Appendix A
Quantifying the Potential Health and Economic Impacts of Increased Trial Diversity
Bryan Tysinger1
INTRODUCTION
Chronic illness decreases quantity of life, quality of life, and years spent in the labor force. Less appreciated is the potential for differential impact of disease for different race/ethnicity-gender groups. In other words, while chronic illness affects outcomes for all groups, some groups might experience a larger impact. The goal in this analysis is to quantify the differential impact of chronic illness for groups that have historically been underrepresented in clinical trials, as clinical trials are a potential way to identify approaches to reduce these disparities. We examine three key outcomes: quantity of life (measured by life expectancy), quality of life (measured by disability-free life), and working life (measured by years in the labor force). The thought experiment considers a hypothetical world where the differential impact is eliminated, that is, that all groups share the same impact of chronic illness.
To do this, we utilize a dynamic microsimulation model, the Future Elderly Model (FEM), to project a baseline scenario for groups of interest for each of three chronic conditions. We then consider a counterfactual scenario in which disparities in disease impact on mortality, disability, and workforce participation are eliminated.
Future Elderly Model
The Future Elderly Model is a dynamic microsimulation of health risk factors, chronic illnesses, disability, and health-related economic outcomes for the U.S. population over the age of 50. It simulates the aging process for individuals, including projecting risk factors like smoking and BMI (body mass
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1 Available at btysinge@usc.edu.
index), chronic conditions like diabetes and heart disease, functional limitations in Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), and economic outcomes such as workforce participation and medical spending. FEM relies on statistical models based on real individuals who participate in a nationally representative panel survey.
The FEM has been used in support of a broad set of research. A previous National Academies of Sciences, Engineering, and Medicine report relied on FEM analyses to quantify the impact of growing disparities in life expectancy on federal programs (NASEM, 2015). Early work with the microsimulation explored trends in health, the value of prevention, and the resulting fiscal consequences (Goldman et al., 2005, 2009, 2010; Lakdawalla et al., 2005). More recent work has targeted disparities and innovation in particular diseases such as congestive heart failure and Alzheimer’s disease (Van Nuys et al., 2018; Zissimopoulos et al., 2018). Crucially, projections from FEM have been extensively validated (Leaf et al., 2020).
Data
This analysis utilizes the Health and Retirement Study (HRS), a nationally representative panel study of Americans over the age of 50. The HRS is sponsored by the National Institute on Aging (grant number NIA U01AG009740) and is conducted by the University of Michigan (RAND HRS, 2021a; RAND HRS, 2021b).
Groups of Interest
We identified six groups of interest in the HRS with sufficient sample size to support this analysis. Throughout, non-Hispanic white males serve as the reference group due to their historical inclusion and representation in clinical trials. Non-Hispanic Black males, Hispanic males, non-Hispanic white females, non-Hispanic Black females, and Hispanic females all potentially benefit from narrowing the differential impact of disease on the outcomes of interest.
Diseases of Interest
We considered three types of chronic conditions that come from self-reported data in the HRS: diabetes, heart diseases, and hypertension. A person is identified as having diabetes based on the question, “Has a doctor ever told you that you have diabetes or high blood sugar?” Heart diseases includes a broad set of conditions that affect the heart. This is based on the question, “Has a doctor ever told you that you have had a heart attack, coronary heart disease, angina, congestive heart failure, or other heart problems?” Hypertension is based on the question, “Has a doctor ever told you that you have high blood pressure or hypertension?”
Due to the wording of these questions, we consider them absorbing states. That is, once a person indicates they were diagnosed with a condition, then they have the condition for the remainder of their life.
Outcomes of Interest
We focused on three key outcomes of interest: mortality, disability, and working for pay. Mortality in the HRS is measured by proxy response. Since the HRS is collected every 2 years, mortality is modeled as 2-year mortality incidence. Disability is a composite measure based on limitations in ADLs, IADLs, or living in a nursing home. If the respondent reports any ADLs, any IADLs, or living in a nursing home, they are considered a person with a disability. Working for pay is derived from self-reported status of working for pay and labor force participation.
Estimation
Transition models are the statistical models that drive the microsimulation. The transition models for disease incidence in the FEM rely on a first-order Markov structure. As such, any time-varying predictors enter as “lagged” variables from the previous wave of the survey. Time-varying predictors include things like BMI, smoking status, and other chronic conditions.
Diabetes incidence is modeled as a function of gender, race, age, BMI, and smoking. Hypertension incidence has a similar structure, but also controls for diabetes. Similarly, heart disease incidence controls for these variables, but also controls for diabetes and hypertension. Risk factors like smoking and BMI are also transitioned within the simulation.
The three key outcomes of interest—mortality, disability, and work—are estimated with a “reduced form” approach. For each disease of interest, transition models for these outcomes are functions of group, group-specific age profiles, the disease, and an underrepresented group indicator variable interacted with the disease. This last term is the key parameter of interest. If this parameter were zero, it would indicate no disparity between the reference group (non-Hispanic white males) and the underrepresented groups.
Transition models are estimated using the HRS respondents’ data from 1998 to 2018. Sample characteristics for the 2018 sample are shown below (see Table A-1).
