Health Disparities by Zip Code, Race and Poverty: Stanford’s Raj Chetty Continues to Find Links

Raj Chetty

[Music]

Mark Masselli: This is Conversations on Health Care I’m Mark Masselli.

Margaret Flinter: I’m Margaret Flinter.

Mark Masselli: Well, Margaret the president traveled to New Hampshire this week to
publicly address the nation's opioid crisis . H e outlined a number of
recommendations to address this serious public health scourge .

Margaret Flinter: Well the president issued a tough on crime approach to the
epidemic even floated the idea of deploying the death penalty for drug dealers . He
also pro posed issuing more money for treatment for those suffering from substance
use disorders , but many observers who are working on the front lines of the opi oid
crisis sa id there must be much more financial support to meet the unmet treatment
burden .

Mark Mas selli: T he president issued an order allocation six billion dollars to address
the opioid crisis over the next two years . Congress is considering a number of
additional bills addressing the crisis as they hammer out agreements on the federal
budget .

Mar garet Flinter: A mong the additional measures that are being considered a bill
that would ensure patients being released from the hospital are given appropriate
access to addiction services and medication assisted treatment or MAT as i t’ s
commonly called , which we know to be very effective in addiction treatment . T he
most recent overdose count for 2017, 45,000 deaths attributed to opioid overdose
truly a continuing devastating public health crisis .

Mark Masselli: I t shines a harsh light o n a big gap in o ur health care system
treatment is costly access to treatment facilities is challenging , those with limited
means have fewer treatment options at their disposal .

Margaret Flinter: Mark we are approaching National Minority Health month, and we
thought we would revisit our interview with the renowned Stanford E conomist R aj
Chetty. T he MacArthur Genius Grant winner has been conducting what is
considered seminal research in the link between zip code , health outcomes and life
expectancy .

Mark Masselli: Marg aret I draw everyone's attention to the project that Raj was
heading up a project between Harvard and the US Census Bureau a quality on
Opportunity Project really lays bare some new findings . W e look forward to t hat
interview and we're also looking forwar d to the conversation with L ori Robertson the
managing editor of F act C heck . org .

Margaret Flinter: R emember you can hear all of our shows by going to
chcr adio . com .

Mark Masselli: As always if you have comments please email us at

1

Raj Chetty

[email protected] or find us on Facebook or Twitter we love hearing from you .

Margaret Flinter: W e'll get to our interview with Raj Chetty in just a moment .

Mark Masselli: F irst here's our producer Marian ne O’Hare with this week's h ea dline
n ews.

[Music]

Marianne O’Hare: I'm Marianne O'Hare with th ese health care headlines . H ealth
disparity and race the two are linked . A recently released study reveals even among
affluent African - Americans their chances for economic upward mobility are seriously
hampered statistically . T he study conducted by renowned Stanford E conomist Raj
Chetty researchers from Harvard and data from the U.S. Census Bureau show that
when it comes to economic opportunity and upward mobility African - American men
and boys fare poorly . T he findings showed that black American men even from
wealthy families are much more likely to end up in lower income brackets than white
men who grew up poor impacting not only economic status but health status as well .

A mericans are n ot taking care of their cardiovascular health . A longitudinal study
covering the period from 1988 to 2014 showed that among adult Americans age 25
and older only about 40% of whites , 25% o f Hispanic Americans and 15% African -
Americans had control blood pr essure within a normal range . G enerally speaking
the proportion of Americans with healthy eating habits and exercise habits as well
has declined over the course of the study . T he numbers especially among younger
Americans of all races declined over that period .

T alking tough on the war on drugs P resident Tr ump use New Hampshire as a
backdrop this week to outline his plans for addressing America’s opioid crisis. The
president promised to offer more resources for treatment to the millions of Americans
gra ppling with substance use disorder , but also leveraging the threat of the death
penalty for drug dealers . A ccording to the CDC. 42,000 Americans died from opioid
overdose in 2016 the numbers for twenty seventeen well not complete yet stand at
about 45,000 .

