Disparities in access to health care in three French regions

Disparities in access to health care in three French regions
Health Policy; 114(1):31-40. doi: 10.1016/j.healthpol.2013.07.011

Gusmano, MK. Weisz, D. Rodwin, VG. Lang, J. Quian, M. Bocquier, A. Moysan, V. and Verger, P.

Objectives: This paper compares access to primary and specialty care in three metropolitan regions of France: Ile de France (IDF), Nord-Pas-de-Calais (NPC) and Provence-Alpes-Côte d’Azur (PACA); and identifies the factors that contribute to disparities in access to care within and among these regions.

Methods: To assess access to primary care, we compare variation among residence-based, age-adjusted hospital discharge rates for ambulatory care sensitive conditions (ASC). To assess access on one dimension of specialty care, we compare residence-based, age- adjusted hospital discharge rates for revascularization – bypass surgery and angioplasty – among patients diagnosed with ischemic heart disease (IHD). In addition, for each region we rely on a multilevel generalized linear mixed effect model to identify a range of individual and area-level factors that affect the discharge rates for ASC and revascularization. Results: In comparison with other large metropolitan regions, in France, access to primary care is greater in Paris and its surrounding region (IDF) than in NPC but worse than in PACA. With regard to revascularization, after controlling for the burden of IHD, use of services is highest in PACA followed by IDF and NPC. In all three regions, disparities in access are much greater for revascularization than for ASC. Residents of low-income areas and those who are treated in public hospitals have poorer access to primary care and revascularizations. In addition, the odds of hospitalization for ASC and revascularization are higher for men. Finally, people who are treated in public hospitals, have poorer access to primary care and revascularization services than those who are admitted for ASC and revascularization services in private hospitals.

Conclusions: Within each region, we find significant income disparities among geographic areas in access to primary care as well as revascularization. Even within a national health insurance system that minimizes the financial barriers to health care and has one of the highest rates of spending on health care in Europe, the challenge of minimizing these disparities remains.

Why Do Higher Income Households Move Into Low Income Neighborhoods: Pioneering or Thrift?

Why Do Higher Income Households Move Into Low Income Neighborhoods: Pioneering or Thrift?
Urban Studies, September 2013; vol. 50, 12: pp. 2478-2495.

Ellen, Ingrid, Katherine O’Regan and Keren Horn

This paper offers several hypotheses about which US higher-income households choose to move into low-income neighbourhoods and why. It first explores whether the probability that a household moves into a relatively low-income neighbourhood (an RLIN move) varies with predicted household and metropolitan area characteristics. Secondly, it estimates a residential choice model to examine the housing and neighbourhood preferences of the households making such moves. Thirdly, it explores responses to survey questions about residential choices. Evidence is found that, in the US, households who place less value on neighbourhood services and those who face greater constraints on their choices are more likely to make an RLIN move. No evidence is found that households making RLIN moves are choosing neighbourhoods that are more accessible to employment. Rather, it is found that households making RLIN moves appear to place less weight on neighbourhood amenities than other households and more weight on housing costs.

Racial Dynamics of Subprime Mortgage Lending at the Peak

Racial Dynamics of Subprime Mortgage Lending at the Peak
Faber, Jacob W. 2013. “Racial Dynamics of Subprime Mortgage Lending at the Peak.” Housing Policy Debate, 23(2): 328-349.

Faber, Jacob William

Subprime mortgage lending in the early 2000s was a leading cause of the Great Recession. From 2003 to 2006, subprime loans jumped from 7.6% of the mortgage market to 20.1%, with black and Latino borrowers receiving a disproportionate share. This article leveraged the Home Mortgage Disclosure Act data and multinomial regression to model home-purchase mortgage lending in 2006, the peak of the housing boom. The findings expose a complicated story of race and income. Consistent with previous research, blacks and Latinos were more likely and Asians less likely to receive subprime loans than whites were. Income was positively associated with receipt of subprime loans for minorities, whereas the opposite was true for whites. When expensive (jumbo) loans were excluded from the sample, regressions found an even stronger, positive association between income and subprime likelihood for minorities, supporting the theory that wealthier minorities were targeted for subprime loans when they could have qualified for prime loans. This finding also provides another example of an aspect of American life in which minorities are unable to leverage higher class position in the same way as whites are. Contrary to previous research, model estimates did not find that borrowers paid a penalty (in increased likelihood of subprime outcome) for buying homes in minority communities.

