Health Disparities in a “Browning” and “Graying” America: Implications and Challenges

James H. Johnson, Jr.

William Rand Kenan, Jr. Distinguished Professor of Management Kenan-Flagler Business School Director, Urban Investment Strategies Center Frank Hawkins Kenan Institute of Private Enterprise University of North Carolina at Chapel Hill

February 2007

I.

Overview

Health Disparities in North Carolina and Beyond II.

III.

Drivers of Change Challenges Ahead IV.

Implications for Health and Competitiveness of our State and Nation

February 2007

   

Lower Socioeconomic Status Associated With Fewer:

Pap smear tests Mammograms Childhood and influenza immunizations Diabetic eye exams

February 2007

Source: Fiscell, et al., 2000

  

Lower Socioeconomic Status Also Associated With:

Lower overall health care use Later enrollment in prenatal care Lower quality ambulatory and hospital care

February 2007

Source: Fiscell, et al., 2000

Race/Ethnic Group Status

   Less intensive/lower quality care Less often seen by specialists Less appropriate preventive care

February 2007

Source: Fiscell, et al., 2000

Blacks receive fewer…

      Cardiovascular procedures Lung resections for cancer Kidney and bone marrow transplants Cesarean Sections Peripheral Vascular procedures Orthopedic procedures

February 2007

Source: Fiscell, et al., 2000

Blacks are also less likely to receive…

      Aggressive treatment of prostate cancer Antiretrovirals for HIV infection Anti-depressants for depression Tympanostomy tubes Hospital Admissions for chest pain Quality Prenatal Care

February 2007

Source: Fiscell, et al., 2000

Elderly Blacks less likely to receive…

   Appropriate preventive care mammograms and flu-vaccinations Quality hospital care Expensive, technological procedures

February 2007

Source: Fiscell, et al., 2000

Latinas receive fewer…

    Mammograms Pap smear tests Influenza vaccinations Cardiovascular procedures

February 2007

Source: Fiscell, et al., 2000

Latinas also receive less…

  Prenatal care Analgesia for metastatic cancer and treatment

February 2007

Source: Fiscell, et al., 2000

Asians receives fewer…

  Pap smear tests Influenza vaccinations

February 2007

Source: Fiscell, et al., 2000

Native Americans receive less…

 Prenatal care

February 2007

Source: Fiscell, et al., 2000



Socioeconomic Status and Race/Ethnicity Associated with Potentially Avoidable Procedures:

Amputation   Orchrectomies Treatments of late stage cancer

February 2007

Source: Fiscell, et al., 2000

  

Socioeconomic Status and Race/Ethnicity also related to avoidable:

Hospitalizations Hospital Readmissions Untreated Disease

February 2007

Source: Fiscell, et al., 2000

      

Factors exacerbating SES and Race/Ethnic Disparities include:

Health care affordability Transportation and access Education Knowledge and literacy Patient attitudes and preferences Competing demands Provider bias

February 2007

Source: Fiscell, et al., 2000

Health Status of North Carolina Adults, 2002-2004 Ratio to Whites Race/Ethnic Group All White African American American Indian Asian/Pacific Islander Hispanic/Latino % in Fair or Poor Health 19.1

17.8

23.6

23.5

9.9

29.7

1.0

1.3

1.3

0.6

1.7

February 2007

Source: NC Department of Health and Human Services, Office of Minority Health and Disparities (2006)

Percent of North Carolina Adults(18+) Who Are Overweight/Obese, 2002-2004 Ratio to Whites Race/Ethnic Group All White African American American Indian Asian/Pacific Islander Hispanic/Latino % 61.4

58.6

72.8

70.0

29.7

59.8

1.0

1.2

1.2

0.5

1.0

February 2007

Source: NC Department of Health and Human Services, Office of Minority Health and Disparities (2006)

February 2007

Drivers of Change

   Rapid growth of foreign born population Aging of native born population “First” and “second” waves of globalization

February 2007

Immigration Population, 1900-2004 40 35 30 25 20 15 10.3

13.5 13.9 14.2

11.6 10.3 9.7 9.6

14.1

10 19.8

5 31.1

33.1 34.2

0 1900 1910 1920 1930 1940 1950 1960 Year 1970 1980 1990 2000 2002 2004 February 2007