O ne drug counted among the most difficult to give up is nicotine , the active
ingredient in cigarettes that keeps about 15% of the American population hooked
and leads to roughly half a million deaths per year in this country FDA D irector Scott
Gottlieb saying he's seeking to issue guidelines for greatly reducing the amount of
nicotine in each cigarette by setting a maximum level allowed . Ex perts predict that
such a move would help five million current adult smokers to quit within a year . T he
FDA s goal to reduce the current U.S. smoking rate from 15% to as low as 1.4% and
prevent some eight million tobacco related deaths by the end of the century . I’m
Marianne O'Hare with these health care headlines.

[Music]

Mark Masselli: We're speaking today with Raj Chetty PhD Professor of Public
Economics at Stanford University where he studies the impact of geography and

2

Raj Chetty

policy on health and economic outcomes . Dr . Che tty previously was the Bloomberg
P rofessor of E conomics and the D irector or L ab for E conomic A p plication and Policy
at Harvard University . H e's won numerous prestigious awards for his work including
the MacArthur Foundation F ellowship in 2012 and the John Bates Clark Award from
the American Economic Association . H e's also been named by the Economi st and
The New York Times a s one of the most influential economist in the world , he
earned his bachelor's and PhD f rom Harvard . Raj welcome to C onversations on
Health Care.

Raj Chetty: T hank you .

Mark Masselli: I think it's axiomatic in the public hea lth circles that zip code is a
b etter predictor of health than genetic code . Y ou've gained quite a reputation in the
economic world for conducting some important research on the link between
person’s economic status , their neighborhood and both their heal th as well as their
economic outcomes . He lp our listeners understand the impact on zip code in
economic status on health outcomes.

Raj Chetty: We've been interested in our research group in studying determinants of
inequality and opportunity in the Unit ed States . T here are two aspects that have
struck me as particularly important and those are inequalities and opportunities for
children , and inequalities in health . W e had done some earlier work in our group
focusing as you noted on economic outcomes an d how they vary across
neighborhoods . U sing big data drawn from de - identified tax and s ocial s ecurity
records we examined in that work how the neighborhood in which you grew up
af f e cts your chances of climbing up the income ladder , and found that
neighbor hoods played a profound role in children's chances of success . T hen
wanted to turn to the second aspect of inequality health aspects , and there we use
data from again social security records link to tax records which gave us information
on 1.4 billion obs ervations covering the entire US population , again allowing us to
look at the link between income and mortality rates and how that varied across
counties in the United States . W e find that higher income people tend to live longer
lives than lower income p eople in the US as a whole , but importantly we find that
there's a great deal of variation across areas . T hat finding then motivates follow up
analysis to ask why is it that there are some places where gaps and life expectancy
are much larger and growing over time .

Margaret Flinter: W ell , Raj I was particularly struck by your findings that those in low
income groups have actually seen their life expectancy decrease since t he great
recession , while those i n upper income brackets saw their life expectancy increase .
What are your sort of preliminary thought zero ing in on what are the causes ?

Raj Chetty: Right, so there are some alarming trend s in terms of inequality in life
expectancy in the US. S ince 2000 the rich have gained about three years in life
e xpectancy . I n contrast the lowest income Americans have gained nothing
essentially on average in life expectancy over the past 15 years , and some might
actually have seen reduction s in life expectancy . T here are some places in America
where gaps in life expectancy are actually shrinking . Birmingham , Alabama is a
place where low income individuals happen to be gaining as much in life expectancy

3

Raj Chetty

as the richest Americans . I n contrast there are other places like Tampa , Florida
where the life expectancy of t he lowest income population is actually steadily falling
over the past 10 or 15 y ears . I think it's really to understand what is it that's different
in Birmingham route of the Tampa, how can w e replicate those successes in places
like Tampa.

Mark Massell i: Well, I think we've known for some time that poverty and social
determin ants are linked to poor health outcomes , unemployment , low wages ,
immigrant status and the like . I wonder if you could sort of illuminate what kinds of
social determinants you loo ked at while conducting the study and what were the
most prevalent factors contributing to mortality divide ?

