Bike Sharing in Low-Income Neighborhoods

Bike Sharing in the United States

Citywide bike sharing programs have rolled out across many major cities in the United States, including:

• B-cycle in Denver and Boulder
• Nice Ride in Minneapolis/St. Paul
• Capital Bikeshare in Washington D.C.
• Citi Bike in New York City
• Divvy Bikes in Chicago
• The Hubway in Boston

Bike sharing programs offer either memberships or hourly access to bikes in a given geographic area. Docking stations for the bikes are usually less than a mile apart and provide ample opportunities to return the bike close to the users’ destination.

Link Between Environments and Health

As stated in our last post, rates of obesity and overweight are alarmingly high across the country, and tend to be higher in minority and lower income communities. In the last decade policy makers have noted the effects the environment has on rates of obesity and overweight individuals. On it’s website, the CDC lists environment as an obesity/overweight cause: “People may make decisions based on their environment or community. For example, a person may choose not to walk to the store or to work because of a lack of sidewalks. Community, home, child care, school, health care, and workplace settings can all influence people's health decisions. Therefore, it is important to create environments in these locations that make it easier to engage in physical activity and eat a healthy diet.” Source: http://www.cdc.gov/obesity/adult/causes/index.html

Bike sharing programs are one of many effective ways of creating healthier environments. Bikes provide physical activity and a mode of active transportation to get to different areas of the city for food, jobs, and health care. Given the CDC’s stated link between environment and obesity, it is no surprise that many cities are interested in bike sharing.

Divvy Bikes

I currently am a member of Divvy Bikes in Chicago. In fact, I probably was one of the first people to sign up for a membership. I was THRILLED. In my experience it works exactly how it should. In fact, I tell people all the time to use Divvy.  However, there is a huge problem with this:

This advertisement is on a bus stop in South Chicago. To be more specific, the advertisement is miles and miles from any current or planned Divvy station.  So, the residents of South Chicago are seeing advertisements for Divvy, but have no access to it.

The area of South Chicago (Chicago Community Area 46) is roughly two-thirds African American and one-fourth Hispanic. Over 25% of households are living below poverty with about 20% unemployed. An estimated 50% of South side residents are overweight or obese and only 20% perceived their health status as fair. Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497558/pdf/12815078.pdf

This bus stop is a block from where I work, so I know the area. I also know that I never see people riding bikes. However, that is not to say people in this low-income neighborhood would not use the bikes.

Barriers in Low-Income Neighborhoods

The Federal Transportation Agency published a report about developing bike share programs. The report does have a couple paragraphs about issues of equity. The report states, “Use of bike share systems by [low income] communities has so far been limited in the U.S., despite [low-income populations] increased reliance on public transportation and historically low rates of auto ownership.” Currently, there are many barriers for low-income individuals including the need for a credit card, perception of neighborhood safety, the internet-based sign up and account creation and language. Source: http://www.bicyclinginfo.org/promote/bikeshareintheus.pdf

I argue that one of the largest barriers to bike sharing among low-income residents might be cultural. What if it was more normal to see people biking? What if low-income residents received the same benefits as residents in higher income neighborhoods? My concern is equity of fitness opportunities. To me this is a perfect example of a positive health-promoting program increasing health disparities. And yes, I am a member of Divvy Bikes and am supporting the program. Hopefully, by talking about how low-income neighborhoods are being left out, I can raise awareness. Then, maybe cities everywhere will take an active role in putting the same resources in low-income neighborhoods as they do in others.

Health Disparities in the US

What Are Health Disparities?

According to the CDC, “health disparities are preventable differences in the burden of disease, injury, violence or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.”  Though there may be some natural differences between races and genders when it comes to the presence of disease, disparities are those differences that are caused by variation in access to care, exposure to risk factors, and the social determinants of health.

What Are the Most Significant Health Disparities?

Although all health disparities are significant, there are some that stand out amongst the rest either because of the extreme difference between races or because they primarily affect children.  I chose to use the CDC’s most recent comprehensive data on health disparities which is from 2006.  Even though that data is older, I felt it would be the best option as I not only trust the CDC’s data interpretation and survey methods, but also their thoroughness.

