The Influence of Race, Place and Income on Colorado’s Health
Though Colorado has made significant gains in providing health coverage to its residents and boasts the lowest obesity rate in the country, data shows that not every Coloradan currently has access, means and opportunity to be the healthiest person they can be.
Our health is considerably influenced by a number of factors outside the doctor’s office. It’s estimated that more than half of our health and wellbeing is driven by the lottery of life — that is, our access to income and opportunity, and the places we live, learn, work and play. As Colorado strives to be one of the healthiest states in the country, it’s clear that the health of Coloradans cannot be addressed by health care alone.
Determinants of Health
It’s estimated that about three-quarters of population health is driven by the following social determinants of health:
- Social characteristics and social environment such as income, race/ethnicity, discrimination;
- Physical environment such as where a person lives and works and quality of housing; and
- Medical care such as access to health care coverage and quality health care.
Genes, biology and health behaviors together account for about 25 percent of population health.
Produced by the Colorado Center on Law and Policy, Vital Signs highlights the dramatic influence of race, place and income on health outcomes. This report also shows how addressing these disparities would enable more Coloradans to maximize their health and wellbeing while building a vibrant and sustainable economy. Income related policies are also public health policies.
Race, Place and Income in Colorado
Colorado is a geographically diverse state with a growing population of people of color and growing economic divide. These broad population trends impact the health of Coloradans and ultimately the overall functioning of the economy; understanding them is a critical step toward ensuring all Coloradans have the opportunity to attain their highest level of health.
The complex relationship between our social structures and economic system often results in significant differences in wages, access to affordable housing, likelihood of living in areas with concentrated poverty or attending a high-poverty school. Low-income people, communities of color and certain areas of the state are more likely to experience these conditions that directly and unequivocally impact health.
The Changing Face of Colorado
Colorado is becoming an increasingly multiracial state. Between 2000 and 2015, people of color increased from one-quarter of the state’s population to nearly one-third. By 2040, an estimated 45 percent of the state’s population will be people of color.
Since 2000, people of color represent over half of Colorado’s population growth, driven primarily by growth in the Latino population. These population shifts are happening across the state—in many urban, suburban and rural areas, people of color are becoming a larger share of the overall population. People of color comprise about 26 percent of the population in rural communities and 31 percent in urban areas.
Did you know?
As people of color comprise a larger share of the labor force, their social and economic progress will determine the success and growth of the state’s economy. Persistent racial gaps in income, employment, opportunity, and ultimately health threaten the prosperity of these individuals, their families, and the state as a whole.
Fig. 1. Colorado is growing increasingly multiracial
Projected State Population by Race and Ethnicity, 2000-2040
Source: Colorado State Demographer’s Office
Colorado’s Geographic and Racial Diversity
Three-quarters of Colorado’s 64 counties are rural and cover about 78,000 of the state’s 104,000 square miles. Less than 15 percent of the state population (about 698,000 people) occupies this vast geographic area that spans the Western Slope, the Eastern Plains and the San Luis Valley. Over 80 percent of the state’s 5.5 million people live in the 12 counties that make up the Front Range.
Real differences exist between urban and rural areas of the state.
- Median household income is 29 percent lower in rural areas of the state compared to urban areas (about a $14k difference). Poverty and unemployment rates are higher in rural counties.
- The nine-county corridor between Colorado Springs and Fort Collins, encompassing the Denver metro area, accounts for 80 percent of the state’s jobs.
- Nearly 40 percent of prime working age people in rural counties have a high school education or less, compared to 31 percent in urban areas.
- The economic gap between urban and rural areas of Colorado has continued to widen since the Great Recession and the uneven recovery that followed. Colorado has one of the largest economic gaps between urban and rural areas in the country (along with Virginia, South Carolina and Florida).
Recent research suggests that where people live significantly impacts health outcomes. Life expectancy for low-income people varies by as much as 5 years depending on where they live. Disparities in life expectancy based on where people live are not inevitable, however. Investments aimed at improving health behaviors (smoking, obesity and exercise) and community infrastructure (mass transit, health services and access to healthy food) positively influence health outcomes.
Map 1: Population density, by race and ethnicity
Source: U.S. Census Bureau, American Community Survey, 2010-2014
Our Growing Economic Divide
While Colorado’s economy has grown substantially in recent decades, the benefits of that growth have not been broadly shared. Income gains have disproportionately flowed to families at the top of the income distribution. Wages for workers in the top 20 percent of earners are up nearly 9 percent since 2000 while earnings for the bottom 20 percent are down nearly 2 percent.
Colorado also has a persistent wage gap by race and ethnicity. Regardless of the economic climate, Latino and Black workers tend to experience higher rates of unemployment, higher poverty and lower wages compared to their White counterparts. Median income for Latino and Black workers is 65 percent of income for White workers.
The Great Recession and the uneven recovery have only widened these income gaps. Wages have been stagnant for the majority of workers while statewide productivity has continued to increase. As a result, the income distribution in the state is more unequal today than the 1920s.
Income affects life expectancy: the richest people in America live 10 to 15 years longer than the poorest Americans. This same trend is true in Colorado. Wealthier Coloradans live 6 to 10 years longer than people at the other end of the income spectrum. Shared prosperity is essential to a sustainable state economy and the health and wellbeing of all Coloradans.
Fig. 2. Gap between high and lower wage groups continues to expand
Hourly wages by income group, 2000 and 2015 (2015$)
Source: U.S. Census Bureau Current Population Survey
Fig 3. Median income substantially lower for Black and Latino households
Median household income by race and ethnicity, 2015
Source: U.S. Census Bureau American Community Survey
Social Determinants of Health in Colorado
The conditions that characterize the places we live, learn, work and play significantly influence our health. While Colorado has made tremendous strides in increasing access to health care by expanding Medicaid, disparities in health outcomes persist. Certain groups of people and places across the state consistently have worse health outcomes.
This section highlights a series of key indicators focused on economic conditions, health care coverage, access and costs, and health outcomes by income, race and place. The purpose is to identify where communities can focus their efforts to ensure opportunity for health, wellbeing and prosperity for all Coloradans.