The parameter estimates and marginal effects for the key transition models are shown in Tables A-11, A-12, and A-13. Adjusted relative risks for the key parameters of interest (the underrepresented group and disease interaction term) are shown in A-2. The reference group, non-Hispanic white males, will always have values of 1.0. Relative to white males, being in an underrepresented group and having diabetes is associated with an increase in mortality of 10 to 11 percent, an increase in disability of 10 to 12 percent, and a decrease in workforce partici-
TABLE A-1 1998–2018 Health and Retirement Study Sample Characteristics
| Mean | SD | |
|---|---|---|
| Age | 69.0 | 10.9 |
| Non-Hispanic white males | 30% | 0.46 |
| Non-Hispanic Black males | 6% | 0.24 |
| Hispanic males | 5% | 0.21 |
| Non-Hispanic white females | 41% | 0.49 |
| Non-Hispanic Black females | 11% | 0.31 |
| Hispanic females | 7% | 0.25 |
| BMI | 28.0 | 6.0 |
| Ever smoke | 57% | 0.50 |
| Current smoker | 13% | 0.34 |
| Ever had diabetes | 22% | 0.41 |
| Ever had heart disease | 25% | 0.43 |
| Ever had hypertension | 57% | 0.49 |
| Any disability | 22% | 0.41 |
| Working for pay | 35% | 0.48 |
| Died | 6% | 0.24 |
| N = 191,036 |
pation of 9 to 12 percent. Heart disease is associated with a mortality increase of 14 to 15 percent, an increase in disability of 19 to 23 percent, and a decrease in workforce participation of 11 to 14 percent. Hypertension is associated with an increase in mortality of 10 to 11 percent, an increase in disability of 14 to 17 percent, and a decrease in workforce participation of 4 to 5 percent.
Simulation
Table A-3 shows the baseline characteristics for the 2016 cohorts of 51–52-year-olds at the start of the simulation. Initial prevalence of disease varies across groups, with the highest rates of diabetes among non-Hispanic Black males, Hispanic males, and Hispanic females. Heart disease at baseline is highest among non-Hispanic white females and non-Hispanic Black males. Hypertension rates are highest for non-Hispanic Black males and females. Rates of disability are higher for females, and workforce participation is higher among males.
TABLE A-2 Adjusted Relative Risks for Key Parameters of Interest
| Diabetes | Heart Disease | Hypertension | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Mortality | Disability | Work | Mortality | Disability | Work | Mortality | Disability | Work | |
| White males | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Black males | 1.10 [1.02, 1.18] | 1.12 [1.07, 1.16] | 0.89 [0.85, 0.92] | 1.14 [1.07, 1.22] | 1.23 [1.18, 1.27] | 0.86 [0.83, 0.90] | 1.10 [1.02, 1.19] | 1.17 [1.13, 1.22] | 0.95 [0.93, 0.98] |
| Hispanic males | 1.11 [1.02, 1.20] | 1.12 [1.07, 1.16] | 0.91 [0.88, 0.94] | 1.15 [1.07, 1.23] | 1.22 [1.18, 1.27] | 0.89 [0.86, 0.92] | 1.11 [1.03, 1.20] | 1.17 [1.12, 1.21] | 0.96 [0.94, 0.98] |
| White females | 1.10 [1.02, 1.19] | 1.11 [1.07, 1.16] | 0.89 [0.85, 0.92] | 1.14 [1.07, 1.21] | 1.21 [1.17, 1.26] | 0.86 [0.82, 0.90] | 1.10 [1.02, 1.18] | 1.16 [1.12, 1.20] | 0.95 [0.92, 0.98] |
| Black females | 1.11 [1.02, 1.20] | 1.10 [1.06, 1.14] | 0.88 [0.85, 0.92] | 1.15 [1.07, 1.23] | 1.19 [1.15, 1.22] | 0.86 [0.83, 0.90] | 1.11 [1.03, 1.20] | 1.15 [1.11, 1.19] | 0.95 [0.93, 0.98] |
| Hispanic females | 1.11 [1.02, 1.21] | 1.10 [1.06, 1.14] | 0.88 [0.85, 0.92] | 1.15 [1.07, 1.23] | 1.18 [1.15, 1.22] | 0.86 [0.82, 0.90] | 1.11 [1.03, 1.20] | 1.14 [1.11, 1.18] | 0.95 [0.92, 0.98] |
TABLE A-3 Baseline Characteristics at Simulation Start
| Non-Hispanic White Males | Non-Hispanic White Females | Non-Hispanic Black Males | Non-Hispanic Black Females | Hispanic Males | Hispanic Females | |
|---|---|---|---|---|---|---|
| Weighted N | 2,879,983 | 2,920,961 | 509,836 | 576,820 | 648,817 | 633,641 |
| Age | 52 | 52 | 52 | 52 | 52 | 52 |
| BMI | 29.3 | 30.6 | 30.7 | 33.3 | 29.9 | 30.7 |
| Current smoker | 25% | 16% | 23% | 19% | 21% | 24% |
| Diabetes | 14% | 11% | 23% | 13% | 26% | 29% |
| Heart disease | 8% | 15% | 10% | 6% | 3% | 7% |
| Hypertension | 39% | 33% | 57% | 55% | 38% | 38% |
| Any disability | 18% | 20% | 15% | 17% | 11% | 20% |
| Working for pay | 81% | 79% | 72% | 66% | 89% | 65% |
PROJECTIONS
Diabetes
In the baseline scenario, average life expectancy for those who develop diabetes prior to death ranges from 27.2 years (non-Hispanic Black males) to 34.0 years (Hispanic females). Eliminating the underrepresented group diabetes effect increases life expectancy by 0.8 to 0.9 years in the counterfactual scenario. Similarly, disability-free life increases by 1.0 to 1.2 years, and workforce participation increases by 0.4 to 0.6 years (see Table A-4).
