -83-1.24# White Total Mortality -41-1.65# Black Female Mortality -37 -0.98 White Female Mortality -11-1.35# Black Male Mortality -167-2.23 White Male Mortality -94-1.41# ___________________________________________________________________________________ Rates are per 100,000 population # Statistical test for 2-way causation significant

27. 1990 & 1997 Black/White Rate Ratios (Averages) 1997-1990 19901997 Change Total1.301.27-.03 Female1.301.28-.02 Male1.341.30-.04 ____________________________________________________________________________

28. Change in Black/White Rate Ratios (1997 – 1990)

29. 1997 - 1990 Change in Black/White Mortality Rate Ratios 1997-1990 changes in LHD expenditures per capita or changes in share of public revenue for LHD are not associated with 1997-1990 changes in Black/White rate ratios

30. Average Infant Mortality Rates 1997-1990 19901997 Change Absolute Change Black 18 15-3 White 8 6-2 B/W Rate Ratio 2.35 2.43 +.08 _________________________________________________________________________ Rates are deaths in children less than 1 year old per 1,000 live births

31. 1997 - 1990 Change in White Infant Mortality Rates 1997-1990 changes in LHD expenditures per capita or share of public revenue for LHD are not associated with 1997-1990 changes in White infant mortality rates

32. 1997 – 1990 Change in Black Infant Mortality Rates A 1-percent increase in share of public revenue to LHD associated with: 0.36 increase in Black infant mortality rate (p =.002) 0.07 increase in B/W rate ratio (p<.001) A $1 increase in LHD expenditures per capita associated with: 0.01 increase in Black infant mortality rate (p=.009)

33. Conclusions Per capita LHD expenditures and share of public revenue going to LHD generally not related to disparities in Black and White mortality rates A greater share of public revenue for LHDs related to small decline in Black male mortality

34. Conclusions Per capita LHD expenditures and share of public revenue going to LHD related to greater Black infant mortality We also are analyzing whether LHD services are related to Black/White disparities in mortality

35. Limitations Correlation or causation Omitted variables (population-level smoking, medical care rates) No data for LHDs without Profile Surveys No data for how LHDs spent funds in 1990/97 Profile Surveys No data for public health spending by other community agencies Black county populations often too small to calculate cause of death mortality rates (by gender) Only 2 racial/ethnic groups