Income & Health Disparities:
Poverty is a Health Issue
The amount of money we make is one of the primary drivers of health. Higher income is associated with better overall health and longer life expectancy. In Colorado, the highest earning men and women in the state live 6 to 10 years longer than those at the bottom of the income spectrum. A recent study concluded that poverty poses a greater societal health burden than any other risk factor.
How is poverty measured?
The official poverty measure, known as the federal poverty level (FPL), was developed in the 1960s. It was based on a low-cost food budget multiplied by three to account for all other costs of living. The thresholds have only been adjusted for inflation since they were first developed. The federal poverty level severely underestimates the cost of modern living. Despite its limitations, it is used widely to calculate eligibility for a variety of poverty and work support programs.
The interactive graph compares the federal poverty level to the Self-Sufficiency Standard basic needs budget by county. The income needed to meet basic needs exceeds the federal poverty level in every county across the state.
Fig. 4. Income required to meet basic needs exceeds federal poverty level
Self-Sufficiency Standard compared to Federal Poverty Level
Physical and Mental Health
Nearly 23 percent of Coloradans living at the federal poverty level (FPL) report experiencing poor or fair physical health. At each progressively higher income level, a declining share of people report poor or fair health. The same trend holds for reports of limited ability to work due to health issues.
People at the lowest end of the income spectrum are also more likely to report a limited ability to work for health reasons. Slightly more than one-third of people making less than the federal poverty level report impaired ability to work. What’s more, nearly 43 percent of private sector workers in Colorado—about 800,000 people across the state—do not have paid sick days.
Fig. 5. Fewer higher income Coloradans report poor/fair health and limited ability to work due to health challenges
Percent Reporting Poor/Fair Health Status and Limited Ability to Work due to Health Issue, by Income, 2015
Source: Colorado Health Access Survey
Living in poverty is taxing and stressful on both adults and children. Research has shown that growing up poor can impair brain function and mental health as an adult. It’s not surprising then that Coloradans living in poverty were three times more likely to report poor mental health compared to people in higher income brackets. Individuals in the lowest income bracket were also twice as likely to skip needed care for mental health compared to people earning two to three times the federal poverty level.
Fig. 6. Fewer higher income Coloradans report poor mental health and skipping needed care
Percent Reporting ≥ 8 Poor Mental Health Days in the Past Month and Skipped Needed Mental Health Care, by Income, 2015
Source: Colorado Health Access Survey
Obesity and Diabetes
Colorado has the lowest obesity rate in the nation. Low statewide obesity, however, masks the disparity in obesity rates by income. People earning less than $15,000 have an obesity rate nearly 10 percentage points higher than people earning $50,000 or more.
Obesity increases the risk of serious health problems, including heart disease, type 2 diabetes, high blood pressure, high cholesterol, stroke and some types of cancer. These conditions increase health care costs and strain the health and wellbeing of families. Diabetes rates are nearly three times higher among people earning less than $15,000 compared to people making $50,000 or more.
Fig. 7. Obesity and diabetes rates decline with income
Rates of Obesity and Diabetes, by Income, 2013-2014
Source: Colorado Behavioral Risk Factor Surveillance System Statistics
Life Expectancy and Income
A direct correlation exists between income and life expectancy. Higher income is unequivocally associated with a longer life span. Recent research found that the wealthiest men in America live 15 years longer than the poorest men. The same is true among women: the wealthiest women in the U.S. live a decade longer than women at the opposite end of the income spectrum.
We see the same trends in life expectancy by income in Colorado.
- Women in the top 25 percent of the income distribution live 6 years longer than women in the bottom 25 percent.
- The gap is even larger among men, where the wealthiest men in the state live over a decade longer than men at the bottom of the income distribution.
- While overall life expectancy has been increasing across the population, these gains have not closed the longevity gap between income groups.
- Men in the bottom quarter of the income distribution in Colorado, in particular, have not seen any improvement in life expectancy in the last 14 years.
- It’s well documented that women tend to live longer than men on average. Yet, that trend is more apparent among low-income people. Low-income women live about 6 years longer than men. At the highest income levels, women live less than year longer than men.
It’s important to note that these findings do not necessarily point to a causal relationship between income and longevity. But the data does suggest a strong association between health and income that likely involves differences in access to opportunity, education and varied health behaviors.
Fig. 8. Wealthier people in Colorado live 6 to 10 years longer than low-income people
Life Expectancy for Women in Colorado, by Income Group, 2001-2014
Life Expectancy for Men in Colorado, by Income Group, 2001-2014
Source: Raj Chetty et al., The Association between Income and Life Expectancy in the United States, 2001 – 2014
Race & Health Outcomes:
How Poverty Drives Health Disparities
Income is a driving force behind the significant disparities in health outcomes facing communities of color. It’s estimated that income explains over 50 percent of the differences in life expectancy between Whites and Blacks. Other research has found that differences in health outcomes between Whites and communities of color are smaller than the disparities found among high and low-income populations within racial and ethnic groups. This is also true in Colorado: health disparities are greatest among low- and high- income groups within the same racial or ethnic groups.
Communities of color are disproportionately low-income and we know that low-income families are at greater risk for poor health outcomes. Understanding this intersection between race/ethnicity and income is important because while we know that health disparities exist by race and ethnicity, the elimination of those disparities is not possible without addressing the income disparities.
The various environmental, economic and social conditions that place low-income families at greater risk for poor health compared to higher income Coloradans, must be addressed to eliminate both race-based and income-based health disparities.
Disparity in Poverty Rates by Race and Ethnicity
The poverty rate among Latino and Black Coloradans is more than two times higher than non-Hispanic Whites in Colorado.
Defining poverty as those with incomes under twice the federal poverty level (FPL) provides a more complete picture of the share of Coloradans experiencing economic hardship. The Self-Sufficiency Standard for Colorado—the level at which families can meet basic needs without public or private support—generally requires an income above 200 percent of FPL. Using this measure, nearly half of all Latinos and Blacks in Colorado in 2014 were living in or near poverty.
