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
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
Population Health Paradox


Population health has increased in many
developed countries
Disparities in population health have
increased in many developed countries
Absolute Change vs. Relative Disparity
in Infant Mortality by Racial/Ethnic Group
1950
44
27
Black
White
B/W Rate
Ratio*
1.63
20022004
14
6
Absolute
Change
30
21
2.33
.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
Absolute Change vs. Relative Disparity
in All-Cause, Age-Adjusted Mortality by
Racial/Ethnic Group
1950
1,722
1,411
Black
White
B/W
Rate Ratio* 1.22
2004
1,027
786
1.31
* Black-White rate ratio in 1950 is 1,722/1,411 = 1.22
Rates are per 100,000 population
Health, United States, 2007
Absolute
Change
695
625
.09 bigger gap
Race & Gender
Health, United States
Determinants of Population Health
& Health Disparities
Physical & Social
Environment
Behavior
Human
Biology
Medical Care
Population
Health &
Disparities
Determinants of Population Health
& Health Disparities
Physical & Social
Environment
Behavior
Human
Biology
Medical Care
Public Health
Population
Health &
Disparities
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?
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
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)
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?
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
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
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)
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
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)
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%)
Local Area Control Variables
Social Environment
Area 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
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
Results
LHD Funding (Medians)
1997-1990
1990
1997
LHD expenditures
per capita
$22*
$30
% share of public
revenue to LHD
0.99%
1.17%
* Adjusted 1997 dollars
Change
$7
0.17
Average Mortality Rates
Black Mortality
Total
Female
Male
White Mortality
Total
Female
Male
1997-1990
1990
1997
Change
1,235
969
1,646
1,152
932
1,479
-83
-37
-167
956
754
1,244
914
743
1,150
-41
-11
-94
___________________________________________________________________________________
Rates are per 100,000 population
Absolute Change in Black Mortality Rates
(1997 – 1990)
Mortality Rates &
1990 + 1997 Profile Surveys
1997-1990 Change
Black mortality
White mortality
Areas
with
Profile
Surveys
Both Yrs
Areas
without
Profile
Surveys
Both Yrs
p-value
-83
-41
-34
-40
.004
.868
-1.8
-1.2
.070
.060
Black infant mortality -3.0
White infant mortality -1.5
___________________________________________________________________________________
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
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
Mortality
Decline
Black Total Mortality
White Total Mortality
-83
-41
-1.24#
-1.65#
Black Female Mortality
White Female Mortality
-37
-11
-0.98
-1.35#
-167
-94
-2.23
-1.41#
Black Male Mortality
White Male Mortality
___________________________________________________________________________________
Rates are per 100,000 population
# Statistical test for 2-way causation significant
1990 & 1997 Black/White Rate Ratios
(Averages)
1997-1990
Total
Female
Male
1990
1997
Change
1.30
1.30
1.34
1.27
1.28
1.30
-.03
-.02
-.04
____________________________________________________________________________
Change in Black/White Rate Ratios
(1997 – 1990)
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
Average Infant Mortality Rates
Absolute Change
Black
White
B/W Rate Ratio
1997-1990
1990
1997
Change
18
8
15
6
-3
-2
2.35
2.43
+.08
_________________________________________________________________________
Rates are deaths in children less than 1 year old per 1,000 live births
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
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)
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
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
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