Economic, Social Inequality in an Aging America

SUMMER 2018 volume 42 number 2

Journal of the American Society on Aging

Land of the Unequal? Economic, Social Inequality in an Aging America

Economic inequality in later life

Gaps do matter: environment, health, and social equity

Lessons from Rutger’s African-American Brain Health Initiative is the quarterly journal of the American Society on Aging. Each issue is devoted to bringing together the most useful and current knowledge about a speciﬁc topic in the ﬁeld of aging, with emphasis on practice, research, and policy.

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Volume 42 .Number 2 | 1 GENERATIONS – Journal of the American Society on Aging

ASA Executive Committee GENERATIONS STAFF Chair, Board of Directors Publisher Karyne Jones, Washington, DC Robert G. Stein Chair-Elect Editor Michael Adams, New York, NY Alison Hood Immediate Past Chair Senior Editor Robert B. Blancato, Washington, DC Alison Biggar Secretary Typography & Production Robert E. Eckardt, Cleveland, OH Michael Zipkin | Lucid Design, Berkeley Treasurer Generations cover and book design Lisa Gables, Alexandria, VA by Lisa Rosowsky, Blue Studio.

ASA Board of Directors Generations Editorial Advisory Board

Jean Accius, Washington, DC Susan C. Reinhard Cynthia Banks, Los Angeles, CA Chair Richard Browdie, Cleveland, OH Richard Browdie Immediate Past Chair Scott Dingfeld, Omaha, NE Wendy Lustbader Paul Downey, San Diego, CA Chair-Elect

Brian M. Duke, Radnor, PA Jean Accius

Joyce Gallagher, Chicago, IL Gretchen Alkema

Maria Henke, Los Angeles, CA Patrick Arbore Brooke A. Hollister, San Francisco, CA Letia Boseman Karen N. Kolb Flude, Chicago, IL Louis Colbert Daniel Lai, Hong Kong Walter Dawson Rebecca C. Morgan, Gulfport, FL Brian Lindberg Scott Peifer, San Francisco, CA Robin Mockenhaupt Kevin Prindiville, Oakland, CA Laura Mosqueda Deborah Royster, Washington, DC Kevin Prindiville Phil Stafford, Bloomington, IA Anne Tumlinson John M. Thompson, Atlanta, GA Front cover image ©Gettyimages/altmodern Joyce Walker, Richmond Heights, OH © 2018 American Society on Aging President and CEO Robert G. Stein, San Francisco, CA

2 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America

inside generations Land of the Unequal? Economic, Social Inequality in an Aging America

4 Our Guest Editor 48 Mass Incarceration, Racial Disparities Karen D. Lincoln in Health, and Successful Aging By Robynn Cox 6 Economic Inequality in Later Life By Karen D. Lincoln 56 Sexual Orientation, Socioeconomic Status, and Healthy Aging America the unequal: societal and social By Bridget K. Gorman and Zelma Oyarvide factors shaping economic inequality among 61 African American Elders, Mental Health, older adults and the Role of the Church 13 Equality and Equity: Expanding By Ann W. Nguyen Opportunities to Remedy Disadvantage By David Takeuchi, Tiziana C. Dearing, Melissa initiatives to address economic, social, and W. Bartholomew, and Ruth G. McRoy environmental inequity

20 Unequal Places: The Impacts of 68 Can Economic Interventions for Children Socioeconomic and Race/Ethnic Reduce Economic Inequality in Adulthood? Differences in Neighborhoods By Trina R. Shanks By Jennifer Ailshire and Catherine García 73 Advocates for African American Elders: 28 Gaps Matter: Environment, Health, Engaging Our Older Adults in Education and Social Equity and Research By Manuel Pastor and Rachel Morello-Frosch By Karen D. Lincoln 34 Intersectionality and Stratification 78 Recruiting Older African Americans in the Labor Market to Brain Health and Aging Research By Kyle K. Moore and Teresa Ghilarducci Through Community Engagement 41 The Public Cost of Low Earnings By Mark A. Gluck, Ashlee Shaw, and Diane Hill Across the Life Course 83 Research in Social, Economic and By Jacqueline L. Angel and Ronald J. Angel Environmental Equity (RISE3) By Tiziana C. Dearing, Ruth McRoy, and Tess Mulrean