Stuck in Place: Urban Neighborhoods and the End of Progress toward Racial Equality

Stuck in Place: Urban Neighborhoods and the End of Progress toward Racial Equality
University of Chicago Press

Sharkey, P.

In the 1960s, many believed that the civil rights movement’s successes would foster a new era of racial equality in America. Four decades later, the degree of racial inequality has barely changed. To understand what went wrong, Patrick Sharkey argues that we have to understand what has happened to African American communities over the last several decades. In Stuck in Place, Sharkey describes how political decisions and social policies have led to severe disinvestment from black neighborhoods, persistent segregation, declining economic opportunities, and a growing link between African American communities and the criminal justice system.

As a result, neighborhood inequality that existed in the 1970s has been passed down to the current generation of African Americans. Some of the most persistent forms of racial inequality, such as gaps in income and test scores, can only be explained by considering the neighborhoods in which black and white families have lived over multiple generations. This multigenerational nature of neighborhood inequality also means that a new kind of urban policy is necessary for our nation’s cities. Sharkey argues for urban policies that have the potential to create transformative and sustained changes in urban communities and the families that live within them, and he outlines a durable urban policy agenda to move in that direction.


Winner of the Mirra Komarovsky Book Award, Eastern Sociological Society.

Winner of The American Publishers Award for Professional and Scholarly Excellence (PROSE Award) in Sociology and Social Work. ​

A new approach to understanding racial disparities in prostate cancer treatment

A new approach to understanding racial disparities in prostate cancer treatment
Journal of Geriatric Oncology, Vol. 4, no. 1, pp. 1-8. DOI: 10.1016/j.jgo.2012.07.005

Presley, C.J., A.C. Raldow, L.D. Cramer, P.R. Soulos, J.B. Long, J.B. Yu, D.V. Makarov, and C.P. Gross

Objective: Previous studies addressing racial disparities in treatment for early-stage prostate cancer have focused on the etiology of undertreatment of black men. Our objective was to determine whether racial disparities are attributable to undertreatment, overtreatment, or both.

Methods: Using the SEER-Medicare dataset, we identified men 67–84 years-old diagnosed with localized prostate cancer from 1998 to 2007. We stratified men into clinical benefit groups using tumor aggressiveness and life expectancy. Low-benefit was defined as low-risk tumors and life expectancy < 10 years; high-benefit as moderate-risk tumors and life expectancy ≥ 10 years; all others were intermediate-benefit. Logistic regression modeled the association between race and treatment (radical prostatectomy or radiotherapy) across benefit groups.

Results: Of 68,817 men (9.8% black and 90.2% white), 56.2% of black and 66.3% of white men received treatment (adjusted odds ratio (OR) = 0.65; 95% CI, 0.62–0.69). The percent of low-, intermediate-, and high-benefit men who received treatment was 56.7%, 68.4%, and 79.6%, respectively (P = < 0.001). In the low-benefit group, 51.9% of black vs. 57.2% of white patients received treatment (OR = 0.74; 95% CI, 0.67–0.81) compared to 57.2% vs. 69.6% in the intermediate-benefit group (OR = 0.64; 95% CI, 0.59–0.70). Racial disparity was largest in the high-benefit group (64.2% of black vs. 81.4% of white patients received treatment; OR = 0.57; 95% CI, 0.48–0.68). The interaction between race and clinical benefit was significant (P < 0.001).

