Article

Health Care In The Suburbs: An Analysis Of Suburban Poverty And Health Care Access

Authors:
  • Dornsife School of Public Health
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

There are 16.9 million Americans living in poverty in the suburbs-more than in cities or rural communities. Despite recent increases in suburban poverty, the perception of the suburbs as areas of uniform affluence remains, and there has been little research into health care barriers experienced by people living in these areas. The objectives of this study were to compare patterns of insurance coverage and health care access in suburban, urban, and rural areas using national survey data from 2005 to 2015 and to compare outcomes by geography before and after the Affordable Care Act took effect. We found that nearly 40 percent of the uninsured population lived in suburban areas. Though unadjusted rates of health care access were better in suburban areas, compared to urban and rural communities, this advantage was greatly reduced after income and other demographics are accounted for. Overall, a substantial portion of the US population residing in the suburbs lacked health insurance and experienced difficulties accessing care. Increased policy attention is needed to address these challenges for vulnerable populations living in the suburbs. © 2017 Project HOPE-The People-to-People Health Foundation, Inc.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Rural areas are known to have higher proportions of uninsured, underinsured, and poor residents, and poor access to care, higher costs of health care services, and longer travel time when compared to urban residents [1] . However, studies have highlighted the difficulties low-income and minority suburban residents experience accessing health care [5] . Recent evidence documents (1): the growing difficulties low-income suburban residents face accessing health care [6] . ...
... These national trends of rapid conversion of many rural areas into suburban areas, increasing suburban minority populations, and increasing suburban poverty [5] . demand that traditional rural-urban classification methods be revised. ...
... Most recent estimates show that a substantial majority of African Americans live in urban or suburban areas-in metropolitan areas like Memphis, which has the 6th highest African American population of any city in the country [3] . Only 10% live in rural communities [5] . However, a year after we started recruiting patients for the MODEL study, we became aware that the RUCA ZIP code classification scheme was inappropriate for our geographic area and the population served by the study because a large majority of patients recruited from practices located in Jackson, TN; Covington, TN; and Holly Springs, MS were being classified as urban patients. ...
Article
Full-text available
This article describes a rationale and approach for modifying the traditional rural-urban commuting area (RUCA) coding scheme used to classify U.S. ZIP codes to enable suburban/rural vs. urban core comparisons in health outcomes research that better reflect current geographic differences in access to care in U.S. populations at risk for health disparities. The proposed method customization is being employed in the Patient-Centered Outcomes Research Institute-funded Management Of Diabetes in Everyday Life (MODEL) study to assess heterogeneity of treatment effect for patient-centered diabetes self-care interventions across the rural-urban spectrum. The proposed suburban/rural vs. urban core classification scheme modification is based on research showing that increasing suburban poverty and rapid conversion of many rural areas into suburban areas in the U.S. has resulted in similar health care access problems in areas designated as rural or suburban. •The RUCA coding scheme was developed when a much higher percentage of U.S. individuals resided in areas with very low population density. •Using the MODEL study example, this study demonstrates that the RUCA classification scheme using ZIP codes does not reflect real differences in health care access experienced by medically underserved study participants. •Both internal and external validation data suggest that the proposed suburban/rural vs. urban core customization of the RUCA geographic coding scheme better reflects real differences in healthcare access and is better able to assess the differential impact of clinical interventions designed to address geographic differences in access among vulnerable populations.
... However, less literature exists focusing on CBOs providing social services to immigrant and minoritized Latine 1 communities in the suburbs, and CBO's related interventions. More work could be conducted on the geographic context of the suburbs and its influences on CBO's service provision (Bielefeld et al., 1997a;Schnake-Mahl & Sommers, 2017). Other work on immigrant geographies takes a legal geographic approach to the transportation issues caused by policing, particularly in suburban areas where travel may require more time in an automobile (Stuesse & Coleman, 2014). ...
... As Latina women navigate constraints to health care access in the suburbs of Chicago, they face a varied and uneven landscape of service providers and economic and geographic barriers (Schnake-Mahl & Sommers, 2017). Further, many Latina women are in mixed-status communities. ...
Article
Throughout the United States, suburbs have seen an increasing number of immigrant populations as residents in the area. Yet, the suburban social and health services available have not developed to serve these immigrant groups, leading to community-based organizations (CBOs) filling in the need for service provision. However, the geographic distribution and resources available to these CBOs to serve these groups is uneven and understanding the constraints these organizations face in delivering services is crucial. Employees in CBOs themselves have crucial insights into immigrants’ needs and concerns, particularly those of immigrant women. This paper examines the understanding of CBO staffers focusing on the Latine population in Chicago and the suburbs, particularly on healthcare access barriers CBOs provide interventions on for Latina women during the COVID-19 pandemic. Qualitative data from a purposeful sample of interviews with CBO staffers during the COVID-19 pandemic supports the findings of financial and legal barriers, particularly access to information, and creative, community-based methods for interventions, specific to the experiences of Latina women.
... These secondary aims were included becaues broader social science literature has suggested that racially minoritized populations are overrepresented in urban environments 11 and face more systemic barriers to mental health care, including differential access to insurance coverage. 12 In summary, issues of racial inequalities are entangled with broader issues of geographic residence and insurance coverage. ...
... Broader public health literature has demonstrated that suburban regions demonstrate higher rates of health insurance when compared to urban regions. 11 Findings at CHOP, where racial disparities were found without significant differences in insurance carriers or geographic location of sites, may suggest that race, in some cases, operates independently of insurance and geographic location to affect a person's access to mental health care. ...
Article
Objective To examined whether racial disparities in access to pediatric mental health care were impacted during the COVID-19 telemedicine transition at both The Children’s Hospital of Philadelphia (CHOP) and Boston Children’s Hospital (BCH). Method Electronic health records were queried for all unique outpatient visits from a pre-pandemic period in 2019 and a within-pandemic period in 2020. Changes in the proportion of patients were compared based on insurance status, clinic location, and racial identification. Hypotheses were tested via logistic regression analyses. Results At CHOP, from 2019 to 2020, the proportion of racially minoritized patients significantly declined within a one-month period from 62% to 51% while the proportion of white-identifying patients increased from 38% to 49% (b =, 0.47; z-value, 3.60; p =0.0003), after controlling for insurance status and clinic location. At BCH, the proportion of racially-minoritized patients significantly declined within a longer six-month period between 2019 and 2020, from 62% to 59%, while the proportion of white-identifying patients increased from 38% to 41% (b=0.13; z-value=2.8; p=0.006), after controlling for insurance status. Conclusion At CHOP and BCH, the COVID-19 telemedicine transition exacerbated pre-existing racial disparities in pediatric mental health services. Our findings may suggest that racially minoritized patients receiving services in urban areas may be particularly at risk of losing access when telemedicine is implemented. While there are limitations to this racial dichotomization, examining differences between white and racially-minoritized patients can highlight ways in which white-identifying have disproportionately received enhanced access to healthcare resources.
... Among studies of MSM in rural areas, multiple forms of stigma (e.g., related to HIV, sexual activity), availability of sexual health resources, healthcare providers' willingness to prescribe PrEP, and PrEP integration into daily life are major barriers to PrEP uptake [11,12]. Suburban areas, though not formally defined, are unique in that they historically have had higher rates of health insurance coverage than urban or rural areas, but due to the recent increase in suburban poverty, there is evidence to suggest that communities within suburban areas may be unable to access or afford health care, including PrEP and other HIV services [13]. Further, an analysis of geographic access to PrEP providers, using National Center for Health Statistics (NCHS) urbanicity categories [14], found that large fringe metro areas were distinct from large central metro areas and other less urban areas with respect to the prevalence of "PrEP deserts" [15]. ...
... While prior studies have specifically focused on disparities existing between urban and rural counties, we added a separate suburban category based on economic and health trends over time in suburban counties. There has been a recent uptick of suburban poverty more resembling that found in urban areas, leading to an increase in populations without health insurance in suburban areas [13]. We observed similar disparities in suburban counties as in rural counties; however, the suburban-urban disparities tended to be smaller in magnitude, and many were not statistically significant. ...
Article
Full-text available
Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention intervention and is critical to the Ending the HIV Epidemic strategy. Most PrEP research has been conducted among urban populations; less is known about PrEP awareness, willingness to use, and actual use among rural and suburban populations. We examined these PrEP indicators by United States region and urbanicity among men who have sex with men who responded to the 2019 cycle of the American Men’s Internet Survey. Rural and suburban men were less likely than urban men to be aware of PrEP, to have discussed PrEP with a healthcare provider in the past 12 months, and to have ever used PrEP. Smaller differences were observed across regions. Notably, willingness to use PrEP was similar across region and urbanicity. Additional work will be needed to increase PrEP awareness and access among rural and suburban populations.
... Building on methods from a previous study and corresponding to geographical distinctions in the Behavioral Risk Factor Surveillance Survey, 29 we classified ZCTAs as urban, suburban, or rural (see eAppendix [available at ajmc.com]). The proportion of individuals in urban areas was high across both low-and high-income areas (eAppendix Table 1). ...
... The stratification of our analyses by urban, suburban, and rural areas generated findings consistent with and complementary to those of Schnake-Mahl and Sommers. 29 Based on data from a nationally representative survey defining access as having health insurance, a usual source of care, unmet need due to cost, and receipt of a routine checkup, they find that suburban low-income residents face higher barriers to accessing care. Combining their findings with ours suggests that suburban areas may be high-potential places for delivery system interventions to close the divide between the low-and high-income residents. ...
... Most studies of structural racism in the form of racial segregation are performed in urban contexts (mostly due to methodological issues) [30,31,36,37]. Little is known about the effects of structural racism on health in non-urban contexts [38,39]. Studies that demonstrate health differences in urban versus rural contexts suggest a confluence of factors negatively impact health including healthcare resources [39,40], contextual factors [41][42][43] and racism [38]. ...