Heart Disease
Baseline and counterfactual projections for the heart disease scenarios are shown in Table A-5. Life expectancy increases between 0.9 and 1.1 years for the underrepresented groups. Disability-free life years increase from 1.4 to 1.6 years. Years working increase from 0.2 to 0.4 years.
Hypertension
As seen in Table A-6 in the hypertension scenarios, life expectancy increases 0.9 to 1.1 years when the underrepresentation gap is eliminated. Disability-free life years increase from 1.4 to 1.7 years. Years working increase between 0.3 and 0.4 years.
Valuing the Potential Gains
To value the potential gains in the counterfactual scenarios, we multiplied the number of individuals in the group, their lifetime risk of the disease, the potential change in the outcome of interest, and valued the gain at a commonly used amount. For life years and disability-free life years, we used $150,000 per year. For earnings, we used $50,000 per year. All future benefits are discounted at 3 percent per year.
Lifetime risk for developing these chronic illnesses is high for the 51–52-year-old cohort in the FEM, as seen in Table A-7, Table A-8, and Table A-9. Diabetes risk ranges from 47 percent for non-Hispanic white females to 77 percent for Hispanic females. Heart disease risk ranges from 57 percent for non-Hispanic Black males to 68 percent for non-Hispanic white females. Hypertension risk is high for all groups.
In aggregate, the potential value in narrowing the disparity in chronic disease outcomes is large. For diabetes (see Table A-7), the total impact associated with life expectancy is $128.5 billion. The value is larger for disability-free life expectancy, at $202.5 billion. Additional working years aggregate to $40.6 billion in foregone wages.
TABLE A-4 Life Years, Disability-free Life Years, and Remaining Work Years for Diabetes Scenario
| Baseline | Conterfactual | Delta | Baseline | Conterfactual | Delta | Baseline | Counterfactual | Delta | |
|---|---|---|---|---|---|---|---|---|---|
| Hispanic females | 34.0 [33.7, 34.3] | 34.9 [34.6, 35.2] | 0.9 [0.9, 0.9] | 21.6 [21.5, 21.7] | 22.8 [22.7, 22.9] | 1.2 [1.1, 1.3] | 7.9 [7.9, 7.9] | 8.3 [8.3, 8.3] | 0.5 [0.5, 0.5] |
| Hispanic males | 30.2 [30.1, 30.3] | 31.1 [31.0, 31.2] | 09 [0.8, 1.0] | 22.5 [22.4, 22.6] | 23.7 [23.6, 23.8] | 1.2 [1.1, 1.3] | 11.7 [11.6, 11.8] | 12.3 [12.2, 12.4] | 0.6 [0.6, 0.6] |
| Non-Hispanic Black females | 31.1 [30.9, 31.3] | 32.0 [31.8, 32.2] | 0.9 [0.8, 1.0] | 20.8 [20.6, 21.0] | 21.8 [21.6, 22.0] | 1.0 [0.9, 1.1] | 9.2 [9.2. 9.2] | 9.7 [9.7, 9.7] | 0.5 [0.5, 0.5] |
| Non-Hispanic Black males | 27.2 [27.1, 27.3] | 28.1 [28.0, 28.2] | 0.9 [0.8, 1.0] | 20.9 [20.8, 21.0] | 22.1 [22.0, 22.2] | 1.1 [1.0, 1.2] | 9.9 [9.8, 10.0] | 10.5 [10.4, 10.6] | 0.6 [0.6, 0.6] |
| Non-Hispanic white females | 32.9 [32.8, 33.0] | 33.7 [33.6, 33.8] | 0.8 [0.8, 0.8] | 25.4 [25.4, 25.4] | 26.4 [26.3, 26.5] | 1.0 [1.0, 1.0] | 10.4 [10.4, 10.4] | 10.8 [10.8, 10.8] | 0.4 [0.4, 0.4] |
| Non-Hispanic white males | 30.5 [30.4, 30.6] | 27.0 [27.0, 27.0] | 13.3 [13.3, 13.3] |
| Baseline | Conterfactual | Delta | Baseline | Conterfactual | Delta | Baseline | Counterfactual | Delta | |
|---|---|---|---|---|---|---|---|---|---|
| Hispanic females | 36.3 [36.3, 36.9] | 37.7 [37.3, 38.1] | 1.0 [0.9, 1.1] | 23.2 [23.1, 23.3] | 24.5 [24.4, 24.6] | 1.4 [1.4, 1.4] | 8.3 [8.3, 8.3] | 8.6 [8.6, 8.6] | 0.2 [0.2, 0.2] |
| Hispanic males | 33.6 [33.5, 33.7] | 34.5 [34.4, 34.6] | 0.9 [0.9, 0.9] | 25.1 [25.0, 25.2] | 26.4 [26.3, 26.5] | 1.4 [1.4, 1.4] | 12.6 [12.5, 12.7] | 12.8 [12.7, 12.9] | 0.3 [0.3, 0.3] |
