Lucie Kalousova

The Great Recession and Health: People, Populations, and Disparities

Two research traditions have evolved to assess links between recessions and health, with seemingly divergent findings. Aggregate-level studies generally find that mortality rates decline during recessionary periods. By contrast, individual-level studies generally find that events that frequently occur during recessions, like job loss, unemployment, and material hardship, carry negative health consequences. We comprehensively review evidence from these two bodies of research, illustrate key findings, and show how the different mechanisms can operate in parallel. We also outline some of the limitations of the extant evidence, discuss studies emerging to address these limits and directions for future research, and provide brief empirical examples to illustrate some of these limits and directions using the Health and Retirement Study and the Michigan Recession and Recovery Study. Our review emphasizes the importance of considering both the aggregate- and individual-level associations when evaluating the likely short- and longer-term consequences of the Great Recession for health and health disparities.

Perceived job insecurity and health: the Michigan Recession and Recovery Study.

Objective: To examine the association between perceived job insecurity in the next 12 months and current health with a sample representing working-aged employed adults in southeast Michigan in late 2009/early 2010 (n, 440 to 443). Methods: Logistic regression was used to compare the health of participants who perceived job insecurity with those who did not, with adjustments for objective employment problems and social characteristics. Results: Insecure workers were more likely to report fair or poor self-rated health (odds ratio [OR], 2.68; 95% confidence interval [CI], 1.14 to 6.32), symptoms suggesting major or minor depression (OR, 6.76; 95% CI, 3.34 to 13.3), and anxiety attacks (OR, 3.73; 95% CI, 1.40 to 9.97), even after correction for confounding factors. Conclusion: This study provides evidence that perceived job insecurity may be linked to health even among those who avoided unemployment in the late-2000s recession.

Unemployment, measured and perceived decline of economic resources: contrasting three measures of recessionary hardships and their implications for adopting negative health behaviors.

Economic downturns could have long-term impacts on population health if they promote changes in health behaviors, but the evidence for whether people are more or less likely to adopt negative health behaviors in economically challenging times has been mixed. This paper argues that researchers need to draw more careful distinctions amongst different types of recessionary hardships and the mechanisms that may underlie their associations with health behaviors. We focus on unemployment experience, measured decline in economic resources, and perceived decline in economic resources, all of which are likely to occur more often during recessions, and explore whether their associations with health behaviors are consistent or different. We use population-based longitudinal data collected by the Michigan Recession and Recovery Study in the wake of the Great Recession in the United States. We evaluate whether those who had experienced each of these three hardships were more likely to adopt new negative health behaviors, specifically cigarette smoking, harmful and hazardous alcohol consumption, or marijuana consumption. We find that, net of controls and the other two recessionary hardships, unemployment experience was associated with increased hazard of starting marijuana use. Measured decline in economic resources was associated with increased hazard of cigarette smoking and lower hazard of starting marijuana use. Perceived decline in economic resources was linked to taking up harmful and hazardous drinking. Our results suggest heterogeneity in the pathways that connect hardship experiences and different health behaviors. They also indicate that relying on only one measure of hardship, as many past studies have done, could lead to an incomplete understanding of the relationship between economic distress and health behaviors.

Debt and foregone medical care.

Most American households carry debt, yet we have little understanding of how debt influences health behavior, especially health care seeking. We examined associations between foregone medical care and debt using a population-based sample of 914 southeastern Michigan residents surveyed in the wake of the late-2000s recession. Overall debt and ratios of debt to income and debt to assets were positively associated with foregoing medical or dental care in the past 12 months, even after adjusting for the poorer socioeconomic and health characteristics of those foregoing care and for respondents’ household incomes and net worth. These overall associations were driven largely by credit card and medical debt, while housing debt and automobile and student loans were not associated with foregoing care. These results suggest that debt is an understudied aspect of health stratification.

E-cigarettes: a harm-reduction strategy for socioeconomically disadvantaged smokers?

598 www.thelancet.com/respiratory Vol 3 August 2015 oxygenator gradually failed, and the patient slowly lost consciousness and died. Generally, when managing patients who no longer have the medical indications for which ECMO was initiated, the options of either to stop ECMO as soon as possible or to continue ECMO indefi nitely can both be defended by straightforward ethical arguments, despite the fact that they reach opposite conclusions. The path that we chose here, of continuing but restricting the use of lifesupport, is ethically and psychologically complex, yet it did provide an emotionally supportive way to share the moral burden of the decisions with the family when the more ethically straightforward approaches seemed diffi cult to accept. From a broader societal perspective, however, further issues arise. ECMO is an expensive resource: can we aff ord to support all patients who might desire ECMO as a destination therapy? Some chemotherapeutic regimens that are expected to extend life by only several months, for example, are similar in cost to the use of ICU care and ECMO. How can we justify the wide use of these agents but not ECMO? However, viewing ECMO as a destination therapy could result in unfair use of scarce intensive care resources for some patients over others. If one patient is allowed to stay on ECMO when they no longer have a possibility of transplantation, why should ECMO therapy be denied to patients who have never been transplantation candidates, but who could also enjoy an extension of a desirable quality of life if supported on ECMO indefi nitely? Patients with isolated but severe forms of pulmonary disease might

Increase in frailty of older workers and retirees predicted by negative psychosocial working conditions on the job

