Health, health care, and inequality among older New Yorkers

Introduction

United Nations’ demographers project that 70% of the world’s population will live in cities by 2050 (1). Since the World Health Organization (WHO) and many cities are promoting strategies to encourage “age-friendly” urban life, it is important to study the experience of cities, worldwide with respect to the health of their populations. There is a well-known literature that emphasizes the problems that come with living in dense urban areas—the so-called urban health penalty (2). As Freudenberg and colleagues explain: “The urban penalty approach posits that cities concentrate poor people and expose them to unhealthy physical and social environments (2).” In contrast, many scholars focus on the “triumph” of the city throughout history—the urban advantage hypothesis (3). This contrasting view emphasizes the health promoting advantages associated with city life, including better opportunities for economic advancement, better social supports, better public health infrastructure, better access to health care services compared with rural and suburban areas (4). The evidence for both views is mixed, and depends on the issues under investigation and the neighborhoods or specific subpopulations of concern. We focus here on older people (65 years and over) in the largest city in the United States (U.S.) and one of the four most populous cities (along with London, Paris, and Tokyo) among some of the wealthiest nations in the world: New York City (NYC).

The purpose of this article is to update findings from a study of older people in world cities published in 2006 (5). Although many studies have examined specific dimensions of health or health care use among older people in NYC since that time, no studies offer a comprehensive overview of the degree to which NYC has addressed the health and health care inequities documented in the 2006 study.

Background

Despite all the evidence one could assemble on the urban health penalties associated with NYC, most recently the exceptionally high excess mortality rates compared to other cities in the U.S., it is perhaps less well known that the health of older New Yorkers in the 1990s and 2000s was better than their counterparts in the rest of the country (5). Compared to other world cities, however, the health status of New Yorkers, and their access to health services was worse (6). Also, NYC stood out among other world cities as having greater health and healthcare inequalities (6).

Rationale and knowledge gap

The health of older NYC residents has not been reviewed systematically, in more than a decade. Although data about the health of older NYC residents are published routinely, it is rare for an article to provide a comprehensive overview of the health of older New Yorkers along with evidence of their access to care.

Objective

In this paper we evaluate how the health of older New Yorkers, and their access to health care, have evolved over the second decade of 21^st century by comparing our analysis of more recent data to the results presented in the 2006 book, Growing Older in World Cities (5). Our measures of population health are routine. To assess access to community-based ambulatory care (CBAC), we compare changes in hospitalizations for ambulatory care sensitive conditions (ACSCs). Next, as a proxy for specialty services, we examine the use of coronary revascularization among older New Yorkers diagnosed with heart disease. We focus on coronary revascularization for two reasons. First, as in the rest of the U.S., heart disease is the leading cause of death among older residents of NYC. Second, a chapter of the Growing Older in World Cities book focuses on the use of revascularization among older people in NYC.

Methods

This article presents a cross-sectional analysis of metrics that capture the health status of older NYC residents and their use of health care services. We use many of the same metrics that were presented in the Growing Older in World Cities book in order to make direct comparisons with the findings from the late 1990s and early 2000s. We use four different outcome measures for health status and access to health services for older New Yorkers: life expectancy at 65 years of age (LE at 65), self-reported health status, hospitalizations for ACSC, and use of revascularization among people hospitalized with heart disease.

LE at 65 was calculated by the NYC Department of Health and Mental Hygiene (DHMH) using data from the U.S. Census Bureau. It represents the mean number of years of life remaining for men or women who have reached the age of 65 years, assuming the rest of their life is subjected to the current mortality rates.

Self-reported health status by race and ethnicity: for self-reported health, we present data from the NYC Community Health Survey. We calculate the percentage of total survey respondents who claim to have excellent, very good, good, fair, and poor health for the entire population and by race and ethnicity.

