County-level Unemployment Rates Research Articles

Enrollee characteristics and receipt of colorectal cancer testing in Pennsylvania after adoption of the Affordable Care Act Medicaid expansion.

Colorectal cancer (CRC) is the fourth most common cancer and the second leading cause of cancer-related death in the U.S. Despite increased CRC screening rates, they remain low among low-income non-older adults, including Medicaid enrollees who are more likely to be diagnosed at advanced stages. Given limited evidence regarding CRC screening service use among Medicaid enrollees, we examined multilevel factors associated with CRC testing among Medicaid enrollees in Pennsylvania after Medicaid expansion in 2015. Using the 2014-2019 Medicaid administrative data, we performed multivariable logistic regression models to assess factors associated with CRC testing, adjusting for enrollment length and primary care services use. We identified 15,439 adults aged 50-64 years newly enrolled through Medicaid expansion. Outcome measures include receiving any CRC testing and by modality. About 32% of our study population received any CRC testing. Significant predictors for any CRC testing include being male, being Hispanic, having any chronic conditions, using primary care services ≤4 times annually, and having a higher county-level median household income. Being 60-64 years at enrollment, using primary care services >4 times annually, and having higher county-level unemployment rates were significantly associated with a decreased likelihood of receiving any CRC tests. CRC testing rates were low among adults newly enrolled in Medicaid under the Medicaid expansion in Pennsylvania relative to adults with high income. We observed different sets of significant factors associated with CRC testing by modality. Our findings underscore the urgency to tailor strategies by patients' racial, geographic, and clinical conditions for CRC screening.

COVID-19 Policies, Pandemic Disruptions, and Changes in Child Mental Health and Sleep in the United States

The adverse effects of COVID-19 containment policies disrupting child mental health and sleep have been debated. However, few current estimates correct biases of these potential effects. To determine whether financial and school disruptions related to COVID-19 containment policies and unemployment rates were separately associated with perceived stress, sadness, positive affect, COVID-19-related worry, and sleep. This cohort study was based on the Adolescent Brain Cognitive Development Study COVID-19 Rapid Response Release and used data collected 5 times between May and December 2020. Indexes of state-level COVID-19 policies (restrictive, supportive) and county-level unemployment rates were used to plausibly address confounding biases through 2-stage limited information maximum likelihood instrumental variables analyses. Data from 6030 US children aged 10 to 13 years were included. Data analysis was conducted from May 2021 to January 2023. Policy-induced financial disruptions (lost wages or work due to COVID-19 economic impact); policy-induced school disruptions (switches to online or partial in-person schooling). Perceived stress scale, National Institutes of Health (NIH)-Toolbox sadness, NIH-Toolbox positive affect, COVID-19-related worry, and sleep (latency, inertia, duration). In this study, 6030 children were included in the mental health sample (weighted median [IQR] age, 13 [12-13] years; 2947 [48.9%] females, 273 [4.5%] Asian children, 461 [7.6%] Black children, 1167 [19.4%] Hispanic children, 3783 [62.7%] White children, 347 [5.7%] children of other or multiracial ethnicity). After imputing missing data, experiencing financial disruption was associated with a 205.2% [95% CI, 52.9%-509.0%] increase in stress, a 112.1% [95% CI, 22.2%-268.1%] increase in sadness, 32.9% [95% CI, 3.5%-53.4%] decrease in positive affect, and a 73.9 [95% CI, 13.2-134.7] percentage-point increase in moderate-to-extreme COVID-19-related worry. There was no association between school disruption and mental health. Neither school disruption nor financial disruption were associated with sleep. To our knowledge, this study presents the first bias-corrected estimates linking COVID-19 policy-related financial disruptions with child mental health outcomes. School disruptions did not affect indices of children's mental health. These findings suggest public policy should consider the economic impact on families due to pandemic containment measures, in part to protect child mental health until vaccines and antiviral drugs become available.