Conclusion: Racial disparities were largest among men most likely to benefit from treatment. However, a substantial proportion of both black and white men with a low clinical benefit received treatment, indicating a high level of overtreatment.

Who Experiences Discrimination in Brazil? Evidence From a Large Metropolitan Region

Who Experiences Discrimination in Brazil? Evidence From a Large Metropolitan Region
International Journal for Equity in Health, 2012 Dec 18;11:80. doi: 10.1186/1475-9276-11-80

Macinko, J., P. Mullachery, F.A. Proietti, and M.F. Lima-Costa

Introduction Perceived discrimination is related to poor health and has been offered as one explanation for the persistence of health inequalities in some societies. In this study, we explore the prevalence and correlates of perceived discrimination in a large, multiracial Brazilian metropolitan area.

Methods The study uses secondary analysis of a regionally representative household survey conducted in 2010 (n=12,213). Bivariate analyses and multiple logistic regression assess the magnitude and statistical significance of covariates associated with reports of any discrimination and with discrimination in specific settings, including when seeking healthcare services, in the work environment, in the family, in social occasions among friends or in public places, or in other situations.

Results Nearly 9% of the sample reported some type of discrimination. In multivariable models, reports of any discrimination were higher among people who identify as black versus white (OR 1.91), higher (OR 1.21) among women than men, higher (OR 1.33) among people in their 30’s and lower (OR 0.63) among older individuals. People with many health problems (OR 4.97) were more likely to report discrimination than those with few health problems. Subjective social status (OR 1.23) and low social trust (OR 1.27) were additional associated factors. Perceived discrimination experienced while seeking healthcare differed from all other types of discrimination, in that it was not associated with skin color, social status or trust, but was associated with sex, poverty, and poor health.

Conclusions There appear to be multiple factors associated with perceived discrimination in this population that may affect health. Policies and programs aimed at reducing discrimination in Brazil will likely need to address this wider set of interrelated risk factors across different populations.

Beyond Black: Diversity among Black Immigrant Students in New York City Public Schools

Beyond Black: Diversity among Black Immigrant Students in New York City Public Schools
Randy Capps and Michael Fix, editors, Young Children of Black Immigrants in America: Changing Flows, Changing Faces. Washington, DC: Migration Policy Institute: 299-331

Doucet, F., Schwartz, A. E., & Debraggio, E.

The child population in the United States is rapidly changing and diversifying — in large part because of immigration. Today, nearly one in four US children under the age of 18 is the child of an immigrant. While research has focused on the largest of these groups (Latinos and Asians), far less academic attention has been paid to the changing Black child population, with the children of Black immigrants representing an increasing share of the US Black child population.

To better understand a unique segment of the child population, chapters in this interdisciplinary volume examine the health, well-being, school readiness, and academic achievement of children in Black immigrant families (most with parents from Africa and the Caribbean).

The volume explores the migration and settlement experiences of Black immigrants to the United States, focusing on contextual factors such as family circumstances, parenting behaviors, social supports, and school climate that influence outcomes during early childhood and the elementary and middle-school years.  Many of its findings hold important policy implications for education, health care, child care, early childhood development, immigrant integration, and refugee assistance.

Changes in ten years of social inequalities in health among elderly Brazilians (1998-2008)

Changes in ten years of social inequalities in health among elderly Brazilians (1998-2008)
Revista de Saude Publica, Vol. 46, supp. 1. 10.1590/S0034-89102012005000059

Lima-Costa, M.F.; L.A. Facchini; D.L. Matos, and J. Macinko

OBJECTIVE: To assess the changes in income-related inequalities in health conditions and in the use of health services among elderly Brazilians.

METHODS: Representative samples of the Brazilian population aged 60 years and more were analyzed between 1998 and 2008 (n = 27,872 and 41,198, respectively), derived from the Pesquisa Nacional por Amostra de Domicílios (National Household Sample Survey). The following variables were considered in this study: per capita monthly household income, self-rated health, physical functioning, medical consultations and hospitalizations in the previous 12 months and exclusive use of the Sistema Único de Saúde (Unified Health System). Data analysis was based on estimates of prevalence and prevalence ratios obtained with robust Poisson regression.