Hospitalizations for ACSC

Hospitalizations for ACSC (heretofore ACSC rates) are those for which access to timely and appropriate CBAC should decrease or avoid the need for hospital admission. To compare ACSC rates in NYC, we use the definition of the indicator developed by Weissman et al. [1992] (7), which has been validated by previous studies (8). This includes pneumonia, congestive heart failure (CHF), asthma, cellulitis, perforated or bleeding ulcer, pyelonephritis, diabetes with ketoacidosis or coma, ruptured appendix, malignant hypertension, hypokalemia, five immunizable conditions, and limb gangrene. We calculate ACSC rates for two periods (2011–2013 and 2014–2017), which allows us to compare the period immediately before and after the implementation of the Patient Protection and Affordable Care Act (ACA). Although most of the attention in the health policy literature focuses on the implications of the ACA for younger uninsured adults in the U.S., the law also made a host of changes to the U.S. Medicare program, which provides health insurance to older people, their dependents, and people living with permanent disabilities. The ACA expanded Medicare benefits, reduced out-of-pocket payments for Medicare beneficiaries, reduced payments to Medicare Advantage plans and some health care providers, and created incentives designed to improve health care quality (9).

To calculate the age-adjusted rates, we employed the direct standardization method using the 2000 U.S. population for adjustment weights (10). We restrict the analysis to the population 65 years and over. Hospital data are from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project. To calculate the population denominators for the descriptive statistics, we rely on U.S. census estimates for the U.S. and the NYC population age 65 years and over.

The data used in our analysis are from publicly available, deidentified sources and do not require institutional review board (IRB) approval. The Healthcare Cost and Utilization Project (HCUP) databases are limited data sets that remove 16 specific direct identifiers. For this study, we used the limited HCUP data sets to conduct statistical analysis. This does not require IRB approval under U.S. law. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Statistical analysis

To identify the factors that explain differences in ACSC rates over the two time periods, we rely on multiple logistic regression models to estimate effects of selected variables on the odds of hospitalization for ACSC. In both models, the independent variables are age, sex, race/ethnicity, number of diagnoses on the record (as a measure of morbidity), education, linguistic isolation, number of physicians per 1,000 population, and median household income quartile by patient area of residence. These factors are frequently included in models that are designed to predict ACSC (11-13). The use of ecological measures for education, linguistic isolation, and median household income also reflects the fact that these measures are not captured at the individual level in hospital administrative data.

The use of revascularization among patients hospitalized with heart disease

To identify hospitalizations for patients with diagnoses of coronary artery disease (CAD) and/or CHF and coronary revascularizations, we rely on hospital administrative data from the AHRQ’s HCUP datasets for New York. Coronary revascularizations include coronary artery bypass surgery (CABG) and percutaneous coronary angioplasty (PCI). To calculate age-adjusted rates, we rely on data from the U.S. Census with weights derived from the 2000 U.S. Census.

To identify the diagnoses of patients and those receiving CABG and PCI, we use the International Classification of Diseases, Nineth Revision (ICD-9-CM) for the years 2011–2014 and the Tenth Revision, Clinical Modification (ICD-10-CM) code for the years 2015–2017. We focus on CAD and CHF to identify the appropriate patient pool for two reasons. First, these are patients for whom coronary revascularization is an appropriate procedure. Coronary angiography is recommended in patients with heart failure, including those with reduced left ventricular function, with or without angina, in order to establish the diagnosis of CAD especially in patients who are considered potentially suitable for coronary revascularization. Second, we confirmed that CAD and CHF, as part of ischemic heart disease, capture more than 99% of the coronary revascularization procedures in the dataset.

For both time periods we conducted multiple logistic regression analysis to assess the factors associated with coronary revascularization for hospitalized patients admitted with CAD and/or CHF. All models estimate the probability that patients with these discharge diagnoses would receive a coronary revascularization procedure (PCI or CABG). We ran models in which the independent variables are age, gender, number of diagnoses on the record, race and ethnicity, education, linguistic isolation, and median household income quartile of the patient’s area of residence. We also include the variable, “age squared”, in our models, in addition to the continuous age variable, because the probability of coronary revascularization increases between the ages of 65 and 75 years and decreases thereafter due to increasing frailty.