Economic crises and obesity: evidence and mechanism from the United States

ABSTRACT Existing studies that explore the relationship between business cycles and health remain debated. This study investigates the effects of economic fluctuation on obesity in the United States. Using the county-level unemployment rates from the Panel Study of Income Dynamics (PSID), we find that people are less likely to be obese during economic downturns. Particularly, a one percentage points increase in unemployment rates would lead to the chances of being obese reduced by 0.45% points. We further explore the underlying mechanisms of how business fluctuations affect obesity. We find that people tend to do more exercise and spend less on food expenditure during the economic downturns.

Changes in economic outcomes before and after rural hospital closures in the United States: A difference-in-differences study.

The objective of this study is to assess changes in local economic outcomes before and after rural hospital closures. Rural hospital closures from January 1, 2005, to December 31, 2018, were obtained from the Sheps Center for Health Services Research. Economic outcomes from this same period were obtained from the Bureau of Labor Statistics, Bureau of Economic Analysis, Quarterly Workforce Indicators, U.S. Federal Reserve Economic Data, RAND Corporation state statistics database, U.S. Social Security Administration, and U.S. Census Bureau. Difference-in-differences study of 2094 rural counties. The primary exposure was county-level rural hospital closures. The primary outcomes were county-level unemployment rates; employment-population ratios; labor force participation-population ratios; per capita income; total jobs; health care sector jobs; disability program participation-population ratios; percent of the population with subprime credit scores; total filings for bankruptcies per 1000 population; and population size. A total of 104 rural counties experienced a hospital closure, compared to 1990 rural counties that did not. Rural hospital closures were associated with significant reductions in health care sector employment (-13.8%; 95% CI: -22%, -5.6%; p < 0.001), but not with changes in any other economic measure. For unemployment rates, employment-population ratios, per capita income, disability program participation-population ratios, and total jobs, we found evidence of adverse trends preceding hospital closures. Findings were robust to adjusting for county-specific time trends, specifying exposure at the commuting zone-level, and using alternate definitions of rurality to define sample counties. With the exception of a decline in jobs within the health care sector, there was no association between rural hospital closures and county-level economic outcomes. Instead, economic conditions were already declining in counties experiencing closures compared to those that did not.

A county-level analysis of unemployment and mental health in the Southeastern U.S.: applying a social determinants of health framework

ABSTRACT Informed by a Social Determinants of Health framework, this study examines associations between county-level unemployment rates and two county-level indicators of mental health challenges. With 2017 data from County Health Rankings, the study focuses on 418 counties in the southeastern U.S., a region with longstanding unmet service needs and ongoing mental health care challenges. Linear regression models show positive associations between unemployment and two county-level indicators of mental health challenges, while accounting for multiple social determinants of health. The study illustrates how county-level analysis can help social workers target mental health needs and increase access to care.

An Epidemiologic Analysis of Associations between County-Level Per Capita Income, Unemployment Rate, and COVID-19 Vaccination Rates in the United States.

The purpose of this longitudinal study was to examine associations between per capita income, unemployment rates, and COVID-19 vaccination rates at the county-level across the United States (U.S.), as well as to identify the interaction effects between county-level per capita income, unemployment rates, and racial/ethnic composition on COVID-19 vaccination rates. All counties in the U.S. that reported COVID-19 vaccination rates from January 2021 to July 2021 were included in this longitudinal study (n = 2857). Pooled ordinary least squares (OLS) with fixed-effects were employed to longitudinally examine economic impacts on racial/ethnic disparities on county-level COVID-19 vaccination rates. County-level per capita income and county-level unemployment rates were both positively associated with county-level COVID-19 vaccination rates across the U.S. However, the associations were divergent in the context of race/ethnicity. Public health efforts to bolster COVID-19 vaccination rates are encouraged to consider economic factors that are associated with decreases in COVID-19 vaccination rates.