| Non-Hispanic Black females | 34.2 [33.8, 34.6] | 35.2 [34.8, 35.6] | 1.0 [0.9, 1.1] | 22.7 [22.3, 23.1] | 24.1 [23.7, 24.5] | 1.4 [1.3, 1.5] | 9.7 [9.7, 9.7] | 10.0 [10.0, 10.0] | 0.3 [0.3, 0.3] |
| Non-Hispanic Black males | 30.2 [30.1, 30.3] | 31.2 [31.1, 31.3] | 1.0 [1.0, 1.0] | 23.2 [23.1, 23.3] | 24.7 [24.6, 24.8] | 1.5 [1.5, 1.5] | 10.4 [10.3, 10.5] | 10.8 [10.7, 10.9] | 0.4 [0.4, 0.4] |
| Non-Hispanic white females | 35.0 [34.9, 35.1] | 36.1 [36.0, 36.2] | 1.1 [1.0, 1.2] | 27.0 [26.9, 27.1] | 28.6 [28.5, 28.7] | 1.6 [1.6, 1.6] | 10.7 [10.7, 10.7] | 11.1 [11.1, 11.1] | 0.4 [0.4, 0.4] |
| Non-Hispanic white males | 33.0 [33.0, 33.0] | 27.7 [27.7. 27.7] | 14.0[14.0, 14.0] |
TABLE A-6 Life Years, Disability-free Life Years, and Remaining Work Years for Hypertension Scenario
| Baseline | Conterfactual | Delta | Baseline | Conterfactual | Delta | Baseline | Counterfactual | Delta | |
|---|---|---|---|---|---|---|---|---|---|
| Hispanic females | 35.9 [35.6, 36.2] | 36.9 [36.6, 37.2] | 1.0 [0.9, 1.1] | 23.6 [23.5, 23.7] | 25.2 [25.1, 25.3] | 1.6 [1.5, 1.7] | 8.4 [8.4, 8.4] | 8.6 [8.6, 8.6] | 0.3 [0.3, 0.3] |
| Hispanic males | 31.6 [31.5, 31.7] | 32.6 [32.5, 32.7] | 1.0 [0.9, 1.1] | 24.3 [24.2, 24.4] | 25.9 [25.8, 26.0] | 1.6 [1.5, 1.7] | 12.3 [12.2, 12.4] | 12.6 [12.5, 12.7] | 0.3 [0.3, 0.3] |
| Non-Hispanic Black females | 31.9 [31.6, 32.2] | 33.0 [32.8, 33.2] | 1.1 [1.0, 1.2] | 22.2 [21.9, 22.5] | 23.9 [23.6, 24.2] | 1.7 [1.6, 1.8] | 9.6 [9.6, 9.6] | 9.9 [9.9, 9.9] | 0.4 [0.4, 0.4] |
| Non-Hispanic Black males | 27.9 [27.8, 28.0] | 28.9 [28.8, 29.0] | 1.0 [0.9, 1.1] | 22.3 [22.2, 22.4] | 24.0 [23.9, 24.1] | 1.6 [1.5, 1.7] | 10.3 [10.2, 10.4] | 10.7 [10.6, 10.8] | 0.4 [0.4, 0.4] |
| Non-Hispanic white females | 34.8 [34.7, 34.9] | 35.7 [35.6, 35.8] | 0.9 [0.8, 1.0] | 27.6 [27.5, 27.7] | 29.0 [28.9, 29.1] | 1.4 [1.4, 1.4] | 11.0 [11.0, 11.0] | 11.3 [11.3, 11.3] | 0.2 [0.3, 0.3] |
| Non-Hispanic white males | 31.4 [31.3, 31.5] | 26.7 [26.7, 26.7] | 13.6 [13.6, 13.6] |
TABLE A-7 Aggregate Value of Diabetes Scenario
| N | Lifetime diabetes risk | LE (discounted) | DFLY (discounted) | Work years (discounted) | Aggregate LE | Aggregate DFLY | Aggregate WY | |
|---|---|---|---|---|---|---|---|---|
| Hispanic females | 633,641 | 77% | 0.29 [0.27, 0.30] | 0.50 [0.48, 0.53] | 0.28 [0.27, 0.29] | $20.9 [$19.7, $22.1] | $36.6 [$34.8, $38.4] | $6.7 [$6.4, $7.0] |
| Hispanic males | 648,817 | 71% | 0.30 [0.27, 0.32] | 0.49 [0.46, 0.51] | 0.32 [0.31, 0.34] | $20.5 [$19.0, $22.0] | $33.9 [$32.2, $35.6] | $7.5 [$7.1, $7.8] |
| Non-Hispanic Black females | 576,820 | 63% | 0.30 [0.27, 0.32] | 0.43 [0.41, 0.46] | 0.25 [0.24, 0.26] | $16.2 [$15.1, $17.3] | $23.7 [$22.3, $25.0] | $4.6 [$4.3, $4.8] |
| Non-Hispanic Black males | 509,836 | 65% | 0.32 [0.30, 0.34] | 0.48 [0.46, 0.50] | 0.33 [0.31, 0.34] | $15.9 [$14.8, $17.0] | $23.9 [$22.8, $24.9] | $5.4 [$5.2, $5.6] |
| Non-Hispanic white females | 2,920,961 | 47% | 0.27 [0.25, 0.28] | 0.41 [0.39, 0.43] | 0.24 [0.23, 0.25] | $54.9 [$51.9, $58.0] | $84.4 [$80.7, $88.1] | $16.5 [$15.8, $17.2] |
| $128.5 [$120.5, $136.4] | $202.5 [$192.9, $212.1] | $40.6 [$38.9, $42.4] |
For heart disease, the potential impacts are large, as seen in Table A-8. The life expectancy differential aggregates to $159 billion, disability-free life expectancy to $278.5 billion, and wages aggregate to $30.9 billion. Note that these are driven in part due to higher lifetime risk for non-Hispanic white females. The impacts for the other groups are similar in size to the diabetes scenario. Wage effects are smaller for heart disease than for diabetes due to later onset of heart disease.
