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2
MEASURING THE EFFECTS OF
SOCIOECONOMIC STATUS
ON HEALTH CARE
Marian E. Gornick
The primary purpose of this paper is to consider ways of
operationalizing and assessing the effects of socioeconomic status on
health care for the National Healthcare Disparities Report (NHDR). To
study the effects of socioeconomic status on health care, researchers
have "borrowed" some of the methods used by social scientists in
studying its effects on health without systematically examining how
suitable they are for this task.) This paper will review these methods to
determine if they are applicable and appropriate for studying
disparities in health care.2 In addition, this paper includes race and
ethnicity in relevant discussions about disparities in health care. In the
past, race was used in studies about disparities in health care mainly
because data for race were available, although race was often seen as a
proxy for income. Now, race and ethnicity are used as independent
variables in studies of disparities in health care.
The first two parts of this paper focus on socioeconomic status
and health. The second two parts focus on socioeconomic status and
health care. Part 2-l contains a brief history of the framework
developed by social scientists to study the effects of socioeconomic
status on health, and Part 2-2 presents an overview of the current
methods that social scientists use in studying socioeconomic status and
health. Part 2-3 presents an overview of the current methods that
health services researchers use in studying disparities in health care.
~ Instead of socioeconomic status, some social scientists use the concept of
socioeconomic position, which they believe takes into account more of the
social and economic factors that influence health.
2 Researchers use the expression "disparities in health care" while social
scientists tend to refer to disparities in health as "inequalities in health."
45
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46 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
Several tabulations are provided to illustrate the approaches and data
sources that have been developed to study disparities by race,
ethnicity, and socioeconomic status. Part 2-4 presents an overview of
common data issues in studies of health care disparities.
2-1. STUDYING THE EFFECTS OF SOCIOECONOMIC
STATUS ON HEALTH
Since 1985 there has been a substantial increase in the number
of studies about the relationships between socioeconomic factors and
health. In an article published in 1999, Nancy E. Adler and Joan M.
Ostrove sketched the evolution of the theoretical framework now used
in studying disparities in health (Adler and Ostrove, 1999~. Before the
mid-1980's, socioeconomic status was largely absent in studies on
health except as a control variable. Studies focused on poverty and its
association with health. The model assumed a threshold effect: the
health of people below the poverty level was believed to improve as
their income increased and reached the poverty threshold. Above the
poverty threshold, the level of health was constant as income
increased.
At a ~ 987 conference sponsored by the Kaiser Family
Foundation, leading social scientists from the U.S. and Great Britain
presented a number of papers that showed that the effect of
socioeconomic factors was much broader than just poverty. In fact,
many social and economic factors are related to health. Moreover,
there is a gradient effect between socioeconomic status and health: as
socioeconomic status increased, health improved. The conference
resulted in the 1989 publication of Pathways to Health (Bunker et al.,
1989).
The papers were groundbreaking and ushered in an era of
profound intellectual and pioneering work to understand the effects of
socioeconomic status on health. A reading of Pathways to Health
today shows that the 1980 Black Rep ort3 (Black, 1982) stimulated the
3 The report is commonly referred to as the Black Report after Sir Douglas
Black, chair of the Research Working Group, Department of Health and
Social Security, U.K..
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2: MEASURING SOCIOECONOMIC STATUS IN HEALTH CARE
47
thinking of many social scientists because it had found that gaps in
health had widened since the establishment of the National Health
Service in 1948. The Black Report became the underpinning of the
belief that health care does not play a very important role in health.
Robert and House describe the prevailing views of social scientists
during the ~ 980s and ~ 990s:
Most research suggests that access to medical care plays a
relatively minor role in explaining socioeconomic
inequalities in health...socioeconomic differences are seen
both in diseases that are amenable to medical treatment and
in diseases that are not amenable to medical treatment
...with deaths from diseases amenable to treatment
representing only a fraction of all deaths in any case
(Robert and House, 2000, p. 121~.
These conference papers also may have encouraged the
development of models that would focus on the effects of
socioeconomic status on health without inclusion of race as an
independent variable. The likely premise has been that racial
differences in morbidity and mortality are reflections of differences in
social and economic factors. However, in recent years social scientists
have noted that "studies may need to address how cIass-related
experiences of racial/ethnic and gender discrimination may harm
health" (Krieger et al., 1997, p. 369~.