Raj Chetty: Yeah one set of factors is the factors that affect health conditional on
income . W e see that people have higher life expectancy and better health outcomes
in some areas relative to others . You can ask what is correlated with those
differences , and what we find there is by far the strongest predictor of the variation is
differences in health behaviors , rates of smoking , rates of exerci se , rates of obesity .
I n contrast we find much weaker correlations with measures of health care access ,
so the number of primary care physician i n an area , there are some predictive power
for some of those measures but nothing like the predictive power of differences in
health behaviors . T here are some places that generate economic outcomes that are
not as good , and those worst economic outcomes also tend to be worse h ealth
outcomes .

T his ties back to the earlier body of work where we've also looked at h ow economic
outcomes of children in particular vary across areas . T here we find that places that
are more segregated or places that have less social capital , these places have
worse economic outcomes and those economic outcomes tend to go hand in hand
wit h worse health outcomes . T here's one set of factors that we should be thinking
about health behaviors in particular that affect health , and then there's another set of
factors that affect both economic outcomes and h ealth together . I think both are very
important to think about from a policy perspective .

Margaret Flinter: Y our research highlighted a few bright spots that low income
people tended to do better if they lived in an urban area with a robust health care
infrastructure . C an you share your fin dings with us on health outcomes for the more
economically challenged that had the good fortune to live near better health systems ,
and how does this cater and play out around the country ?

Raj Chetty: Y es , so the lowest income individuals tend to have th e best health
outcomes in cities like New York and San Francisco for example , so urban areas
w ith actually relatively high costs of living , liberal progressive cities that have a lot of
spending on public health . One possibility is that these types of cit ies tend to be
exactly the places that have regulations that might improve the health of the entire
population . F or example , what are the cities where smoking bans and work place
those are bans on trans fats , and those types of legislative changes would a ffect not
only the health of the wretch but also the help of the poor . Another possibility is that
if you live in an area with a lot of affluent people , maybe you yourself c hange your
health behaviors or there's a greater availability of healthy foods , ex ercise options

4

Raj Chetty

and so forth .

A third possibility is that the low income people who live in New York and San
Francisco are just different from the low income people who live in cities where we
find much lower life expectanc ies like Detroit or Tulsa , Oklaho ma . L ife expectancy
for the poor is higher in urban affluent educated areas . U rban areas tend to have
better outcomes than rural areas . O ften we find in other studies that the s outh tends
to exhibit worse outcomes , in this case we find that the s outh ac tually doesn't look
like it has worse health outcomes than the rest of the country . H owever , because
incomes are on average lower in the s outh health outcomes in the south look worse ,
but we think that's because th e economic outcomes in the south are wors e on
average . A gain , getting back to be the issue that the economic and health outcomes
are really intertwined here .

Mark Masselli: W e're speaking today with Raj Chetty PhD Professor of Public
Economics at Stanford University where he studies the impact of geography and
policy on health and economic outcomes . Raj you’ve been examining disparities in
income and housing education for a number of years , and I know one of the studies
gain ed a great deal of attention and showed that children born in poverty who are
still living in high poverty communities by their early teens are unlikely to ever elevate
themselves out of that poverty t o achieve the so - called American dream . I know as
an organization that provides primary care which is about to go into the c ity of
Hartford and take on a pediatric practice of 15,000 children , really concerned about
all the work that we might be able to do might not change their trajectory . I'm
wondering if you could share some details of your study on childhood poverty .

Raj Chetty: W hat we did in the study that you're referring to is w e examined children
who moved to lower poverty or higher opportunity areas and examined h ow t heir
outcomes change d. W e focused on a well known experiment called the Moving to
Opportunity experi ment which involved about 5000 families . S ome of them were
randomly assigned a housing voucher that gave them access to move to a lower
poverty area while other families that were in the control group ended up continuing
to live and quite high poverty pub lic housing projects . W e've tracked the children in
this experiment over about a 20 or 25 year period , and what we find is that the
children who were given the opportunity to move to a lower poverty area at a young
age e nd up having dramatically better ou tcomes . They’re 30% more as adults ,
they ’ re significantly more likely to go to college , they're significantly less likely to
have a teenage pregnancy .