Narrowing the gap in hypertension’s impact on these populations also shows significant potential for value. In aggregate, the life expectancy gains are valued at $217.4 billion. Disability-free life expectancy gains are valued at $442.1 billion. Wage impacts total $42.2 billion.
Valuing the Potential Gains for the Future Elderly Population
Finally, expanding beyond the narrow birth cohort considered above, we assessed the potential for innovation by looking at the U.S. population of underrepresented individuals over the age of 50 through 2050. The approach is comparable to the cohort results, but now incorporates all individuals 51 and older through 2050 and values the potential for narrowing disparities. These results are presented in Table A-10.
The combination of a large number of aging individuals, high lifetime risk, and large disparities aggregates to sizable potential gains. The estimated potential in diabetes is $2.8 trillion for life expectancy, $4.3 trillion for disability-free life, and $800 billion in years of work. Heart disease aggregates to $3.5 trillion in life expectancy, $5.8 trillion in disability-free life, and $500 billion in years of work. Hypertension is the largest in longevity-related measures, with $4.8 trillion in life expectancy and $9.4 trillion in disability-free life, with $700 billion in years of work.
Discussion
The reduced-form estimates of the differential impact of disease on lesser-represented groups in clinical trials translate into large impacts for individuals who are projected to develop those diseases. Across the diseases, life expectancy impacts range from 0.8 to 1.1 years. Disability-free life expectancy impacts are larger, ranging from 1.0 to 1.7 years. The impact on workforce participation ranges from 0.2 to 0.6 years. When valued in aggregate across all individuals affected in the 51–52-year-old cohort, the potential value is large, ranging from tens to hundreds of billions of dollars. Critically, this is only for one particular cohort of individuals, so the societal value across additional cohorts is even larger.
When aggregated to the over-50 population through 2050, the societal value is sizable.
TABLE A-8 Aggregate Value of Heart Disease Scenario
| N | Lifetime heart disease risk | LE (discounted) | DFLY (discounted) | Work years (discounted) | Aggregate LE | Aggregate DFLY | Aggregate WY | |
|---|---|---|---|---|---|---|---|---|
| Hispanic females | 633,641 | 70% | 0.30 [0.29, 0.32] | 0.51 [0.50, 0.52] | 0.12 [0.12, 0.13] | $20.3 [$19.4, $21.2] | $34.0 [$33.1, $34.9] | $2.7 [$2.7, $2.8] |
| Hispanic males | 648,817 | 68% | 0.28 [0.26, 0.29] | 0.48 [0.46, 0.49] | 0.13 [0.13, 0.14] | $18.2 [$17.3, $19.1] | $31.3 [$30.5, $32.2] | $3.0 [$2.9, $3.0] |
| Non-Hispanic Black females | 576,820 | 57% | 0.31 [0.29, 0.32] | 0.51 [0.50, 0.52] | 0.15 [0.15, 0.16] | $15.1 [$14.4, $15.8] | $25.0 [$24.3, $25.7] | $2.5 [$2.4, $2.5] |
| Non-Hispanic Black males | 509,836 | 62% | 0.35 [0.33, 0.36] | 0.57 [0.55, 0.58] | 0.21 [0.20, 0.21] | $16.3 [$15.5, $17.0] | $26.8 [$26.1, $27.5] | $3.2 [$3.2, $3.3] |
| Non-Hispanic white females | 2,920,961 | 61% | 0.33 [0.32, 0.35] | 0.60 [0.59, 0.62] | 0.22 [0.21, 0.23] | $89.2 [$84.9, $93.4] | $161.3 [$156.9, $165.6] | $19.5 [$19.0, $20.1] |
| $159.0 [$151.5, $166.6] | $278.5 [$270.9, $286.0] | $30.9 [$30.0, $31.8] |
TABLE A-9 Aggregate Value of Hypertension Scenario
| N | Lifetime hypertension risk | LE (discounted) | DFLY (discounted) | Work years (discounted) | Aggregate LE | Aggregate DFLY | Aggregate WY | |
|---|---|---|---|---|---|---|---|---|
| Hispanic females | 633,641 | 86% | 0.28 [0.26, 0.30] | 0.66 [0.64, 0.68] | 0.15 [0.14, 0.15] | $23.1 [$21.6, $24.5] | $54.3 [$52.5, $56.0] | $4.0 [$3.8, $4.2] |
| Hispanic males | 648,817 | 88% | 0.31 [0.29, 0.33] | 0.64 [0.62, 0.66] | 0.18 [0.17, 0.19] | $26.6 [$24.9, $28.6] | $54.7 [$53.0, $56.5] | $5.1 [$4.9, $5.4] |
| Non-Hispanic Black females | 576,820 | 93% | 0.36 [0.31, 0.41] | 0.73 [0.68, 0.78] | 0.21 [0.19, 0.23] | $29.1 [$25.3, $32.9] | $58.7 [$54.9, $62.8] | $5.7 [$5.2, $6.1] |
| Non-Hispanic Black males | 509,836 | 95% | 0.36 [0.33, 0.39] | 0.69 [0.67, 0.72] | 0.23 [0.22, 0.24] | $26.3 [$24.0, $28.5] | $50.0 [$48.1, $51.9] | $5.5 [$5.2, $5.8] |
| Non-Hispanic white females | 2,920,961 | 93% | 0.28 [0.26, 0.30] | 0.55 [0.54, 0.57] | 0.16 [0.15, 0.17] | $112.3 [$104.9, $119.8] | $224.3 [$217.1, $231.4] | $21.9 [$20.8, $23.0] |
| $217.4 [$200.5, $234.2] | $442.1 [$425.4, $458.7] | $42.2 [$39.9, $44.6] |
TABLE A-10 Population Value for Scenarios through 2050
| Disease | N | Lifetime risk | LE (discounted) | DFLY (discounted) | Work Years (discounted) | Aggregate LE ($T) | Aggregate DFLY ($T) | Aggregate WY ($T) |
|---|---|---|---|---|---|---|---|---|
| Diabetes | 161,500,000 | 57% | 0.20 [0.17, 0.23] | 0.31 [0.28, 0.35] | 0.17 [0.15, 0.19] | $2.8 [2.4, 3.2] | $4.3 [3.8, 4.8] | $.8 [0.7, 0.9] |
| Heart disease | 161,500,000 | 64% | 0.23 [0.20, 0.25] | 0.37 [0.35, 0.40] | 0.09[0.09, 0.10] | $3.5 [3.2, 3.9] | $5.8 [5.4, 6.2] | $.5 [0.5, 0.5] |
| Hypertension | 161,500,000 | 91% | 0.22 [0.19, 0.26] | 0.43 [0.39, 0.46] | 0.10 [0.09, 0.11] | $4.8 [4.1, 5.6] | $9.4 [8.6, 10.1] | $.7 [0.6. 0.8] |
| $11.2 [9.6, 12.7] | $19.5 [17.9, 21.2] | $2.0 [1.8, 2.2] |
Limitations
This type of analysis is subject to many limitations. A key assumption is that the transition models estimated using the HRS data will hold into the future. A reduced-form approach to modeling likely leaves out important factors, loading the estimated effect onto a particular variable.
Transition Model Estimates
Diabetes includes the transition model estimates for 2-year mortality, disability, and working for pay, as well as the marginal effects for diabetes (see Table A-11). The key parameter of interest, “underrepresented and has diabetes,” has a 0.6 percentage point increase in 2-year mortality, a 2.8 percentage point increase in reporting disability, and a 3.3 percentage point reduction in working for pay.
Similarly, Table A-12 shows the transition models for key outcomes in the heart disease analysis. Here, the key parameter of interest, “underrepresented and has heart disease,” is associated with a 0.9 percentage point increase in 2-year mortality, a 5.6 percentage point increase in reporting disability, and a 3.8 percentage point reduction in working for pay.
Finally, hypertension shows comparable estimates for the hypertension analysis (see Table A-13). In this specification, “underrepresented and has hypertension” is associated with a 0.6 percentage point increase in 2-year mortality, a 3.5 percentage point increase in reporting disability, and a 1.4 percentage point decrease in working for pay.