RESULTS: In 1998 and 2008, the prevalence of poor self-rated health, mobility limitations and inability to perform activities of daily living (ADLs), adjusted for age and sex, showed strong gradients associated with per capita household income quintiles, with the lowest values being found among those in the lowest income quintile. The prevalence ratios adjusted for age and sex between the lowest quintile (poorest individuals) and highest quintile (richest individuals) of income remained stable for poor self-rated health (PR = 3.12 [95%CI 2.79;3.51] in 1998 and 2.98 [95%CI 2.69;3.29] in 2008), mobility limitations (PR = 1.54 [95%CI 1.44;1.65 and 1.69 [95%CI 1.60;1.78], respectively) and inability to perform ADLs (PR = 1.79 [95%CI 1.52;2.11] and 2.02 [95%CI 1.78;2.29], respectively). There was a reduction in income-related disparities when three or more medical consultations had been made and with the exclusive use of the Unified Health System. Inequalities were not observed for hospitalizations. 

CONCLUSIONS: Despite reductions in income-related inequalities among indicators of use of health services, the magnitude of disparities in health conditions has not decreased. Longitudinal studies are necessary to better understand the persistence of such inequalities among elderly Brazilians.

Do Federally Assisted Households Have Access to High Performing Public Schools?

Do Federally Assisted Households Have Access to High Performing Public Schools?
Poverty & Race Research Action Council

Ellen, Ingrid Gould and Horn, Keren Mertens.

A family’s housing unit provides more than simply shelter. It also provides a set of neighborhood amenities and a package of local public services, including, most critically, a local school. Yet housing and education policymakers rarely coordinate their efforts, and there has been little examination of the schools that voucher holders or other assisted households actually reach. In this project we describe the elementary schools nearest to households receiving four different forms of housing assistance in the country as a whole, in each of the 50 states, and in the 100 largest metropolitan areas.We compare the characteristics of these schools to those accessible to other comparable households. We pay particular attention to whether voucher holders are able to reach neighborhoods with higher performing schools than other low-income households in the same geographic area.


In brief, we find that assisted households as a whole are more likely to live near low-performing schools than other households. Surprisingly, Housing Choice Voucher holders do not generally live near higher performing schools than households receiving other forms of housing assistance, even though the voucher program was created, in part, to help low-income households reach a broader range of neighborhoods and schools. While voucher holders typically live near schools that are higher performing than those nearest to public housing tenants, they also typically live near schools that are slightly lower performing than those nearest to households living in Low Income Housing Tax Credit (LIHTC) and Projectbased Section 8 developments and lower performing than those nearest to other poor households.

Residential Mobility and the Reproduction of Unequal Neighborhoods

Residential Mobility and the Reproduction of Unequal Neighborhoods
Cityscape: A Journal of Policy Development and Research, 2012. Volume 14, Number 3

Sharkey, P.

Housing assistance policy has shifted away from project-based assistance toward tenantbased assistance. This shift in approach reflects a common assumption that, if families have the option to find homes on their own in the private market, they will seek out better quality homes in racially diverse neighborhoods with lower levels of poverty. This article presents evidence to qualify this assumption by highlighting the limits of residential mobility in reducing, in any substantive way, the degree of racial and ethnic inequality in urban America. Two empirical observations form the basis of the argument. The first observation is that residential mobility typically serves to reproduce urban inequality instead of disrupting it. The second is that urban inequality is resilient: even when individuals or families make moves that disrupt patterns of racial and ethnic inequality, the changes such moves induce are undermined by system-level processes that serve to reproduce inequality in the urban landscape. As a result, changes in families’ neighborhood environments arising from residential mobility are often temporary and are diluted by subsequent changes occurring around families. The article concludes with a discussion of implications for housing assistance policy.


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