February 2001

Grant Results

SUMMARY

The National Public Health and Hospitals Institute, Washington, analyzed health and sociodemographic factors in the 100 largest U.S. cities and disseminated the findings.

The investigators examined changes that occurred between 1980 and 1990 (or in some cases 1993), using a database they had established under an earlier grant from the Robert Wood Johnson Foundation (RWJF) (see Grant Results on ID# 018634) based on information about the 100 largest cities and 851 hospitals in these cities.

Key Findings

  • From 1980 to 1990, the 25 largest cities fared better in the areas of child poverty, single female-headed households, violent crime, and incidence of some diseases than the nation as a whole.
  • Mid-sized cities in the study (ranked 26–50 in population, including Wichita, Kan., Raleigh, N.C., and Rochester, N.Y.) experienced explosive population growth in the 1980s, outpacing growth in larger and smaller cities as well as in the nation as a whole.
  • Between 1980 and 1990, the population of the cities in the West included in the study grew 21 percent, far faster than in cities in other regions and more than twice the rate of increase nationwide.
  • Socioeconomically, the West showed mixed progress compared to other regions, faring better on female-headed households, births to teens, and infant mortality rates, but also experiencing the largest regional increase in child poverty and the slowest increase in high school graduation rates.
  • On average, urban public hospitals provided more costly essential communitywide services than did non-public hospitals, as well as more emergency services and a disproportionate share of care to low-income populations.
  • Public hospitals reported sharp increases in care for low-income populations since 1980, compared with other hospital sectors.

Funding
RWJF supported the research with a grant of $247,719 from May 1994 to January 1996.

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THE PROBLEM

In 1991, RWJF made a grant (see Grant Results on ID# 018634) to the National Public Health and Hospitals Institute for an updated look at the status of urban public hospitals, which provide a disproportionate share of hospital care to the poor and uninsured.

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THE PROJECT

This grant (ID# 022724) supported further analysis of data the investigators had previously gathered on urban hospitals and the changing environment of the 100 largest cities between 1980 and 1990. Products included a chartbook comparing health-related indicators, two in-depth city profiles, and special analyses of particular findings, such as those related to urban violence. Overall, the initiative was expected to help health professionals and policymakers plan for the health care needs of inner cities in a more informed way.

An advisory group convened by the project director (see the Appendix) helped to determine which urban health issues should be examined and what aggregations of data would be appropriate.

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FINDINGS

The investigators reported their findings in Urban Social Health: A Chartbook Profiling the Nation's 100 Largest Cities, which reports the incidence of selected diseases by cities, and ranks the cities on selected sociodemographic factors in 1980 and in the latest year for which data were available (either 1990 or 1993). The Chartbook also describes the status of hospitals in these cities by ownership (public general, private general, university public, and university private). Key findings follow:

Changes in the Largest Cities

  • From 1980 to 1990, the 25 largest cities fared better in the areas of child poverty, single female-headed households, violent crime, and incidence of some diseases than the nation as a whole.
    • Between 1990 and 1993, the largest cities were the only group of cities to show a decline in total violent crime, although the rate nationwide showed a larger decrease.
    • The increase in child poverty in the 25 largest cities was 9.4 percent between 1980 and 1990, compared to a national increase of 12 percent. The increase in child poverty in cities of other sizes also tended to exceed that of the largest urban centers.
    • The increase in single female-headed households in the largest 25 cities was 13.6 percent in the 1980s, below the national rate of 15.8 percent, and among the lowest for cities of all sizes.
    • From 1990 to 1993, the rate of tuberculosis decreased 38 percent for the 25 largest cities, compared to a 5 percent decrease nationwide. Primary and secondary syphilis case rates declined 62 percent in the largest cities during this period, compared to a 49 percent decrease across the country. (Rates of these diseases had fluctuated during the 1980s.)