| Mortality | Margins | Disability | Margins | Work | Margins | |
|---|---|---|---|---|---|---|
| b | b | b | b | b | b | |
| Main | ||||||
| 2-year lag of diabetes ever | 0.288*** | 0.034*** | 0.323*** | 0.093*** | -0.224*** | -0.062*** |
| Underrepresented and has diabetes | 0.058* | 0.006* | 0.100*** | 0.028*** | -0.118*** | -0.033*** |
| White males | 0 | 0 | 0 | 0 | 0 | 0 |
| Black males | 0.412 | 0.012*** | -0.327 | 0.057*** | -2.045*** | -0.077*** |
| Hispanic males | 0.136 | -0.009** | -0.459 | 0.059*** | -1.962*** | -0.042*** |
| White females | 0.227 | -0.020*** | -0.21 | 0.013*** | -1.926*** | -0.096*** |
| Black females | 0.81 | -0.014*** | -0.299 | 0.117*** | -3.134*** | -0.118*** |
| Hispanic females | 1.012 | -0.032*** | -1.434*** | 0.111*** | -3.511*** | -0.161*** |
| Age spline under 65 | 0.037*** | 0.003*** | -0.002 | 0.001*** | -0.089*** | -0.019*** |
| Mortality | Margins | Disability | Margins | Work | Margins | |
|---|---|---|---|---|---|---|
| b | b | b | b | b | b | |
| Main | ||||||
| Age spline 65–74 | 0.036*** | 0.004*** | 0.026*** | 0.005*** | -0.077*** | -0.027*** |
| Age spline 75–84 | 0.052*** | 0.006*** | 0.056*** | 0.016*** | -0.062*** | -0.020*** |
| Age spline over 85 | 0.083*** | 0.008*** | 0.067*** | 0.019*** | -0.086*** | -0.021*** |
| Black males # age spline under 65 | -0.004 | 0.010* | 0.029*** | |||
| Hispanic males # age spline under 65 | -0.005 | 0.012* | 0.033*** | |||
| White females # age spline under 65 | -0.007 | 0.004 | 0.028*** | |||
| Black females # age spline under 65 | -0.013 | 0.012*** | 0.046*** | |||
| Hispanic females # age spline under 65 | -0.022* | 0.032*** | 0.052*** | |||
| Black males # age spline 65–74 | -0.002 | -0.019*** | 0.015** | |||
| Hispanic males # age spline 65–74 | 0.012 | -0.006 | -0.043*** | |||
| White females # age spline 65–74 | 0.002 | -0.003 | -0.024*** | |||
| Black females # age spline 65–74 | -0.012 | -0.015*** | -0.019*** | |||
| Hispanic females # age spline 65–74 | 0.002 | -0.022*** | -0.065*** | |||
| Black males # age spline 75–84 | -0.002 | 0.01 | -0.027* | |||
| Hispanic males # age spline 75–84 | 0.008 | 0.004 | -0.048** | |||
| White females # age spline 75–84 | 0 | 0.006 | -0.004 | |||
| Black females # age spline 75–84 | 0.003 | 0.016** | -0.012 | |||
| Hispanic females # age spline 75–84 | 0.01 | 0.002 | -0.004 | |||
| Black males # age spline over 85 | -0.016 | -0.041** | 0.115*** | |||
| Hispanic males # age spline over 85 | -0.024 | -0.036* | -0.055 | |||
| Mortality | Margins | Disability | Margins | Work | Margins | |
|---|---|---|---|---|---|---|
| b | b | b | b | b | b | |
| Main | ||||||
| White females # age spline over 85 | -0.002 | 0.022*** | 0.003 | |||
| Black females # age spline over 85 | -0.012 | -0.016 | 0.004 | |||
| Hispanic females # age spline over 85 | -0.013 | 0.008 | 0.06 | |||
| Constant | -4.232*** | -1.151*** | 5.678*** | |||
| r2_p | 0.16 | 0.089 | 0.23 | |||
| N | 191,036 | 191,036 | 178,803 | 178,803 | 166,827 | 166,827 |
NOTE: Asterisks represent statistical significance. ***p<0.001, ** p<0.01, * p<0.05.