Abstract 106: Twenty Year Trends In US Stroke Mortality In Younger Vs Older Adults

Introduction: After decades of consistent declines, stroke mortality started to level off beginning in 2013, with increases seen in younger stroke patients. Methods: We performed a post hoc analysis of county-level stroke death rate per 100,000 adults, for ischemic and hemorrhagic stroke, from 1999-2018 using CDC estimates. We stratified by age 35-64 (young) and ≥65 (old), and by county-level geographic factors and unemployment rate. Results: We included data from over 3,000 counties. Figure 1 shows stroke mortality began to increase for younger patients in 2013-14, but continued to decline for older patients. The second row shows that the disparity in stroke death rate for younger rural patients was no longer significant from 2005-13 (overlapping 95% CIs), but from 2014-18, younger rural patients had a significantly higher rate of stroke death compared to urban/suburban patients. Younger patients in counties with more unemployment (vs. less) or in the South (vs. other Census regions) had higher rates of stroke death. Figure 2 shows county-level changes by 5-year periods (e.g. 1999-2003 vs. 2004-08), which highlight the spread over time of increased stroke death rate in all regions of the contiguous United States for younger patients. Conclusions: The trend of consistently decreasing stroke death rate stabilized in 2013, with subsequent increase seen for younger adults aged 35-64, particularly in rural, Southern, and high unemployment counties.

Turnover events of animal caretakers and its impact on productivity in swine farms

Attracting and retaining quality animal caretaking personnel is one of most pressing issues the US swine industry currently faces. On-farm employee turnover can be costly and have an impact on productivity. The primary objectives of this study were to describe the amount of animal caretaker turnover events that occurred in a single year in eleven swine farms, and to investigate associations between employee turnover events and two subsequent production parameters of interest: number of pigs weaned per sow (PWS) and pre-weaning mortality (PWM). A retrospective cohort study was conducted with eleven commercial farrow-to-wean swine farms belonging to two vertically integrated multi-site production systems within two swine production companies. Human resources and production data for the year of 2019 were obtained monthly from each farm. The primary predictor of interest was the occurrence of an employee turnover event, defined as ‘voluntary’ (employee decided to leave or quit) or ‘involuntary’ (employee was terminated by company decision). The primary outcomes of interest included the monthly average PWS and PWM. These associations were assessed with 1-, 2-, 3-, and 6-months between the turnover events and the outcome. Linear mixed effects models were fit in STATA 15, with system and farm included as random effects. To account for temporal and seasonal trends of production, season and the monthly production were included in the models. There were a total of 152 turnover events, with 4 and 148 turnover events in systems 1 and 2, respectively. The average turnover, calculated as a percent of total turnover among full time employee positions, was 92 % (SD = 62 %; Range = 8–217 %). Improved production efficiency in both monthly PWS (p = 0.01) and PWM (p = 0.02) was observed with the occurrence of an involuntary turnover event two months prior, after controlling for season, previous month production, farm, and system. For the PWS outcome, there was a significant interaction between an involuntary turnover event two months prior and monthly county-level unemployment rate (p = 0.02), indicative of the improved performance being most profound at the lowest levels of unemployment rate and diminishing at the highest levels. Turnover of animal caretaking personnel in farrow-to-wean farms was confirmed to be highly variable and high for the majority of farms in this study. Furthermore, animal caretaker turnover was associated with subsequent trends of production efficiency, warranting closer consideration of prioritizing managerial efforts in worker recruitment, training and retention.

Child Maltreatment, Unemployment, and Safety Nets

This paper studies the impact of unemployment on child abuse and neglect between 2004 and 2012 in the United States, by using unique administrative data on every reported incident of child maltreatment made to the state Child Protective Services for nearly every county. We identify the effect of county-level unemployment rates using an industry shift-share instrument which we create by interacting initial county industry shares and national industry unemployment rates. We estimate a large positive effect of unemployment on child neglect. We show that this result captures an impact on the actual incidence of neglect and not reporting behaviour, is not only driven by the manufacturing sector which explains most of the variation in our shift-share instrument, and is robust to alternative instruments. We find indication for a direct income channel: higher unemployment leads to a decrease in real expenditure on basic goods, like food and beverages. We further support this evidence by showing that the effect of unemployment on neglect is significantly smaller in states that introduced longer extensions to the duration of unemployment benefits following the onset of the Great Recession.

