Percent Of State Research Articles

The Use of the CDC Preventive Health and Health Services Block Grant to Address Social Determinants of Health to Advance Health Equity.

State public health departments use federal funding to examine and address social determinants of health (SDOH) within their communities to improve health and advance health equity. Yet, most federal funding is categorical (ie, funding used for a specific program or narrow purpose), which can create barriers to addressing social and structural drivers of inequity. The Preventive Health and Health Services Block Grant (PHHS Block Grant) is a flexible funding mechanism that provides health departments the latitude to identify and fund initiatives that address local public health needs. It is unclear, however, to what extent health departments use this flexible resource to incorporate SDOH into their programs. Cross-sectional, descriptive analysis of state health department PHHS Block Grant program administrative data. This study examined PHHS Block Grant budgets and workplans for the federal Fiscal Year 2021 to assess whether state health departments aligned their grant-funded program with the national objectives associated with the Healthy People 2030 SDOH Framework. Forty-seven states and the District of Columbia were included in this study. Percent of states that used PHHS Block Grant funds to address SDOH; proportion of funding allocated to address SDOH; percentage of programs that addressed SDOH. Three-fourths (75%) of states allocated funds to 97 programs aligning with at least 1 Healthy People 2030 SDOH-related objective. Fifty of the programs were fully or primarily funded by the PHHS Block Grant. Results also show that as the states' PHHS Block Grant funding level increased so did the percent of states that allocated funding toward SDOH programs. This study shows that state health departments are using the PHHS Block Grant to address SDOH, and that the grant plays an important funding role for these programs. States are incorporating the grant into their funding strategies to address SDOH.

Trajectories of State-Level Sepsis-Related Mortality by Race and Ethnicity Group in the United States.

Background: Recent reports on the national temporal trends of sepsis-related mortality in the United States (US) suggested improvement of outcomes in several race and ethnicity groups. However, it is unknown whether national data reflect state-level trajectories. Methods: We used the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research Multiple Cause of Death data set to identify all decedents with sepsis in the US during 2010-2019. Negative binomial regression models were fit to estimate national and state-level trends of age-adjusted sepsis-related mortality rates within race and ethnicity groups. Results: There were 1,852,610 sepsis-related deaths in the US during 2010-2019. Nationally, sepsis-related mortality rates decreased among Blacks and Asians, were unchanged among Hispanics and Native Americans, and rose among Whites. The percent of states with similar trends were 30.0% among Blacks, 32.1% among Asians, 74.3% among Hispanics, 75.0% among Native Americans, and 66.7%% among Whites, while trending in opposite direction from 3.6% among Asians to 15.0% among Blacks. Conclusions: National trends in sepsis-related mortality in the US did not represent state-level trajectories in race ethnicity groups. Gains in sepsis outcomes among race and ethnicity groups at the national level were not shared equitably at the state level.

Income assistance programs and population health – The dual impact of minimum wages and the earned income tax credit

In this study, we provide new evidence on the interaction of state-level minimum wages and Earned Income Tax Credit (EITC) laws on several measures of population health. Using data from the National Vital Statistics Reports between 1999 and 2018, we estimate difference-in-differences models to evaluate the dual impact of minimum wages and the EITC on various causes of mortality, such as suicides, motor accidents and assaults. While several researchers have examined the health effects of both these policies separately, few studies have examined the potential interaction effects of these policies. Specifically, while previous work has provided evidence that both minimum wages and the EITC can reduce suicide rates, our study contributes to the literature by showing that the policies have a positive dual impact on population health. We find that a $1 increase in minimum wages reduces death rates due to suicides and assaults by 3.8 percent and 15.2 percent in states with EITC laws, respectively. In contrast, we show that minimum wages do not impact these outcomes in states without state-level EITC laws.

