Trends and structural factors affecting health equity in the United States at the local level, 1990-2019

Abstract

Health equity is fundamental to improving the health of populations, but in recent decades progress towards this goal has been mixed. To better support this mission, a deeper understanding of the local heterogeneity within population-level health equity is vital. This analysis presents trends in average health and health equity in the United States at the local level from 1990 to 2019 using three different health outcomes: mortality, self-reported health status, and healthy days. Furthermore, it examines the association between these measures of average health and health equity with several structural factors. Results indicate growing levels of geographic inequality disproportionately impacting less urbanized parts of the country, with rural counties experiencing the largest declines in health equity, followed by Medium and Small Metropolitan counties. Additionally, lower levels of health equity are associated with poorer local socioeconomic context, including several measures that are proxies for structural racism. Altogether, these findings strongly suggest social and economic factors play a pivotal role in explaining growing levels of geographic health inequality in the United States. Policymakers invested in improving health equity must adopt holistic and upstream approaches to improve and equalize economic opportunity as a means of fostering health equity.

Keywords: Health equity; Population health; Social determinants of health; Structural racism.

Fig. 1

Distribution of County Grouping Average Health and Health Equity Metric Scores, 1990-2019. Notes: See Appendix Table 3 for County Groups definitions. Self-Reported Health and Healthy Days estimates are based on three-year aggregated files, where the data is assigned to the last year in the period. The gap between 2010 and 2013 in each of the BRFSS outcomes reflects changes to the sampling and weighting procedures of the complex survey design, which resulted in estimates up to 2010 not being comparable with those from afterwards (Centers for Disease Control and Prevention, 2012). Additionally, estimates from 1996 to 2010 are shifted so that 2010 value matches that of 2013, in order to account for complex survey redesign which occurred between 2010/2011. Source: Author’s Calculations from National Vital Statistics System and Behavior Risk Factor Surveillance System

Fig. 2

Trends in Average Health and Health Equity Metric Scores by Urbanicity, 1990-2019. Notes: Self-Reported Health and Healthy Days estimates are based on three-year aggregated files, where the data is assigned to the last year in the period. The gap between 2010 and 2013 in each of the BRFSS outcomes reflects changes to the sampling and weighting procedures of the complex survey design, which resulted in estimates up to 2010 not being comparable with those from afterwards (Centers for Disease Control and Prevention, 2012). Additionally, estimates from 1996 to 2010 are shifted so that 2010 value matches that of 2013. Source: Author’s Calculations from National Vital Statistics System and Behavior Risk Factor Surveillance System

Fig. 3

Health Inequity from Major Causes by Urbanicity, 1990-2019. Notes: This figure shows health inequity, as opposed to previous figures which show health equity. Health inequity for all causes sums up to the distance between the national Health Equity Metric and 100. Causes in the key are arranged from top to bottom in the figure. Deaths of Despair include mortalities attributed to drug overdose, suicide, and alcohol-related liver disease. Chronic conditions include mortalities attributed to respiratory disease, stroke, Alzheimer’s, kidney disease, flu, septicemia, and hypertension. Black vertical line represents the change from ICD-9 to ICD-10 cause of death coding. We adopt the comparability ratio methodology proposed by Anderson to make the two periods more comparable (R. N. Anderson et al., 2001). Source: Author’s Calculations from National Vital Statistics System.