2-2. REVIEW OF METHODS USED
IN STUDYING THE EFFECTS OF
SOCIOECONOMIC STATUS ON HEALTH
The following is an overview of the methods that social
scientists use in studying the effects of socioeconomic status on health
to determine what is applicable to studying the effects of
socioeconomic status on health care. Cross-fertilization of knowledge
between social scientists and health services research promises to be
beneficial all around. The dissemination of information about
disparities in the use of Medicare services has helped to change the
perception that health insurance by itself assures equal access and use
of health care (Robert and House, 2000~. An example of the beneficial
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48 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
effects of cross-fertilization of knowledge from social scientists and
one that is central to this paper is the recent recognition by
researchers that socioeconomic status is an important variable in
studying disparities in health care, particularly disparities by race and
ethnicity.
There is no simple conclusion or overwhelming agreement on
the causes of disparities in health, reasons for growing gaps in health,
ways to address them, or even how to study the issues. As Robert and
House observe, "we still do not well and consensually understand why
socioeconomic inequalities in health exist and persist, nor what
policies are most likely and necessary to reduce these inequalities"
(Robert and House, 2000, p. ~ 15~.
Nonetheless, a significant body of knowledge is available
from studying the effects of socioeconomic status on health that is
useful in studying the effects of socioeconomic status on health care.
Four major issues on which a consensus has been reached are
discussed next:
I. Is There a Single Best Approach to Measuring or
Analyzing Socioeconomic Status?
The field of research about the effects of socioeconomic status
on health (sometimes termed health status or health outcomes) is still
new. The link between socioeconomic status and health is not well
understood. Among social scientists there is a consensus that there are
many different pathways connecting socioeconomic status and health.
This means that a broad perspective is needed to understand the
multiple pathways linking socioeconomic status and health.
This literature addresses two fundamental questions about
methods of study: first, among the variables used as measures of
socioeconomic status, is there a single best measure? Secondly, are
some approaches used to analyze the effects of socioeconomic status
better than others? The answers are, in general, "No." There are
inherent imperfections and limitations in all of the measures of
socioeconomic status just as there are in measures of race and
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49
ethnicity. But, when used thoughtfully, each measure can have its own
ring of truth.
Research about socioeconomic status and health began to gain
momentum in the mid-19SOs. While much has been learned,
frequently lacking in research is a clear conceptualization of what is
being studied and why a particular measure of socioeconomic status is
used. In fact, measures and methods are at times chosen because of
data availability rather than because of theoretical premises. For
example, in the U.K. occupation is used more frequently in studies
about disparities in health. In the U.S. income and education are used
more frequently. These choices are due, in part, to the type of social
and economic information collected.
Recently, the use of composite measures has gained attention.
Different composite measures of deprivation relating to material and
social disadvantage have been developed for studying the effects of
socioeconomic status on the individual and area levels (Pampalon and
Raymond, 2000~. Composite indices are generally constructed by
combining information (often from a national census) about factors
such as income, employment, communications, transportation,
support, education, owned home, and living space. Peter Townsend
(Townsend, 1987) and Morns and Carstairs (Morris and Carstairs,
1991) in the U.K. introduced composite indices for area-level analyses
based on four factors. Three factors in both of the indices are
unemployment, lack of a car, and overcrowded housing. For the fourth
factor the Townsend index uses home ownership while the Carstairs
index uses lower social class.
A different formulation of a composite index (named
CAPSES) has been developed based on the theory that socioeconomic
status is a function of three domains of capital: material capital (such
as incomes, homes, and stocks); human capital (such as education,
skills, and abilities); and social capital (such as membership in social
networks).4 A recent pilot study testing CAPSES against individual
and other composite indices of socioeconomic status showed
4 CAPSES is an acronym formed from the words capital and socioeconomic
status (SES).
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considerable consistency across the various socioeconomic status
measures (Oakes and Rossi, forthcoming).