Fig. 9: Poverty rates are consistently higher for people of color in Colorado
Poverty Rates by Race/Ethnicity, 2014
Poverty is now widely viewed as one of the most significant threats to child health—so harmful, in fact, that doctors are calling for classifying childhood poverty as a disease. Living in poverty puts children at risk of developing conditions with lifelong consequences, including premature birth, low birthweight, asthma, obesity, diabetes and mental illness.
Latino and Black children are considerably more likely to live in poverty than White and Asian children in Colorado. Over half of all Latino and Black children in Colorado live in or near poverty, compared to 24 percent of White or Asian children.
Physical and Mental Health by Race/Ethnicity and Income
Disparities in health outcomes and access to quality health care by race and ethnicity are well documented. The health disparities of low-income people have also been studied extensively. Most research looks at these important contributors to health separately making it difficult to understand the distinct effects of income and race on health outcomes. Recent research examining health status by both income and race has found that that some of the largest health disparities exist between high and low-income people within the same racial and ethnic group.
The graphs below support this small but growing body of evidence. These graphs still show differences between White, Black and Latino Coloradans. They also show that differences within racial/ethnic groups by income are more dramatic than differences between racial/ethnic groups. Low-income White, Latino and Black Coloradans are nearly twice as likely to report poor or fair physical health compared to higher income Coloradans within the same racial or ethnic group.
The same is true for mental health. The share of Coloradans reporting poor mental health is substantially higher among lower-income people across racial and ethnic groups. In fact, when broken out by income, differences in physical and mental health between White, Black and Latino Coloradans narrow.
Fig. 10: Larger health disparities between high and low income people within racial and ethnic groups
Self-Reported Health Status, by Race/Ethnicity and Income, 2015
Source: Colorado Health Access Survey 2015
Place & Health:
Geography Makes a Difference
Recent research suggests that where people live significantly impacts health outcomes—particularly for low-income people. Wealthy people live longer than lower income people in America, regardless of where they live. But geography matters a great deal for the longevity of people at the lower end of the income spectrum.
In the maps below, it is apparent that not every Coloradan has access, means and opportunity to be the healthiest person they can be. Fairly substantial gaps exist between counties—sometimes neighboring counties—in overall health outcomes.
Health Outcome Rankings by County
Health outcomes vary greatly across the state. People living in some counties in the state are more likely to die prematurely or report poorer health than residents of another county. The healthiest counties experience substantially lower rates of premature death, poor physical health and low birthweight babies than counties at the other end of the health spectrum.
The health outcome measures below are combined into an overall health ranking for each county. In Map 2, we can see how differences in health outcomes play out across the state. Counties ranking in the top third are concentrated along the Front Range and among wealthier mountain resort communities. Counties in the middle third are found along the Eastern Plains and Western Slope. And counties with the worst health outcomes are concentrated in the southern regions of the state—in and around the San Luis Valley.
Table 1. Disparity in health outcomes between best and worst counties in Colorado
Health Outcome Measures, 2016
|Measure||Best CO Counties||Worst CO Counties||CO Mean||Best US Counties|
|Premature Death – Years of potential life lost before age 75 per 100,000 population ||3,400||11,000||5,700||5,200|
|Poor or Fair Health – Percent of adults reporting poor or fair health ||7%||22%||13%||12%|
|Poor Physical Health Days – Average number of physically unhealthy days reported in the last 30 days||2.3||4.4||3.3||2.9|
|Poor Mental Health Days – Average number of mentally unhealthy days reported in the last 30 days||2.6||3.8||3.2||2.8|
|Low Birthweight Births – Percent of live births that are born low birthweight (< 5.5 pounds)||6%||14%||9%||6%|
Map 2. Some areas of the state are clearly healthier than others
Health Outcomes Rankings, 2016
Source: Robert Wood Johnson Foundation, County Health Rankings
Premature death—that is, death before age 75—is a common measure of overall population health. Nationally, premature death rates have been slowly declining over the last several decades. We do, however, see differences in the rate of premature death by place. Rural counties consistently have the highest premature death rates.
The map below shows trends in premature death by frontier, rural and urban counties in Colorado. Frontier counties—essentially the most rural areas of the state having 6 or fewer people per square mile— have the highest rate of premature death. In recent years, premature death rates have been declining in frontier counties but increasing in rural counties. Urban counties consistently have the lowest level of premature death.
A complex mix of factors influence differences in health outcomes between rural and urban areas, including differences in health behaviors, access to health care, social and economic factors, and the physical environment.
Map 3. Counties have higher rates of premature death
Years of Potential Lost Life* Under Age 75 per 100k Population, 2016
Source: Robert Wood Johnson Foundation, County Health Rankings
* Premature death is represented by the years of potential life lost before age 75. Every death occurring before the age of 75 contributes to the total number of years of potential life lost. For example, a person who dies at age 25 contributes 50 years of life lost, whereas a person who dies at age 65 contributes 10 years of life lost to a county’s YPLL.
Places Where Lower-Income People Live Longest
The previous maps examined how overall health and longevity varies across the state. This section examines how life expectancy varies by both income and place. Recent research has found geography matters most for the life expectancy of lower income people in America. Nationally, life expectancy for low-income people varies by as much as five years depending on where they live. To put this life expectancy gap in perspective, the Centers for Disease Control estimated that eliminating cancer in the U.S. would increase overall life expectancy by about 3 years.
The maps below show how life expectancy varies for Coloradans in the bottom 25 percent of the income spectrum depending on where they live. (Data was only available for 16 of Colorado’s 64 counties.) What it shows is striking: life expectancy for the lowest income men in Colorado differs by nearly 8 years depending on where they reside in the state. Among women, the difference in life expectancy by geography is nearly 6 years.
Disparities in life expectancy based on geography are not inevitable, however. Lower income people tend to live longest in areas with higher average income (and lower poverty rates), higher levels of education and higher government and community investment. Specifically, investments aimed at health behaviors (smoking, obesity and exercise) and infrastructure benefiting entire communities (mass transit, health services and access to healthy food) positively influence health.