In contrast , children who moved at older ages exhibit much , much smaller gains from
moving to these low er poverty areas . W hat these data show is that neighborhoods
matter through a mechanism of childhood exposure , every extra year that you spend
growing up in a better area appears to improve your long term outcomes . W hen one
looks at health outcomes again you see significant improvements when people move
to higher opportunity areas . Here interestingly we find significant gains even for
people who moved at older ages , even for adults there are significant improvements
in terms of mental health , reduced rat es of diabetes and so forth . N eighborhoods
really seem to play a very important role in both economic and health out comes . L et
me reiterate that study does not show by any means that other interventions like

5

Raj Chetty

primary care inter vention s or improvements in schools in a given area and so forth ,
do not matter . The lesson is simply that neighborhoods are one powerful
determinant of economic and health outcomes .

Margaret Flinter: Raj the work you do at Stanford along with your colleagues around
the country w o uld seem ha s accelerated in recent years partly because of the
advances in having big data . H ow much has that impacted the kind of research that
you're able to conduct and how are you able to translate that data to inform
policymakers that will directly a ffect a q uality of opportunity in the country ?

Raj Chetty: T here's really been a transformation in social science in recent years as
the field has shifted from using data from small surveys where you really have limited
samples , and particular difficulty in tracking people over time to the use of what is
co lloquially called b ig d ata , large data sets that are created to our interactions with
various systems like the tax system or the s ocial s ecurity system or here in Silicon
Valley things like Facebook and Google . T he vision of our research group is
basically that we can harness these data not just to improve the products that the
private sector offers , our vision is we can use these data to tackle important social
and economic policy questions . It’s crit ical for the United States to continue to
provide researchers access to these sorts of data . Mu ch of my interaction with
policymakers in DC and other levels of government is around showing that the very
valuable lessons that you can get from th ese data wh ich translate directly into policy .

For i nstance the Housing and Urban Development Agency is thinking about
changing the way in which the 45 billion dollars a year we spend on affordable
housing programs is structured in light of the evidence that I've be en describing .
S eeing that very tangible in fact on policy I think motivates policymakers to recognize
the value of these data , and creating an infrastructure where researchers can access
these data and deliver lessons that can help public policy more bro adly .

Mark Masselli: Y ou know as you were talking about better outcomes in urban
affluent educated areas and that neighborhoods matter i0 t had me reflect on a
couple of people we've talked with in the past Robert Putnam and his work at
Bowling Alone , and Nick Christakis who's been working on social networking , and
r eally both of them coming out with little variation of the thing . Wh at's your
recommendation for people who are frustrated with all of this data in terms of the
work that they can do ?

Raj Che tty: Yeah I mean Mark you’re absolutely right that there ’s a connection to
the work of Bob Putnam and Nick Christakis here , as an example we find that Salt
Lake City with the Mormon Church thought to be a place with a great deal of social
capital is one o f the best places in the US to realize the American dream, it has
some of the highest rates of social mobility . W hen you see those very positive
economic outcomes as I've been emphasizing they tend to go hand in hand with
better health outcomes as well . E conomists tend to gravitate towards solutions like
investing in better schools or trying to change zoning laws and affordable housing
policies . W e have less of a sense of how to change those from a policy perspective
particularly in a scalable way , but w hen you're thinking about policy and how you
might change things on the scale you tend to gravitate more naturally towards things

6

Raj Chetty

that we're able to control through funding for public schools or the way teachers are
hired or things like that . I think we n eed to think creatively about how we might be
able to set up systems that will change social capital and change networks more
systematically .

Margaret Flinter: W e've been speaking today with Dr Raj Chetty MacArthur
Foundation fellow and P rofessor of Publ ic Economics at Stanford University . Y ou
can learn more about his work by going to I nequality . Stanford. edu/users/Raj - Chetty.
Y ou can also find links to his work on Twitter . Dr . Ch etty thank you so much for
joining us today on Conversations on Health Car e for this very important
conversation .