Composite indices for area-level analyses have been used in
different ways. They may be particularly useful as area-wide planning
tools. For example, in the ~ 960s, the Planning Department in
Baltimore City designed a composite index for census tract areas
based on several social and economic factors. The index was used to
rank census tracts from the most advantaged to the most deprived. For
an experimental program set up in Baltimore in the 1970s, these
rankings were used to establish a health program for children and
youth in census tract areas that were most deprived.s
A Quebec study provides some insight into the potential
difficulties in interpreting results of area rankings from a composite
index of deprivation. Comparisons between area rankings and factors
used in the index showed that areas deprived socially were not
necessarily deprived materially and vice versa. Thus, the Quebec study
provides a cautionary note that "lumping" socioeconomic status
measures together can be confounding because the index does not
necessarily provide a measure of area-level socioeconomic status that
can be readily interpreted.
In their review of methods used in studying socioeconomic
status and health, Robert and House conclude that questions about
which measures and methods to use "remain unanswered and perhaps
unanswerable in a generic sense" (Robert and House, 2000, p. 8~.
Moreover, there are many remaining methodological problems relating
to studying the effects of socioeconomic status on health. These
problems include:
1. The lack of precision and reliability of various measures as
well as difficulties in generating measures of socioeconomic
status;
Unresolved questions about how to measure the effects of
socioeconomic status over the life course that would reflect
change in social and economic factors from birth to old age;
5 From personal participation in the Baltimore City Health Department study.
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51
3. Some measures of socioeconomic status that are useful for
studying their effects within some races and ethnic groups
may not be useful for other races and ethnic groups, a
methodological issue that also applies to gender;
4. A lack of understanding about why the relationships between
socioeconomic status and health are stronger for men than for
women;
Difficulties with classifying married women, the unemployed,
and retired persons in a household;
Difficulty of including mental and other psychosocial factors
that affect health in measures of socioeconomic status; and
7. The intertwining of race, ethnicity, and socioeconomic status,
and how to assess the separate effects.
The list of unresolved conceptual and measurement questions
is long although the viewpoint of experts such as Krieger, Williams,
and Moss is clear about certain issues: "we underscore the issue is not
whether one measure is 'right' or another 'wrong'...rather, numerous
studies suggest that measures at each level, over time, may be
informative, separately and in combination" (Krieger et al., 1997, p.
349). They add that "the utility of socioeconomic indices for public
health research remains unclear.... One concern is that combining
measures of income and education into one index...can conflate
pathways and obscure each component's distinct -- and conceivably
different -- contribution to specified health outcomes" (Krieger et al.,
1997, p. 366).
This overview of methods used to study the effects of
socioeconomic status indicates that there is no one right measure. The
choice of a "right" measure depends upon the study. Table 2-1 briefly
summarizes the advantages and disadvantages of using specific
measures of socioeconomic status.
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2. What is the Relationship between Socioeconomic Status
and Health?
The direction of the relationship between socioeconomic
status and health is a fundamental issue in understanding pathways
leading to disparities in health. While some economists believe that
health drives socioeconomic status -- because poor health has a
negative effect on job opportunities and socioeconomic position
(social drift) -- most social scientists believe the direction of the
relationship is the other way around. Among those who have studied
disparities in health, there is a consensus that biological and genetic
differences account for a relatively small proportion of the disparities
in health. Supporting that belief is a study of the effects of six risk
factors smoking, alcohol consumption, systolic blood pressure,
cholesterol level, body mass index, and diabetes. The study showed
that these six factors together accounted for only 31 percent of the
difference in mortality between Blacks and Whites. Income accounted
for 38 percent of the difference in mortality, while the remaining 31
percent of excess mortality among Blacks was unexplained (Often et
al., 1990~.
Among those who have studied disparities in health care,
there is also a consensus that biological, genetic, and health status
differences account for very little of the persistent disparities by race
in health care. For example, one study found that Black veterans with
coronary artery disease were 64 percent less likely than White veterans
to undergo coronary artery bypass graft (CABG) and balloon
angioplasty (Peterson et al., ~ 994~. Several other studies in the
literature have found disparities by race in the use of revascularization
procedures (Ayanian et al., 1993; Ubvarhelyi et al., 1992; Wenneker
and Epstein, 1988; Whittle et al., 1993~. However, because certain
diseases such as hypertension, diabetes, and osteoporosis are not
uniformly distributed in the population, such differences must be
recognized because they can lie at the crux of the credibility of studies
about disparities in access, utilization, and quality of health care. For
example, differences in amputations of all or part of the Tower limb
must be examined in light of differences in diabetes (Gornick et al.,
1996~.