The Uneven Effect of the COVID-19 Pandemic on US Fatal Road Accidents

One of the lesser-known categories of excess deaths of the COVID-19 pandemic in the US was that of fatal car crashes—road-death incidents went up despite the fact that driving decreased due to the lockdowns. Remarkably, then, while there was significantly less traffic in 2020 compared to 2019—the total miles traveled by car decreased by 11% in 2020—there was at the same time a 6.8% increase in fatal car crashes. This meant that the fatality rate per vehicle miles traveled increased by 21% from 2019 to 2020. But the increase was not uniform: states that voted for Biden in 2020 had a much larger percentage increase in fatal car accidents per miles driven during the March to June 2020 period (the first four months of the pandemic) relative to the same period in 2019. In the case of states that voted for Biden, the average percentage increase in fatal car accidents per miles driven per state was 45 percent while the increase was just 22 percent in states that voted for Trump. During the next four months of the pandemic (July – October 2020), when COVID-19 was less prominent in the news and lockdowns had eased, the differences in the percentage increase in fatal car accidents per miles driven between Biden and Trump states was much smaller: 29% for Biden states versus 25% for states that voted for Trump. Using regression analysis, we show that a higher percentage vote for Biden in 2020 is associated with a statistically significant increase in fatal accidents per vehicle miles travelled during the first four months (March – June 2020) of the pandemic relative to the same period in 2019. On the other hand, there is no statistical difference between the next four months of the pandemic (July-October 2020) relative to 2019.

Disparities Made Invisible: Gaps in COVID-19 Data for American Indian and Alaska Native Populations.

IntroductionComplete COVID-19 data for American Indian/Alaska Native (AI/AN) populations are critical to equitable pandemic response.MethodsWe used the COVID-19 U.S. State Policy database to document gaps in COVID-19 data reporting for AI/AN people.ResultsSixty-four percent of states do not report AI/AN data for at least one COVID-19 health metric: cases, hospitalizations, deaths, or vaccinations.DiscussionThe lack of AI/AN-specific data masks the disproportionate burden of COVID-19 and presents challenges to COVID-19 prevention, policy implementation, and health equity.ConclusionsPublic-facing data disaggregated by race may facilitate rapid response COVID-19 research and policymaking to support AI/AN communities.

Impact of state-level training requirements for medical providers on receipt of preventive oral health services for young children enrolled in Medicaid.

Young children enrolled in Medicaid make few dental visits and have high rates of tooth decay. To improve access to care, state Medicaid programs have enacted policies encouraging nondental providers to deliver preventive oral health services (POHS) in medical offices. Policies vary by state, with some states requiring medical providers to obtain training prior to delivering POHS. Our objective was to test whether these training requirements were associated with higher rates of POHS for Medicaid-enrolled children <6 years. This study took advantage of a natural experiment in which policy enactment occurred across states at different times. We used Medicaid Analytic eXtract enrollment and claims data, public policy data, and Area Health Resource Files data. We examined an unweighted sample of 8,711,192 (45,107,240 weighted) Medicaid-enrolled children <6 years in 38 states from 2006 to 2014. Multivariable logistic regression models estimated the odds a child received POHS in a calendar year. Results are presented as adjusted probabilities. Five or more years after policy enactment, the probability of a child receiving POHS in medical offices was 10.7percent in states with training requirements compared to 5.0percent in states without training requirements (P=0.01). Findings were similar when receipt of any POHS in medical or dental offices was examined 5 or more years post-policy-enactment (requirement=42.5percent, no requirement=33.6percent, P < 0.001). Medicaid policies increased young children's receipt of POHS and at higher rates in states that required POHS training. These results suggest that oral health training for nondental practitioners is a key component of policy success.

Misallocation in Indian Agriculture

We exploit substantial variation in land-market institutions across Indian states and detailed micro household-level panel data to assess the effect of distortions in land rental markets on agricultural productivity. We provide empirical evidence that states with more rental-market activity feature less misallocation and reallocate land more efficiently over time. We develop a model of heterogeneous farms and land rentals to estimate land-market distortions in each state. Land rentals have substantial positive effects on agricultural productivity: an efficient reallocation of land increases agricultural productivity by 38 percent on average and by more than 50 percent in states with highly distorted rental markets. Both farm and state-level land market distortions are quantitatively important, with state-level wedges accounting for a significant fraction of rental market participation differences across states. Land market distortions contribute about one-third to the large differences in agricultural total factor productivity across Indian states.