Association of Medicaid Expansion With Coverage and Access to Care for Pregnant Women.

To identify the association of the Affordable Care Act's Medicaid expansion with payment for delivery, early access to prenatal care, preterm birth, and birth weights considered small for gestational age (SGA). A difference-in-difference design was used to assess changes in outcomes before and after Medicaid expansion in expansion states, using nonexpansion states as a control group. We used national birth certificate data from 2009 to 2017. Difference-in-difference linear probability models were used to assess the effects of the policy implementation, adjusting for demographics, month of birth, state, year, and county-level unemployment rates. Standard errors were clustered at the state level. Two prespecified subgroup analyses were performed of nulliparous women and women with no more than a high school diploma. The study sample included 8,701,889 women from 15 expansion states and 9,509,994 from 11 nonexpansion states. In the adjusted analysis, the percentage of Medicaid-covered deliveries increased by 2.3 absolute percentage points (95% CI 0.2-4.4, P=.04) in expansion states compared with nonexpansion states. There were no significant changes in the proportion of women who were uninsured, as there was a relative decrease in the percentage of deliveries covered by private insurance (-2.8 percentage points [95% CI -4.9 to -0.8, P=.01]). There were also no significant differences in the rate of women initiating prenatal care in the first trimester, preterm birth rates, or rates of low birth weight after the Medicaid expansion. Findings were similar in both subgroups. Medicaid expansion was associated with increased Medicaid coverage for childbirth in expansion states; similar gains in private coverage were seen in nonexpansion states. There were no associations with changes in early access to prenatal care, preterm birth, or SGA birth weights.

County-Level Unemployment Rates and Service Intensity in Primary Care Physician Offices for Medicare Patients.

The macroeconomic environment has been shown to affect health-care service utilization. We examined the relationship between unemployment rate and service intensity among a nationally representative sample of primary care office visits from Medicare patients by merging data from the 2006-2012 National Ambulatory Medical Care Survey with unemployment data from the Bureau of Labor Statistics. Multispecialty practices demonstrated increases in the number of electrocardiogram tests prescribed and the number of return appointments scheduled. In contrast, single-specialty practices did not respond on those margins and instead increased the likelihood of administering diagnostic and screening examinations. We found no significant relationship between unemployment rates and the number of laboratory and imaging services, magnetic resonance imaging use, referrals, or medication prescribing. These results were robust to controlling for extensive visit characteristics and county-, year-, and month-fixed effects. Our results suggest that physicians responded to the Great Recession by changing their practice behavior.

Environmental justice in the oil refinery industry: A panel analysis across United States counties

Environmental injustice due to economic inequality and its correlates and consequences has been a focus for researchers and policy makers alike over many years, with much of that research focusing on race as the major determinant of inequality. In this paper we extend this literature by focussing on emissions from the oil refinery industry at the community level. In particular, based on the use of panel data, we analyse econometrically how the environmental performance of individual petroleum refineries (emissions of benzene and toluene to the atmosphere) associates with determinants of economic inequality at the micro-level in terms of average per capita income at the level of United States counties as well as average county-level unemployment rates. The paper finds evidence of environmental injustice as a result of unemployment levels in areas around refineries and, to a slightly lesser extent, as a result of income inequality. It discusses these results in a wider context, referring amongst other things to the role of county-level community characteristics and the potential for private firms to substitute for the intervention of public institutions, if these are lacking.

Is the Quality of Nursing Homes Countercyclical? Evidence From 2001 Through 2015.