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TABLE 2-1 Summary of Measures of Socioeconomic Status:
Methodological Advantages and Disadvantages
ADVANTAGES I DISADVANTAGES
53
Income from Surveys
Household income a generally accepted May not be a fully logical measure for
measure. Three or more categories persons with insurance, especially if
preferred, but cell sizes may permit only service does not require cost sharing. May
two. not be able to adjust for family size.
Income, from U.S. Census Data
Median household income in ZIP code a
generally accepted measure. Median
income in ZIP code a proxy for
individual income. Reflects
characteristics of area of residence and
may indicate availability of resources.
Smaller areas such as census tracts
preferable, but only 70 percent of
addresses in census tracts. Cannot be
adjusted for family size.
Education
Comments about income generally Surveys that contain education for
apply to education. But education may household head may not be valid measure
be a more coherent measure, especially for other members. From census data,
in assessing use of services such as education and income not statistically
preventive services, which are often self valid when used together in multivariate
initiated. analyses because of multicollinearity.
Poverty Level
Can be a more sensitive economic
measure than income, suggesting how
Medicaid affects access and utilization.
Not as readily accepted by public because
of concerns about what the levels mean.
Occupation
An important measure in U.K. because
information collected about occupation.
Could be used in studies based on
household surveys. In census data,
summary measure of occupation not
available.
, _ . _ _ .
Wealth
A useful measure for analyzing access to
costly services not generally covered by
insurance, such as nursing home care.
Not a commonly used measure for
services covered by insurance.
1
Composite Indices
.
Composite indices may be useful,
adding context. The CAPSES scale has
been found consistent with other
measures of socioeconomic status.
A summary measure must be used
cautiously. Could be difficult to interpret
because it combines several measures of
socioeconomic status.
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3. Should Socioeconomic Status Be Used as a Primary
Independent Variable to Analyze Health Outcomes?
Social scientists ceased using socioeconomic status as a
control variable when they recognized that health was affected not
only by poverty, but also by a much broader set of variables including
income, education, and occupation. Thus, if the intent is to understand
factors that affect disparities in access, utilization, or quality of care,
socioeconomic status should not be used as a control variable.
This is critical to studying the effects of socioeconomic status
on health care, especially in relatively new areas of research. For
example, suppose it were found that on average highly educated
people rate health plans better than less educated people. It could be
hypothesized that this consistent pattern biases the ratings, and
therefore controlling for education across plans is warranted.
However, better-educated members of a plan may get better health
care if their interactions with the plan are more successful. For
example, they may experience less waiting time for appointments or
they may be more successful getting referrals to specialists than less
educated members of the plan (Fiscella et al., 2000~.
4. Why Does Research on Disparities Require a Clear
Conceptualization?
Ameliorating disparities in health care requires a conceptual
framework that evolves from hypothesis testing, especially those
hypotheses that can help pinpoint potential agents of change. For
example, a framework might first evolve from fo~ulating hypotheses
about how individuals and the health care delivery system interact in
terms of behaviors of individuals, providers, and institutions. This
would be followed by testing how these interactions are associated
with access, utilization, and quality of care. Behaviors have been
shown to be factors associated with disparities in the use of preventive
services because these services are often self initiated (Gornick et al.,
2001; Lemon et al., 2001~.
As an example, elderly women with higher incomes and
supplementary insurance are more likely to obtain mammograms than
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55
Tower income women and women without additional coverage. Under
Medicare, mammography requires a co-payment, which suggests that
the co-payment may lead to the disparities associated with income. In
every insurance category—Medicare only, Medicaid, and private
supplementary coverage mammography use rises with income
(Blustein, 1995~. Yet, there are even greater disparities in the use of flu
shots, which are "free." These facts do not rule out the effect of
income, but they do suggest that there are likely to be multiple
pathways leading to disparities in utilization.
2-3. REVIEW OF METHODS USED IN STUDYING
DISPARITIES IN HEALTH CARE
Disparities in health care have been studied for many years.