Growth in Mid-Sized Cities

  • Mid-sized cities in the study (ranked 26–50 in population, including Wichita, Kan., Raleigh, N.C., and Rochester, N.Y.) experienced explosive population growth in the 1980s, outpacing growth in larger and smaller cities as well as in the nation as a whole, and also experienced exceptionally high increases in the number of children and foreign-born, as well as in some social indicators.
    • During the 1980s, mid-sized cities gained more foreign-born residents than cities of any other size. Foreign-born residents increased 66.5 percent in these cities, exceeding the national rate of 40.4 percent by two-thirds. By 1990, more than one in ten residents of these cities were foreign-born.
    • The number of children under age 5 in mid-sized cities grew by 22 percent from 1980 to 1990, almost double the US increase of 12.3 percent.
    • The increase in total violent crime rates in mid-sized cities shifted from the slowest-growing to the fastest-growing. From 1980 to 1990, this rate increased 16.8 percent, more slowly than in all other city groups and the nation. However, the trend reversed itself from 1990 to 1993, when these cities' 14.4 percent increase exceeded all other city groups and was more than double the 7.1 percent increase in the US violent crime rate for the period.
    • Births to teenage mothers in middle-sized cities increased 20.8 percent from 1980 to 1989, well above the US increase of 9.7 percent but below that of other cities.

Striking Changes in the West

  • Between 1980 and 1990, the population of the cities in the West included in the study grew 21 percent, far faster than in cities in other regions and more than twice the rate of increase nationwide; these cities' populations also grew more diverse.
    • The number of Hispanics grew 64.7 percent, compared to a national increase of 53 percent.
    • The rising number of whites and blacks surpassed growth in all other regions, as did the growth in the foreign-born population.
    • By 1990, the percentage of foreign-born residents in the West came to equal that of the Northeast, with more than one in five people from the cities of these regions born on foreign soil.
  • Socioeconomically, the West showed mixed progress compared to other regions, faring better on female-headed households, births to teens, and infant mortality rates, but also experiencing the largest regional increase in child poverty and the slowest increase in high school graduation rates.
    • On a regional basis, from 1980 to 1989, teenage births showed the smallest increases in cities in the South (19.4 percent) and in the West (22.9 percent). However, these rates were well above the US increase of 9.7 percent for the period.
    • Cities in both the West and South experienced a 20 percent decrease in infant mortality, better than cities in other regions and only slightly behind the national decrease of 22 percent.
    • Western cities saw one of the largest increases in children in poverty at 22 percent, nearly double the US increase of 12 percent.

Pressures on Public Hospitals

  • On average, urban public hospitals provided more costly essential communitywide services than did non-public hospitals, as well as more emergency services and a disproportionate share of care to low-income populations.
    • In the 100 largest cities, while representing only 11 percent of all hospital beds in 1993, public hospitals provided 21 percent of pediatric intensive care days, 18 percent of all emergency room visits, and close to 27 percent of all burn care.
    • The percentage of Medicaid patients treated in public hospitals grew from an average of 24 percent in 1980 to 44 percent in 1993. By contrast, private general hospitals had an average of 16 percent of patients on Medicaid in 1993.
  • Public hospitals reported sharp increases in care for low-income populations since 1980, compared with other hospital sectors.
    • In 1980, self-pay, or bad debt/charity care, represented 17 percent of gross revenues in public hospitals. By 1993, that proportion had risen to 22 percent. By contrast, private hospitals reported 11 percent of gross revenues from self-pay in 1980 and only 6 percent in 1993.

Communications

NPHHI distributed 5,000 copies of the Chartbook. It was sent to the mayors of the 100 largest cities and their health department directors, to all members of Congress, government agencies as DHHS, and the World Bank. Senator Jay Rockefeller (D-W.Va.), then the ranking Democrat of the Senate Finance Committee's Subcommittee on Medicare, Long Term Care and Health Insurance wrote in a letter to NPHHI that the Chartbook "helps draw connections between federal health and social policies on Medicaid, Medicare and our public health infrastructure and the real life health and social circumstances of people living in our nation's cities…"

Approximately 50 associations either received copies or placed notices of its availability in their newsletters. On December 4, 1995, NPHHI held a news conference announcing the report and issued a four-page news release to newspapers, radio stations, and television stations in the 100 largest cities. The Chartbook generated interest at the national level, with coverage by C-Span, The New York Times, the Associated Press, and the Knight-Ridder chain. Investigators at NPHHI gave presentations at the Institute for State Policy Studies, the National Committee on Vital and Health Statistics, the Texas Department of Health Community Health Conference, the Centers for Disease Control Urban Centers Initiative, and the Association for Health Services Research. An article comparing hospitals in Jersey City and Newark appeared in New Jersey Medicine. See the Bibliography for details.