... Little is known about the effects of structural racism on health in non-urban contexts [38,39]. Studies that demonstrate health differences in urban versus rural contexts suggest a confluence of factors negatively impact health including healthcare resources [39,40], contextual factors [41][42][43] and racism [38]. However, urban-rural classification may affect the types of and manner in which policies that can lead to racial inequities are implemented, and thus affect health. ...
Article
Full-text available
Recent attention to the interrelationship between racism, socioeconomic status (SES) and health has led to a small, but growing literature of empirical work on the role of structural racism in population health. Area-level racial inequities in SES are an indicator of structural racism, and the associations between structural racism indicators and self-rated health are unknown. Further, because urban-rural differences have been observed in population health and are associated with different manifestations of structural racism, explicating the role of urban-rural classification is warranted. This study examined the associations between racial inequities in SES and self-rated health by county urban-rural classification. Using data from County Health Rankings and American Communities Surveys, black-white ratios of SES were regressed on rates of fair/poor health in U.S. counties. Racial inequities in homeownership were negatively associated with fair/poor health (β = −0.87, s.e. = 0.18), but racial inequities in unemployment were positively associated with fair/poor health (β = 0.03, s.e. = 0.01). The associations between structural racism and fair/poor health varied by county urban-rural classification. Potential mechanisms include the concentration of resources in racially segregated counties with high racial inequities that lead to better health outcomes, but are associated with extreme black SES disadvantage. Racial inequities in SES are a social justice imperative with implications for population health that can be targeted by urban-rural classification and other social contextual characteristics.
... Moreover, the cultural norms and customs of poor areas restrict women's role to caring for family members at home and have led to gender discrimination. This discrimination prevents women and girls from participating in social activities, limits their access to health care, and reflects the poor structural conditions of these communities, including the lack of proper health facilities, lack of health insurance, limited public transportation options, and long distances from healthcare centers, which pose great challenges for equity in health and development [18,19]. ...
Article
Full-text available
Background Suburban populations in developing countries are affected by poor environmental conditions affecting their ongoing health. Given the low reproductive health indicators of women residing in the suburbs of eastern Iran, planning to improve their health by assessing the needs of the target group through qualitative research is essential. The present study seeks to elucidate the views of women living in the suburbs of Zabol, Iran, regarding sexual and reproductive health needs. Methods This qualitative study was conducted in healthcare centers in the suburbs of Zabol in 2023. The sample comprised 22 women, including 16 women of reproductive age (age 15–49 years) living in the suburbs and six key informants (service providers and people who were in close contact with these women). The sample was selected purposively with maximum variation. Data were collected through semi-structured, in-depth, individual interviews, which continued until data saturation was reached. The data were then analyzed using conventional content analysis. Results The data analysis yielded seven categories (gender-based violence, psychological problems, women’s lack of empowerment, barriers to equity in sexual and reproductive health, support seeking, sexual issues, and pregnancy, childbirth, and postpartum care needs) and 24 subcategories. The results revealed that suburban women did not have adequate information or knowledge about their sexual and reproductive health or the available services, and most of them suggested that they required training. Conclusion Women living in the suburbs of Zabol were faced with challenges in their sexual and reproductive health and well-being. It is crucial to provide these women with sexual and reproductive health education and services that are accessible and suitable to their conditions by targeted interventions aiming to improve their health and well-being. The findings of the current study can serve as a basis for future health policymaking, planning, and research by providing evidence and strengthening the body of knowledge about this domain of health.
... The observations from the experts participating in the panel highlighted connections between multiple social and health inequalities-related factors potentially contributing to frailty and pressure ulcers, such as a lack of desire to eat when having to stay in bed, moving less due to high body weight because of lack of access to healthy food, eating or drinking less due to fear of incontinence or inability to afford continence wear on a daily basis. This is very concerning because it is a well-known fact that inadequate access to health and social care services could directly and indirectly lead to poor physical and mental health (40). ...
Article
Pressure ulcers affect many people in acute care and community settings. People with pressure ulcers may have delayed ulcer healing due to various factors, such as malnutrition and frailty. Prevention of pressure ulcers by addressing individual risk factors is essential, as it can help maintain skin integrity and functional ability, prevent or delay frailty, reduce care-associated costs, and improve quality of life. There are key factors leading to both frailty and pressure ulcers but the psychosocial aspects of these factors are often overlooked. In the current literature and clinical practice, the key concepts related to the bio-psychosocial aspects of frailty and pressure ulcer prevention are under-explored and not fully considered as part of routine care services. To address this gap in research and practice, a group of experts were invited to an online panel discussion. The expert panel included academics, researchers, and specialist clinical professionals in key leadership roles such as consultant geriatricians, advanced nurse practitioners and tissue viability nurse specialists, the national lead for older person services in Ireland, and the lead person for the National Wound Care Strategy in England. In March 2024, an expert panel meeting was held online with participation from experts in the areas of frailty, wound care, and nutrition to discuss key concepts of frailty and pressure ulcers. The main focus of this expert panel was to identify the connections between frailty and pressure ulcers and discuss priority areas to help address the needs of an ageing population who are at risk of developing pressure ulcers. This opinion paper presents the summary of the expert panel under a number of headings based on the focus of the panel discussions. It highlights the key concepts of frailty and pressure ulcers, discusses the bidirectional complex vicious cycle between them, and emphasises the importance of a preventative approach. While there are many definitions and classifications of frailty in the literature, this paper aims to describe the impact of frailty on the development, treatment and prevention of pressure ulcers from the perspective of experts in wound care, older persons care and nutrition. The key focus explored in this paper is the complex interplay between frailty and pressure ulcers and the role of modifiable risk factors including nutrition, socioeconomic status, and other factors in that relationship.
... reported that vaccination coverage may be lower in rural areas than in urban areas due to greater 194 barriers to accessing health services than in urban areas. 7,20 In this study, population density was also To the best of our knowledge, this is the first study to focus on regional disparities in measles 207 vaccination coverage and to clarify that vaccination coverage is lower in areas with a higher 208 ...
Article
Full-text available
Background: The decline in measles vaccination coverage is a global concern. In Japan, coverage of the first-dose of measles vaccine, which had exceeded the target of 95.0% since fiscal year (FY) 2010, fell to 93.5% in FY 2021. Vaccination coverage increased to 95.4% in FY 2022 but varied by municipality. Few studies have focused on regional disparities in measles vaccination coverage. This study aimed to clarify the regional disparities in measles vaccination coverage by municipality in Japan and their associated factors. Methods: In this ecological study, the measles vaccination coverage in FY 2022; population density; area deprivation index (ADI, an indicator of socioeconomic status); proportion of foreign nationals, single-father households, single-mother households, and mothers aged ≥30 years; and number of medical facilities, pediatricians, and non-pediatric medical doctors in 1,698 municipalities were extracted from Japanese government statistics. Negative binomial regression was performed with the number of children vaccinated against measles as the dependent variable, number of children eligible for measles vaccination as the offset term, and other factors as independent variables. Results: Vaccination coverage was less than 95.0% in 54.3% of municipalities. Vaccination coverage was significantly positively associated with population density and negatively associated with the proportion of single-father households, mothers aged ≥30 years, and the ADI (incidence rate ratio [IRR]: 1.004, 0.976, 0.999, 0.970, respectively). Conclusion: This study showed regional disparities in measles vaccination coverage in Japan. Single-father households, age of mothers, and socioeconomic status may be key factors when municipalities consider strategies to improve vaccination coverage.
... Poverty is associated with poor health 1-3 ; however, the association of poverty with the utilisation of healthcare is less clear. In some settings, low-income individuals have been shown to use, or have less access to, appropriate care, [4][5][6] and in other settings, the reverse has been found, especially when factors such as insurance, ethnicity and language are considered. [7][8][9] Complicating our understanding of the relationship between poverty and healthcare utilisation is a consideration of how poverty is measured. ...
Article
Full-text available
Objective The objective of this research was to examine how different measurements of poverty (household-level and neighborhood-level) were associated with asthma care utilisation outcomes in a community health centre setting among Latino, non-Latino black and non-Latino white children. Design, setting and participants We used 2012–2017 electronic health record data of an open cohort of children aged <18 years with asthma from the OCHIN, Inc. network. Independent variables included household-level and neighborhood-level poverty using income as a percent of federal poverty level (FPL). Covariate-adjusted generalised estimating equations logistic and negative binomial regression were used to model three outcomes: (1) ≥2 asthma visits/year, (2) albuterol prescription orders and (3) prescription of inhaled corticosteroids over the total study period. Results The full sample (n=30 196) was 46% Latino, 26% non-Latino black, 31% aged 6–10 years at first clinic visit. Most patients had household FPL <100% (78%), yet more than half lived in a neighbourhood with >200% FPL (55%). Overall, neighbourhood poverty (<100% FPL) was associated with more asthma visits (covariate-adjusted OR 1.26, 95% CI 1.12 to 1.41), and living in a low-income neighbourhood (≥100% to <200% FPL) was associated with more albuterol prescriptions (covariate-adjusted rate ratio 1.07, 95% CI 1.02 to 1.13). When stratified by race/ethnicity, we saw differences in both directions in associations of household/neighbourhood income and care outcomes between groups. Conclusions This study enhances understanding of measurements of race/ethnicity differences in asthma care utilisation by income, revealing different associations of living in low-income neighbourhoods and households for Latino, non-Latino white and non-Latino black children with asthma. This implies that markers of family and community poverty may both need to be considered when evaluating the association between economic status and healthcare utilisation. Tools to measure both kinds of poverty (family and community) may already exist within clinics, and can both be used to better tailor asthma care and reduce disparities in primary care safety net settings.
... Additionally, HIV/AIDS further perpetuates poverty because of loss of employment to those infected or affected members of the family member, resulting in loss of household income. In a study, Schnake and Sommers [25] indicated that pregnant women who lived in poverty faced many barriers to access prenatal care, structural barriers (i.e., lack of transportation, no telephone), healthcare provider shortages, cultural and linguistic barriers, and high levels of stress. Furthermore, the authors observed that poverty leads uncontrolled maternal health conditions, such as diabetes, hypertension, anemia, and obesity, as these conditions can lead to poor PMTCT among pregnant mothers. ...