Raj Chetty: T hank you.

[Music]

Mark Masselli: At Conversations on Health C are, we want our audience to be truly in
the know when it comes to the facts about health care reform and policy, Lori
Robertson is an aw ard - winning journalist and Managing Editor of FactCheck.org, a
non - partisan, nonprofit consumer advocate for voters that aim to reduce the level of
deception in U.S. politics. Lori, what have you got for us this week?

Lori Robertson: I n the wake of the F lorida school shooting in February , politicians
have raised concern over the influence of violent video games and films on young
people . T he president claimed that violence in video games is quote , “S haping
young people ’s thought s.” S cientists still debat e d but the majority of studies show
that extensive exposure to media violence is a risk factor for aggressive thoughts ,
feelings and behaviors . T here's less consensus on whether media violence is a risk
factor for criminal violence in which the perpetrato r is subject to arrest and
incarceration . T he link between media violence and mass shooting is yet more
tenuous . The 2015 review of the scientific literature on video game violence by the
American Psychological Association cautioned that the nuance of th is research is
often left out in news coverage . I t's found that quote . “V iolent video game use has
an effect on aggression .” T his effect manifests as an increase in aggressive
behaviors , thoughts and feelings and a decrease in helping others empathy and
sensitivity to aggression .

S ome researchers however have found that experimental evidence backing a causal
relationship between video games and aggression may not be that solid. O ne study
in the journal Psychological B ulletin last year found experimental studies may be
subject to publication bias . A s for a link between a violent video game use and
criminal violence scientist disagree about how much evidence is e nough to
sufficiently support a causal link between media violence and real world violence .
T rump and other politicians concern aren't unfounded , and that's my f act c heck for
this week . I'm Lori Robertson Managing Editor of F act C heck . O rg

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you ’d like checked, email us at

7

Raj Chetty

CHCradio.com we ’ ll have FactCheck.org’s, Lori Robertson check it out for you, here
on Conversations on Healt hcare.

[Music]

Mark Masselli: Each week conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Fitness trackers have
become all the rage especially among upwardly mobile fitness conscious people
seeking to monitor their own health and fitness goals. Another trend has emerged in
the age of wearable devices. After a few months about a third of users simply stop
using them leaving a lot of costly devices sitting on the shelf and not in use. The
re ality captured the imagination of Tufts University School of Medicine professor Dr
Lisa Gualtieri.

Dr. Lisa Gualtieri: I had read about the abandonment rage and I thought what if you
could take all of these abandoned trackers and give them to the people who could
benefit most from them.

Mark Masselli: She thought what if we could get disinterested owners to donate their
used fitness trackers to be repurposed and donated to under - served populations.

Dr. Lisa Gualtieri: For a lot of people they're quite interested in owning one of these
devices to help them increase their fitness and cost is precipitate, so I think that
that's a barrier for a lot of people.

Mark Masselli: In 2015 she launched her nonprofit enterprise Recycle Health an
online social med ia campaign to raise awareness for her program which seeks
donated wearable devices no longer in use to provide these expensive devices for
free to those in need. She partner with organizations working with low income adults
in wellness programs and those with mental health issues. Her goal is to start
collecting vital data on the deployment of these devices and the impact they may be
having on behavior change in vulnerable populations.

Dr. Lisa Gualtieri: We talk to people about how sedentary they are, and coming up
with a reasonable and achievable where they might start off with 2000, 3000 steps
but they know how to make that higher.

Mark Masselli: Recycle Health a simple repurposing of personalized wearables
providing these tools for free to vulnera ble populations empowering them to engage
in activities that can improve their own health, now that's a bright idea.

[Music]

Margaret Flinter: This is Conversations on Health Care I’m Margaret Flinter.

Mark Masselli: I’m Mark Masselli, peace and healt h.

8

Raj Chetty
Conversations on Health C are broadcast from WESU at Wesleyan University,
streaming live at www.wesufm.org and brought to you by the Community Health
Center.

9