For example, before the advent of Medicare it was known that the
elderly who were minorities and who were poor received inpatient
hospital care at a much Tower rate than Whites and more advantaged
persons. Early studies focused primarily on known "barners to care."
Lack of health insurance and a regular source of health care were
identifiable obstructions to obtaining health care. When these barriers
were removed and the elderly and the poor could enter the health care
system, it was expected that there would be equal access to covered
services and that the use of any particular service would reflect need.
In the past decade, disparities in Medicare have led to the awareness
that there are other barriers to health care that are related to race
ethnicity, and socioeconomic status.
I,
We do not know how great a role medical care plays in
explaining disparities by race and socioeconomic status in health and
health care. What is known is that patterns of health care utilization
among the healthiest elderly differ from those of the least healthy.
Moreover, the patterns of health care use among the healthiest are
those that experts recommend, specifically a concentration on
prevention and health promotion. In the Medicare program, three
distinct patterns have become evident. Compared to Whites and
beneficiaries (White or Black) of higher socioeconomic status, Blacks
and beneficiaries (White or Black) of lower socioeconomic status use
fewer preventive and health promotion services such as influenza
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64 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
descriptive analyses are valuable in identifying disparities in health
care and are needed to raise concerns about unequal access and
utilization of health care. But the question remains: why do disparities
in health care exist? The lack of knowledge about why disparities exist
-- even among insured populations -- indicates that ongoing
monitoring of health care disparities should be joined by research that
focuses on analyses to understand the pathways that lead to disparities
in health care and the testing of initiatives to effect a change. Table 2-7
briefly summarizes the approaches used by researchers to examine
disparities.
2-4. METHODOLOGICAL ISSUES IN STUDIES OF
HEALTH CARE DISPARITIES
In addition to the advantages and disadvantages of specific
measures of socioeconomic status, certain other data issues must also
be considered. The following presents five issues common in studies
of health care disparities.
1. Availability of data on socioeconomic status and other
factors that affect disparities in health care. Surveys that generate
information about use of health care generally contain only limited
information about socioeconomic status. The two measures of
socioeconomic status generally collected are income and education.
These measures of socioeconomic status may be useful indicators of
social and economic status for some subgroups of the population, but
are often relatively insensitive for other subgroups, especially for
Blacks. In part, this is due to sample size. Other measures of
socioeconomic status, such as wealth, would very likely be useful
indicators of social and economic status. However, wealth can be
extremely difficult to capture using surveys alone since people are
generally unwilling to provide that information in household surveys.
Moreover, recent studies indicate that lifestyle factors such as
nutrition, exercise, obesity, and behavioral characteristics such as
smoking cessation are also associated with disparities in health care.
This suggests that the role of socioeconomic status will be difficult to
disentangle from lifestyle and behavior factors especially because
information about lifestyle and behaviors is generally unavailable.
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65
2. Using census data for measures of socioeconomic status.
Databases that lack information on socioeconomic status have been
linked with U.S. census data at the census tract or ZIP code area level
to assign an individual in the database the median income and
educational attainment corresponding to his or her area of residence.
For analytic purposes, individuals are often distributed into quartiles.
If specifications for the quartiles are based on the income of the total
population, then the distribution for Blacks will be uneven given the
substantial differences between Blacks and Whites in income. Table
2-5 illustrates this problem. The study had a total of 10,124 White
patients and 860 Black patients; 52 percent of Black patients fell into
the lowest income quartile. Evidently, the three highest quartiles of
patients were grouped together to overcome the problem of small cell
size. Experience with this approach has shown that the problem can be
avoided if income quartiles are specified separately for Blacks and for
Whites. However, researchers are often limited to using databases in
which certain variables, such as income, are put into a pre-specified
grouping. Therefore, the "raw" data are no longer available to alter the
groupings.
3. Small cell sizes even with large samples. Except for
preventive services, utilization rates may be relatively Tow. Even with
large databases, cell sizes may be too small to analyze rates by age,
sex, race, ethnicity and socioeconomic status. Table 2-6 illustrates this
problem. This study had 29,1 19 White patients and 4,522 Black
patients. This study was published in 1994, a time when
socioeconomic status had not yet been commonly used in studying
disparities in health care. Had socioeconomic status been included in
this study, sample size would have been sufficient. But had the data
also been presented by age and sex, cell sizes for Black patients would
have been too small.