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AFTER THE GRANT

Using material from this project, the grantee produced a chartbook on the 16 largest California cities, Urban Social Health: A Report Card on California Cities, 1996, supported by the Henry J. Kaiser Family Foundation. NPHHI received another grant from RWJF in August 1996 (ID# 029644) for a study comparing the largest cities with their surrounding counties.

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GRANT DETAILS & CONTACT INFORMATION

Project

Analyses of Health and Sociodemographic Factors in Urban Areas

Grantee

National Public Health and Hospital Institute (Washington,  DC)

  • Amount: $ 247,719
    Dates: May 1994 to January 1996
    ID#:  022724

Contact

Dennis P. Andrulis, M.P.H., Ph.D.
(718) 270-7726
dandrulis@netmail.hscbklyn.edu

Web Site

http://www.naph.org/Main-Menu-Category/About-NAPH.aspx

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Advisory Group for the Analyses of Health and Sociodemographic Factors in Urban Areas

Thomas Chapman
Chief Executive Officer
The George Washington University Hospital
Washington, D.C.

Benjamin K. Chu
Vice President for Clinical Affairs and Associate Dean
New York University Medical Center
New York, N.Y.

Kathryn Johnson
President/CEO
The Healthcare Forum
San Francisco, Calif.

Judith Kurland
Founder
Healthy Boston
Boston, Mass.

Daniel B. McLaughlin
Associate County Administrator
Hennepin County, Wash.

Sara Rosenbaum
Co-Director
The George Washington University Center for Health Policy Research
Washington, D.C.

Charles Royer
Former Director
Institute of Politics
Harvard University
Cambridge, Mass.

Don Steinwachs
Director
Health Services Research & Development Center
The Johns Hopkins University
Baltimore, Md.

Robert Valdez
Deputy Assistant Secretary of Health for Interagency Policy
US Department of Health and Human Services
Washington, D.C.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Books and Reports

Andrulis DP, Ginsberg C, Shaw-Taylor Y and Martin V. Urban Social Health: A Chartbook Profiling the Nation's One Hundred Largest Cities. Washington: National Public Health and Hospital Institute, 1995.

Articles

Andrulis DP and Shaw-Taylor Y. "The Social and Health Characteristics of California Cities." Health Affairs, 15(1): 131–142, 1996. Abstract available online.

Goodman N, Benesch B and Andrulis D. "A Tale of Two New Jersey Cities." New Jersey Medicine, 94(5): 47–53, 1997. Abstract available online.

News Conferences

News Conference announcing findings of the National Public Health and Hospital Institute's report on urban social health in the 100 largest US cities, Washington, December 4, 1995.

Press Kits and News Releases

A four-page release was sent to newspapers, radio stations, and television stations in the 100 largest cities, December 4, 1995.

Print Coverage

"Public Hospitals," in America Online, December 4, 1995.

"Larger Cities Gain Ground on Ills, Smaller Ones Lose," in The New York Times, December 5, 1995.

"Cities Worst Woes Beginning to Ease but Smaller Towns Suffer," in International Herald Tribune, December 6, 1995.

"Fresno Faces Rise in Poverty, Study Says," in The Fresno Bee, December 7, 1995.

"Study: Medicaid Plan Ignores Inner-City Needs," in AHA News, December 11, 1995.

Rovner J. "Us Versus Us: Whose Problems Are the Cities, Anyway?" in Advances. Special Supplement, 1, 1997: 1–4. The Robert Wood Johnson Foundation.

Presentations and Testimony

Presentations to the Institute for State Policy Studies, National Committee on Vital and Health Statistics, Texas Department of Health Community Health Conference, US Centers for Disease Control and Prevention Urban Initiative, Association for Health Services Research. No dates, sites, or speakers' names available.

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Report prepared by: Sybil L. Stokes
Reviewed by: Janet Heroux
Reviewed by: Robert Narus
Program Officer: Rush L. Russell

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