Mitigating the consequences of a health condition: The role of intra- and interhousehold assistance

Mortgage Borrowing and Chronic Disease Outcomes in Older Age: Evidence From Biomarker Data in the Health and Retirement Study

OBJECTIVES

The medical diagnosis of a disease is common in older age and can carry significant financial costs. For many older adults, equity in a home is their primary component of wealth; however, housing wealth is illiquid. We analyze the relationship between the liquidation of housing wealth through mortgage borrowing on older homeowners' ability to successfully control a disease.

METHODS

We use data on homeowners aged 65 and older from the 1998-2016 waves of the Health and Retirement Study (N = 3,457). We use biomarkers and physical health indicators to measure disease control following a medical diagnosis of diabetes, heart condition, high blood pressure, lung disease, or cancer. Random effects linear probability and instrumental variable regressions estimate the associations of housing wealth, new mortgage borrowing, and disease control.

RESULTS

Descriptively, 28% of older homeowners who borrow against home equity are not controlled on their disease, compared to 33% of non-borrowers. Panel data instrumental variable regressions show that each $10,000 borrowed from home equity after diagnosis is associated with a 17-percentage-point reduction in the probability of the disease not being controlled.

DISCUSSION

Many older adults are not able or willing to liquidate housing wealth, and the ability to borrow also depends on changes in home values. Thus, housing wealth is not a uniform social determinant of health but is shaped by older adults' participation in financial markets.

Black/white differences in the relationship between debt and risk of heart attack across cohorts

Background

Numerous studies show that increasing levels of education, income, assets, and occupational status are linked to greater improvements in White adults' health than Black adults'. Research has yet to determine, however, whether there are racial differences in the relationship between health and debt and whether this relationship varies across cohorts.

Methods

Using data from the 1992-2018 Health and Retirement Study, we use survival analyses to examine the link between debt and heart attack risk among the Prewar Cohort, born 1931-1941, and Baby Boomers, born 1948-1959.

Results

Higher unsecured debt is associated with increased heart attack risk for Black adults, especially among Baby Boomers and during economic recessions. Higher mortgage debt is associated with lower risk of heart attack for White but not Black Baby Boomers. The relationship between debt and heart attack risk remains after controlling for health behaviors, depressive symptoms, and other economic resources that are concentrated among respondents with high levels of debt.

Conclusion

Debt is predictive of heart attack risk, but the direction and strength of the relationship varies by type of debt, debtors' racial identity, and economic context.

Managing the onset of a new disease in older age: Housing wealth, mortgage borrowing, and medication adherence

The relationship between wealth and health is an important yet complex topic for health research. While prior studies document the importance of wealth for healthy aging, the understanding of the mechanisms through which wealth supports health consumption is limited. We investigate the wealth-to-health link by explicitly modeling the effect of liquidating home equity through borrowing on health expenditures, measured here as cost-related non-adherence to prescription medications (CRN), following the onset of one of six costly diseases on or after age 65. Using individual-level data from the 2002-2018 waves of the U.S. Health and Retirement Study (3,772 respondents; 13,708 observations), we exploit exogenous spatial and intertemporal variation in ZIP-code level house values to instrument for borrowing. Results indicate each additional $10,000 in new mortgage borrowing is associated with a 1.6 percentage point reduction in CRN. In subsample regressions, this relationship is strongest for older adults for whom home equity is their largest source of wealth. In a falsification test, we find no relationship between house value changes and CRN for older renters, and no effect of mortgage borrowing on prescription drug non-adherence for health or memory reasons. Our results contribute to the literature by documenting how housing wealth can be tapped by older adults through borrowing to smooth health-related consumption following disease diagnosis. However, not all older homeowners are willing or able to borrow from home equity. Our findings suggest that it is not simply the stock of housing wealth that leads to better health outcomes, but instead the liquidation of housing wealth. Housing wealth is thus not a uniform social determinate of health for older homeowners as it is moderated by the ability to borrow.

"Like pouring salt in a wound": A qualitative exploration of the consequences of unmet housing needs for cancer patients and survivors in New York City

OBJECTIVE

To identify consequences of unmet housing needs in the period following cancer diagnosis.

DESIGN

Qualitative descriptive design.

PARTICIPANTS

New York City-based cancer patients and survivors (n = 21) who reported experience of unmet housing needs while receiving cancer treatment. Key informants (n = 9) with relevant expertise (e.g. oncology social workers).

METHODS

One-time semi-structured telephone or in-person interviews were conducted with all participants. Inductive thematic coding was conducted using a pragmatic paradigm.

FINDINGS

Four categories of consequences emerged: 1) cancer management and health (rest and recovery, illness/injury risk, medical care); 2) psychological (stress and anxiety, lack of control and independence, self-esteem/pride, sadness/depression, cancer coping); 3) social (relationships, consequences for others, isolation); and 4) standard of functional living.

CONCLUSION

The simultaneous experience of cancer and unmet housing needs is broadly burdensome.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

Screening and resources for addressing unmet housing needs must be prioritized to holistically care for patients.

The role of consumer and mortgage debt for financial stress

OBJECTIVES

Financial debt held by older adults in the U.S. has grown over the past two decades. This study examines the extent to which credit cards, other consumer debts, and mortgage debt increase financial stress. Outcome measures of financial stress include the material domain ("bill-paying difficulty") and psychological domain ("ongoing financial strain").

METHOD

We analyzed adults age 62 and older in the 2004 to 2016 waves of the Health and Retirement Study using random-effects logit regressions.