Volume 42 .Number 2 | 3 GENERATIONS – Journal of the American Society on Aging

Our Guest Editor Solving America’s “wicked problems” through social innovation and action

espite the surging stock market Work, co-director of the Southern Cali- Dand wealth evident in America’s big fornia Clinical and Translational Sci- cities, especially those with thriving ence Institute, and senior scientist at the technology sectors, homelessness and Edward R. Roybal Institute on Aging, poverty are equally we are thankful that she could spend the ‘We need to find ways on display, often on considerable time necessary to guest- to close the distance the same block. In the edit this issue of Generations. Though between “us” current atmosphere of pulled in many directions, Lincoln liberal versus conser- seems to identify most as a teacher and and “them.” ’ vative teeth-gnash- mentor to her students at USC. KAREN D. LINCOLN ing, it was refreshing “It is rewarding to see how a small to engage with Guest (and sometimes large) investment of Editor Karen D. Lincoln on this issue time, advice, support, and a few kind of Generations, which focuses on eco- words, can signifcantly impact the nomic and social inequality in America experience and careers of young schol- as it pertains to older adults. Lincoln ars,” she says, in the same breath credit- takes a levelheaded and persistent ing mentors for her own successes. approach in her efforts to work through Lincoln is a fellow of the Geronto- the often overwhelming landscape of logical Society of America and a Hart- American inequality. ford Faculty Scholar. In 2014, she was She cites a highlight to her career as ranked third among the most influen- founding Advocates for African Ameri- tial African American social work schol- can Elders (AAAE; see her article on ars in the United States and, in 2015, page 73), which began in 2011 with her was ranked 12th among all female social desire to end social, economic, and work scholars in the United States. She health disparities among older African has testifed before the Senate Select Americans in South Los Angeles. The Committee on Aging and Long-Term group now “is a dynamic academic− Care and was appointed to the Califor- community partnership with a history nia Task force on Family Caregiving by of service and participatory research Sen. Kevin De León (D-Los Angeles). that is making an impact on the lives of She has published more than 60 their neighbors.” articles and book chapters, and received As associate professor in the Suzanne more than $2.8 million in grant funding Dworak-Peck School of Social Work at to support her research on improving the University of Southern California clinical and community-based treatment (USC), director of the USC Hartford of African Americans with mental health Center of Excellence in Geriatric Social disorders and chronic health conditions.

For this issue of Generations, Lincoln Lincoln’s most recent work is both turned her sights on social and econo personal and professional: she has mic disparities in America, especially as designed an intervention to increase they relate to older adults. Reflecting on Alzheimer’s disease literacy among the turbulence around America’s eco- African Americans. “My mother is cur- nomic and social inequalities, she says, rently suffering from severe demen- “I am not sure we have seen all of the tia, and I have also seen frsthand how challenges around economic and so- low knowledge of Alzheimer’s disease cial inequality ahead. We continue to impacts families,” through her work at witness widening gaps in income and the AAAE. social distance between different groups The pilot intervention showed such of people.” promise that Lincoln is working to fund Lincoln places her hope in younger it on a much wider scale through the people. “It is this generation of disrup- Patient-Centered Out- tors that will likely be the change agent comes Research Insti- Lincoln hopes solutions we need to redefne the way we think tute (PCORI). launched in university about and solve the problem of eco- Acting locally is settings can work nomic and social inequality,” she says. one of Lincoln’s ongo- It is the job of the older generations, ing priorities. Circling for lower-income she believes, to instill in the young a back to social and eco- communities. sense of civic and public engagement nomic disparities, she “that encourages their thinking around says it is critical to “foster ties between inequality of any kind and how it im community-based organizations and pacts them, personally. It’s not about those in other disciplines to create ideology.” ‘transformative science’ to better under- Lincoln believes it also is the job of stand the factors that interact over the teachers and other thought leaders to life course to create conditions that engage politically and civically—to teach put older adults at risk of being poor or via example. “We need to fnd ways homeless in late life.” to close the distance between ‘us’ and Lincoln is hopeful that some solu- ‘them,’ ” she says, referring to economi- tions launched in university settings can cally and socially diverse populations, also work in lower-income communi- “[and] sometimes that distance is just a ties. “Universities such as USC and the few blocks.” University of Michigan have programs She lauds efforts like that of Har- for graduate students that foster inno- vard University, which through their vation and social entrepreneurship. admissions policy now considers socio- These programs allow students to be economic diversity. This has resulted, socially engaged and to create solutions Lincoln says, in an increase in the num- to some of our most ‘wicked problems.’ ber of students attending the school Similar programs should be available in who are from low-income families. underserved communities, so that those “Next is the necessary culture shift so most impacted by social and economic that the campus is more welcoming to inequality can be part of the solution.” these students.” —Alison Biggar and Alison Hood