... In the suburbs, the social and material infrastructure of civic institutions is unevenly developed to support the healthcare needs of Latinas and their households. The suburban healthcare landscape may be limited in available specialists, the variety of insurances taken, or the ability of the healthcare facilities and providers to accommodate the patient's linguistic, social, and economic needs (Guhlincozzi, 2020;Portes et al., 2009;Schnake-Mahl & Sommers, 2017). This paper explores how Latina immigrant women and Latinas from mixed-status households' linguistically-concordant healthcare needs are or are not met in suburban contexts, the barriers faced when seeking healthcare, and how they overcome these barriers. ...
Article
How accessible is linguistically-appropriate health care to Latina women in demographically shifting suburban landscapes in the United States? Using data from a survey of Latina immigrant women and those from mixed-status households in the Chicago suburbs, this research examines barriers Latinas face in accessing healthcare for themselves and their families. This research also asks how those barriers vary among suburban contexts. Qualitative GIS mapping is used to situate women’s experiences in relation to the local availability of healthcare services. The findings show Latina women must make complex spatial, financial, and temporal trade-offs when seeking high quality, linguistically-appropriate healthcare in the Chicago suburbs, especially in exurban areas where services that meet their needs are in short supply. Latina women’s qualitative healthcare experiences in the suburbs are valuable for policy insights targeting this social group. Further, this paper demonstrates how qualitative GIS can be used in understanding spatial access to health services for vulnerable populations.
... Areas of concentrated poverty (that is, with poverty rates exceeding 40 percent) are beginning to present challenges to suburbia." 19 It is widely understood that socioeconomic inequity and poverty are foundational causes of vulnerability in everyday life and certainly opposite disasters. 17,20,21 The last four decades has seen the systematic and ongoing division of wealth and rising income inequity, 22,23 which will only serve to compound this community-level vulnerability. ...
Article
The current emergency standards for training, exercises, communication, coordination, and response utilized by the United States (US) healthcare system are inadequate to meet patient needs before, during, and after disasters. Through a focused review of the literature and supporting expert interviews, this study aims to identify major barriers to US healthcare system resiliency in an emergency management context. Findings include that organizations across the healthcare system remain fragmented, often acting as standalone entities instead of being part of a larger ecosystem, which weakens the overall healthcare response framework. Despite advances in collaborative technology, many healthcare organizations rely on technologies that cannot meet their needs during a major emergency or disaster. Additionally, this research indicates that training and education standards need updates to match current and future disaster healthcare needs. Finally, based on the findings, seven recommendations were made as a starting point to what must be an ongoing discussion. While the recommendations are based on data from the US, this research has both national and international implications.
... It is unclear whether access to HPV vaccine information and limited knowledge about HPV vaccines persists as a key barrier to vaccine uptake among immigrant parents living in surburban, higher socioeconomic areas. Prior studies in suburban communities have shown that while these areas have higher unadjusted access to health care overall, a large proportion of surburban residents lack access to health care and remain medically vulnerable [13,14]. Studying this population may provide a better understanding of why HPV vaccine knowledge and HPV vaccine uptake remain lower in New Jersey compared to neighboring metropolitan areas such as Philadelphia and New York City [15] despite having higher education and socioeconomic status at the population level. ...
Article
Full-text available
Background Suboptimal human papillomavirus (HPV) vaccination rates persist among adolescents in the United States (U.S.). New Jersey (NJ), among the top, most racially/ethnically diverse states in the U.S., had among the lowest HPV vaccine initiation rates, prior to 2018. This study examined parental HPV vaccine knowledge and adolescent HPV vaccine initiation among multiethnic parents in NJ, where access to language concordant HPV vaccine information and vaccination services may differ, for immigrant parents. Methods We surveyed parents of adolescents (ages 11–18) at community events in NJ to examine parental HPV vaccine knowledge and adolescent HPV vaccine uptake. Vaccine knowledge was assessed using an 11-item question stem that covered vaccine efficacy, gender recommendation, vaccine protection, and myths. Multivariable models assessed the association of parent nativity on HPV vaccine knowledge scores and adolescent HPV vaccine initiation, controlling for sociodemographic factors. Results Of the 77 parents, most parents (84%) were aware of the HPV vaccine. However, knowledge scores were low and differed by parent nativity. Non-U.S. born parents had significantly lower knowledge scores − 1.7 [− 3.1, − 0.4] and lower odds of adolescent children initiating the HPV vaccine 0.3 [0.1, 0.9] compared to U.S.-born parents after adjusting demographic characteristics. Conclusions Our findings reveal that parental HPV vaccine knowledge remains low among suburban dwelling, immigrant parents, even though they have higher education and access to health care. Multilevel strategies to reduce missed opportunities for HPV vaccine education among parents and HPV vaccination for adolescents are needed, including for suburban, immigrant communities.
... Relatedly, another barrier is the suboptimal distribution of PrEP-providing clinics in relation to populations in need in suburban communities. We have reported that suburban areas have fewer PrEP-providing clinics per PrEP-eligible MSM (1.9 clinics per 1,000 MSM) than any other urbanicity type, including rural areas (2.5 clinics per 1,000 MSM).28 Lastly, over time, persons in suburban areas have been increasingly affected by rising levels of poverty and other socioeconomic inequities that have made accessing health care services in these areas challenging.56 Considering these barriers, suburban communities in the United States may need targeted interventions to establish more PrEP-providing clinics, including clinics with financial navigation services and services for uninsured populations, to serve MSM at high risk for HIV infection residing in such communities. ...
Article
Purpose The US HIV epidemic has become a public health issue that increasingly affects men who have sex with men (MSM), including those residing in nonurban areas. Increasing access to pre-exposure prophylaxis (PrEP) in nonurban areas will prevent HIV acquisition and could address the growing HIV epidemic. No studies have quantified the associations between PrEP access and PrEP use among nonurban MSM. Methods Using 2020 PrEP Locator data and American Men's Internet Survey data, we conducted multilevel log-binomial regression to examine the association between area-level geographic accessibility of PrEP-providing clinics and individual-level PrEP use among MSM residing in nonurban areas in the United States. Findings Of 4,792 PrEP-eligible nonurban MSM, 20.1% resided in a PrEP desert (defined as more than a 30-minute drive to access PrEP), and 15.2% used PrEP in the past 12 months. In adjusted models, suburban MSM residing in PrEP deserts were less likely to use PrEP in the past year (adjusted prevalence ratio [aPR] = 0.35; 95% confidence interval [CI] = 0.15, 0.80) than suburban MSM not residing in PrEP deserts, and other nonurban MSM residing in PrEP deserts were less likely to use PrEP in the past year (aPR = 0.75; 95% CI = 0.60, 0.95) than other nonurban MSM not residing in PrEP deserts. Conclusions Structural interventions designed to decrease barriers to PrEP access that are unique to nonurban areas in the United States are needed to address the growing HIV epidemic in these communities.
... Persons living in these counties might experience unique challenges in accessing vaccination. For example, residents of large fringe metropolitan counties might face socioeconomic challenges, including substantial barriers to accessing health care services (6,7). COVID-19 vaccination coverage has been lower in rural than in urban areas, and persons in rural areas are more likely to travel outside their county of residence for vaccination (8). ...
... Persons living in these counties might experience unique challenges in accessing vaccination. For example, residents of large fringe metropolitan counties might face socioeconomic challenges, including substantial barriers to accessing health care services (6,7). COVID-19 vaccination coverage has been lower in rural than in urban areas, and persons in rural areas are more likely to travel outside their county of residence for vaccination (8). ...
... Contextual factors associated with COVID-19 variation, such as the location of specific industries (e.g. agriculture, meat packing(1, 11)), overcrowding, political ideology (12), preexisting policy environments (13), and health care resources (14) differ substantially between urban, suburban, and rural places. Similarly, the composition of these geographies differs substantially: cities have younger populations than other geographies; larger immigrant populations live in urban and suburban areas than rural(15); rural residents have higher rates of chronic disease (16); and consistently rural areas vote conservative, suburbs increasingly lean democratic, and urban areas reliably vote democratic (17), although this may also reflect voter suppression and disengagement rather than composition (18). ...
Article
In their commentary, Zalla et al. argue that the approach taken by Centers for Disease Control (CDC) comparing the proportion of COVID-19 deaths by race/ethnicity to a weighted population distribution ignores how systemic racism structures the composition of places. While the CDC has abandoned their measure, they do so because of the changing geographic distribution of COVID-19, not because the measure underestimates racial disparities. We further Zalla et al.’s argument, advocating for a relational approach to estimating COVID-19 racial inequities that integrates the reciprocal relationship between context and composition through the interaction of places and people over time. To support our argument, we present a series of figures exploring the heterogeneous relationships between places, people, and time, using US county-level publicly available COVID-19 mortality data from February to December 2020 from Johns Hopkins University. Longitudinal and more geographically granular data that allows for disaggregation by person, place, and time will improve our estimation and understanding of inequities in COVID-19.
... Rurality is associated with poor health outcomes, 6,7 as well as inhospital mortality 8 and a variety of health risk factors. [9][10][11][12] While urban core areas have historically had higher rates of uninsurance and poor health outcomes than suburban areas, 13 this has not been explored in the context of SMM. Location could be a factor influencing Black women's outcomes, particularly in underserved rural areas or dense urban cores. ...