1.) Infant Mortality - this is an important metric for any country as it is a strong indicator of overall health.  In the US, it is also one of the most stark indicators that disparities exist.  Overall, in 2006 the US Infant Mortality Rate (the number of infant deaths < 1 year per 1,000 live births) is 6.68.  As you can see below, there is a great deal of variation when it comes to race. (CDC Health Disparities and Inequalities Report - United States, 2011)

As of 2011, the US’ Infant Mortality Rate has dropped to 6.05 which was in big part because of a 16% drop in infant mortality in the Black community; however, that was not enough to close the gap (New York Times - U.S. Infant Mortality Rate Fell Steadily from ‘05 to ‘11)

2.) Asthma - Although asthma affects adults, the disease more often starts in childhood.  Having asthma causes symptoms such as coughing, wheezing and shortness of breath. Asthma, especially uncontrolled asthma, is the most common cause for school absences accounting for an average of 8 days per student per year (Asthmapolis).  Acute attacks also often require emergency room visits and can require hospital stays.  Although I won’t go into it here, there is a great deal of evidence suggesting that asthma risk increases as the amount of particulate matter increases.  Particulate matter in the air tends to be greatest in urban areas and near highways and other busy streets.

(CDC Health Disparities and Inequalities Report - United States, 2011)

3.) Obesity - The obesity epidemic in the US has been getting a lot of news time in the last few years and for good reason.  A recent study has shown that the obesity rates in all states except one have leveled off this year which is good news.  However, those rates are still very high.  Currently, 13 states have adult obesity rates higher than 30% while 41 have adult rates higher than 25% (Obesity Rate Levels Off in Most States).  As you can see below, no group studied in the CDC Health Disparities and Inequalities Report was doing well in 2006, but as usual, minorities are doing worse.

There are many other startling health disparities in the US and the common pattern is that minorities (especially Black Americans) are doing worse that white Americans.  Two more disparities of note are death by cardiovascular disease and stroke as well as the presence of diabetes.

How Do Health Disparities Affect Us All?

In 2012 the National Urban League published a report on the cost of health disparities (The State of Urban Health: Eliminating Health Disparities to Save Lives and Cut Costs) that found that health disparities cost the US $82.2 billion in direct healthcare costs and lost productivity.  Unsurprisingly, Black Americans pay a disproportionate amount of that cost - $54.9 billion or more than 66%.  Imagine how much we as a country could save, in lives and dollars, if we achieved health equity.

Medicaid expansion and the Affordable Care Act

The Background

The ACA provides states with the option to expand Medicaid programs to cover up to 138% of the federal poverty level (for individuals that is $15,856 in 2013).  However, concerned with how much this will cost, some states are choosing not to expand their programs in 2014 and so states will continue to vary in the income and age qualifications for Medicaid benefits.

Below are two scenarios for residents in states that do not extend Medicaid.  

1.)     If individual income is greater than 133% of the federal poverty level, insurance can be bought in the Insurance Marketplace for a price based on income. The law provides subsidies to help individuals who earn between 100 and 400 percent of the poverty level.

2.)     If individuals earn less than 100% of the federal poverty level and live in a state not expanding Medicaid, they  have few options for affordable insurance. They can purchase insurance in the Insurance Marketplace, but will not make enough annually to qualify for financial assistance.

Therefore, for states that do not expand Medicaid, people that make ‘too much’ for the current Medicaid program, but ‘not enough’ for tax credits on the Insurance Marketplace will pay full price for insurance.  These individuals will be allowed an ‘exemption’ from the individual mandate and remain without access to insurance.

An illustration of the difference between states

It is confusing. Let me illustrate.

1.) Micky lives in Wisconsin and makes $12,500 annually. With this income, he ‘makes too much’ and does not qualify for the current Medicaid program. Wisconsin is not expanding Medicaid. Therefore, Micky can either pay full price on the Insurance Marketplace or file for an exemption from the individual mandate.

2.) Hector lives in Illinois and makes $12,500 annually. With this income he will receive Medicaid because Illinois is expanding the program. 