Well-established evidence has shown that negative psychosocial working conditions adversely affect the health and well-being of prime-age workers, yet little is known about the consequences on the health of older workers. Our article examines the associations between declines in health in later life, measured as frailty, and negative psychosocial working conditions, and considers the role of retirement. We use longitudinal cross-national data collected by SHARE I and SHARE IV and focus on the respondents who were working at baseline. We find that low reward, high effort, effort to reward ratio, and effort to control ratio were all predictors of increasing frailty. The association between low reward and change in frailty was modified by retirement status at follow-up, with nonretired respondents in low-reward jobs experiencing the largest increases in frailty at follow-up. These results suggest that the effect of psychosocial working conditions on physical health may extend well past the prime working age, and retirement may have a protective effect on the health of older workers in low reward jobs.

Tough Choices in Tough Times: Debt and Medication Nonadherence

Debt is a ubiquitous component of households’ financial portfolios. Yet we have scant understanding of how household debt constrains spending on needed health care. Diverse types of debt have different financial properties and recent work has shown that they may have varying implications for spending on needed health care. In this article, we explore the associations between indebtedness and medication nonadherence. First, we consider overall debt levels and then we disaggregate debt into types. We use a population-based sample of 434 residents of southeast Michigan who had been prescribed medications, collected in 2009-2010, the wake of the Great Recession. We find no association between medication nonadherence and total indebtedness. However, when we assess each type of debt separately, we find that having medical or credit card debt is positively associated with medication nonadherence, even net of household income, net worth, and other characteristics. Furthermore, patients with greater amounts of medical or credit card debt are more likely to be nonadherent than those with less. Our results suggest that credit card debt and medical debt may have serious implications for the relative affordability of prescription medications. These associations have been overlooked in past research and deserve further examination.

Curing over-use by prescribing fees: an evaluation of the effect of user fees’ implementation on healthcare use in the Czech Republic

In 2008, the Czech Republic instituted a new policy that requires most patients to pay a small fee for some inpatient and outpatient healthcare services. Using the Survey of Health Aging and Retirement in Europe, this article examines the changes in healthcare utilization of Czechs 50 years and older following the new fee requirement by constructing difference-in-differences regression models focusing on four outcome measures: any visits to primary care physician, any hospitalization, number of visits to the primary care physician and number of nights hospitalized. For this population, I find that the likelihood of having any primary care visit decreased after the policy was instituted. The likelihood of reporting any hospitalization was not significantly changed. The predicted number of primary care visits per person declined, but the predicted number of nights spent in a hospital did not. I find only mixed evidence of greater effect of the user fees on some subpopulations compared with others. Those 65 or older reduced their use more than those between 50 and 64, and so did those who consider their health to be good, and the less educated.

Rent assistance and health: findings from Detroit

Abstract This study assesses the relationship between rent assistance and health in a longitudinal, population-representative sample collected in the Detroit metro area. Previous research has found that rent assistance recipients are less healthy than otherwise similar non-recipients in the cross-section, but the evidence about the effects of rent assistance on health in the long run is ambiguous. Our study uses panel survey data to compare the health of recipients and eligible non-recipients at the study’s onset and four years later at follow-up with respect to an extensive set of physical, mental and behavioural health outcomes. Our results demonstrate that rent assistance recipients are in worse overall health than non-recipients, but also provide suggestive evidence that the programme may buffer health declines in the medium term. However, the positive buffering effects may be erased in the long run, as we simultaneously observed an increase in smoking among rent assistance recipients. Our study shows that the current shortage of rent assistance may have implications for population health.

The real challenge is to make e-cigarettes accessible for poor smokers – Author's reply

Based on her Comment on e-cigarettes, it is hard to avoid the impression that Lucie Kalousova would be happier if there was more smoking-related disease, providing it was more evenly distributed. That poorer groups face barriers to realising the benefi ts of substituting cigarettes for e-cigarettes is indisputable, but that is a reason to address those barriers, not to argue that e-cigarettes are of no value to poor smokers. By saving money, improving wellbeing, relieving chronic illness, and reducing risks of serious disease, a switch from smoking to vaping could be a major life-enhancing option for the poorest smokers. Low-income status is associated with a greater degree of nicotine dependence, and although the lowest income smokers are just as likely to try to quit smoking, they are about half as likely to succeed as the highest. It follows that a strategy to reduce harm to continuing nicotine users is a promising opportunity for poorer smokers, and not one that should be discarded because it is also popular with more affl uent smokers. Throughout the world, the public sector has approached this opportunity with denial or equivocation, apparently unable to break away from a medical model of smoking cessation. That is beginning to change, at least in England, with the publication of constructive guidance on e-cigarettes from the National Centre for Smoking Cessation and Training together with Public Health England. Further gains could be made through more proactive concern for the welfare of poor smokers: clear statements by trusted bodies affi rming that vaping is likely to have at least a 95% lower risk of serious disease than smoking; the availability of high quality, easily accessible guidance on how to get started; assistance with the upfront microinvestment necessary to access the more effective vaping products with much lower overall costs; and, fi nally, creation of a supportive policy environment that does not penalise low-income e-cigarette users by imposing a blanket ban on vaping in public places and does not obstruct e-cigarettes from competing with the entrenched cigarette trade.