Fig. 11. Disparity in life expectancy by income varies across the state
Life expectancy for men and women in select Colorado counties, by income group, 2014
Source: Raj Chetty et al., The Association between Income and Life Expectancy in the United States, 2001 – 2014
Closing the Divide:
Income-Related Approaches to Improving Health
Income is a primary determinant of a healthy and long life. In Colorado and the nation as a whole, higher income means healthier outcomes and a longer life span. This relationship between income and health holds true across the income spectrum for most measures of health and over the life course starting at birth.
Some of the pathways linking income and health are clear. More income means more resources to afford healthier food and better health insurance coverage. Income also influences health by determining where people live, work, play and attend school. Higher income families can choose to live in safe neighborhoods with high performing schools, plentiful parks, access to grocery stores with healthy food choices and a range of transportation options. Lower income people who live in economically distressed communities are exposed to a range of stressors—such as higher crime, poorer quality housing, environmental hazards and strained school systems—that directly affect their health.
These various pathways between income and health point to opportunities for income-based policies that can improve both our economy and the overall health and wellbeing of our communities. In other words, income-related policies are also public health policies.
Policies that promote income security focus on encouraging work and providing access to basic needs, like food, health care and housing. For most people, assistance provided by income and work support programs is temporary—needed only for a short time to overcome an unexpected job loss, a medical crisis, or some other significant life event. Most research has focused on the employment, education and poverty effects of these government programs. Recent research has documented the health benefits of income and work supports.
Central to healthy communities is affordable health care coverage and access to services. Colorado has made tremendous gains in health care coverage rates. The historic drop in the percentage of Coloradans without health insurance is due in large part to expanded Medicaid eligibility.
Colorado expanded Medicaid to all people at or below 138 percent of the federal poverty level. Medicaid enrollment more than doubled between 2009 and 2015. Recent research has concluded that Medicaid expansion states are experiencing a range of healthier outcomes compared to non-expansion states. Benefits of expanded access to Medicaid for low-income people include increased use of preventative care, reduced emergency room visits and improved self-reported health.
Despite the dramatic drop in the uninsured rate, Latinos still have the highest uninsured rate in the state—more than double that of White Coloradans. And looking across our vast and diverse geography, much of the Western Slope still has high rates of people without insurance.
Fig. 12. Dramatic drop in uninsured Coloradans but Latinos still have high uninsured rate
Source: Colorado Health Access Survey
Food assistance available through the Supplemental Nutrition Assistance Program (SNAP) provides eligible families with a monthly stipend to purchase food, averaging about $1.40 per person, per meal. Most recipients are children, seniors, working adults, veterans and those who are disabled.
A growing body of research shows the importance of SNAP benefits in improving short and long-term health outcomes, lowering health care costs, promoting work and economic stability, enhancing academic performance and early childhood education outcomes, helping seniors maintain their independence, and boosting economic development, such as grocery sales.
Expanding access to food assistance could be beneficial to health in Colorado. An estimated 57 percent of the eligible population is enrolled in food assistance in Colorado, well below the national enrollment average of 75 percent of the eligible population. Underenrollment in this program also means that local communities are losing nearly $690 million in annual grocery sales.
Initiatives that provide an income boost to low-income families—such as the Earned Income Tax Credit (EITC) and Child Tax Credit—also have documented health benefits, particularly for children. The EITC has been linked to improved infant and maternal health through reducing the likelihood of babies being born at low birth weight, which can result in costly health complications. In 2014, nearly 380,000 Coloradans received the EITC, putting another $810 million in federal EITC funds in the pockets of low-income families.
Research also suggests that Social Security benefits have contributed to increasing the life span of people age 65 and older and that Supplemental Security Income (SSI), a cash transfer program for low-income elderly people, reduced disability rates.
Community and Economic Development
These approaches focus on improving the lives of low-income people while also improving the communities in which they live, learn, work and play. Local interventions matter: lower income people tend to live longer in places with a high concentration of college graduates and higher local government spending. Higher poverty rates point to places and populations that may benefit from the right set of interventions aimed at improving public health and creating a vibrant economy.
Adequate income to support basic needs and paid leave
The Colorado economy has experienced steady growth in recent years, but without broadly shared prosperity. Since 2000, the cost of living has increased three times faster than wages. And for the lowest paid workers in the state, inflation adjusted wages have been flat or falling for the last decade. Income gains from our growing economy have disproportionately gone to earners at the top of the income ladder.
Having an adequate income is a prerequisite for good health and thriving communities. Policies that directly increase income, such as raising the minimum wage and creating opportunities for asset building and retirement savings, are economic and public health policies. People who earn more income live longer, regardless of where they live. Income also makes a difference in how you start out in life. A recent analysis by the National Bureau of Economic Research concluded that raising the minimum wage reduces the likelihood of infants being born at a low birth weight.
Another important aspect of health is ensuring workers can take time off when they are sick or have sick family members. Nearly 43 percent of workers in Colorado do not have access to paid sick leave. Allowing workers to earn paid sick days promotes healthy families, communities and ultimately a healthy economy.
Equal opportunity for economic security
A growing economy characterized by equitable opportunity for economic security and health would see low rates of unemployment for all workers and equal pay for equal work regardless of race or ethnicity.
Regardless of the economic climate, Blacks and Latinos in Colorado tend to experience higher rates of unemployment and underemployment relative to White workers. (Underemployment counts unemployed workers along with people involuntarily working part-time jobs and those who have given up looking for work.) Median income among Latino and Black households lags significantly behind White households. In 2015, Latinos and Black workers earned just 65 percent of income earned by non-Hispanic White workers in Colorado.
Fig. 13: Work is more difficult to find for Latino and Black Coloradans
Unemployment and underemployment rates, by race and ethnicity, 2015
Source: U.S. Census Bureau Current Population Survey
Differences in pay and job quality by race and ethnicity result from differences in education, training and experience. These differences are also due to concrete barriers to employment for workers of color, such as English language skills, lack of transportation, criminal records and bias among employers and institutions. As people of color comprise a larger share of the labor force, their social and economic progress will increasingly determine the health and prosperity of the state. Addressing these barriers to equal opportunity is essential to the health of communities across the state and building a sustainable economy.