Source: Center for Immigration Studies; U.S. Census Bureau, Current Population Survey

February 2007

February 2007

States with Fastest Growing Immigrant Populations, 1990-2000 274% 233% 202% 196% 171% 169% 165% 160% 136% 135%

States US Avg 57%

NC (1) GA (2) NV (3) AR (4) UT (5) TN (6) NE (7) CO (8) AZ (9) KY (10) February 2007

Source: 1990, 2000 U.S. Census

States with Fastest Growing Immigrant Populations, 2000-2005 47% 40% 40% 38% 38% 37% 34% 31% 30% 30%

States US Avg. 15%

SC (1) TN (2) DE (3) GA (4) AL (5) AR (6) NH (7) NV (8) NC (9) IN (10) February 2007

Source: 2000 U.S. Census, 2005 American Community Survey

States with Fastest Growing Hispanic Populations, 2000 2005 48% 46% 45% 45% 43% 43% 40% 39% 36% 36%

States US Avg 19%

AR (1) SC (2) GA (3) TN (4) NV (5) NC (6) NH (7) MD (8) AL (9) SD (10) February 2007

Source: 2000 U.S. Census

Blacks Return to the South Change in Population, 1990 2000 579,491

600,000 500,000 400,000 300,000 200,000 100,000 0 -100,000 -200,000 -300,000 -400,000

-387,019 -149,674 -42,798 Northeast Midwest South West February 2007

Net Population Change in North Carolina by Race and Hispanic or Latino Origin, 1990-2000 Race and Hispanic or Latino Total 2000 Population Net Gain 1990-2000 8,049,313 1,420,676 Percent Change 21.4% White Black or African American American Indian or Alaska Native 5,804,656 1,737,545 99,551 796,237 281,222 19,396 15.9% 19.3% 24.2% Asian Native Hawaiian and other Pacific Islander Some other race

Hispanic or Latino (of any race)

113,689 3,983 186,629

378,963

63,719 127.5% 1,787 81.4% 155,127 492.4%

302,237 393.9%

February 2007

Source: U.S. Bureau of the Census, American Fact Finder.

Net Population Change in North Carolina Race and Hispanic or Latino Origin, 2000-2005 Race and Hispanic or Latino Total 2005 Population 8,411,041 Net Gain 2000-2005 361,728 Percent Change 5% White Black or African American 6,005,471 1,765,698 200,815 28,153 3% 1% American Indian or Alaska Native Asian Native Hawaiian and other Pacific Islander Some Other Race

Hispanic or Latino (of any race)

106,931 146,795 3,344 257,169

533,087

7,380 33,106 -639 70,540

154,124

7% 29% -16% 38%

41%

February 2007

Source: US Census Bureau, 2004 American Community Survey; 2000 US Census

Population in North Carolina by Age and Hispanic Origin, 2004

February 2007

North Carolina Births by Race/Ethnicity, 1990 and 2003 1990 2003 % Change All Races White Black American Indian Asian/Pacific Islander

Hispanic

10,525 69,512 30,726 1,516 1,052

1,754

118,308 70,458 27,170 1,637 3,106

16,084

13.2

1.4

-11.6

8.0

195.2

817.0

February 2007

Source: Centers for Disease Control, National Vital Statistics Reports, 1990 and 2003

Net Change in Total and Hispanic Enrollment in NC Public Schools, 1985-2004 Years 1 1985-1990 1990-1995 1995-2000 2000-2004 Total Enrollment Change -3,558 90,378 95,472 78,755 Hispanic Enrollment Change 4,795 13,769 33,933 45,148 % Change 15.2

35.6

57.3

February 2007 Source

: North Carolina Department of Public Instruction, 2005 1 As of September of each school year

Hispanic Resident Costs and Benefits to State, 2004

Total Estimated Major Public Costs $816,559,000 Total Estimated Taxes Contributed Net Cost to State

($102 per Hispanic resident)

$755,520,000 $61,039,000



Broader Economic Benefits:



$9.2 billion in total NC Business Revenue

  

89,000 additional jobs $1.9 billion in overall statewide private-sector wage savings (1.4% of NC’s private sector wage bill) Increased labor output for NC industries February 2007

Aging America: U.S. Median Age, 1820-2000

40 35 30 25 20 15 10 5 0

18 20 18 30 18 40 18 50 18 60 18 70 18 80 18 90 19 00 19 10 19 20 19 30 19 40 19 50 19 60 19 70 19 80 19 90 20 00

February 2007

Source: U.S. Census Bureau, San Francisco Chronicle

Absolute and Relative Change in the Gender/Age Composition of the U.S. Population, 2000-2005 Gender/Age Total Male Female Age 18-34

Age 35-54

Age 55-64 Age 65+ 2005 Population 292,261,463 143,203,258 149,058,205 65,962,739

86,399,619

30,528,710 35,199,481 Net Change 2000-2005 10,839,557 5,149,695 5,689,862 -1,072,439

3,573,140

6,254,026 207,728 % Change 2000-2005 3.9% 3.7% 4.0% -1.6%

4.3%

25.8% 0.6% February 2007

Source: 2000 U.S. Census; 2005 American Community Survey, PUMS Estimates

Absolute and Relative Change in the Gender/Age Composition of the North Carolina Population, 1990-2000 Gender/Age 2000 Population Net Change 1990-2000 Percent Change 1990-2000 Total Male Female Age 18-34

Age 35-54

Age 55-64 Age 65+ 8,049,313 3,942,695 4,106,618 2,020,236

2,372,270

723,712 969,048 1,420,676 728,405 692,271 95,308

665,954

136,809 164,707 21.4% 22.6% 20.3% 4.9%

39.0%

23.3% 20.5% February 2007

Source: U.S. Bureau of Census (2000)

Absolute and Relative Change in the Gender/Age Composition of the North Carolina Population, 2000-2005 Gender/Age Total Male Female Age 18-34

Age 35-54

Age 55-64 Age 65+ 2005 Population 8,411,041 4,112,482 4,298,559 1,888,012

2,496,261

890,668 988,887 Net Change 2000-2005 361,728 169,787 191,941 -132,224

123,991

166,956 19,839 % Change 2000-2005 5% 4% 5% -7%

5%

23% 2% February 2007

Source: 2000 U.S. Census; 2004 American Community Survey

Age Profile of UNC-CH Faculty, 2002 Employee Type Tenured/Tenure Track (%) Number 1,821 (100) < 40 310 (17) 40-59 1,213 (67) 60+ 298 (16) Average Age 50.4

45.5

Fixed Term (%) Total (%) 870 (100) 254 (29) 570 (66) 46 (5) 2,691 (100) 564 (21) 1,783 (66) 344 (13) 48.8

February 2007

Source: Institutional Research - University of North Carolina at Chapel Hill

Population Projections, by Race and Hispanic Origin, 2000-2050, All Ages 2000 2010 2020 2030 2040 2050 0% 20% 40% 60% 282,125 308,936 335,936 363,584 391,946 419,854 80% 100% Black Asian Other Hispanic (any race) White (non-Hispanic) February 2007

Globalization’s Impact on the American Worker Globalization

First Wave (1980-present) Second Wave (1990-present)

Job Migration Blue Collar White Collar Manufacturing Information Technology Business Process Outsourcing Knowledge Process Outsourcing Onshore Outsourcing Near Shore Outsourcing Far Shore Outsourcing Right Sourcing February 2007

Challenges Ahead

     Denial of basic services Racial demography of American communities “Re”segregation of public schools Economic plight of American youth Medical Tourism

February 2007

Denial of Basic Services

 

Annexation Extraterritorial Jurisdiction February 2007

February 2007

Raeford and Silver City N. C.

City Limits ETJ

Silver City ETJ Raeford, NC City Limit

Micro, Johnston County, N.C.

City Limit ETJ

1990 City Limits

Creedmoor Granville County, N.C.

Excluded Minority neighborhoods 2000 City Limits

Southern Moore County, N.C.

N.C.