Article
Background: Severe maternal morbidity is related to maternal mortality and an important measure of maternal health outcomes. Our objective was to evaluate differences in rates of severe maternal morbidity and mortality (SMM&M) by rurality and race, and examine these trends over time. Materials and Methods: It involves the retrospective cohort study of delivery hospitalizations from January 1, 2012 to December 31, 2017 from the National Inpatient Sample. We identified delivery hospitalizations using International Classification of Diseases, Ninth Revision, Clinical Modification and International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis and procedure codes and diagnosis-related groups. We used hierarchical regression models controlling for insurance status, income, age, comorbidities, and hospital characteristics to model odds of SMM&M. Results: The eligible cohort contained 4,494,089 delivery hospitalizations. Compared with women from small cities, women in the most urban and most rural areas had higher odds of SMM&M (urban adjusted odds ratio [aOR] 1.09, 95% confidence interval [1.04-1.14]; noncore rural aOR 1.24 [1.18-1.31]). Among White women, the highest odds of SMM&M were in noncore rural counties (aOR 1.20 [1.12-1.27]), while among Black women the highest odds were in urban (aOR 1.21 [1.11-1.31]) and micropolitan areas (aOR 1.36 [1.19-1.57]). Findings were similar for Hispanic, Native American, and other race women. Rates of SMM&M increased from 2012 to 2017, especially among urban patients. Conclusions: Women in the most urban and most rural counties experienced higher odds of SMM&M, and these relationships differed by race. These findings suggest particular areas for clinical leaders and policymakers to target to reduce geographic and racial disparities in maternal outcomes.
... While studies have pointed to higher infection and spread of COVID-19 in metro compared to non-metro areas (Hamidi et al., 2020), and in more deprived neighborhoods of Louisiana (Oral et al., 2020), there has been limited examination of spatial inequities in COVID-19 between geographies. Given the economic and social interdependence of suburbs and cities, metropolitan-level COVID-19 policies can help reduce variability in outcomes and ensure access to testing and treatment across suburbs and cities, including 40% of the uninsured population who live in the suburbs (Schnake-Mahl and Sommers, 2017). The NOLA success in the second peak and high infection and positivity rates in nearby areas emphasize the importance of allowing local authority to determine stricter policies to protect their populations. ...
Preprint
Full-text available
The national COVID-19 conversation in the US has mostly focused on urban areas, without sufficient examination of another geography with large vulnerable populations: the suburbs. While suburbs are often thought of as areas of uniform affluence and racial homogeneity, over the past 20 years, poverty and diversity have increased substantially in the suburbs. In this study, we compare geographic and temporal trends in COVID-19 cases and deaths in Louisiana, one of the few states with high rates of COVID-19 during both the spring and summer. We find that incidence and mortality rates were initially highest in New Orleans. By the second peak, trends reversed: suburban areas experienced higher rates than New Orleans and similar rates to other urban and rural areas. We also find that increased social vulnerability was associated with increased positivity and incidence during the first peak. During the second peak, these associations reversed in New Orleans while persisting in other urban, suburban, and rural areas. The work draws attention to the high rates of COVID-19 cases and deaths in suburban areas and the importance of metropolitan-wide actions to address COVID-19. Registration N/A Funding source NIH (DP5OD26429) and RWJF (77644) Code and data availability Code for replication along with data is available here: https://github.com/alinasmahl1/COVID_Louisiana_Suburban/ .
... Our work indicates that between 2005 and 2015, the suburbs had on average lower rates of uninsurance and barriers to health care, but this advantage relative to urban areas fell over the study period and had disappeared by 2015. Nearly 40% of low-income suburban residents had an unmet care need due to cost in the past year, suggesting that if low-income residents move out of or are displaced to the suburbs, they likely face substantial barriers accessing care [125]. Further, a small body of literature has begun to examine gentrification in suburban areas [126]. ...
Article
Despite a proliferation of research on neighborhood effects on health, how neighborhood economic development, in the form of gentrification, affects health and well-being in the USA is poorly understood, and no systematic assessment of the potential health impacts has been conducted. Further, we know little about whether health impacts differ for residents of neighborhoods undergoing gentrification versus urban development, or other forms of neighborhood socioeconomic ascent. We followed current guidelines for systematic reviews and present data on the study characteristics of the 22 empirical articles that met our inclusion criteria and were published on associations between gentrification, and similar but differently termed processes (e.g., urban regeneration, urban development, neighborhood upgrading), and health published between 2000 and 2018. Our results show that impacts on health vary by outcome assessed, exposure measurement, the larger context-specific determinants of neighborhood change, and analysis decisions including which reference and treatment groups to examine. Studies of the health impacts of gentrification, urban development, and urban regeneration describe similar processes, and synthesis and comparison of their results helps bridge differing theoretical approaches to this emerging research. Our article helps to inform the debate on the impacts of gentrification and urban development for health and suggests that these neighborhood change processes likely have both detrimental and beneficial effects on health. Given the influence of place on health and the trend of increasing gentrification and urban development in many American cities, we discuss how future research can approach understanding and researching the impacts of these processes for population health.
... Vegetation index derived from remotely sensed data can potentially serve as a proxy for pollen release, which is closely associated with the spring leaf unfolding and thereafter flowering (Khwarahm et al., 2017). Satellite observations are able to offer the information on advancement or delay of vegetation phenology, which is helpful to mitigate risks of pollen induced allergies (Schnake-Mahl and Sommers, 2017). However, studies on the relationship between vegetation phenology and pollen concentration are still limited. ...
Article
Pollen released by vegetation in urban and surrounding rural areas is an important risk factor for respiratory allergies. Mapping the onset, duration, and severity of pollen is difficult, because of insufficient stations and/or monitoring networks at the national and international levels. To address this challenge, we evaluated the spatiotemporal relationship between satellite derived vegetation phenology and in-situ station derived information of pollen season during 2001–2015 at five stations in Canada. First, we calculated annual indicators of start of season (SOS) and start of pollen season (SPS) for birch from Landsat time series and pollen concentration data, respectively, at the five stations. Second, we explored the relationship between derived indicators of SOS and SPS and investigated the scale effect on the relationship. Our results indicate the Landsat based SOS is a good proxy for the indicator of SPS in the birch dominated area. The mean SOS and SPS in the study period are close (within 2.7 days) across the five stations. The interannual variability of SOS and SPS suggests the satellite derived phenology indicator can capture well the dynamics of pollen season in spring. Our analysis also indicates that the annual SOS at a finer resolution (30 m) is more consistent with SPS as compared to the indicators derived from coarser resolution satellite observations. This study shows the potential of using fine spatial resolution satellite data (e.g., Landsat) to derive the pollen season indicators, which is important for predicting pollen season severity and risk, and assessment of their impacts on respiratory allergies in urban domains.
... The maps depicted here are our own and were created using data from among the 50,510 NJCEED-enrolled women included in the analysis ( Fig. 3a and b) and New Jersey State cervical cancer incidence and mortality data retrieved from www.statecancerprofiles.cancer.gov (Fig. 3c and d) utilization among individuals residing in the most inner city, socioeconomically deprived areas compared to those residing in less socioeconomically deprived areas outside of the immediate inner city [22][23][24][25][26]. Furthermore, geographic variations in testing across the state and lower screening rates in specific NJCEED Program areas, particularly more rural areas with low SES women, warrants a focus on targeted strategies for women living in these areas who may face different barriers than urban, minority women. ...
Article
Full-text available
Background: Current cervical cancer screening guidelines recommend a Pap test every 3 years for women age 21-65 years, or for women 30-65 years who want to lengthen the screening interval, a combination of Pap test and high-risk human papilloma virus testing (co-testing) every 5 years. Little population-based data are available on human papilloma virus test utilization and human papilloma virus infection rates. The objective of this study was to examine the patient-level, cervical cancer screening, and area-level factors associated with human papilloma virus testing and infection among a diverse sample of uninsured and underinsured women enrolled in the New Jersey Cancer Early Education and Detection (NJCEED) Program. Methods: We used data for a sample of 50,510 uninsured/underinsured women, age ≥ 29 years, who screened for cervical cancer through NJCEED between January 1, 2009 and December 31, 2015. Multivariable logistic regression models were used to estimate associations between ever having a human papilloma virus test or a positive test result, and individual- (age, race/ethnicity, birthplace) and area-level covariates (% below federal poverty level, % minority, % uninsured), and number of screening visits. Results: Only 26.6% (13,440) of the sample had at least one human papilloma virus test. Among women who underwent testing, 13.3% (1792) tested positive for human papilloma virus. Most women who were positive for human papilloma virus (99.4%) had their first test as a co-test. Human papilloma virus test utilization and infection were significantly associated with age, race/ethnicity, birthplace (country), and residential area-level poverty. Rates of human papilloma virus testing and infection also differed significantly across counties in the state of New Jersey. Conclusions: These findings suggest that despite access to no-cost cervical cancer screening for eligible women, human papilloma virus test utilization was relatively low among diverse, uninsured and underinsured women in New Jersey, and test utilization and infection were associated with individual-level and area-level factors.
Article
Objective: To determine whether there are differences in healthcare utilization for chronic pain based on location (rural vs urban/suburban) or healthcare system (civilians vs Military Service Members and Veterans [SMVs]) after moderate-severe TBI. Setting: Eighteen Traumatic Brain Injury Model Systems (TBIMS) Centers. Participants: A total of 1,741 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview. Primary measures: Sociodemographic, injury, function outcome, pain, and pain treatment characteristics. Results: Participants were mostly male (72.9%), White (75.2%), civilian (76.9%), 46 years old on average, and had greater than high school education (59.9%). 32% of participants resided in rural areas and 67% in urban/suburban areas. No significant difference in healthcare utilization for chronic pain was observed between individuals living in rural versus urban/suburban locations after adjustment for relevant covariates. However, rural SMVs had odds ratios >3 for each major treatment category including medical services (OR = 3.56), exercise therapies (OR = 5.23), psychological services (OR = 4.43), complementary and alternative therapies (OR = 3.23), and pain rehabilitation program (OR = 4.16) compared to rural civilians. This same pattern of findings was seen SMVs in urban/suburban settings as well. Being married versus single, bachelor/graduate education versus high school or less, and employed versus unemployed all had odds ratios >1 for exercise therapies, psychological services, complementary and alternative therapies, and pain rehab program. Conclusion: Contrary to initial hypotheses, there were no significant differences in healthcare utilization for chronic pain treatment comparing those in rural versus urban/suburban areas. However, differences were found between SMVs and civilians across both rural and urban/suburban locations suggesting that SMVs have more access to chronic pain treatment. The improved access to social and financial services afforded by VHA programs to SMVs may serve as a model for improving healthcare utilization in similar civilian populations.