Close gender pay gap
Women earn less than men at every educational level and the gap widens with increasingly higher levels of education. Colorado women working full-time earn only 82 percent of what men earn. The gap grows substantially at the upper rungs of the education ladder, with the largest income gap existing at the highest levels of education.
Women of color in Colorado earn even less compared to non-Hispanic White men. Latina workers earn just 54 percent of White men followed closely by Native American women earning 58 percent and African American women earning 64 percent of White men.
Fig. 14: Gender wage gap is even greater for women of color in Colorado
Median Earnings by Gender, Race and Ethnicity, 2014
|Women||White Men||Lifetime lost
Source: National Women’s Law Center
Women are more likely to live in poverty and poverty rates are highest among single mother families. Women also make up the majority of minimum wage workers. Policies aimed at closing the gender wage gap, such as increasing the minimum wage and providing paid leave, will positively improve the health and economic security of women and their children in the state.
Higher levels of education are associated with lower morbidity from the most common diseases, such as heart disease, diabetes and hypertension. Education is also a key pathway out of poverty—another serious risk factor for poor health. Less than 5 percent of Coloradans with at least a bachelor’s degree live in poverty. On the other end of the education spectrum, nearly one-quarter of those without a high school diploma live in poverty.
Fig. 15: Education is a key pathway out of poverty
Poverty rates by educational attainment, 2015
Source: U.S. Census Bureau American Community Survey
Fig. 16: Educational attainment varies by race and ethnicity
Highest educational level completed, by race and ethnicity, 2014
Source: U.S. Census Bureau American Community Survey
Educational attainment in Colorado varies by race and ethnicity. Communities of color are more likely to stop their formal education at high school, while White and Asian Coloradans are more likely to have completed a bachelor’s degree or higher. Nearly one-third of Latinos have completed less than a high school education. These disparities in educational attainment are stubbornly persistent and defy easy explanation. We do know that struggling students are more likely to be low-income. And low-income student are more likely to attend struggling schools. These students leave school for a variety of reasons directly related to the circumstances in their lives—frequent family moves, caregiving responsibilities or the need to work. Others are pushed out due to discipline problems or academic struggles.
Finishing high school and seeking additional training is critical to financial security in today’s economy. The share of jobs that only require a high school diploma are shrinking in Colorado. By 2020, an estimated three-quarters of all jobs in Colorado will require some level of post-secondary training. Having access to training and education and understanding the career pathways that lead to better paying jobs is critical to our growing economy and the health of Colorado families.
Access to affordable housing
Affordable and safe housing is central to healthy and thriving families and communities. Access to affordable housing is a growing problem across the state. In 40 of Colorado’s 64 counties, more than 40 percent of families are rent burdened, meaning they spend more than 30 percent of their total household income on rent. One-quarter of all renter households in Colorado spend over half their income on housing. These households are at greatest risk of homelessness.
Map 4: High cost of housing is felt across the state
Percent of Population Paying Rent in Excess of 30 Percent of Household Income, 2010-2014
Source: U.S. Census Bureau American Community Survey
The cost and quality of housing are influenced by the community in which it is located. Black and Latino Coloradans are substantially more likely to live in high-poverty communities (defined as neighborhoods with a poverty rate of 20 percent or higher). While 15 percent of Whites live in neighborhoods marked by high poverty, 42 percent of Blacks and 40 percent Latinos live in these neighborhoods. The clustering of low-income families in poverty can amplify the experience of living in poverty. Being surrounded by widespread poverty compounds the stress of living in economic hardship and can make it feel more pervasive because it extends outside the home and touches the entire community.
Fig. 17: Larger share of Latino and Black Coloradans live in high poverty neighborhoods
Percent of population living in concentrated poverty, by race and ethnicity, 2014
Source: U.S. Census Bureau American Community Survey
Fig. 18: Children of color are more likely to attend high poverty schools
Percent of students attending high poverty schools, by race and ethnicity, 2014
Source: National Center for Education Statistics
Given disproportionate rates of living in concentrated poverty, it follows that children of color are also more likely to attend high-poverty schools (where 75 percent of students are eligible for free or reduced price lunch). Nearly one-third of students of color in Colorado attended high-poverty schools in 2014 compared to less than 5 percent of White students. Recent analysis of test scores across thousands of school districts found that schools with the highest concentrations of kids living in poverty score on average four grade levels below their peers in the wealthiest school districts. Over half the achievement gap can be explained by racial or ethnic differences in exposure to poverty.
The toxic effect of concentrated poverty on children and families and the power of mobility and community investment to interrupt intergenerational poverty are now well documented. Zip code more than genetic code determines health outcomes for low-income families. Policies that expand access to affordable housing and reduce the burden of rent on low-income families can free up more family and financial resources for children, reduce the risk of homelessness and result in healthier outcomes. Infrastructure investments benefiting entire communities—such as access to mass transit options, health services, parks and healthy food options—can improve the health of entire communities.
Poverty reduction policies are public health policies
The Centers for Disease Control and Prevention has found that the broadest influence on health outcomes is not to deliver more health care (as important as that is) but rather from changing the context of people’s lives. As illustrated in the vignettes that accompany this report, helping people manage the circumstances of their lives directly influences their ability to be the healthiest person they can be.
Chronic diseases go untreated when transportation to a health clinic is unaffordable or unavailable. Eating well takes a back seat to paying rent when the alternative is eviction.
Early childhood education, well-resourced schools, connection to training that leads to a job paying adequate income, access to healthy food, transportation options along with safe and affordable housing all belong in the poverty reduction and health care tool boxes.
Center bridges the mind-body connection
Dollar Lee’s parents came to Colorado during the Vietnam War as young refugees from Laos. The communist-like government in Laos was unfriendly to the Hmong community of which they were both part, so they separately made parallel moves — first to Thailand and then to Colorado.