Balloon Annexation Satellite Annexation

Colerain, N. C.

Racial Demography of American Communities

   Racial/Generation Gap Minority/Majority Majority/Majority

February 2007

A Racial/Ethnic Typology of U.S. Counties, 2004 February 2007

Source: U.S. Census Bureau, Population Division (2004)

Percent Nonwhite Population, Adult and Youth, by County Type, 2004 Area All Counties Racial Generation Gap Minority-Majority Majority-Majority Other Number of Counties 3,141 242 Total Population (% Nonwhite) 33% 46% Adult Population (% Nonwhite ≥ 15 years) 30% 42% Youth Population (% Nonwhite < 15 years) 42% 58% 235 2,663 1 65% 19% 50% 62% 17% 52% 75% 25% 43% February 2007

Source: U.S. Census Bureau, Population Division (2004)

“Re”-segregation of Public Schools

February 2007

February 2007

Source: North Carolina Department of Public Instruction

Racial Composition of North Carolina’s Low-Performing High Schools, 2004-2005 NC Schools All High Schools Low Performing High Schools Hillside High School Southern High School Total Enrollment 399,261 20,123 1,576 1,509 Black Enrollment 123,779 15,924 1,450 1,121 Percent Black 31% 79% 92% 74% February 2007

Source: North Carolina Department of Public Instruction

Selected Indicators of North Carolina Student Preparedness and Performance on… State End of Course Test 74.8

District P/LP Black Students 58.0

46.0

43.0

Average SAT Score Nation 1,028 State District P/LP 1,010 941 829 Nation SAT Participation State P/LP February 2007 49% 74% 59%

P/LP = Priority/Low Performing School

North Carolina Indicators of Teacher Quality, 2004-2005 Fully Licensed Teachers Emergency/Provisional License/Lateral Entry Tech 15%

State

85%

State LP/P Schools District

78%

0% 20% 40%

Teacher Turnover

60% 80% 100% State

19%

LP/P Schools

69% 27%

District

21%

0% 5% 10%

February 2007

15% 20% 25% 30% LP/P Schools

27%

District

22%

0% 5% 10% 15% 20% 25% 30% Source: North Carolina Department of Public Instruction

County Appropriations and Supplemental Taxes for Education (Current Expenses), Year 2004-05

$1,400 $1,200 $1,000 $800 $600 $400 $200 $0 2000-01 2001-02 2002-03

Year

Source: http://www.ncpublicschools.org/docs/fbs/resources/data/financialdata/2004-05data.pdf

2004-05 All Counties Majority-Majority Minority-Majority Racial Generation Gap

February 2007

Economic Plight of America’s Youth

February 2007

Population of U.S. children under 18 years by race/ethnicity, income, and other social characteristics, 2004 All White Non-white Hispanic 72,879,035 42,845,704 16,142,067 13,891,264 All Children under 18 Families w/ low income($30,000/yr) Householders or Parents w/ no college experience Householders or Parents w/ no college experience and low income 29.1% 47.7% 18.8% 19.5% 41.6% 10.6% 43.1% 46.4% 25.9% 42.6% 68.2% 35.7% February 2007

Source: American Community Survey (2004).

Population of U.S. children under 18 years by race/ethnicity, income, and other social characteristics, 2004 All Children under 18 Non-Homeowner Families Foreign-born Head of Household w/ no college experience All White Non-white Hispanic 72,879,035 42,845,704 16,142,067 13,891,264 33.2% 12.9% 15.9% 2.8% 50.8% 10.4% 66.2% 46.9% February 2007

Source: American Community Survey (2004).

Medical Tourism Cost Comparison

Type Hip Replacement (partial) Hip Replacement (full) Orthopedic surgery Cardiac surgery Gall bladder surgery U.S.

$18,000 $39,000 $18,000 $40,000 $60,000 India $4,500 $3,000 $ 4,500 $6,500 $7,500 February 2007

Source: http://www.cbc.ca

    

Implications for NC’s Health and Competitiveness

Create healthy and viable communities Active living by design Health eating by design Infuse health and wellness education throughout K-16 curriculum Strategically re-position health disparities as a competitiveness issue.

February 2007