| Mortality | Margins | Disability | Margins | Work | Margins | |
|---|---|---|---|---|---|---|
| b | b | b | b | b | b | |
| Main | ||||||
| Lag of heart disease ever | 0.355*** | 0.041*** | 0.277*** | 0.079*** | -0.261*** | -0.073*** |
| Underrepresented and has heart disease | 0.087*** | 0.009*** | 0.197*** | 0.056*** | -0.135*** | -0.038*** |
| White males | 0 | 0 | 0 | 0 | 0 | 0 |
| Black males | 0.26 | 0.019*** | -0.466 | 0.066*** | -1.940*** | -0.089*** |
| Hispanic males | 0.227 | 0 | -0.381 | 0.075*** | -2.036*** | -0.057*** |
| White females | 0.111 | -0.019*** | -0.242 | 0.008** | -1.881*** | -0.098*** |
| Black females | 0.65 | -0.007** | -0.429* | 0.128*** | -3.021*** | -0.130*** |
| Hispanic females | 0.981 | -0.022*** | -1.536*** | 0.139*** | -3.407*** | -0.178*** |
| Age spline under 65 | 0.034*** | 0.003*** | -0.003 | 0.001*** | -0.088*** | -0.019*** |
| Age spline 65–74 | 0.032*** | 0.003*** | 0.024*** | 0.005*** | -0.075*** | -0.026*** |
| Age spline 75–84 | 0.047*** | 0.005*** | 0.052*** | 0.015*** | -0.058*** | -0.019*** |
| Age spline over 85 | 0.081*** | 0.008*** | 0.066*** | 0.018*** | -0.085*** | -0.020*** |
| Black males # age spline under 65 | -0.001 | 0.013** | 0.026*** | |||
| Hispanic males # age spline under 65 | -0.006 | 0.011* | 0.033*** | |||
| Mortality | Margins | Disability | Margins | Work | Margins | |
|---|---|---|---|---|---|---|
| b | b | b | b | b | b | |
| Main | ||||||
| White females # age spline under 65 | -0.005 | 0.004 | 0.027*** | |||
| Black females # age spline under 65 | -0.01 | 0.015*** | 0.044*** | |||
| Hispanic females # age spline under 65 | -0.021* | 0.035*** | 0.049*** | |||
| Black males # age spline 65–74 | -0.004 | -0.022*** | 0.016** | |||
| Hispanic males # age spline 65–74 | 0.014 | -0.004 | -0.043*** | |||
| White females # age spline 65–74 | 0.001 | -0.004 | -0.024*** | |||
| Black females # age spline 65–74 | -0.01 | -0.013** | -0.020*** | |||
| Hispanic females # age spline 65–74 | 0.008 | -0.018*** | -0.066*** | |||
| Black males # age spline 75–84 | 0.001 | 0.011 | -0.029** | |||
| Hispanic males # age spline 75–84 | 0.01 | 0.005 | -0.052** | |||
| White females # age spline 75–84 | 0 | 0.006 | -0.005 | |||
| Black females # age spline 75–84 | 0.002 | 0.013* | -0.011 | |||
| Hispanic females # age spline 75–84 | 0.009 | 0 | -0.006 | |||
| Black males # age spline over 85 | -0.02 | -0.048*** | 0.122*** | |||
| Hispanic males # age spline over 85 | -0.024 | -0.037* | -0.046 | |||
| White females # age spline over 85 | -0.004 | 0.020*** | 0.004 | |||
| Black females # age spline over 85 | -0.016* | -0.020* | 0.007 | |||
| Hispanic females # age spline over 85 | -0.016 | 0.004 | 0.067 | |||
| Constant | -4.113*** | -1.097*** | 5.620*** | |||
| Mortality | Margins | Disability | Margins | Work | Margins | |
|---|---|---|---|---|---|---|
| b | b | b | b | b | b | |
| Main | ||||||
| r2_p | 0.168 | 0.091 | 0.231 | |||
| N | 191055 | 191055 | 178824 | 178824 | 166848 | 166848 |
NOTE: Asterisks represent statistical significance. ***p<0.001, ** p<0.01, * p<0.05.
