Eliminating health disparities among segments of the population is one of the two goals of Healthy People 2010 - the United State national statement on health objectives. Achieving the goals needs effective public policies that require precise and consistent measures of quality of health and health inequalities. Following recent developments in measuring quality of health and health inequality, we use self-assessed health status conditioned by several objective determinants as a comprehensive measure of individual quality of health. The individual quality of health is used to measure health inequality between and within racial/ethnic groups of the U.S. population as well as within states. In addition, we also measure quality of health and health inequality between and within groups of a smaller population, which is the New York State population and across 17 geographic areas of New York State.
As different groups have different demographic and socioeconomic characteristics, the causes of health inequality within groups may vary. Decomposition analysis is conducted to determine the contribution of each factor to health inequality between and within racial/ethnic groups.
An index of individual health is estimated based on self-assessed health status conditioned by several objective determinants including different diseases/risk factors and socio-demographic characteristics in an ordered Probit framework, in which the threshold parameters are scaled to control for heterogeneity. Based on the index, three types of health inequality—total health inequality, income-related health inequality, and racial/ethnic inequality in health—are calculated using Gini coefficient, concentration index, and disparity index, respectively. In addition, Health Adjusted Life Expectancy is also computed based on the estimated health index and U.S. life tables. The presence of health inequality is not only between groups or states but also within groups or states. The Inequalities are particularly high within groups or states with low quality of health. American Indian/Alaskan Natives have the lowest quality of health as well as the highest total and income-related health inequalities; and Kentucky and West Virginia have the lowest quality of health and the highest health inequalities.
For policy purposes, it is important to distinguish the sources of health inequality between and within groups of the population. Health disparities between non-Hispanic Withes and other minority groups are decomposed into socio-demographic factors, and so do the total and income-related health inequalities within each group.
Whereas 72% of health disparity between non-Hispanic Whites and Blacks is attributable to the inferior endowments of Blacks, it is only 50% for Hispanics compared Whites. On average Asians have better health than Whites, but this is mainly due to better endowments (Asians are much younger in the sample); however, the coefficient estimates favor Whites. For American Indians and Alaskan Natives (AIANs), endowments account for 65% in favor of Whites. Interestingly, the intercept contributes 28% to the disparity in favor of AIANs, suggesting the efficacy of various socio-economic programs sponsored by US Government to improve the quality of health of AIANs.
The strongest factors contributing to within-groups health inequalities are employment, education, income, and age. The contribution of each of these factors varies considerably among racial/ethnic groups. For example, employment is the strongest factor contributing to total health inequality within AIANs and Blacks, but within Hispanics income and education are the most important factors.
Using the same methods as presented in chapter 2, we study quality of health, total health inequality, income-related health inequality within each of racial/ethnic groups as well as across 17 geographic areas of New York State. American Indian/Alaskan Natives and Hispanics are found to do the worst. Interestingly, the worst health and health inequality are found in Bronx – the highest % of Blacks – and North Country – the lowest % of Blacks. While, two best geographic areas in both quality of health and health inequality are Nassau and Westchester. These two regions have a rather high percent of minorities. Three major contributing factors to income-related health inequality are found to be income, employment, and education. However, the contribution of each of these determinants varies significantly among racial/ethnic groups as well as across geographic areas, for example, in North Country 42% of health disparity is explained by employment, while in Suffolk it is only 14%.
Our findings suggest that public health initiatives to eliminate health inequalities should be targeted differently for different racial/ethnic groups and regions by targeting the most vulnerable.