Risk Factor Management in Medical Tourism Organizations

Risk Factor Management in Medical Tourism Organizations

Statewide COVID-19 Stay-at-Home Orders and Population Mobility in the United States.

Many jurisdictions enacted stay‐at‐home orders (also called shelter‐in‐place orders, safer‐at‐home orders, or lockdowns) when SARS‐CoV‐2 began spreading in the United States. Based on Google mobility data, every state had substantially fewer visits to transit stations, retail and recreation facilities, workplaces, grocery stores, and pharmacies by the end of March 2020 than in the previous two months. The mean decrease in visitation rates across destination categories was about 30 percent in states without stay‐at‐home orders and 40 percent in states with stay‐at‐home orders. Similarly, there were fewer routing requests received by Apple in large cities for public transportation, walking, and driving, with a 10 percentage point greater mean reduction in metropolitan areas under statewide stay‐at‐home orders. The pandemic led to large decreases in mobility even in states without legal restrictions on travel, but statewide orders were effective public health policy tools for reducing human movement below the level achieved through voluntary behavior change.

Another Gendered Demographic Dividend: Adjusting to a Future without Sons.

Sonless families may pose another gendered demographic dividend. As fertility declines, families with only daughters are likely to grow. In turn, patriarchal family systems may weaken when many families are unable to engage in patriarchal practices. I examine some of these theorized dynamics in India. Sonless families did grow as fertility declined, reaching 10 percent in India as a whole in 2015 and approaching 20 percent in states with earlier fertility declines. I also identify a substantial influence of children's sex on mothers' expectations of old-age support. Using panel data from the India Human Development Survey (IHDS), I compare women's expectations after they had children to earlier expectations when they did not yet have children. Women with sons kept or further embraced patriarchal expectations that a son would provide support. Sonless mothers largely gave up patriarchal expectations, turning to daughters or away from children altogether.

Who Signs Up for E-Verify? Insights from DHS Enrollment Records

E-Verify is a federal electronic verification system that allows employers to check whether their newly hired workers are authorized to work in the United States. To use E-Verify, firms first must enroll with the Department of Homeland Security (DHS). Participation is voluntary for most private-sector employers in the United States, but eight states currently require all or most employers to use E-Verify. This article uses confidential data from DHS to examine patterns of employer enrollment in E-Verify. The results indicate that employers are much more likely to sign up in mandatory E-Verify states than in states without such mandates, but enrollment is still below 50 percent in states that require its use. Large employers are far more likely to sign up than small employers. In addition, employers are more likely to newly enroll in E-Verify when a state’s unemployment rate or the state’s population share of likely unauthorized immigrants rises. However, enrollment rates are lower in industries with higher shares of unauthorized workers. Taken as a whole, the results suggest that enrolling in the program is costly for employers in terms of both compliance and difficulty in hiring workers. A strictly enforced nationwide mandate that all employers use an employment eligibility program like E-Verify would be incompatible with the current reliance on a large unauthorized workforce. Allowing more workers to enter legally or legalizing existing workers might be necessary before implementing E-Verify nationally.

Who Signs up for E-Verify? Insights from DHS Enrollment Records

E-Verify is a federal electronic verification system that allows employers to check whether their newly hired workers are authorized to work in the United States. To use E-Verify, firms first must enroll with the Department of Homeland Security (DHS). Participation is voluntary for most private-sector employers in the United States, but eight states currently require all or most employers to use E-Verify. This article uses confidential data from DHS to examine patterns of employer enrollment in E-Verify. The results indicate that employers are much more likely to sign up in mandatory E-Verify states than in states without such mandates, but enrollment is still below 50 percent in states that require its use. Large employers are far more likely to sign up than small employers. In addition, employers are more likely to newly enroll in E-Verify when a state’s unemployment rate or population share of likely unauthorized immigrants rises. However, enrollment rates are lower in industries with higher shares of unauthorized workers. Taken as a whole, the results suggest that enrolling in the program is costly for employers in terms of both compliance and difficulty in hiring workers. A strictly enforced nationwide mandate that all employers use an employment eligibility program like E-Verify would be incompatible with the current reliance on a large unauthorized workforce. Allowing more workers to enter legally or legalizing existing workers might be necessary before implementing E-Verify nationally.