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E E E - C E
EN ~ ~ ~ ~ W ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ E
. . . . ~ . . . . .
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68 GUIDANCE FOR THE NATIONAL HEALTHCARE DISPARITIES REPORT
4. Differences by race and ethnicity in risk factors. Linking
health to health care requires that differences in risk factors be
recognized. To make a creditable case that disparities exist in health
care, reference needs to be made to differences in risk factors. For
example, the rate of amputations of all or part of the lower limb for
Black Medicare beneficiaries is substantially higher than the rate for
White beneficiaries. In this example, it is important to show that
among elderly Blacks, diabetes (frequently the underlying cause of
limb amputations) was I.7 times the rate for elderly Whites. However,
as shown in Table 2-2, the amputation rate in 1993 for Blacks was
3.64 times the rate for Whites, far greater than expected based on the
difference in diabetes rates (Gornick et al., 1996~.
5. Data for persons in managed" care plans. Data are generally
not available to study the effects of race and socioeconomic status on
utilization in managed care plans. Policy papers have discussed the
inadequacy of current information from health plans to assess
disparities by race and socioeconomic status.
2-5. CONCLUSION
incorporating knowledge from the social sciences about
methods for studying socioeconomic status will help to put the NHDR
on a sounder scientific footing and expand the perspective of its
audiences. The examples in this paper illustrate the insights that can be
gained about racial and ethnic disparities in health care when measures
of socioeconomic status are included. Disparities in health care
between Blacks and Whites and between Hispanics and Whites were
generally reduced even with adjustment by a single measure of
socioeconomic status such as income. It is important to recognize that
examples in this paper show that substantial disparities in health care
also occur within the White population. As income or education
increased among Whites, the gradient effect was notable in several
instances: the use of preventive and diagnostic services increased
while the use of procedures associated with poor outcomes of care
(such as Tower limb amputation) decreased as income increased.
Research has shown that there are a myriad number of social
and economic factors that can influence health and health care. It
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69
follows that future analyses of disparities in health care that are better
able to measure and adjust for socioeconomic differences are likely to
reduce racial and ethnic disparities even further. The major lesson
learned from this review of research is that knowledge about
disparities in health care increases when we are able to disentangle the
separate effects of race, ethnicity, and socioeconomic status. In the
example showing White, Black, and Hispanic rates of mammography,
flu shots, and Pap smears by income groups, the rates for Hispanic
women in the higher income groups differed substantially not only
from White women but from Black women as well. Thus, studies of
disparities in health care that aggregate data for all minority persons
and present an overall measure of access and utilization are likely to
obscure the fact that barriers to health care can differ for population
subgroups.
The NHDR provides a major opportunity to focus attention on
disparities in health care in the U.S., especially in the use of preventive
and health promotion services. The vast amount of information
available in U.S. data systems- as well as the experience gained in
analyzing data collected in household surveys, administrative data, and
medical records—can serve as a foundation for the NHDR. The
challenge is to provide useful inflation on whether or not the health
care received by vulnerable subgroups continues to differ from the
health care received by persons who are more economically and
socially advantaged.
Disparities in health care are likely to be more meaningful to
Congress and the nation if the NHDR provides information that
indicates disparities matter in terms of health outcomes. For example,
rates of colonoscopy and sigmoidoscopy for Black Medicare
beneficiaries have been consistently lower than rates for White
beneficiaries. These differences are more likely to capture the attention
of policy experts, the health care community, and the nation if they are
juxtaposed against information showing that Black persons aged 65 or
older have more advanced stages of cancer at the time of diagnosis and
higher colon cancer death rates than White persons their age.
By depicting the types of disparities that occur in health care
by race, ethnicity, and social status, the NHDR can serve a vital
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function not only in reporting disparities in health care, but in
stimulating questions about why disparities exist. Thus, the report can
serve as a foundation for conceptualizing a framework for testing
hypotheses about pathways that lead to disparities in health and health
care and ways of effecting a change.
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Representative terms from entire chapter:
care disparities
