Explaining Inequalities in Women s Mortality Between U.S. States. Jennifer Karas Montez Anna Zajacova Mark D. Hayward

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1 Explaining Inequalities in Women s Mortality Between U.S. States Jennifer Karas Montez Anna Zajacova Mark D. Hayward

2 Data from (

3 Is this variation large?

4 Range in life expectancy across US states exceeds the range across high-income countries Range in LE at birth Range in LE at age 50 States of the US Comparable high-income countries Data from 2000 Source: Wilmoth et al 2011 High-income countries include: Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Iceland, Ireland, Italy, Japan, Luxembourg, the Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, the United Kingdom, and the United States.

5 But things are improving, right?

6 Life expectancy has stagnated or declined * in some states, and inequalities have increased years Female life expectancy at age 50 Massachusetts Oregon Mississippi West Virginia *among women in Wyoming and West Virginia

7 Two main hypotheses People vs. place Composition vs. context Women s characteristics vs. state characteristics

8 Why haven t these hypotheses been tested before? Data limitations Public-use data that has mortality does not have states Reliance on county-level or state-level data from vital stats Generally conceptualized as a demographic phenomenon But geographic variation in mortality is inherently multilevel State policies/programs can theoretically shape mortality: income tax policy economic well-being Medicaid eligibility rules & abortion laws access to medical care corporate tax incentives employment tobacco control strategies health behaviors Federal aid to states has declined. States given more discretion over how to legislate & fund policies & programs (Conlan 1998)

9 Study Aims 1. How much of the inequality in women s mortality reflects states characteristics, net of women s characteristics? 2. Which state characteristics are most important? 3. Are states more important for women than men?

10 Data & Approach Multilevel approach Individual level dataset with state identifiers 2013 public-use NLMS Respondents surveyed in 1980s-1990s, followed 6 years U.S.-born women aged Person-quarter file with 25,850 deaths Focus on fundamental characteristics race, education, income, employment, marital status Collect and merge state-level contextual data

11 State Characteristics (circa 1990) 1. Gross state product per capita 2. Median household income 3. % of individuals living below poverty 4. % of female householder families below poverty 5. Education expenditures per capita 6. % of tax revenue from sales tax 7. % of adults 25+ years with BS+ 8. Gini coefficient of income inequality 9. Social capital index 10. Unemployment rate 11. Violent crime rate 12. % of federal EITC offered by state EITC 13. Public welfare expenditures per capita 14. % presidential elections voters favored republican 15. Medicaid program score 16. % population in SMSA 17. % of rental units costing 35%+ of household income 18. % of workers 16+ using public transportation 19. Tobacco manufacturing as % of GSP 20. State tax as % of retail price of cigarettes 21. Cigarette pack sales per capita

12 State Characteristics (circa 1990) 1. Gross state product per capita 2. Median household income 3. % of individuals living below poverty 4. % of female householder families below poverty 5. Education expenditures per capita 6. % of tax revenue from sales tax 7. % of adults 25+ years with BS+ 8. Gini coefficient of income inequality 9. Social capital index 10. Unemployment rate 11. Violent crime rate 12. % of federal EITC offered by state EITC 13. Public welfare expenditures per capita 14. % presidential elections voters favored republican 15. Medicaid program score 16. % population in SMSA 17. % of rental units costing 35%+ of household income 18. % of workers 16+ using public transportation 19. Tobacco manufacturing as % of GSP 20. State tax as % of retail price of cigarettes 21. Cigarette pack sales per capita Economic Social Cohesion Sociopolitical Infrastructure Tobacco

13 Multilevel logistic regression model effect of state j i = individual j = state State-level residual

15 ME

16 ME

17 SD ME WV

18 SD MN NDHI NE KS UT OR WI IA ME MS IN OH MD MI LA IL NV TN WV

19 SD MN NDHI NE KS UT OR WI IA MT ID MA VT NH NM WA COFL GA ME CA TX CT AZ WY RI MO AR NC AK NJ KY SC AL NY PA OK VA DE MS IN OH MD MI LA IL NV TN WV s = 0.090

20 SD MN NDHI NE KS UT OR WI IA MT ID MA VT NH NM WA COFL GA ME CA TX CT AZ WY RI MO AR NC AK NJ KY SC AL NY PA OK VA DE MS IN OH MD MI LA IL NV TN WV s = 0.000

21 SD MN NDHI NE KS UT OR WI IA MT ID MA VT NH NM WA COFL GA ME CA TX CT AZ WY RI MO AR NC AK NJ KY SC AL NY PA OK VA DE MS IN OH MD MI LA IL NV TN WV s = 0.000

22 SD MN NDHI NE KS UT OR WI IA MT ID MA VT NH NM WA COFL GA ME CA TX CT AZ WY RI MO AR NC AK NJ KY SC AL NY PA OK VA DE MS IN OH MD MI LA IL NV TN WV s = 0.090

23 SD MN NDHI NE KS UT WI OR IA GA MT MA ID FL NC VT NM SC NH MS WA CO AL TX AR CA MO CT LA VA ME WY AZ MD AK KY NJ RI DE NY OK PA MI IN OH TNIL NV WV s = 0.072

24 SD MN NDHI NE KS WI GA UT OR IA MT AL NC SC ID NM MS AR MA TX VT NH LA FL MO KY CO WA CT VA ME RI MD NJ CA AK WY PA DE AZ NY TN OK IN MI OH IL WV NV s = 0.068

25 SD MN NDHI NE KS UT WI GA OR IA AL MT MS NM AR SC ID NC TX LA FL VT MA MO KY NH WA CO ME VA RI MD CT AZ CA TN PA OK WY NJ DE AK MI NY IN OHIL WV NV s = 0.066

26 SD MN NDHI NE KS GA WI UT OR IA AL MT MS NM AR SC NC MA LA ID TX VT NH MO KY FL WA CO ME RI VA MD CT CA PA NJ AZ AK TN DE NY WY OK MI IN 0HIL WV NV s = 0.058

27 SD MN NDHI NE KS GA WI UT OR IA AL MT MS NM AR SC NC MA LA ID TX VT NH MO KY FL WA CO ME RI VA MD CT CA PA NJ AZ AK TN DE NY WY OK MI IN 0HIL WV NV s = 0.058

28 SD MN NDHI NE KS GA WI UT OR IA AL MT MS NM AR SC NC MA LA ID TX VT NH MO KY FL WA CO ME RI VA MD CT CA PA NJ AZ AK TN DE NY WY OK MI IN 0HIL WV NV s = 0.058

29 s = 0.027

30 s = 0.027

31 How much of the inequality in women s mortality reflects states characteristics, net of women s characteristics? Women Men Composition 36% 38% Composition & Context 70% 49% Context 57% 28% Economic environment Social cohesion Tobacco environment

32 Tentative conclusions Variation in women s mortality across states reflects differences between states in composition AND context States have stronger & more pernicious consequences for women The ways that states matter differ for women and men Inequalities in women s mortality cannot be brushed aside as reflecting individual choices, characteristics, or behaviors States appear to have played an important role Will continued devolution further exacerbate the inequalities?

33 Issues we Plan to Address Age-specific analyses Focus on ages Some indication that states more important for older ages Cause of death Time trends No migration history State effects may be conservative 3-level analyses to incorporate counties

34 Thank you

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