Article
Climate warming and the growing urban heat island effect are exacerbating the unequal public health crisis in megacities, and thus it is important to assess the equity of matching relationship between the healthcare services and the heat exposure risk. We selected 255 census units in Tianjin city for the study, and calculated a heat exposure index based on the universal thermal climate index (UTCI) and constructed a comprehensive urban healthcare services evaluation system to measure the degree of mismatch between the two. The results showed the following. (1) The heat exposure risk and healthcare services followed an increasing pattern from the Outer suburb area (OSA) to the Metropolitan development area (MDA) and then to the Main urban area (MUA). (2) The overall imbalance in matching was low in the OSA, whereas the healthcare services were relatively insufficient in the MDA, and the heat exposure risk and healthcare services were relatively balanced in the MUA. (3) The degree of matching between the core and peripheral parts of the MUA was severely polarized, with an overall pattern of excess healthcare in the core area and a high risk of heat exposure in the peripheral areas. The results can provide effective guidance for rationalizing the allocation of healthcare resources from a heat exposure perspective, and provide a policy basis for risk management and fund investment.
Article
Purpose Recent studies have demonstrated an increased risk of severe maternal morbidity (SMM) for people living in rural versus urban counties. Studies have not considered rurality at the more nuanced subcounty census‐tract level. This study assessed the relationship between census‐tract‐level rurality and SMM for birthing people in California. Methods We used linked vital statistics and hospital discharge records for births between 1997 and 2018 in California. SMM was defined by at least 1 of 21 potentially fatal conditions and lifesaving procedures. Rural‐Urban Commuting Area codes were used to characterize census tract rurality dichotomously (2‐category) and at 4 levels (4‐category). Covariates included sociocultural‐demographic, pregnancy‐related, and neighborhood‐level factors. We ran a series of mixed‐effects logistic regression models with tract‐level clustering, reporting risk ratios and 95% confidence intervals (CIs). We used the STROBE reporting guidelines. Findings Of 10,091,415 births, 1.1% had SMM. Overall, 94.3% of participants resided in urban/metropolitan and 5.7% in rural tracts (3.9% micropolitan, 0.9% small town, 0.8% rural). In 2‐category models, the risk of SMM was 10% higher for birthing people in rural versus urban tracts (95% CI: 6%, 13%). In 4‐category models, the risk of SMM was 16% higher in micropolitan versus metropolitan tracts (95% CI: 12%, 21%). Conclusion The observed rurality and SMM relationship was driven by living in a micropolitan versus metropolitan tract. Increased risk may result from resource access inequities within suburban areas. Our findings demonstrate the importance of considering rurality at a subcounty level to understand locality‐related inequities in the risk of SMM.
Article
Full-text available
Suburban inequality is the focus of this double issue of RSF: The Russell Sage Foundation Journal of the Social Sciences. This introduction addresses the limited related scholarship, describes how inequality unfolds differently in suburban communities than in urban and rural communities, and draws attention to urgent issues related to stratification between and within suburban communities. We argue that inattention to the study of suburban space, methodological and disciplinary silos, and the changing nature of the suburbs have left large holes in our understanding of how inequality operates. This critical review covers areas such as measurement, forgotten suburban scholarship, demographic change, suburban poverty, social supports, race, immigration, education, politics, policing, and future directions for suburban studies. In our call for resisting amnesia, we also draw attention to forgotten suburban histories and studies of a diverse range of suburban communities.
Article
Nonprofits provide a range of human and social services in the United States, producing what some call the delegated welfare state. The authors aim to quantify inequities in nonprofit service provision by focusing on two types of vulnerabilities: spatial and socio-demographic. Specifically, the authors develop a service accessibility index to identify mismatch between population demand and locational supply of nonprofits. The authors apply the index to an original data set of more than 1,500 immigrant-serving legal and health organization in California, Nevada, and Arizona. The authors find that immigrants living in rural areas are underserved, especially in access to justice, compared with those in metropolitan areas but that residents of smaller cities have better access, especially to health services, than those in larger cities. The service accessibility index not only brings such inequities into relief but raises critical questions about the determinants and consequences of service-access variability, for vulnerable immigrants and others dependent on the nonprofit safety net.
Chapter
Access to health care is a complex notion that has been explained in different ways by different authors. In the literature, the terms “access,” “availability,” and “utilization” have been used interchangeably to illustrate whether people’s care-related needs are provided effectively by the available health care services. Conceptualizations of access seek to understand the common elements outside of specific contexts; these concepts are then applied in the particular local contexts. Access to health care is recognized as the key influential factor for improved population health outcomes and health care system sustainability. Generally, access to health care is measured in relation to the utilization or availability of health care services. Many researchers had developed multiple dimensions to measure access to health care such as the behavioral model of Aday and Anderson (1974), and the three barrier-focused models of Penchansky and Thomas (1981), Russell et al. (2013), and Saurman (2016). The conceptual frameworks of access to health are categorized into two core approaches, which are the system-centered approach and the patient-centered approach. This chapter provides the history of the conceptual frameworks of access to health care in global public health and discusses some empirical research that applied these frameworks. Measuring access to health care could recognize barriers, in turn contributing effectively to addressing difficulties in order to improve access to health care services to many individuals who are in need to sensitive health care in their everyday lives.
Article
Introduction The purpose of this study was to examine geographic variation in the availability of and barriers to school-based mental health services. Methods A weighted, nationally representative sample of U.S. public schools from the 2017–2018 School Survey on Crime and Safety was used. Schools reported the provision of diagnostic mental health assessments and/or treatment as well as factors that limited the provision of mental health services. Availability of mental health services and factors limiting service provision were examined across rurality, adjusting for school enrollment and grade level. The analysis was conducted in December 2021. Results Half (51.2%) of schools reported providing mental health assessments, and 38.3% reported providing treatment. After adjusting for enrollment and grade level, rural schools were 19% less likely, town schools were 21% less likely, and suburban schools were 11% less likely to report providing mental health assessments than city schools. Only suburban schools were less likely than city schools to provide mental health treatment (incidence rate ratio=0.85; 95% CI=0.72, 1.00). Factors limiting the provision of services included inadequate access to professionals (70.9%) and inadequate funding (77.0%), which were most common among rural schools. Conclusions Significant inequities in school-based mental health services exist outside of urban areas.
Article
Background: Life expectancy in the United States has declined since 2014 but characterization of disparities within and across metropolitan areas of the country is lacking. Methods: Using census tract-level life expectancy from the 2010 to 2015 US Small-area Life Expectancy Estimates Project, we calculate 10 measures of total and income-based disparities in life expectancy at birth, age 25, and age 65 within and across 377 metropolitan statistical areas (MSAs) of the United States. Results: We found wide heterogeneity in disparities in life expectancy at birth across MSAs and regions: MSAs in the West show the narrowest disparities (absolute disparity: 8.7 years, relative disparity: 1.1), while MSAs in the South (absolute disparity: 9.1 years, relative disparity: 1.1) and Midwest (absolute disparity: 9.8 years, relative disparity: 1.1) have the widest life expectancy disparities. We also observed greater variability in life expectancy across MSAs for lower income census tracts (coefficient of variation [CoV] 3.7 for first vs. tenth decile of income) than for higher income census tracts (CoV 2.3). Finally, we found that a series of MSA-level variables, including larger MSAs and greater proportion college graduates, predicted wider life expectancy disparities for all age groups. Conclusions: Sociodemographic and policy factors likely help explain variation in life expectancy disparities within and across metro areas.
Article
This study examines exposure to four contextual Determinants of Health (cDOH): healthcare access (Medically Underserved Areas), socioeconomic condition (Area Deprivation Index), air pollution (Nitrogen Dioxide (NO2), Particulate Matter 2.5 (PM 2.5) and Particulate Matter 10 (PM 10)), and walkability (National Walkability Index) among residents of gentrifying and not gentrifying lower income neighborhoods in central cities for the 100 largest metropolitan regions in the US using their location in 2006 and 2019 based on individual level consumer trace data. Individuals who lived in gentrifying neighborhoods as of 2006 had more favorable cDOH in terms of MUA, ADI and Walkability Index and similar levels of pollution. Between 2006 and 2019, they experienced worse changes in MUAs, ADI, and Walkability Index but a greater improvement in exposure to air pollutants. The negative changes are driven by movers, while stayers actually experience a relative improvement in MUAs and ADI and larger improvements in exposure to air pollutants. The findings indicate that gentrification may contribute to health disparities through changes in exposure to cDOH through mobility to communities with worse cDOH among residents of gentrifying neighborhoods although results in terms of exposure to health pollutants are mixed.