Micky and Hector make the same amount of money.  Micky won’t receive insurance through Medicaid but Hector will. The only difference is the state they live in. With that income, it will be difficult for Micky (and people like him) to afford insurance at full price and therefore he will file for exemptions and  will remain uninsured.

Source: https://www.healthcare.gov/what-if-my-state-is-not-expanding-medicaid/

Below is a map of the Status of state action on Medicaid expansion decision, as of July 1, 2013. On the map key ‘moving forward at this time’ means that a state has committed to expanding Medicaid.

Source: http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/#

Now compare the map of states that are expanding Medicaid with the map that ranks the overall health of people in each state. The orange states are the healthiest and dark blue are the least healthy states. People on Medicaid have increased access to care and improved self-reported health compared to the uninsured population. Many of the states with the lowest health rankings are also the states that are not expanding Medicaid.

(Source:http://kff.org/report-section/what-is-medicaids-impact-on-access-to-care-health-outcomes-and-quality-of-care-setting-the-record-straight-on-the-evidence-issue-brief/)

Source: http://www.americashealthrankings.org/rankings

The question remains

Should those concerned with health equity be celebrating because the Medicaid expansion will help many families get health care? Or should the current Medicaid, given the variations by state, be considered a driving force for further change? Personally, the state variations in the Medicaid expansion is confusing and all Americans would benefit from sweeping, nationwide Medicaid expansion.

What Health Reform Means to You and Me

The Law

The Affordable Care Act was signed into law by President Obama in March 2010.  Most of the provisions haven’t gone into effect yet, so many people still wonder what health reform will mean to them.  The next, and biggest, provision to go into effect happens on October 1st when health insurance marketplaces will begin open enrollment for plans starting in January of 2015.  The plans offered in these marketplaces need to provide at least the following basic health coverages (Healthcare.gov):

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services

The law also requires that all plans cover certain preventive services at no cost, including immunizations and screening for common health issues like high blood pressure.  For more info check out Healthcare.gov’s breakdown here https://www.healthcare.gov/what-are-my-preventive-care-benefits/.

What Happened In Massachusetts

    Many people are worried about how the law will affect insurance prices, their personal budgets and government spending.  The good news is we can use Massachusetts to get an idea of what may happen.  Massachusetts passed Health Reform in 2006, and the federal law is largely modeled after it.  Here’s what has happened in MA over the last 7 years.

   

1.) Health insurance rates increased -  Massachusetts has the highest rate of health insurance in the country with 98.1% insured at some point in the year (mahealthconnector.org) and 96% insured year round (http://www.hhs.gov/healthcare/facts/bystate/ma.html) compared to 81.8% nationally (CDC). 

2.) Uninsurance rates fell the most for minorities going from 15% uninsured to 3.4% for African Americans and from 20% to 9.2% for Hispanics. (Study: Romneycare Didn't Increase Hospital Costs)

3.) The State budget increased.  Getting near universal coverage in a fair and equitable way unsurprisingly costs money; however, health reform only increased the budget by 1% (mahealthconnector.org) and Massachusetts purposely left out cost containment from the bill with the idea that those measures would be passed later.

4.) Premiums and health care use did not increase faster than they would have.  When increases in premiums and use were compared to New Jersey, New York and Pennsylvania (similar states without health reform), there were few to no differences.  Yes, Massachusetts has the highest premiums in the nation, but that was true before health reform. (Study: Romneycare Didn't Increase Hospital Costs)

5.) Finding and understand health insurance got easier.  As a resident of Massachusetts who has purchased health insurance through the Connector twice now, I can honestly say that the process is very straightforward.  It is never easy to understand everything about how you will be covered with health insurance, but the bronze, silver and gold ratings make it easier to get a general idea without reading hours of technical insurance documents.  Below is a snapshot from mahealthconnector.org to help you get an idea of what Massachusett's exchange looks like.

Conclusion

    Though you can never know everything that will come from a law the magnitude of the Affordable Care Act, most of the evidence we have so far suggests positive results.  With the recent releases of lower than expected premium rates from Maryland, New York, Oregon, Montana, California and Louisiana, it looks like states other than Massachusetts will be able to benefit from universal (or near to) health care coverage.