RESULTS

Unsecured consumer debt is associated with more financial stress per dollar than mortgage debt. A detailed assessment of mortgage debt finds that greater levels of both first and secondary mortgages are associated with greater bill-paying difficulty and greater ongoing financial strain. An increase in new mortgage debt obtained after age 62 is associated with an increase in bill-paying difficulty, but is not significantly associated with ongoing financial strain. In contrast, a reduction in mortgage debt since age 62 is associated with lower bill-paying difficulty and lower levels of ongoing financial strain.

CONCLUSION

The relationship between consumer debt, mortgages, and financial stress is nuanced, and depends on both the type and timing of the debt.

A double safety net? Understanding interactions between disability benefits, formal assistance, and family support

While the main insurance sources for individuals with disability are understood, less is known about how family support interacts with federal disability benefits. Using the Health and Retirement Study matched to administrative records, I examine how disability benefits affect family support by comparing accepted and rejected disability applicants before and after benefit receipt. Receipt of disability insurance increases the probability of receiving any assistance from children by 18 percent and more than doubles the amount of in-kind assistance. Disability insurance also increases the probability that children are paid for their help and reduces children's labor supply. These findings are largest for low-income beneficiaries and those who recently lost a spouse, suggesting that child assistance complements income provided by disability insurance, and substitutes for other family assistance. Receipt of disability benefits allows the family to re-optimize how they provide support, and disability insurance is shared within the family in complementary ways.

Family Change and Changing Family Demography

Increases in life expectancy, high rates of movement into and out of couple relationships, and increasing exposure to stepfamilies raise new questions about who is in a family, the distinction between who lives together and who is a family member, and the extent to which family members are expected to meet the long-term obligations that define kinship. These questions are important because families have traditionally served as a vital private safety net for family members. Demographic changes increase family members' uncertainty about their relationships. Family ties are less stable and more uncertain among the economically disadvantaged, and uncertainty may exacerbate these disadvantages by weakening individuals' ability to rely on family members' support to alleviate hardship. I argue that demographers should focus on individuals' family relationships to gain insight into living arrangements and family dynamics. I also outline the development of family concepts and improvements in study design to identify principles that demographers should incorporate in new research to shed light on families' support for their members.

Stepfamily Structure and Transfers Between Generations in U.S. Families

Unstable couple relationships and high rates of repartnering have increased the share of U.S. families with stepkin. Yet data on stepfamily structure are from earlier periods, include only coresident stepkin, or cover only older adults. In this study, we use new data on family structure and transfers in the Panel Study of Income Dynamics (PSID) to describe the prevalence and numbers of stepparents and stepchildren for adults of all ages and to characterize the relationship between having stepkin and transfers of time and money between generations, regardless of whether the kin live together. We find that having stepparents and stepchildren is very common among U.S. households, especially younger households. Furthermore, stepkin substantially increase the typical household's family size; stepparents and stepchildren increase a household's number of parents and adult children by nearly 40 % for married/cohabiting couples with living parents and children. However, having stepkin is associated with fewer transfers, particularly time transfers between married women and their stepparents and stepchildren. The increase in the number of family members due to stepkin is insufficient to compensate for the lower likelihood of transfers in stepfamilies. Our findings suggest that recent cohorts with more stepkin may give less time assistance to adult children and receive less time assistance from children in old age than prior generations.

Effect of Social Support on Psychological Distress and Disease Activity in Inflammatory Bowel Disease Patients

BACKGROUND

Psychological distress increases morbidity in ulcerative colitis (UC) and Crohn's disease (CD). We examined whether social support is associated with distress and disease activity.

METHODS

There were 110 UC and 147 CD patients who completed sociodemography, economic status, disease activity (UC: Patient Simple Clinical Colitis Activity Index (P-SCCAI), CD: Patient Harvey-Bradshaw Index . (P-HBI), Multidimensional Scale of Perceived Social Support (MSPSS), Brief Symptom Inventory with Global Severity Index (GSI) of psychological distress, and 2 health-related quality-of-life scales (SF-36 Physical Health and Mental Health, and Short Inflammatory Bowel Disease Questionnaire (SIBDQ). Analysis included multiple linear regressions and structural equation modeling.

RESULTS

Disease activity was mild: UC: P-SCCAI 2.9 ± 3.5, CD: P-HBI 4.7 ± 4.7. Physical Health was better in UC 46.6 ± 11.4 versus CD 43.7 ± 10.9 (P < .02). GSI was lower in UC 0.6 ± 0.7 than CD 0.8 ± 0.7 (P = .002). MSPSS total score was equal in UC (5.9 ± 1.2) and CD (5.9 ± 1.1). MSPSS total correlated with P-SCCAI (correlation coefficient ‒0.240), GSI in UC (‒0.470), and GSI in CD (‒0.333). Economic status correlated with GSI in UC (‒0.408) and CD (‒0.356). MSPSS predicted GSI, Mental Health, and SIBDQ in UC and CD, and predicted P-SCCAI but not P-HBI; economic status predicted all the foregoing. Path analysis depicted GSI as mediating the effects of MSPSS and economic status on disease activity in both UC and CD. MSPSS (UC: β ‒0.34, CD: β ‒0.37) and economic status (UC: β ‒0.38, CD: β ‒0.22) reduced GSI, which then increased the disease activity (UC: β 0.56, CD: β 0.42).

CONCLUSIONS

Social support and economic status are linked to UC and CD patients' well-being. Interventions addressing these issues should be part of management.