Near Denver, the couple met, married, and had two sons – Dollar, now 22, and his older brother, Silver. “They thought their kids would be their fortune,” he said.
The Lees both graduated from high school and found work in Colorado. The father was employed as a mechanic and the mother worked the graveyard shift at a factory. “It wasn’t always easy,” Dollar said.
There was, to start, a language barrier. But there continue to be cultural differences, especially when it comes to health. “When one of us gets sick, we would turn to cultural medicine first,” Dollar said. That might involve visiting a shaman, using herbs, or making offerings to spirits. “We believe in the physical and spiritual aspects of health.”
The Lee family’s story of fresh starts and cross-continental moves, and of navigating a new culture, is familiar in Aurora, where more than a fifth of current residents were born outside of the U.S. It’s especially familiar at the Asian Pacific Development Center (APDC), a nonprofit founded during the Vietnam War by a group of psychologists and social workers concerned about the mental and physical health of refugees arriving in Colorado.
Located in a building off of bustling Colfax Avenue, the Asian Pacific Development Center has evolved into a community-driven organization focused on empowering refugees and immigrants through a constellation of culturally responsive and integrated services. The Aurora building is home to the behavioral health clinic, a co-located Metro Community Provider Network primary care clinic with two bilingual medical providers, insurance enrollment services, a victim assistance unit, a legal aid clinic, adult education classes, interpreting/translation services, a community garden and youth leadership programs – all part of a collaborative team effort to help bridge gaps between refugees and immigrants and their new country.
While their numbers in Aurora are growing, refugees and immigrants still fly under the radar of many policymakers and health care providers, according to Harry Budisidharta, a deputy director at the center.
Budisidharta says that health statistics highlighting trends in larger demographic groups can disguise the challenges facing many refugees and immigrants. Asian-Americans rank higher than average on indicators of income and fitness.
“We’re often seen as one homogenous group,” he said.
But many refugees and new immigrants from Asia are dealing with anxiety, depression, or other mental and physical remnants of their traumatic experiences. Acclimating to a new country can be alienating and isolating. Bhutanese refugees in Colorado, for instance, have suicide and depression rates more than twice the national average. Many newcomers’ incomes are well below the poverty line.
They also may be transitioning from facing diseases that pose an immediate threat, like malaria, to chronic diseases like diabetes or heart disease that they may not know how to manage. Positive health practices like meditation or eating less processed food may fall to the wayside in a new environment.
Accessing health care can be an additional challenge. “Many of our clients don’t understand how health insurance works, due to language and cultural barriers,” Budisidharta said.
“Sometimes they feel discriminaton from the mainstream society,” said Jyoti Sapkota, a patient navigator at the APDC. “They feel so lonely.”
Add to that navigating sometimes less-than-ideal housing conditions, new school systems and laws, a new physical climate, and a new language, and the value of a place like the APDC is clear.
At APDC, awareness of those and many other challenges is key. Nearly all of the staff speak more than one language. Many are refugees or immigrants themselves.
The organization’s enrollment specialist helps newcomers sign up for Medicaid or other health insurance. Patient navigators like Sapkota provide health education and work closely with providers and other care team members to help patients manage their medical conditions. They also serve as cultural brokers, communicating patients’ experiences and perspectives to providers in order to help staff understand where their patients are coming from.
Because they know the cultures and experiences of their clients, behavioral health providers at the Asian Pacific Development Center know the right questions to ask to identify depression and other mental disorders in refugees, Sapkota said. Refugees might not answer yes to the question, “are you depressed,” but they may be exhibiting signs of depression, like not leaving their homes or talking to friends.
The Center’s roots in mental health are still evident, but having so many programs under one roof helps address the clients’ needs, Budisidharta said. There is still a stigma against acknowledging mental health challenges in some Asian cultures, he said, and it is helpful to have a place where one might as easily be going to a language class as a therapy session.
Budisidharta said that while refugees and immigrants need supports, they don’t need pity. “These are proud and resourceful people, and if we give them a chance to succeed, chances are they will succeed.” He cited one group of immigrants that are starting a taxi company.
Dollar Lee, now a student at the University of Colorado Denver, said that offerings like the Center’s youth leadership program, which he participated in, can build both community and leadership skills.
Lee is now on the board of the Asian Pacific Development Center. He is studying policy and ethnic studies, and hopes to close the gap between communities and policymakers, particularly when it comes to health. And as a student employee at the admissions office at his university, he’s hoping to help younger people find their paths.
”It’s more of a home than a place for services,” Lee said of the Center. “I see young people spending time there, clients coming back to hang out – it’s a home feeling, the feeling of people who have their back.”
– Jackie Zubrzycki
Disability amplifies family’s health challenges
For Margaret Williams, caring for her 31-year-old son Christopher, has been a full-time job for nearly a decade.
On July 4, 2006, Christopher was involved in a catastrophic car accident that threw him out across Interstate 25 near Pueblo.
After a series of life-saving surgeries, Christopher went comatose. First, he was placed in a hospital, then in a series of care facilities. Concerned about his treatment in the facilities and convinced her son could thrive, Margaret Williams eventually brought Christopher to his childhood home in Colorado Springs.
Now, Christopher can speak in short phrases and smile. His bedroom – a converted garage made wheelchair accessible with the help of a group of Habitat for Humanity volunteers – is covered in photos of the late rapper Tupac Shakur and advertisements/posters for Joe Boxer underwear brand. (He loves the Joe Boxer logo, a yellow happy face, because of the smile, he says.) He is assisted by various caretakers, including music therapists, a nurse, and certified nursing assistants who help with everything from simple cognitive exercises to medical care to household tasks like laundry.
Margaret Williams characterizes Christopher’s return home as a miracle, facilitated by a number of angels who helped the family obtain housing, a wheelchair-accessible van, and employment for Margaret.
But getting Christopher home — and maintaining the kind of medical care that supports him without overwhelming Margaret — was also an ordeal that involved an unimaginable amount of paperwork, advocacy – and emotional strain.