Thesis
Full-text available
Quantitative measurement of the urban-rural continuum for examination of U.S. rural health disparities is a relatively new research area, where only a handful of studies have investigated health disparities using quantitative rural measures and even fewer have attempted to integrate health variables within said measures. Most U.S. rural health disparity studies and more specifically, rural colorectal cancer disparity studies, utilize various categorical and demographics/economics-based rural coding systems, which were not created for health disparity research. Further, both categorical rural classification schemes and more recent attempts to build quantitative health-focused measures are spatially and temporally static, which reduces translatability for study of cancer disparities across spatial units and time frames. In other words, to the knowledge of the author, no previous research has produced health-focused quantitative rural metrics that can be both flexibly translated to match the relevant time frames of health datasets and upscaled/downscaled to the desired spatial unit of analysis. Finally, spatial principles are inconsistently applied in rural colorectal cancer disparity studies, reducing inferential ability from results. Colorectal cancer is considered one of the most burdensome cancers for U.S. rural areas, so improvement of both measurement of the urban-rural divide for study of health disparities and application of spatial methods may help solidify findings of previous work. In this manuscript, there were two overarching goals: 1) construct spatiotemporal health disparity-focused continuous measurements of rural disadvantage that could be upscaled and downscaled and 2) utilize statistical and spatial methods to assess relationships between rural disadvantage and U.S. colorectal cancer mortality and screening. In Chapter 1, a county-level rural disadvantage index with integrated health factors was constructed using principal component analysis to weight ten rural indicator variables in three rural dimensions, followed by application to overall county-level cancer mortality via quantile regression. To the knowledge of the author, the index produced in this chapter is the first county-level quantitative rural measure with integrated health variables. Based on choropleth mapping, the constructed index showed improved numeric range and gradient over a popular existing rural measure while still retaining expected urban/rural trends. Spatiotemporal analysis showed only gradual change in index values for most U.S. counties, indicating stability over time. Results of the quantile regression showed that higher rural disadvantage index values were associated with higher cancer mortality rates, reflecting previous rural cancer disparity work. However, this effect was only present in the upper deciles of the probability distribution of mortality rates, indicating more complexity than previously understood. The county rural disadvantage index computed in this chapter should be considered a first step in attempting to integrate health variables into county-level quantitative rural measures. In Chapter 2, I applied the county-level rural disadvantage index to both global and local spatial models to explore rural colorectal cancer mortality and screening disparities. For the global mortality and screening linear models, Moran eigenvector spatial filtering was utilized to remove spatial autocorrelation from the residuals, while for the local models, geographically weighted regressions were used to determine if spatial non-stationarity existed in the relationships between rural disadvantage and both mortality and screening rates. To the best knowledge of the author, this paper constitutes the first instance of Moran eigenvector spatial filtering being used for spatial analysis of colorectal cancer mortality and screening. The global spatially filtered models displayed increasing colorectal cancer mortality rates and decreasing colorectal screening rates, respectively, as rural disadvantage increased, which reflected findings from previous work. In comparison to base global linear models, however, the magnitudes of effect of the spatially filtered models were reduced, displaying the importance of modeling spatial nuance. The geographically weighted regressions suggested that spatial non-stationarity existed in relationships between rural disadvantage and both mortality and screening, indicating the utility of local modeling. This Chapter provided a spatial modeling framework on which future rural colorectal cancer disparity analyses can account for spatial autocorrelation and spatial non-stationarity. In Chapter 3, the same rural indicator variables used in Chapter 1 were extended to construction of a sub-neighborhood grid-based rural disadvantage index for the state of Texas. A negative binomial hurdle model was then fit to examine the association between gridded index values and high spatial resolution colorectal cancer incidence-based mortality rates, while empirical Bayesian kriging and a spatial union procedure were also utilized to identify high colorectal cancer mortality risk-at-diagnosis areas. The rural disadvantage index produced in this chapter is the first sub-neighborhood quantitative rural measure produced for the state of Texas and the third sub-neighborhood quantitative rural measure for the U.S. more generally. Moreover, this paper is the first instance of empirical Bayesian kriging being utilized for cancer outcome spatial point data. Choropleth mapping showed that the constructed index had improved numeric range and gradient over an existing high resolution rural measure while mostly retaining expected urban/rural structure. The negative binomial hurdle model found that among Texas grid cells with at least one death, incidence-based mortality rates increased significantly as rural disadvantage values increased. The empirical Bayesian kriging procedure successfully identified high colorectal cancer mortality risk-at-diagnosis areas for the state of Texas, while the spatial union procedure displayed where these areas overlap with high rural disadvantage areas. The resulting sub-neighborhood maps have potential to inform where funding, colorectal cancer screening, and/or clinical services may best be micro-targeted.
Article
Full-text available
While the first wave of COVID-19 primarily impacted urban areas, subsequent waves were more widespread. Most analysis of Covid-19 rates examine state or metropolitan areas, ignoring potential heterogeneity within states and metro areas, over time, and between populations with differing contextual and compositional features. In this study, we compare spatial and temporal trends in Covid-19 cases and deaths in Louisiana, USA, over time and across populations and geographies (New Orleans, other urban areas, suburban, rural) and parish-level political lean. We employ publicly available longitudinal census tract and parish-level Covid-19 data reported from February 27th, 2020 to October 27th, 2021. We find that incidence and mortality rates were initially highest in New Orleans and Democratic areas and higher in other geographies and more conservative areas during subsequent waves. We also find wide relative disparities during the first wave, where increased social vulnerability was associated with increased positivity and incidence across geographies and political contexts. However, relative disparities diverged by geography and political lean and outcome across the remaining waves. This work draws attention to the differential rates of Covid-19 cases and deaths by geography, time, and population throughout the pandemic, and importance of political and geographic boundaries for rates of Covid-19.
Article
Eviction has been studied almost exclusively as an urban phenomenon. The growing suburbanization of poverty in the United States, however, provides new cause to analyze the prevalence and correlates of displacement beyond cities. This study analyzes urban-suburban disparities in eviction rates across 71 large metropolitan areas. We show that eviction is a common experience in suburbs as well as cities. Urban eviction rates exceed suburban rates in most cases, but in one in six metropolitan areas experienced higher eviction rates in the suburbs. Multilevel models show that key correlates of eviction—especially poverty and median rent—influence eviction patterns differently in urban and suburban contexts. We explore variations in urban-suburban disparities through case studies of Milwaukee, Seattle, and Miami. Metropolitan areas with larger shifts toward suburban poverty, more expensive urban rental markets, and more segregated suburbs experience more suburban evictions.
Article
Objective To evaluate associations of race/ethnicity and social determinants with 90-day rehospitalization for mental health conditions to acute care non-psychiatric children’s hospitals. Study design We conducted a retrospective cohort analysis of mental health hospitalizations for children aged 5 to 18 years from 2016-2018 at 32 freestanding U.S. children’s hospitals using the Children’s Hospital Association’s Pediatric Health Information System (PHIS) database to assess the association of race/ethnicity and social determinants (insurance payer, neighborhood median household income, and rurality of patient home location) with 90-day rehospitalization. Risk factors for rehospitalization were modeled using mixed-effects multivariable logistic regression. Results Among 23,556 index hospitalizations, there were 1382 mental health rehospitalizations (5.9%) within 90 days. Non-Hispanic Black children were 26% more likely to be rehospitalized than non-Hispanic White children (adjusted odds ratio [aOR] 1.26, 95% CI 1.08-1.48). Those with government insurance were 18% more likely to be rehospitalized than those with private insurance (aOR 1.18, 95% CI 1.04-1.34). In contrast, those living in a suburban location were 22% less likely to be rehospitalized than those living in an urban location (suburban: aOR 0.78, 95% CI 0.63-0.97). Conclusions Non-Hispanic Black children and those with public insurance were at highest risk for 90-day rehospitalization, and risk was lower in those residing in suburban locations. Future work could focus on upstream interventions that will best attenuate social disparities to promote equity in pediatric mental healthcare.
Article
Introduction: Although access to a motor vehicle is essential for pursuing social and economic opportunity and ensuring health and well-being, states have increasingly used driver's license suspensions as a means of compelling compliance with a variety of laws and regulations unrelated to driving, including failure to pay a fine or appear in court. Little known about the population of suspended drivers and what geographic resources may be available to them to help mitigate the impact of a suspension. Methods: Using data from the New Jersey Safety Health Outcomes (NJ-SHO) data warehouse 2004-2018, we compared characteristics of suspended drivers, their residential census tract, as well as access to public transportation and jobs, by reason for the suspension (driving or non-driving related). In addition, we examined trends in the incidence and prevalence of driving- and non-driving-related suspensions by sub-type over time. Results: We found that the vast majority (91%) of license suspensions were for non-driving-related events, with the most common reason for a suspension being failure to pay a fine. Compared to drivers with a driving-related suspension or no suspension, non-driving-related suspended drivers lived in census tracts with a lower household median income, higher proportion of black and Hispanic residents and higher unemployment rates, but also better walkability scores and better access to public transportation and jobs. Conclusions: Our study contributes to a growing literature that shows, despite public perception that they are meant to address traffic safety, the majority of suspensions are for non-driving-related events. Further, these non-driving-related suspensions are most common in low-income communities and communities with a high-proportion of black and Hispanic residents. Although non-driving-related suspensions are also concentrated in communities with better access to public transportation and nearby jobs, additional work is needed to determine what effect this has for the social and economic well-being of suspended drivers.
Article
Full-text available
Kentsel yoksulluğun, mekânsal ayrışmanın ve bunlara bağlı olarak sosyal dışlanmanın yoğun olduğu mekânlarda yaşanan sosyal sorunlar bu çalışmanın kapsamını oluşturmaktadır. Çalışmanın amacı; öteki mekânlardaki insanlarının yaşadıkları sosyal sorunları ortaya koymak ve bu sorunları sosyal poli-tika bakış açısıyla değerlendirmektir. Nitel araştırma yöntemine uygun olarak Web of Science Core Collection endekslerinde taranan öteki mekân çalışmalarında, yoksulluk, kent yoksulluğu, sosyal dışlanma, sosyal içerme ve sosyal politika anahtar kelimelerinin başlıklarında yer aldığı, son on yılda yayımlanan 42 makale derlenerek sosyal hizmet ve sosyal politika perspektifiyle içerik analizine tabi tutulmuştur. Yapılan analiz sonucunda slum, ghetto, squatter, favela, banliyö ve gecekondu gibi öteki mekânlarda rastlanan başlıca sorunların; kentsel yoksulluk, temel ihtiyaçların karşılanamaması, barınma ve altyapı hizmetlerinden yoksunluk, eşitsizlik, gecekondu turizmi, yoksulluğun temsili, sosyal dışlanma, toplum-sal sapma ve toplumsal cinsiyet ayrımcılığı olduğu bulunmuştur. Bu sosyal sorunların çözülebilmesi ve sosyal bütünleşmenin, sosyal gelişmenin sağlanabilmesi için sosyal hizmet uygulamalarına ve uygulanabilir sosyal politika önerilerine ihtiyaç duyulmaktadır. Anahtar Kelimeler: kentsel yoksulluk, sosyal dışlanma, öteki mekân, sosyal hizmet, sosyal politika
Article
Objectives. To examine the relationship between Medicaid expansion under the 2010 Patient Protection and Affordable Care Act and both HIV testing and risk behavior among nonelderly adults in the United States. Methods. We pooled 2010 to 2017 data from the Behavioral Risk Factor Surveillance System and focused our main analysis on respondents aged between 25 and 64 years from families with incomes below 138% of the federal poverty level. We used the difference-in-difference method and sample-weighted multivariable models to control for individual, state-area–level, and trend factors. Results. Medicaid expansion was associated with a significant 3.22-percentage-point increase in HIV test rates (P < .01) for individuals below 138% of the federal poverty level, with the largest impacts on non-Hispanic Blacks, age groups 35 to 44 years and 55 to 64 years, and rural areas. Expansion was not related to changes in HIV-related risk behavior. Conclusions. Medicaid expansion promoted HIV testing without increasing HIV risk behavior, but there were large disparities across race/ethnicity, age, and geographic area types. Public Health Implications. Nonexpansion states, mostly in the South, might have missed an opportunity to increase HIV test rates, which could have serious future health and financial consequences.