Results

In Table 1, we present several common population health metrics, including the percentage of people with asthma, diabetes, hypertension, under-weight, and serious psychological distress, from the NYC Community Health Surveys in 2006, 2010, 2013, and 2018. We find that neighborhood level differences in rates of disease are consistent over this time period (Table 1). Older residents of lower income neighborhoods report poorer outcomes and these differences have remained unchanged over time.

LE at 65 did not change significantly in NYC, or the U.S. as a whole, between 2011 and 2019 (Table 2). Overall, it remains higher in NYC than in the U.S., but the trend for men in NYC is worse. Between 2011 and 2019, LE at 65 among men living in NYC decreased from 19.1 to 18.7 years. In February 2020, the U.S. Census Bureau projected continued gains in LE through 2060. These projections did not bear out, largely due to the COVID-19 pandemic, which led to decreases in LE at birth and at 65, in NYC and the U.S. The Census Bureau, however, noted that after decades of rapid increases, the increase in LE at 65 had slowed considerably in recent decades.

Self-reported health

Along with LE at 65 years, we compare self-rated health among people 65 years and older using the NYC Community Health Survey from the years 2009 and 2019. The survey shows that, overall, the self-rated health among older NYC residents did not change substantially during the decade before the pandemic. But it also shows that large racial and ethnic differences among older New Yorkers that existed in 2009 remained statistically significant in 2019. There was a decrease in the gap between older Non-Hispanic White residents and older Hispanic residents, but the difference between older Non-Hispanic Whites and all other groups increased. The percentage of older Non-Hispanic White residents reporting that they were in poor health fell from 9.7% in 2009 to 7.9% in 2019 and the percentage of older Hispanic patients who reported that they were in poor health fell from 19.7% to 11.8%.

In contrast, the percentage of older Non-Hispanic Black residents who reported that they were in poor health increased from 12.5% to 13.2%, and the percentage of older Non-Hispanic Asian/Pacific Islander and Non-Hispanic “other” residents reporting that they were in poor health nearly doubled between 2009 and 2019 (Table 3).

In 2009, older Non-Hispanic Blacks, Hispanics, Non-Hispanic Asians, and “other” Non-Hispanic residents were all significantly more likely to report that they were in poor health than were Non-Hispanic Whites (Table 3). In 2019, these differences remained statistically significant (Table 4).

Access to health care among older New Yorkers

As we suggest above, high ACSC rates often reflect barriers to health care (6). Hospitalization for ACSC is recognized as a valid indicator of access to CBAC, an important dimension of health system performance (14-18). We compared ACSC rates among older residents over 2011–2013 and 2015–2017. Overall, the ACSC rate fell by just over 11% (Figure 1).

Figure 1 AHC among older residents (65+ years) of New York City, 2011–2013 and 2015–2017. Source: AHRQ HCUP, State Inpatient Databases for New York, 2011, 2012, 2013, 2015, 2016, and 2017. AHC, hospital discharges for ambulatory care sensitive conditions; AHRQ, Agency for Healthcare Research and Quality; HCUP, Healthcare Cost and Utilization Project.

The logistic regression models for the two time periods indicate that, although the age-adjusted ACSC rate fell between the 2011–2013 and 2015–2017 periods, inequities in ACSC rates have not declined. We conducted logistic regression models for the periods 2011–2013 and 2014–2017. In both of these time periods, we note large inequities by gender, race, ethnicity, education and income of residence. In fact, the differences by race, ethnicity and neighborhood income are larger in the 2014–2017 periods (Table 5) than over the 2011–2013 period (Table 6).