To examine whether nursing homes (NHs) provide better quality when unemployment rates rise (countercyclical) and explore mechanisms contributing to the relationship between quality and unemployment rates. The study uses the data on privately owned, freestanding NHs in the continental United States that span a period from 2001 through 2015. The empirical analysis relies on panel fixed-effect regressions with the key independent variable being the county-level unemployment rate. NH quality is measured using deficiencies, outcomes, and care process measures. We also examine nursing staff levels, as well as employee turnover and retention. NHs have better quality when unemployment rates increase. Higher unemployment rates are associated with fewer deficiencies and lower deficiency scores. This countercyclical relationship is also found among other quality measures. In terms of mechanisms, we find higher nursing staff levels, lower employee turnover, and better workforce retention when unemployment rates rise. Improvement in staffing is likely contributing to better quality during recessions. Interestingly, these effects predominately occur in for-profit NHs for deficiencies and staffing levels. NH quality is countercyclical. With near record-low unemployment rates in 2018, regulatory agencies should pay close attention to NH quality when and where the local economy registers strong growth. On the other hand, the finding of the unemployment rate-staffing/turnover relationship also suggests that policies increasing staffing and reducing employee turnover may not only improve NH quality but also have the potential to smooth quality fluctuations between business cycles.

Drivers of potentially avoidable emergency admissions in Ireland: an ecological analysis

BackgroundMany emergency admissions are deemed to be potentially avoidable in a well-performing health system.ObjectiveTo measure the impact of population and health system factors on county-level variation in potentially avoidable emergency...

Are Recessions Good for Staffing in Nursing Homes?

The quality and cost of care in nursing homes depend critically on the number and types of nurses. Recent research suggests that the nursing supply adjusts to macroeconomic conditions. However, prior work has failed to consider the effect of macroeconomic conditions on demand for nurses through the effect on revenues. We test how county-level unemployment rates affect direct-care staffing rates in nursing homes using California data. We exploit the wide variation in the unemployment rates across counties and over time in 2005-2012. We also test whether there are heterogeneous effects of unemployment rates by facility size, staffing level, and profit status. We find that as unemployment rates increase, staffing by registered nurses (RNs) decreases but staffing by licensed practical nurses (LPNs) increases. The increase in LPNs is larger in large nursing homes, nursing homes with higher staffing levels, and in for-profit nursing homes. We also find that as unemployment rates increase, nursing home revenue decreases. While the effect of macroeconomic conditions on nursing supply may be important for cost and quality of care, the mechanism is not simple, direct, or homogeneous for all types of nurses and nursing homes.

Local Labor Market Condition and Influenza Vaccination

Influenza vaccination is a cost-effective preventive service, but its utilization rate is below the recommended level. Many studies have explored possible predictors and causes for low vaccination rates. Despite a large volume of studies in this area, there is limited research on how local economic conditions can affect individual influenza vaccination. This study explores this topic by merging the 2008–2012 individual-level data from the Behavioral Risk Factor Surveillance System (BRFSS) with the Area Health Resources Files (AHRF), and the Bureau of Labor Statistics Local Area Unemployment Statistics (LAUS). Using county-level unemployment rates as a measurement of local economic conditions, we used multivariate probit models to examine its relationship with individual flu vaccination while controlling for individual socioeconomic and demographic factors and contextual characteristics. We found that county-level unemployment rates were significantly and negatively associated with individual influenza vaccination, especially for people who were employed or living in metropolitan counties. Our results support public health interventions to improve flu vaccination during economic recessions.

Recent declines in cancer incidence: related to the Great Recession?