Information and the Persistence of the Gender Wage Gap; Early Evidence from California's Salary History Ban

Aiming to reduce the gender wage gap, several states and cities have recently adopted legislation that prohibits employers from asking about previously earned salaries. The advocates of these salary history bans (SHBs) have suggested pay history perpetuates past discrimination. We study the early net impact of the first state-wide SHBs. Using both difference-in-difference and synthetic control approaches, we find the gender earnings ratio increased by 1 percent in states with SHBs. We find these population wide increases are driven by an increase of the gender earnings ratio for households with all children over 5 years old, by workers over 35, and are principally driven by those who have recently switched jobs.

A U.S. State-level Analysis of the Presidential Election in 2016: IQ, Race, and Well-being Emerge as Mutually-Suppressed Predictors

I report U.S. state-level relationships between measures of race, IQ, other well-being variables (e.g., income, health), and the results of the 2016 U.S. presidential election. Based on prior research (Pesta & McDaniel, 2014), I predicted first that IQ and race would be relatively unrelated to election results in bivariate analysis. Instead, a mutual suppression effect was expected, such that IQ would more strongly predict election outcomes when controlling for race, and vice versa. The predicted pattern appeared; so too did mutual suppression effects between racial composition and most but not all other measures of state well-being (i.e., religiosity, crime, education, health, and income) used here. The suppression patterns consistently revealed that after adjusting for racial composition, blue states were smarter and more prosperous than were red states. I conclude that at the aggregate level of the U.S. state, conservatism (as measured here by the state percent of votes cast for Trump) is inversely related to IQ and other measures of well-being.

Now That We're “Well Rounded,” Let's Commit to Quality Physical Education Assessment

With the authorization of the Every Student Succeeds Act (ESSA) in December 2015, the role of physical education in public schools has the potential to change significantly. It is imperative that physical education be supported by assessment-driven evidence in order to reach and speak to legislators, national boards, school administrators, educators and the students themselves. However, with only 32.7 percent of states requiring student assessments that directly relate to state physical education standards, there is currently little accountability for physical educators, programs and students to meet the requirements of comprehensive, skills-based physical education. To increase the perceived value of physical education and justify its importance as a part of students' well-rounded education, physical educators need to examine the means by which they define, measure and report student achievement in the physical education setting, and commit to developing and implementing quality assessment.

Physical Activity Stories: Assessing the “Meaning Standard” in Physical Education

The presence of the “meaning standard” in both national and state content standards suggests that professionals consider it an important outcome of a quality physical education program. However, only 10 percent of states require an assessment to examine whether students achieve this standard. The purpose of this article is to introduce the concept of a physical activity story as a way to examine student achievement of the meaning standard. A physical activity story is a firsthand account of a person's relationship with physical activity. Examples of student physical activity stories are offered to illustrate why such stories deserve a place in physical education curricula. While it may be challenging for students to describe the meanings they develop in physical activity, this is not an excuse for teachers to withhold efforts to help students uncover these meanings. Teachers can use the physical activity story model to assess student achievement of the meaning standard.

The effects of state-level expenditures for home- and community-based services on the risk of becoming a long-stay nursing home resident after hip fracture.

This study measures the effect of spending policies for long-term care services on the risk of becoming a long-stay nursing home resident after a hip fracture. Relative spending on community-based services may reduce the risk of long-term nursing home residence. Policies favoring alternative sources of care may provide opportunities for older adults to remain community-bound. This study aims to understand how long-term care policies affect outcomes by investigating the effect of state-level spending for home- and community-based services (HCBSs) on the likelihood of an individual's nursing home placement following hip fracture. This study uses data from the 5% sample of Medicare beneficiaries from 2005 to 2010 to identify incident hip fractures among dual-eligibility, community-dwelling adults aged at least 65 years. A multilevel generalized estimating equation (GEE) model estimated the association between an individual's risk of nursing home residence within 1 year and the percent of states' Medicaid long-term support service (LTSS) budget allocated to HCBS. Other covariates included expenditures for Title III services and individual demographic and health status characteristics. States vary considerably in HCBS spending, ranging from 17.7 to 83.8% of the Medicaid LTSS budget in 2009. Hip fractures were observed from claims among 7778 beneficiaries; 34% were admitted to a nursing home and 25% died within 1 year. HCBS spending was associated with a decreased risk of nursing home residence by 0.17 percentage points (p 0.056). Consistent with other studies, our findings suggest that state policies favoring an emphasis on HCBS may reduce nursing home residence among low-income older adults with hip fracture who are at high risk for institutionalization.