That’s where the Colorado Cross-Disability Coalition came in. CCDC helps Coloradans navigate the bureaucracy that disabled individuals and their caregivers often encounter in trying to participate in their communities. CCDC also advocates for better policies and access to care for disabled Coloradans. “We have more in common than differences,” said Donna Sablan, a patient advocate with CCDC.
Many disabled Coloradans are in dire economic straits. Just 25 percent have full-time full year jobs, and those that do are paid a third less than their peers, according to Julie Reiskin, the executive director of the Coalition.
That can in turn have a negative impact on physical and mental health, Sablan said. Lower-income Coloradans live between 10 and 15 years less than the rest of the state.
The recent addition of Colorado’s Medicaid program that allows disabled adults to earn and save money and buy into Medicaid should let more disabled people work while retaining their benefits, according to Sablan. That’s a big positive change. “The system wanted you to become broke and poor and stay home and complain about it,” she said.
Reiskin said that the Colorado Cross-Disability Coalition is increasingly using a racial equity lens to frame its work, which has illuminated the fact that “every time you talk about statistics for people with disabilities – employment, health outcomes– the numbers are even more horrific, and that’s not acceptable.”
Research has found that differences in health outcomes between whites and communities of color are smaller than the disparities found among high and low-income populations within racial and ethnic groups.
Though help is available to individuals with disabilities through Medicaid and other programs, making sure that people get access to those benefits is not always so simple.
The Coalition helps disabled Coloradans identify if they are eligible for Medicaid or other health benefits. CCDC also notices glitches – such as inaccurate copays – that affect many individuals.
“We see when problems are not individual problems, but also a systems problem,” Sablan said. The organization is in the early stages of creating a wiki where people can share the most up-to-date information – a necessity when regulations and rules change regularly.
The majority of the CCDC’s employees are disabled themselves. Often, people have come to the Coalition as clients and then become volunteers. Sometimes, as they learn to navigate the unwieldy systems that govern health care, they become staff.
For someone like Margaret Williams, the empathy that comes from shared experience is invaluable.
Caring for Christopher has cost millions of dollars. “It means you go without – you don’t take trips,” she said. Williams, who prepares taxes for a living, said it took her eight years to save up enough money to buy a van to transport Christopher around town.
Some people don’t understand the lengths Margaret has gone through to to get the best available care for her son.
” You’re always being underestimated,” she said.
But with the help from CCDC, Margaret says she has improved her quality life and the life of the son she loves. Advocates with CCDC pushed to change the Williams’ benefits to let her hire nursing assistants directly rather than go through agencies that might have left her high and dry financially. CCDC also helped her locate insurance when Margaret’s own health began to falter.
Williams is considering becoming a CCDC advocate herself and hopes to provide comfort for “people who aren’t as fortunate to have these angels step in.”
“The advocates help to strengthen people that are trying to fight and feel they just can’t do it,” she said. “They step in when you’re down.”
-By Jackie Zubrzycki
Program helps rural Coloradans move past health barriers
There is nowhere Mark Davis would rather live than the mountains of Colorado.
Now 60 years old, Davis is a carpenter who specialized in remodeling houses in the Front Range and, later, in Grand County. For nearly 10 years, he lived near Grand Lake in an apartment with his dog, Patches.
But in his 50s, he began noticing that he had less control over his muscles and his speech. Davis was diagnosed with Parkinson’s disease, a disorder of the nervous system. “The tremors were getting worse,” he said. “Your whole body gets tired.”
Over time, his deteriorating muscle control made it nearly impossible to ride his bicycle or drive around, let alone do his work. “I can’t drive at all now,” he said.
Having lost his primary source of income, Davis didn’t have insurance to support his medical care, and without it, just one of the medications he needed to manage his Parkinson’s cost hundreds of dollars a month. For a person living alone and without insurance, the situation wasn’t easy.
A friend recommended that Davis get in touch with the Grand County Rural Health Network, a nonprofit founded 15 years ago that focuses on making sure that residents in this Western Slope county have access to health care.
The Grand County Rural Health Network’s staff helped Davis apply for Medicaid and Social Security Disability benefits. They also connected him with Maureen Wenger, a patient navigator who has been working with Davis for nearly five years. Wenger has done everything from accompanying Davis to doctor’s appointments to helping him find a spot at the Cliffview Assisted Living Center once it became too difficult for him to continue living alone.
In Grand County and throughout rural Colorado, Jennifer Fanning, the executive director of the Rural Health Network, says, “geography is the biggest social determinant of health.”
That shows up in a variety of ways. In Grand County, the eastern part of the county has a large number of jobs in ski tourism. The western part of the county has more ranchers. But all of those active lifestyles come along with high rates of injuries – and, often, with the instability of a seasonal income.
A higher percentage of rural Coloradans have incomes under the federal poverty line than urban Coloradans; a greater portion of children, in particular, live under the poverty line, according to the most recent Kids Count report.
In rural Colorado, many commodities and services — from groceries to daycare to housing — are scarcer and more expensive. There’s also a shortage in health care providers in many counties, including Grand County. That can make it especially difficult for patients on Medicaid to get appointments and care.
In 2014, Grand County had one of the highest rates of uninsured children in the state. The situation has improved since then, with the expansion of access to Medicaid and the introduction of the Affordable Care Act. But the Western Slope of Colorado has some of the highest insurance and health care costs in the country.
Another challenge: transportation. In Grand County, there’s very little public transportation in the county for residents like Davis who can’t drive. That makes getting to doctors’ appointments challenging. Long commutes from more affordable towns to work in the resorts in East Grand County can take a toll on one’s mental and physical health.
The Grand County Rural Health Network takes a variety of approaches to help rural residents’ health, all developed with the input of community members.
One program, the A.C.H.E.S. (Advocacy for Children’s Health and Education Services) and P.A.I.N.S (Partners for Adults in Need of Services) program, provided more than $25,000 in vouchers for acute and preventive health care in 2015. The county doesn’t have a low-cost health clinic for those without insurance, so the vouchers help uninsured adults and children access services.