The use of revascularization among older patients with heart disease

As our proxy for access to specialty care among older New Yorkers, we examine the use of revascularization among residents hospitalized with CAD or CHF. The incidence of CAD and CHF have fallen in the past decade, but they are still leading causes of death among older people in NYC and the U.S. Similarly, despite the increased use of non-surgical interventions to treat CAD and CHF, coronary revascularization procedures are an important tool for treating these conditions (19-23). Despite the widespread use and effectiveness of revascularization, previous research in NYC has found inequities in the use of these procedures by gender, race, ethnicity, and zip code of residence.

The age-adjusted rates of CAD and CHF among older residents of NYC decreased by more than 15% over our two time periods, but the use of revascularization decreased by almost twice the percentage (Table 7). As we suggest above, this is likely due to the increased use of non-surgical treatments.

As with our measures of population health and access to ambulatory care, we found large inequities among older people in the use of revascularization. When we predict the factors associated with the use of revascularization among older residents with CAD and/or CHF over the two time periods (Tables 8,9), we find large and persistent differences by gender, race, ethnicity, education, and income of zip code.

Summary of key findings

Our present analysis documents that differences in LE at 65, self-reported health status, ACSC rates, and the use of revascularizations among older people hospitalized with heart disease continue to be large and statistically significant. These enormous health and health care inequities were on full display during the COVID-19 pandemic, which hit NYC particularly hard in the Spring of 2020. As previous analysis has shown, there were large differences in COVID-19 deaths by race, ethnicity, nativity-status and zip code (24).

Discussion

Two decades ago, NYC residents enjoyed better health than those living in the country as a whole, but these aggregate metrics of population health masked enormous inequities in health and the use of health care among older people. Among older New Yorkers, there were stark differences in health and access to health care services by race and neighborhood of residence. The findings we present in this article indicate that these inequalities have remained largely unchanged.

With regard to LE at 65, the Census Bureau suggested that limited gains since 2010 “may have resulted from stalled progress in treating the leading causes of death and other degenerative diseases. Moreover, the prevalence of preventable health risks—such as smoking, obesity, and, more recently, opioid-related overdoses—hinders overall population health and contributes to slowed gains in life expectancy (25)”. Montez and colleagues add that, between 2010 and 2014, “states that implemented more conservative policies were more likely to experience a reduction in life expectancy (26)”. They point to a range of policies that may have negative consequences for health and longevity. These include state laws that “prohibit localities from enacting laws such as smoke-free ordinances, nutrition labeling in restaurants, paid sick days, and raising the minimum wage (26)”. They find that states that enacted such laws experienced slower gains in life expectancy than states that enacted more liberal laws (26).

New York State and NYC have relatively generous health and social programs and liberal public health policies. NYC has been a leader in the adoption of smoke-free ordinances and nutrition labeling in restaurants (27,28). Similarly, rather than prohibiting increases in the minimum wage, New York has increased the minimum wage (29-31). Despite this, LE at 65 has largely stagnated since 2010 and decreased slightly among men (see Table 1). One possible explanation for this trend is the higher rate of obesity among adult men in NYC (32).

The COVID-19 pandemic exacerbated these issues and led to a disproportionate share of deaths among people aged 65 years and over. During the first three waves of the pandemic in 2020, the population aged 65 years and over accounted for about 81% of deaths. In contrast, the same population “accounted for 74% of all-cause deaths in 2019 (33)”.

NYC experienced the highest rate of excess mortality in the country (34). Although a large portion of these deaths took place during the first COVID-19 wave in the Spring of 2020, no other metropolitan area in the U.S. experienced higher rates of COVID-19 deaths since that time (35). After LE at birth in NYC reached a high of 82.6 years in 2019, it fell to 78 years in 2020. The decline in LE at birth experienced in 2020 was the largest in nearly 200 years (35). By 2021 LE at birth in NYC increased to 80.7 years, but remains lower than it was before the pandemic and, aside from 2020, LE at birth was at its lowest point since 2009.