In recent years, cancer case counts in the U.S. underwent a large, rapid decline-an unexpected change given population growth for older persons at highest cancer risk. As these declines coincided with the Great Recession, we examined whether they were related to economic conditions. Using California Cancer Registry data from California's 30 most populous counties, we analyzed trends in cancer incidence during pre-recession (1996-2007) and recession/recovery (2008-2012) periods for all cancers combined and the ten most common sites. We evaluated the recession's association with rates using a multifactorial index that measured recession impact, and modeled associations between case counts and county-level unemployment rates using Poisson regression. Yearly cancer incidence rate declines were greater during the recession/recovery (3.3% among males, 1.4% among females) than before (0.7 and 0.5%, respectively), particularly for prostate, lung, and colorectal cancers. Lower case counts, especially for prostate and liver cancer among males and breast cancer, melanoma, and ovarian cancer among females, were associated with higher unemployment rates, irrespective of time period, but independent of secular effects. The associations for melanoma translated up to a 3.6% decrease in cases with each 1% increase in unemployment. Incidence declines were not greater in counties with higher recession impact index. Although recent declines in incidence of certain cancers are not differentially impacted by economic conditions related to the Great Recession relative to pre-recession conditions, the large recent absolute declines in the case counts of some cancer may be attributable to the large declines in unemployment in the recessionary period. This may occur through decreased engagement in preventive health behaviors, particularly for clinically less urgent cancers. Continued monitoring of trends is important to detect any rises in incidence rates as deferred diagnoses come to clinical attention.

The impact of changing economic conditions on overweight risk among children in California from 2008 to 2012

BackgroundThe recent economic recession represents an opportunity to test whether decreases in economic resources may have deleterious consequences on childhood overweight/obesity risk.MethodsWe investigated the association between indicators of changing macroeconomic...

The Great Recession of 2007-2009 and Public Insurance Coverage for Children in Alabama: Enrollment and Claims Data from 1999-2011.

This study examined the impact of the Great Recession of 2007-2009 on public health insurance enrollment and expenditures in Alabama. Our analysis was designed to provide a framework for other states to conduct similar analyses to better understand the relationship between macroeconomic conditions and public health insurance costs. We analyzed enrollment and claims data from Medicaid and the Children's Health Insurance Program (CHIP) in Alabama from 1999 through 2011. We examined the relationship between county-level unemployment rates and enrollment in Medicaid and CHIP, as well as total county-level expenditures in the two programs. We used linear regressions with county fixed effects to estimate the impact of unemployment changes on enrollment and expenditures after controlling for population and programmatic changes in eligibility and cost sharing. A one-percentage-point increase in a county's unemployment rate was associated with a 4.3% increase in Medicaid enrollment, a 0.9% increase in CHIP enrollment, and an overall increase in public health insurance enrollment of 3.7%. Each percentage-point increase in unemployment was associated with a 6.2% increase in total public health insurance expenditures on children, with Medicaid spending rising by 7.5% and CHIP spending rising by 1.8%. In response to the 6.4 percentage-point increase in the state's unemployment rate during the Great Recession, combined enrollment of children in Alabama's public health insurance programs increased by 24% and total expenditures rose by 40%. Recessions have a substantial impact on the number of children enrolled in CHIP and Medicaid, and a disproportionate impact on program spending. Programs should be aware of the likely magnitudes of the effects in their budget planning.

Psychological well-being during the great recession: changes in mental health care utilization in an occupational cohort.

We examined the mental health effects of the Great Recession of 2008 to 2009 on workers who remained continuously employed and insured. We examined utilization trends for mental health services and medications during 2007 to 2012 among a panel of workers in the 25 largest plants, located in 15 states, of a US manufacturing firm. We used piecewise regression to compare trends from 2007 to 2010 in service and medication use before and after 2009, the year of mass layoffs at the firm and the peak of the recession. Our models accounted for changes in county-level unemployment rates and individual-level fixed effects. Mental health inpatient and outpatient visits and the yearly supply of mental health-related medications increased among all workers after 2009. The magnitude of the increase in medication usage was higher for workers at plants with more layoffs. The negative effects of the recession on mental health extend to employed individuals, a group considered at lower risk of psychological distress.