Article
Full-text available
The Affordable Care Act (ACA) completed its second open enrollment period in February 2015. Assessing the law's effects has major policy implications. To estimate national changes in self-reported coverage, access to care, and health during the ACA's first 2 open enrollment periods and to assess differences between low-income adults in states that expanded Medicaid and in states that did not expand Medicaid. Analysis of the 2012-2015 Gallup-Healthways Well-Being Index, a daily national telephone survey. Using multivariable regression to adjust for pre-ACA trends and sociodemographics, we examined changes in outcomes for the nonelderly US adult population aged 18 through 64 years (n = 507 055) since the first open enrollment period began in October 2013. Linear regressions were used to model each outcome as a function of a linear monthly time trend and quarterly indicators. Then, pre-ACA (January 2012-September 2013) and post-ACA (January 2014-March 2015) changes for adults with incomes below 138% of the poverty level in Medicaid expansion states (n = 48 905 among 28 states and Washington, DC) vs nonexpansion states (n = 37 283 among 22 states) were compared using a differences-in-differences approach. Beginning of the ACA's first open enrollment period (October 2013). Self-reported rates of being uninsured, lacking a personal physician, lacking easy access to medicine, inability to afford needed care, overall health status, and health-related activity limitations. Among the 507 055 adults in this survey, pre-ACA trends were significantly worsening for all outcomes. Compared with the pre-ACA trends, by the first quarter of 2015, the adjusted proportions who were uninsured decreased by 7.9 percentage points (95% CI, -9.1 to -6.7); who lacked a personal physician, -3.5 percentage points (95% CI, -4.8 to -2.2); who lacked easy access to medicine, -2.4 percentage points (95% CI, -3.3 to -1.5); who were unable to afford care, -5.5 percentage points (95% CI, -6.7 to -4.2); who reported fair/poor health, -3.4 percentage points (95% CI, -4.6 to -2.2); and the percentage of days with activities limited by health, -1.7 percentage points (95% CI, -2.4 to -0.9). Coverage changes were largest among minorities; for example, the decrease in the uninsured rate was larger among Latino adults (-11.9 percentage points [95% CI, -15.3 to -8.5]) than white adults (-6.1 percentage points [95% CI, -7.3 to -4.8]). Medicaid expansion was associated with significant reductions among low-income adults in the uninsured rate (differences-in-differences estimate, -5.2 percentage points [95% CI, -7.9 to -2.6]), lacking a personal physician (-1.8 percentage points [95% CI, -3.4 to -0.3]), and difficulty accessing medicine (-2.2 percentage points [95% CI, -3.8 to -0.7]). The ACA's first 2 open enrollment periods were associated with significantly improved trends in self-reported coverage, access to primary care and medications, affordability, and health. Low-income adults in states that expanded Medicaid reported significant gains in insurance coverage and access compared with adults in states that did not expand Medicaid.
Article
Full-text available
Background In recent years response rates on telephone surveys have been declining. Rates for the behavioral risk factor surveillance system (BRFSS) have also declined, prompting the use of new methods of weighting and the inclusion of cell phone sampling frames. A number of scholars and researchers have conducted studies of the reliability and validity of the BRFSS estimates in the context of these changes. As the BRFSS makes changes in its methods of sampling and weighting, a review of reliability and validity studies of the BRFSS is needed. Methods In order to assess the reliability and validity of prevalence estimates taken from the BRFSS, scholarship published from 2004–2011 dealing with tests of reliability and validity of BRFSS measures was compiled and presented by topics of health risk behavior. Assessments of the quality of each publication were undertaken using a categorical rubric. Higher rankings were achieved by authors who conducted reliability tests using repeated test/retest measures, or who conducted tests using multiple samples. A similar rubric was used to rank validity assessments. Validity tests which compared the BRFSS to physical measures were ranked higher than those comparing the BRFSS to other self-reported data. Literature which undertook more sophisticated statistical comparisons was also ranked higher. Results Overall findings indicated that BRFSS prevalence rates were comparable to other national surveys which rely on self-reports, although specific differences are noted for some categories of response. BRFSS prevalence rates were less similar to surveys which utilize physical measures in addition to self-reported data. There is very little research on reliability and validity for some health topics, but a great deal of information supporting the validity of the BRFSS data for others. Conclusions Limitations of the examination of the BRFSS were due to question differences among surveys used as comparisons, as well as mode of data collection differences. As the BRFSS moves to incorporating cell phone data and changing weighting methods, a review of reliability and validity research indicated that past BRFSS landline only data were reliable and valid as measured against other surveys. New analyses and comparisons of BRFSS data which include the new methodologies and cell phone data will be needed to ascertain the impact of these changes on estimates in the future.
Article
Full-text available
Findings An examination of neighborhood variation in access to social services in three metropolitan areas—Chicago, Los Angeles, and Washington, D.C.—finds that: n On average, poor populations in urban centers have greater spatial access to social services than poor populations living in suburban areas. In all three metropolitan areas, tracts with higher poverty rates are located in closer proximity to social service providers than tracts with lower poverty rates. On average, tracts with low poverty rates are within 1.5 miles of one-third, one-fifth, and one-quarter as many providers in metropolitan Chicago, Washington, D.C., and Los Angeles respectively, as tracts with high poverty rates. n While spatial access to social service providers is greatest in central city areas, potential demand for services is also much greater in central city areas than in subur-ban areas. Service providers in the city of Chicago are in proximity to ten times as many poor households as providers in suburban Chicago. Social service providers located in the District of Columbia are proximate to about six times more poor households than service providers in suburban Washington, depending on the particular service area. Because poverty is less centralized in Los Angeles, however, potential demand facing social service providers in central city is only about twice that of the potential demand in suburban areas. n The location of social service providers does not always match well to the changing demographic compositions of cities. Central city tracts that transitioned to a higher poverty status between 1990 and 2000 generally have less access to providers than tracts where poverty rates remained high over the past decade. In all three cities, suburban tracts experiencing significant increases in poverty rates between 1990 and 2000 were proximate to far fewer service providers than central city tracts experiencing such increases in the poverty rate. n High poverty central city tracts with large percentages of Hispanics are located within the greatest proximity to service providers. Access disparities also exist between whites and African-Americans in Los Angeles and Washington. These findings appear in large part to be a product of the patterns and degree of racial and ethnic segregation in each city. Governmental and non-governmental social service providers offering assistance to low-income populations locate in urban centers, near where disadvantaged populations are most concentrated and where services can be delivered most efficiently. However, the shifting geography of concentrated poverty, and the transformation of governmental assistance from cash to services, increases the importance of the location of these facilities, requiring greater attention from policymakers and service providers.
Article
Full-text available
Objectives. Given the recent rise of poverty in U.S. suburbs, this study asks: What poor neighborhoods are most disadvantageous, those in the city or those in the suburbs? Building on recent urban sociological work demonstrating the importance of neighborhood organizations for the poor, we are concerned with one aspect of disadvantage—the lack of availability of organizational resources oriented toward the poor. By breaking down organizations into those that promote mobility versus those that help individuals meet their daily subsistence needs, we seek to explore potential variations in the type of disadvantage that may exist. Methods. We test whether poor urban or suburban neighborhoods are more likely to be organizationally deprived by breaking down organizations into three types: hardship organizations, educational organizations, and employment organizations. We use data from the 2000 U.S. County Business Patterns and the 2000 U.S. Census and test neighborhood deprivation using logistic regression models. Results. We find that suburban poor neighborhoods are more likely to be organizationally deprived than are urban poor neighborhoods, especially with respect to organizations that promote upward mobility. Interesting racial and ethnic composition factors shape this more general finding. Conclusion. Our findings suggest that if a poor individual is to live in a poor neighborhood, with respect to access to organizational resources, he or she would be better off living in the central city. Suburban residence engenders isolation from organizations that will help meet one's daily needs and even more so from those offering opportunities for mobility.
Article
Full-text available
An analysis of trends in hospital use and capacity by ownership status and community poverty levels for large urban and suburban areas was undertaken to examine changes that may have important implications for the future of the hospital safety net in large metropolitan areas. Using data on general acute care hospitals located in the 100 largest cities and their suburbs for the years 1996, 1999, and 2002, we examined a number of measures of use and capacity, including staffed beds, admissions, outpatient and emergency department visits, trauma centers, and positron emission tomography scanners. Over the 6-year period, the number of for-profit, nonprofit, and public hospitals declined in both cities and suburbs, with public hospitals showing the largest percentage of decreases. By 2002, for-profit hospitals were responsible for more Medicaid admissions than public hospitals for the 100 largest cities combined. Public hospitals, however, maintained the longest Medicaid average length of stay. The proportion of urban hospital resources located in high poverty cities was slightly higher than the proportion of urban population living in high poverty cities. However, the results demonstrate for the first time, a highly disproportionate share of hospital resources and use among suburbs with a low poverty rate compared to suburbs with a high poverty rate. High poverty communities represented the greatest proportion of suburban population in 2000 but had the smallest proportion of hospital use and specialty care capacity, whereas the opposite was true of low poverty suburbs. The results raise questions about the effects of the expanding role of private hospitals as safety net providers, and have implications for poor residents in high poverty suburban areas, and for urban safety net hospitals that care for poor suburban residents in surrounding communities.