| Mortality | Margins | Disability | Margins | Work | Margins | |
|---|---|---|---|---|---|---|
| b | b | b | b | b | b | |
| Main | ||||||
| Lag of hypertension ever | 0.183*** | 0.019*** | 0.172*** | 0.046*** | -0.219*** | -0.063*** |
| Underrepresented and has hypertension | 0.057** | 0.006** | 0.129*** | 0.035*** | -0.050** | -0.014** |
| White males | 0 | 0 | 0 | 0 | 0 | 0 |
| Black males | 0.336 | 0.009** | -0.379 | 0.041*** | -1.976*** | -0.071*** |
| Hispanic males | 0.234 | -0.008* | -0.363 | 0.057*** | -2.053*** | -0.048*** |
| White females | 0.336 | -0.025*** | -0.094 | -0.005 | -2.010*** | -0.093*** |
| Black females | 0.744 | -0.017*** | -0.327 | 0.097*** | -3.121*** | -0.108*** |
| Hispanic females | 1.064* | -0.033*** | -1.391*** | 0.110*** | -3.544*** | -0.166*** |
| Age spline under 65 | 0.037*** | 0.003*** | -0.002 | 0.001*** | -0.088*** | -0.018*** |
| Age spline 65–74 | 0.036*** | 0.004*** | 0.026*** | 0.005*** | -0.077*** | -0.026*** |
| Age spline 75–84 | 0.052*** | 0.006*** | 0.055*** | 0.016*** | -0.062*** | -0.019*** |
| Age spline over 85 | 0.082*** | 0.008*** | 0.067*** | 0.018*** | -0.086*** | -0.021*** |
| Black males # age spline under 65 | -0.003 | 0.010* | 0.028*** | |||
| Hispanic males # age spline under 65 | -0.006 | 0.010* | 0.034*** | |||
| White females # age spline under 65 | -0.009 | 0.001 | 0.029*** | |||
| Black females # age spline under 65 | -0.013 | 0.012** | 0.047*** | |||
| Hispanic females # age spline under 65 | -0.023* | 0.031*** | 0.052*** | |||
| Black males # age spline 65–74 | -0.003 | -0.021*** | 0.016** | |||
| Mortality | Margins | Disability | Margins | Work | Margins | |
|---|---|---|---|---|---|---|
| b | b | b | b | b | b | |
| Main | ||||||
| Hispanic males # age spline 65–74 | 0.013 | -0.007 | -0.041*** | |||
| White females # age spline 65–74 | 0.001 | -0.006 | -0.022*** | |||
| Black females # age spline 65–74 | -0.011 | -0.013** | -0.020*** | |||
| Hispanic females # age spline 65–74 | 0.002 | -0.023*** | -0.063*** | |||
| Black males # age spline 75–84 | -0.001 | 0.01 | -0.026* | |||
| Hispanic males # age spline 75–84 | 0.005 | 0.003 | -0.049** | |||
| White females # age spline 75–84 | -0.001 | 0.004 | -0.002 | |||
| Black females # age spline 75–84 | 0 | 0.012* | -0.008 | |||
| Hispanic females # age spline 75–84 | 0.007 | -0.001 | -0.003 | |||
| Black males # age spline over 85 | -0.017 | -0.044** | 0.112*** | |||
| Hispanic males # age spline over 85 | -0.025 | -0.037* | -0.046 | |||
| White females # age spline over 85 | -0.004 | 0.021*** | 0.003 | |||
| Black females # age spline over 85 | -0.015* | -0.019* | 0.007 | |||
| Hispanic females # age spline over 85 | -0.014 | 0.006 | 0.062 | |||
| Constant | -4.289*** | -1.188*** | 5.683*** | |||
| r2_p | 0.156 | 0.085 | 0.231 | |||
| N | 191014 | 191014 | 178786 | 178786 | 166815 | 166815 |
NOTE: Asterisks represent statistical significance. ***p<0.001, ** p<0.01, * p<0.05.
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