Economic Inequality in Later Life

By Karen D. Lincoln A reflection of cumulative advantages and disadvantages across the life course.

evels of economic inequality—encompassing $26,200 per year; while 25 percent have incomes Linequality in the distribution of income and below $15,250. Only 5 percent have incomes wealth—have hit unprecedented heights and above $103,450 (Jacobson et al., 2017). appear to be rising. In 2014, the average income Studies also show that economic insecurity is for adults in the United States was $64,600. How- particularly concentrated among older women of ever, this average obscures a great deal of hetero- color. In 2013, African American single women geneity (Piketty, Saez, and Zucman, 2018). The between ages 65 and 84 had a median wealth of bottom 50 percent of adults earned on average $55,700, compared to $187,000 for non-Hispanic $16,200 per year, while the middle 40 percent white single women in the same age category earned roughly the same income as the U.S. aver- (Sullivan and Meschede, 2016). Among educated age. In stark contrast, the top 10 percent received women, older, single African American women 47 percent of all U.S. income—$304,000, which is with a college degree have a mere $11,000 in 4.7 times the national average, while the top 1 per wealth, which is the lowest of any women in that cent of adults earned $1,300,000—twenty times age range and is in stark contrast to the $384,400 the national average income. Today, the top 1 per in median wealth among single white women cent takes home more than 20 percent of all in with a bachelor’s degree (Zaw et al., 2017). This come in the United States. wealth gap is present across all age categories The extreme disparity in income and wealth and begins much earlier in the life course (Sulli- distribution has a real and distinct impact on van and Meschede, 2016). older adults. According to the latest data, more Aging is a stratifed process that reflects the than 7 million older adults are living below the inequalities that structure our life chances from Federal Poverty Line, per the Supplemental Pov- birth onward. Barriers to accessing wealth- erty Measure (Cubanski et al., 2018). This number building opportunities, wages, and workplace will increase to 72 million by 2030. A 2016 study benefts, as well as experiencing household by the Kaiser Family Foundation found that half responsibilities that restrict labor force partici- of all Medicare benefciaries have incomes below pation by race and by gender are circumstances

abstract The rapid increase of economic inequality in the past few decades is one of the most disturbing social and economic issues of our time. Economic opportunities are not randomly distributed, but determined by people’s positions within the social structure. Multiple social identities—race, class, gender, and sexual orientation—shape economic and social experiences that accumulate over the life course and determine economic status in late life. This article provides an overview of economic inequality across race, class, and gender, and introduces the articles in the Summer 2018 issue of Generations. | key words: inequality, inequity, socioeconomic status, race, class, gender, sexual orientation