Book
Americans think of suburbs as prosperous areas that are relatively free from poverty and unemployment. Yet, today more poor people live in the suburbs than in cities themselves. In Places in Need, social policy expert Scott W. Allard tracks how the number of poor people living in suburbs has more than doubled over the last 25 years, with little attention from either academics or policymakers. Rising suburban poverty has not coincided with a decrease in urban poverty, meaning that solutions for reducing poverty must work in both cities and suburbs. Allard notes that because the suburban social safety net is less-developed than the urban safety net, a better understanding of suburban communities is critical for understanding and alleviating poverty in metropolitan areas. Using census data, administrative data from safety net programs, and interviews with nonprofit leaders in the Chicago, Los Angeles, and Washington, D.C. metropolitan areas, Allard shows that poor suburban households resemble their urban counterparts in terms of labor force participation, family structure, and educational attainment. In the last few decades, suburbs have seen increases in single-parent households, decreases in the number of college graduates, and higher unemployment rates. As a result, suburban demand for safety net assistance has increased. Concerning is evidence suburban social service providers�-which serve clients spread out over large geographical areas, and often lack the political and philanthropic support that urban nonprofit organizations can command-do not have sufficient resources to meet the demand. To strengthen local safety nets, Allard argues for expanding funding and eligibility to federal programs such as SNAP and the Earned Income Tax Credit, which have proven effective in urban and suburban communities alike. He also proposes to increase the capabilities of community-based service providers through a mix of new funding and capacity-building efforts. Places in Need demonstrates why researchers, policymakers, and nonprofit leaders should focus more on the shared fate of poor urban and suburban communities. This account of suburban vulnerability amidst persistent urban poverty provides a valuable foundation for developing more effective antipoverty strategies.
Article
Purpose: To analyze the differential rural-urban impacts of the Affordable Care Act Medicaid expansion on low-income childless adults' health insurance coverage. Methods: Using data from the American Community Survey years 2011-2015, we conducted a difference-in-differences regression analysis to test for changes in the probability of low-income childless adults having insurance in states that expanded Medicaid versus states that did not expand, in rural versus urban areas. Analyses employed survey weights, adjusted for covariates, and included a set of falsification tests as well as sensitivity analyses. Findings: Medicaid expansion under the Affordable Care Act increased the probability of Medicaid coverage for targeted populations in rural and urban areas, with a significantly greater increase in rural areas (P < .05), but some of these gains were offset by reductions in individual purchased insurance among rural populations (P < .01). Falsification tests showed that the insurance increases were specific to low-income childless adults, as expected, and were largely insignificant for other populations. Conclusions: The Medicaid expansion increased the probability of having "any insurance" for the pooled urban and rural low-income populations, and it specifically increased Medicaid coverage more in rural versus urban populations. There was some evidence that the expansion was accompanied by some shifting from individual purchased insurance to Medicaid in rural areas, and there is a need for future work to understand the implications of this shift on expenditures, access to care and utilization.
Article
It has been nearly a half century since President Lyndon Johnson declared war on poverty. Back in the 1960s tackling poverty “in place” meant focusing resources in the inner city and in rural areas. The suburbs were seen as home to middle- and upper-class families affluent commuters and homeowners looking for good schools and safe communities in which to raise their kids. But today’s America is a very different place. Poverty is no longer just an urban or rural problem, but increasingly a suburban one as well. In Confronting Suburban Poverty in America, Elizabeth Kneebone and Alan Berube take on the new reality of metropolitan poverty and opportunity in America. After decades in which suburbs added poor residents at a faster pace than cities, the 2000s marked a tipping point. Suburbia is now home to the largest and fastest-growing poor population in the country and more than half of the metropolitan poor. However, the antipoverty infrastructure built over the past several decades does not fit this rapidly changing geography. As Kneebone and Berube cogently demonstrate, the solution no longer fits the problem. The spread of suburban poverty has many causes, including shifts in affordable housing and jobs, population dynamics, immigration, and a struggling economy. The phenomenon raises several daunting challenges, such as the need for more (and better) transportation options, services, and financial resources. But necessity also produces opportunity in this case, the opportunity to rethink and modernize services, structures, and procedures so that they work in more scaled, cross-cutting, and resource-efficient ways to address widespread need. This book embraces that opportunity. Kneebone and Berube paint a new picture of poverty in America as well as the best ways to combat it. Confronting Suburban Poverty in America offers a series of workable recommendations for public, private, and nonprofit leaders seeking to modernize poverty alleviation and community development strategies and connect residents with economic opportunity. The authors highlight efforts in metro areas where local leaders are learning how to do more with less and adjusting their approaches to address the metropolitan scale of poverty for example, integrating services and service delivery, collaborating across sectors and jurisdictions, and using data-driven and flexible funding strategies. “We believe the goal of public policy must be to provide all families with access to communities, whether in cities or suburbs, that offer a high quality of life and solid platform for upward mobility over time. Understanding the new reality of poverty in metropolitan America is a critical step toward realizing that goal.”.
Article
Public transit is a critical part of the economic and social fabric of metropolitan areas. Nearly 30 million trips are made every day using public transit. Almost all of these trips occur in the nation’s 100 largest metro areas, which account for over 95 percent of all transit passenger miles traveled. People take transit for any number of reasons, but one of the most common is to get to work. However, when it comes to the question of how effectively transit connects people and jobs within and across these metropolitan areas, strikingly little is known. With governments at all levels considering deep budget cuts, it is increasingly important to understand not just the location and frequency of transit service, but ultimately how well transit aligns with where people work and live. To better understand these issues, the Metropolitan Policy Program developed a comprehensive database that provides the first comparable, detailed look at transit coverage and connectivity across and within the nation’s major metro areas. Nearly 70 percent of large metropolitan residents live in neighborhoods with access to transit service of some kind.In neighborhoods covered by transit, morning rush hour service occurs about once every 10 minutes for the typical metropolitan commuter. The typical metropolitan resident can reach about 30 percent of jobs in their metropolitan area via transit in 90 minutes. About one-quarter of jobs in low- and middle-skill industries are accessible via transit within 90 minutes for the typical metropolitan commuter, compared to one-third of jobs in high-skill industries.
Article
The Affordable Care Act enables young adults to remain as dependents on their parents' health insurance until age twenty-six, and recent evidence suggests that as many as three million young adults have gained coverage as a result. However, there has been no evidence yet on the policy's effect on access to care, and questions remain about the coverage impact on important subgroups. Using data from two nationally representative surveys, comparing young adults who gained access to dependent coverage to a control group (adults ages 26-34) who were not affected by the new policy, we found sizable coverage gains for adults ages 19-25. The gains continued to grow throughout 2011 (up 6.7 percentage points from September 2010 to September 2011), with the largest gains seen in unmarried adults, nonstudents, and men. Analysis of the timing of the policy impact suggested that early gains in coverage were greatest for people in worse health. We found strong evidence of increased access to care because of the law, with significant reductions in the number of young adults who delayed getting care and in those who did not receive needed care because of cost.
Article
Community health centers have evolved from fringe providers to mainstays of many local health care systems. Those designated as federally qualified health centers (FQHCs), in particular, have largely established themselves as key providers of comprehensive, efficient, high-quality primary care services to low-income people, especially Medicaid and uninsured patients. The Center for Studying Health System Change's (HSC's) site visits to 12 nationally representative metropolitan communities since 1996 document substantial growth in FQHC capacity, based on growing numbers of Medicaid enrollees and uninsured people, increased federal support, and improved managerial acumen. At the same time, FQHC development has varied considerably across communities because of several important factors, including local health system characteristics and financial and political support at federal, state and local levels. Some communities--Boston; Syracuse, N.Y.; Miami; and Seattle--have relatively extensive FQHC capacity for their Medicaid and uninsured populations, while other communities--Lansing, Mich.; northern New Jersey; Indianapolis; and Greenville, S.C.--fall in the middle. FQHC growth in Phoenix; Little Rock, Ark.; Cleveland; and Orange County, Calif.; has lagged in comparison. Today, FQHCs seem poised to play a key role in federal health care reform, including coverage expansions and the emphasis on primary care and medical homes.
Melting pot cities and suburbs: racial and ethnic change in metro America in the 2000s. Washington (DC): Brookings Institution, Metropolitan Policy Program
  • W H Frey
Frey WH. Melting pot cities and suburbs: racial and ethnic change in metro America in the 2000s. Washington (DC): Brookings Institution, Metropolitan Policy Program; 2011 May 4.
The growth and spread of concentrated poverty
  • E Kneebone
Kneebone E. The growth and spread of concentrated poverty, 2000 to 2008-2012. Washington (DC): Brookings Institution; 2014.
A shared destiny: community effects of uninsurance
  • Institute Of Medicine
Institute of Medicine. A shared destiny: community effects of uninsurance. Washington (DC): National Academies Press; 2002.
Assessing the cell phone challenge to survey research in 2010. Presentation to: Annual meeting of the American Association for Public Opinion Research
  • L Christian
  • S Keeter
  • K Purcell
  • A Smith
Christian L, Keeter S, Purcell K, Smith A, editors. Assessing the cell phone challenge to survey research in 2010. Presentation to: Annual meeting of the American Association for Public Opinion Research; 2010 May 13-16;
Washington (DC): Center for Studying Health System Change
  • L E Felland
  • J R Lauer
  • P J Cunningham
Felland LE, Lauer JR, Cunningham PJ. Suburban poverty and the health care safety net [Internet]. Washington (DC): Center for Studying Health System Change; 2009 Jul [cited 2017