The economy robbed Americans of insurance, exacerbated psychological stress, and, paradoxically, saw fewer people die.
Amid the sleaze and cynicism of the last election cycle, a Priorities USA spot titled "Understands" transcended the normal boundaries of smear. The ad insinuated that by eliminating steelworker Joe Soptic's job and health insurance, Romney and Bain Capital forced Soptic's wife to forego treatment for the early signs of the cancer that ultimately took her life. But although fact-checkers found the causality in this story overstated, public health research shows that recessions do carry human costs that are often neglected.
Public health practitioners have acknowledged the power of economic and social forces on peoples' health since German physician Rudolph Virchow first blamed poverty for a 19th century Typhus outbreak. Now, attempts to catalog the myriad mechanisms that allow socioeconomic conditions to "get under our skin" are a central public health concern. In 2005, the World Health Organization established a Commission on Social Determinants of Health to advise on how to reduce their harm. Three years after the end of the Great Recession, it's clear that this downturn affected health of Americans in three ways: robbing them of insurance, exacerbating psychological stress, and, paradoxically, causing fewer people to die.
Unlike all other high-income nations that have universal healthcare systems, in the United States health insurance coverage fluctuates with the whims of the economy. Those without insurance, like Joe Soptic's wife, may refrain from preventative care or screenings necessary to identify illness early in its progression. While a small number of people lost insurance because their employer terminated healthcare benefits, the vast majority of the 5.6 million added to the rolls of the uninsured between 2007 and 2009 came from those that lost full-time employment. Young people, aged 19 to 34, composed nearly half of those that lost insurance during the official period of recession.
To mitigate the loss of insurance, the American Recovery and Reinvestment Act provided money to states for expanded children's health insurance programs and Medicaid as well as subsidized insurance premiums for the unemployed buying COBRA coverage. Such expansions not only prevented more widespread coverage loss among adults, but helped reduce the number of uninsured children by 600,000 in spite of the recession. Thankfully, provisions in the Affordable Care Act should help prevent future swings in insurance coverage and the Great Recession should be the last downturn to rob people of health coverage.
Beyond harm caused by loss of insurance, unemployment and job insecurity directly diminish peoples' health. A 2007 study by researchers at the University of Michigan and UCLA examined longitudinal interview data from American adults and found that while job loss leads to a significant decline in self-reported health and an increase in depression, the effects are concentrated among those that lost jobs because of poor health. Those that lost jobs for all other reasons -- such as a recession -- experienced only a slight increase in depressive symptoms and no significant decline in health. Instead, the authors found that persistent perception of job insecurity led to diminished self-reported health and increased depression even after adjusting for prior health and socioeconomic demographics. This confirms findings from a study of white-collar British civil servants and suggests that long-term anxiety over employment degrades health.
Accordingly, suicides, the most dramatic manifestation of depression and anxiety, proliferate during economic downturns. In twelve out of fourteen recessions since the 1920s the suicide rate accelerated upwards. Rates among 25 to 64-year-olds are more volatile than other age groups because, as many of them serve as primary breadwinners for their families, anxiety over job loss is compounded by fear of its impact on their dependents. According to a model recently published in the Lancet, between 2007 and 2010 in the United States approximately 4,750 people took their lives beyond the level that would be expected without the recession. Taken together, loss of insurance, persistent job insecurity and increased suicide rate paint a dour picture of health for individuals during recessions.
Yet, when looking at mortality data for the entire United States, a paradox emerges: despite the harmful aspects for workers, overall death rates fall and people live longer during recessions. In a study examining mortality between 1900 and 1996, death rates rise and fall with economic growth so that the fewest deaths occur during the sharpest downturns. By one estimate a one percent decrease in employment positively correlates with a decrease of 0.54% in the mortality rate: more than 13,000 averted deaths per year. Economist Tyler Cowen published an essay in the New York Times during the deepest point of the Great Recession that exalted how, counterintuitively, the recession would improve quality of life.
One explanation for this trend relies on the changing behavioral patterns as the economy fluctuates. Christopher Ruhm, professor of Public Policy and Economics at the University of Virginia, has demonstrated that during economic expansions use of tobacco and alcohol as well as obesity increase while exercise decreases. Additionally, boom periods are accompanied by reduced nightly sleep. Between tightening budgets and less busy schedules, recessions free people to partake in healthy activities that, in turn, decrease mortality.
As economic activity slows in recessions, according to another theory, transportation and production slow as well. Changes in economic output produce swings in the total level of particulate air pollution and, while this has little impact on adults, the increased air quality during recessions notably improves infant mortality rates. Deaths from auto vehicle accidents follow the same trend of pro-cyclic mortality.
Neither of these explains how during recessions individuals are harmed but the populace prospers. In order to reconcile these trends, a study published by the National Bureau of Economic Research looks at cause of death and unemployment from 1978 to 2006 broken down by demographics. For working-age adults, changes in vehicle accidents account for almost all of the changes in death rates. However, working-age adults and vehicle accidents do not power this national trend: they barely make up 10 percent of the change. Elderly Americans, those not themselves working, drive the decreased mortality during recessions as 70 percent of averted deaths come from those over 70.
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Therefore, while grandma living longer causes the trend seen across the population, changes in her interactions with people in the workforce must explain why she lives longer in the first place. One such regular interaction takes place for the elderly living in nursing homes. For Americans over 65, the death rate for those in nursing homes drastically decreases during recessions while death rate slightly increases for those not in nursing care. Enough deaths are averted in nursing homes to compromise the entire effect among those over 65. Plus, in comparison between states, those with the greatest percentage of elderly living in nursing care saw the most substantial decrease in the death rate.
Nursing homes are chronically understaffed in times of economic prosperity. But, when the job market tightens, a one percent increase in unemployment sees full time employment in nursing facilities rise three times as fast. After a recession, when the economy picks back up and jobs become available again, low skilled workers abandon nursing homes jobs' low pay and even fewer accolades for better prospects. The shift of workers in and out of nursing jobs drives the swings in the national death rate and underscores the importance of these under-appreciated jobs.
A look at the relationship between economic downturns and health outcomes in the United States reveals a complex picture: harm from lost insurance and increased anxiety but better care for the elderly. These two trends coexist because, while harm concentrates in working age people, retirees reap the majority of the benefit. They do not offset one another but instead further deepen our nation's indefensible health disparities. While the Affordable Care Act should help prevent harm in future recessions from loss of insurance, an aging populace and uncertainty around the economy will allow these trends to recur for the foreseeable future.
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