Strengths and limitations

By drawing on several different sources of population-based data, our analysis provides a comprehensive assessment of the health of older residents of NYC. Because we rely on inpatient hospital data, we are limited in our ability to investigate access to ambulatory health care. Age-adjusted rates of ACSC is a measure that is commonly used to assess access to ambulatory care, but it is an indirect measure that may be influenced by other factors. Similarly, our reliance on hospital administrative data limits our ability to know whether the gender, neighborhood, and race/ethnicity differences in the use of revascularization represent inappropriate inequalities in the use of these services because we do not have the clinical data that would be necessary to make such an assessment. Nevertheless, our findings are consistent with other studies that have raised concerns about differences of this sort.

Comparison with similar research studies

The analysis presented here replicates much of the analysis included in the 2006 review of inequalities in health and health care among older New Yorkers and represents one of the few articles that offer a comprehensive look at the health of older NYC residents (5). A host of other studies examine specific dimensions of health or access to care for older NYC residents, and a number recent articles have presented data about health or health care inequalities (36), but no others combine life expectancy, self-reported, health, hospitalizations for ACSCs and the use of revascularization among residents with heart disease to offer a comprehensive understanding of health and access to health care among older residents of NYC. By doing so, we are able to demonstrate that the health and health care inequalities that existed in NYC in the late 1990s have continued into the first decades of the 21^st century.

Explanations of findings

As Friedman and colleagues explain, “decades of racial and ethnic residential segregation and disinvestment and the resultant poverty and unemployment have tragically ended many lives in neighborhoods with concentrations of immigrants and people of color. Investment in the infrastructure of these neighborhoods is needed so that future lives are not lost (24)”. Furthermore, even though the Medicare program helps to overcome financial barriers to care for the vast majority of older New Yorkers, health insurance coverage is insufficient to overcome the inequalities in health and access to care that many Medicare beneficiaries experienced over the course of their lives (37,38). Making matters worse, the Medicare program does not cover all older New Yorkers because many older immigrants do not qualify for the program because they failed to pay Social Security and Medicare payroll tax for a sufficient number of years, so there are a large percentage of older NYC residents who continue to live with limited health insurance coverage and more limited access to health care services. These various sources of inequality, that are realized over a life course, are reflected in differences in health status and access to care that we document in this article.

Implications and actions needed

It is clear from our analysis that sufficient investments to promote the health of older New Yorkers and to reduce inequalities among them remain an unrealized aspiration. Although NYC has the largest public hospital system in the U.S. and NYC and New York State have one of the most generous Medicaid programs in the U.S., there are significant gaps in health and access to health care services among the city’s older population.

Conclusions

NYC has made remarkable investments in the health of its population, including the health of its older residents. The city has the largest public hospital system in the U.S., one of the most generous Medicaid programs in the country, and has made large investments in subsidies housing for older people and operates a vast network of senior centers that provide health and social services to older residents of the city. Despite this, there are large inequalities in health and access to health care among older New Yorkers. The combination of residential segregation, enormous income and wealth differences among older New Yorkers, and the long-term implications of differences in access to health care among younger New Yorkers have conspired to perpetuate the inequalities we document in this article. Policy efforts to reduce health and health care inequalities among older people should adopt a life course perspective and should address the broader social determinants of health, rather than focus narrowly on health insurance or the health care delivery system.

Acknowledgments

None

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Hospital Management and Health Policy for the series “Health Systems and Health in World Cities: Challenges for the Future”. The article has undergone external peer review.

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-97/prf

Funding: None

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-97/coif). The series “Health Systems and Health in World Cities: Challenges for the Future” was commissioned by the editorial office without any funding or sponsorship. V.G.R. serves as an unpaid editorial board member of Journal of Hospital Management and Health Policy from September 2024 to December 2026. M.K.G. and V.G.R. served as the unpaid Guest Editors of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The data used in our analysis are from publicly available, deidentified sources and do not IRB approval. The HCUP databases are limited data sets that remove 16 specific direct identifiers. For this study, we used the limited HCUP data sets to conduct statistical analysis. This does not require IRB approval under U.S. law.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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