Acceptance of New Medicaid Patients by Primary Care Physicians and Experiences with Physician Availability among Children on Medicaid or the Children's Health Insurance Program.

To estimate the relationship between physicians' acceptance of new Medicaid patients and access to health care. The National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records Survey and the National Health Interview Survey (NHIS) 2011/2012. Linear probability models estimated the relationship between measures of experiences with physician availability among children on Medicaid or the Children's Health Insurance Program (CHIP) from the NHIS and state-level estimates of the percent of primary care physicians accepting new Medicaid patients from the NAMCS, controlling for other factors. Nearly 16 percent of children with a significant health condition or development delay had a doctor's office or clinic indicate that the child's health insurance was not accepted in states with less than 60 percent of physicians accepting new Medicaid patients, compared to less than 4 percent in states with at least 75 percent of physicians accepting new Medicaid patients. Adjusted estimates and estimates for other measures of access to care were similar. Measures of experiences with physician availability for children on Medicaid/CHIP were generally good, though better in states where more primary care physicians accepted new Medicaid patients.

Coverage for low-income immigrant children increased 24.5 percent in states that expanded CHIPRA eligibility.

The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 provided states with the option of expanding eligibility for federally funded public insurance to low-income immigrant children within their first five years of legal residence in the United States. By 2011 twenty states and the District of Columbia had adopted that option. Using cross-sectional data from the 2003, 2007, and 2011-12 National Survey of Children's Health, we compared trends in coverage and access to care among immigrant children in states that did expand eligibility to children in states that did not. Compared to immigrant children in states that did not expand eligibility, children in states expanding eligibility experienced a 24.5 percent increase in insurance coverage, largely due to greater enrollment in public insurance. Immigrant children in states that expanded eligibility also experienced significant reductions in unmet health care needs, compared to their counterparts in nonexpansion states. Disparities relative to children in nonimmigrant families were substantially reduced in states that expanded eligibility, compared to states that did not. Expanding eligibility for federally funded public insurance to immigrant children within their first five years of legal residence in other states could improve coverage for immigrant children and might also increase access to care.

Structures, Roles, and Procedures of State Advisory Committees on Immunization

Advisory committees have the potential to play a critical role in decision making and implementation at the state level. Many states have advisory committees for their immunization programs to assist in decision making on topics such as implementing new vaccines in their states, school and childcare requirements and exemptions and addressing concerns about vaccine safety. This article describes how immunization advisory committees work; their roles, formation, organization, and structure; membership; the issues they address; and their benefit to state immunization programs. In 2011, the Association of State and Territorial Health Officials, in collaboration with the Centers for Disease Control and Prevention, conducted an online survey of immunization program managers to determine which states have immunization advisory committees, how these committees function, and the perceived benefits of the committees to state immunization programs. Follow-up half-hour telephone interviews were conducted with 5 states to gain in-depth information on specific advisory committees. One hundred percent of states and 3 territories responded, giving an overall response rate of 91%. Thirty-four of the 53 respondents (64%) reported having an advisory committee for immunization issues. Membership is composed of physicians, public health representatives, and nurses as well as public advocates and members of the public. States reported a variety of issues their committee has worked on; the most frequently mentioned issue was school and childcare vaccination requirements. Others included immunization information systems and vaccination of health care personnel. Overall, states with immunization advisory committees reported that the committees were helpful on issues faced by the program and worth the time and monetary commitment. Given the reported benefits of state immunization advisory committees and the complex program and policy decisions that states face in the dynamic immunization environment, additional states may want to consider establishing immunization advisory committees.