A health care guide helps residents enroll in Medicaid or find insurance. And a growing program helps screen young children for developmental and health challenges and connects health records between providers.
The Rural Health Network’s patient navigator program teaches residents like Davis about their chronic diseases and helps them access the services they need to remain healthy.
The patient navigator program isn’t unique to Grand County. But in Grand County, the navigator – Wenger – also is a certified nurse. Fanning said that it’s more expensive to employ a nurse as a navigator. But she said that the value of having a nurse is evident in the Rural Health Network’s scores on the “Patient Activation Measure,” a commonly used tool for gauging patients’ knowledge, skills and confidence. Patients showed nearly a tripling in scores on measures such as empowerment and knowledge about their own health conditions after working with the nurse navigator. “Our nurse navigator has the ability to empower people,” Fanning said.
Another sign of success: In the Robert Wood Johnson Foundation’s rankings of the health in states around the country, Grand County’s rating went up – from 24th in the state in 2011, to 11th in the state in 2016. That change mainly reflects a reduction in preventable hospital stays and a drop in uninsured rates – both outcomes of programs the Rural Health Network is focused on.
For Davis, managing his health is an ongoing project. A recent change in medication left him concerned about tremors again. It can be difficult to schedule appointments with high-quality providers who are accepting Medicaid at a time when he can also find transportation.
But he is glad to be in Grand County, where he can still see the mountains. “I love the pace,” he said.
And he says the Rural Health Network has been an important part of allowing him to stay. “It’s great to have these guys in your corner,” he said. “It really makes a big difference.”
– Jackie Zubrzycki
Community gardens harvest better health outcomes
On an overcast Friday in October, four women walked out of a kitchen at the future site of the Westwood Food Cooperative in southwest Denver, talking and laughing. Matilde Garcia, their teacher, closed up the kitchen behind them. The class had produced trays of drying squash, which Garcia planned to gather over the weekend.
Just a few years ago, you wouldn’t have found Garcia teaching about healthy eating.
When she was a child, Garcia lived on a farm in Mexico where her father grew chilies, tomatoes, peanuts, corn and squash. As a young adult in Denver, however, Garcia rarely ate vegetables. The food that was most appealing and easiest to come by was Cheetos, soda or candy.
“I [am not] rich, but I can buy that stuff,” she said.
In Westwood, a neighborhood in southwest Denver where the future food co-op is located, Garcia wasn’t alone. Westwood is home to some 17,000 people, 80 percent of whom are Latino. It is also a food desert – defined by the United States Department of Agriculture as a non-rural area where 500 people and/or at least 33 percent of the population reside more than a mile from a supermarket or large grocery store.
Since 2007, the local nonprofit Re:Vision has attempted to fill that void by helping Westwood residents access healthier food. Along with access to mass transit and health services, access to healthy food is among the infrastructural factors proven to positively influence health outcomes.
Eric Kornacki, now Re:Vision’s CEO, and Joseph Teipel, now its director of operations, started planting and maintaining gardens in Westwood backyards in 2009. Families would agree to have Re:Vision’s staff build raised beds and plant food, and they’d be visited by staff over the course of the year to help maintain the garden so that they had fresh vegetables to eat.
The organization has built gardens for more than 450 families. It also offers classes on cooking and nutrition. A market with fresh foods and vegetables is open several days a week and plans to open a co-operatively owned grocery store are in full swing.
In Westwood, the average lifespan of residents is 12 years less than in surrounding areas. More than a third of residents are obese, and the neighborhood has a higher rate of childhood obesity than the city as a whole. Forty-four percent of the area’s children live in poverty, which is tied to higher rates of other chronic diseases later in life.
Many of the neighborhood’s residents are undocumented immigrants, which means they don’t have access to health insurance. Residents often avoid seeing doctors until it’s absolutely necessary. And the stress of living with the possibility or reality of deportation also takes a toll.
Kornacki said it’s important to acknowledge all of the dynamics at play instead of assuming people just need more education about how to eat healthfully. “There are other systems that are barriers to making decisions. You come here and can’t find healthy food.”
He said that Re:Vision’s place in the community has evolved over time. In their second year of building gardens, for instance, the organization started recruiting employees from the neighborhood. They didn’t want to be “two white guys saying, ‘Do you want a vegetable garden?’”
And while there was initially talk of expanding Re:Vision’s work to other locations, Kornacki said the organization is now focused on growing deeper relationships and expanding in Westwood.
“Everything’s rooted in community, it’s rooted in place,” he said. “What we do has its roots in agriculture, but it’s broader than that. Being resident-led is so crucial.”
For Garcia, getting involved with Re:Vision changed more than the layout of her backyard. It wasn’t until Garcia noticed that her daughter was gaining weight that she and her sister, with whom she lives, decided to check out Re:Vision.
At first, Garcia wasn’t convinced. The garden seemed like a lot of work, and her memories of living on a farm were not all positive. But her sister convinced her it was worth a try. And over time, she found that she and her children got satisfaction from the garden.
Now Garcia is one of three full-time “promotoras” working at Re:Vision. Promotoras are local residents trained to do outreach in their communities on urban gardens and healthy living. In addition to helping families grow their own food, Garcia also registers her neighbors for food assistance. (In Colorado, just 57 percent of the eligible population is enrolled in the food assistance program known as SNAP— far below the national average of 75 percent.)
In her healthy cooking classes, she tries to make familiar foods healthy rather than introducing entirely new cuisines. A popular recipe involves making enchiladas with more shredded vegetables and less cheese.
At home, the five children in Garcia’s household all have sections of the garden to tend and plant their favorite vegetables. And she sees her own growing confidence rubbing off on her children, especially her youngest daughter. “When they were small, they played alone,” she said. “Now, I look and she has six [children] following her around.”
That’s the kind of change that’s harder to measure, Kornacki said. “What we’re doing might have roots in agriculture, but it’s broader than that,” he said. “The more we can have Matilde and other residents at the forefront of sharing their experiences, being the ones to implement and own the change, the more successful we’ll be in advancing health equity.”
– Jackie Zubrzycki