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 6 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America that converge, accumulate, and lead to aston- higher levels of formal education tend to have ishingly high rates of poverty and economic higher household incomes. However, the black− inequality in later life. While some of these white gap in income occurs across all educa- wealth-building opportunities are based upon tional levels. For example, the median adjusted economic factors, such as income and wages, household income among African American others are based upon social factors. householders with at least a bachelor’s degree Social inequality has economic implications. was $82,300 in 2014, while the income of col- For example, racial segregation in the United lege-educated non-Hispanic white householders States has been slowly declining over the past four was $106,600. decades, yet it remains very high. At the same Clearly, more studies are needed to under- time, residential segregation by income, which stand the causes and consequences of inequal- was very low in 1970, has risen sharply (Logan, ity. However, there is growing recognition that 2011; Reardon and Bischoff, 2011; Watson, 2009). economic inequality is due to the convergence of One study reported that poor whites tend to live a multitude of factors—political, social, and economic—that intersect to contribute to the prob- The top 1 percent of U.S. adults lem. Both past and present racism and sexism, lack of healthcare access and educational oppor- earned $1,300,000—twenty times tunities, environmental risks and hazards, and the national average income. more all contribute to inequality—particularly among those who are affected, negatively or posi- in more affluent neighborhoods than do middle- tively, by more than one of these interconnected class African Americans and Latinos, which issues. For older adults, how they experience in means that these groups are more likely to con- equality as they age is really the result of a life- tend with lower-quality schools, higher crime, less time of experiences. access to resources, and greater social problems, To understand the persistence of economic all of which structure economic opportunities for inequality, the individual determinants of un children in the future. The gap separating African equal treatment of social groups must be exam- Americans and Latino neighborhoods from white ined. For example, studies that focus on social neighborhoods persists up and down the income determinants of inequality highlight the unequal ladder (Reardon, Fox, and Townsend, 2015). distribution of resources that promote economic Consequently, racial economic inequality stability, such as access to education, employ- continues to be strikingly high. A recent Pew re ment, and housing. These social determinants, search analysis of the Current Population Survey however, are determined by a broader set of fac- found that racial gaps in income and earnings, tors that structure and shape the contexts in with white households earning more than their which people live, work, and age. It is in the black counterparts, remained largely constant broader societal factors—e.g., capitalism, racism, or even widened between 1967 and 2015 (Bialik and patriarchy—whereby income disparities take and Cilluffo, 2017; Gittleman and Wolff, 2004). root, inequalities grow, and inequities reproduce. For example, in 2014, the median African Ameri- In this Summer 2018 issue of Generations, the can and Latino household incomes were about twelve articles that follow explore societal and $43,300, while non-Hispanic white household social factors that create and maintain economic income was about $71,300 (Pew Research Cen- inequality among older adults. The authors rep- ter, 2016). resent the disciplines of social work, gerontology, The return on income and education also dif- environmental science, economics, neuropsy- fers by race. On average, household heads with chology, and sociology. Various forms of inequal-

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 7 GENERATIONS – Journal of the American Society on Aging ities are investigated based upon race, ethnicity, vironment, and health, including initiating more gender, sexual orientation, and migratory status. studies that elucidate causal pathways and Reflecting the interdisciplinary nature of these points of intervention. contributing authors, a broad range of societal The next set of feature articles highlights the and social factors are considered as potential mechanisms linking unequal environments to determinants of economic inequality across the economic inequality and the well-being of indi- life course. viduals, communities, and society. Ailshire and García document the link between race, ethnic- Introduction of Feature Articles ity, socioeconomic position, and disadvantaged Is the distribution of resources fair? This is a environments. They argue that unequal environ- question of equity in income and wealth. Is the ments limit the opportunities for older adults to distribution of the population within economic lead healthy, active, and engaged lives. Pastor and categories the same regardless of social position? Morello-Frosch raise the argument that reducing This is a question of equality, and the metric we economic and social inequality may not only help use to measure progress toward achieving eco- those who are most exposed to health-damaging nomic equity and eradicating inequities. Equity pollutants in their neighborhoods, but also may is the means. Equality is the outcome. Inequity, improve environmental conditions for all. inequality, and disparities often are used inter- Multiple identities such as race, ethnic- changeably. However, these concepts are not the ity, class, and gender intersect and have multi- same, and the difference between them is crucial ple effects on one’s ability to participate in the for understanding and addressing economic in labor market, to achieve economic security, and equality in the United States. to plan for old age. The next set of feature arti- The frst feature article by Takeuchi and col- cles highlights the causes and consequences of leagues highlights the distinction between economic insecurity for older women and older equity and equality and reveals the complexity adults of color. of these two constructs. The authors argue that Moore and Ghilarducci describe the eco- most research on equity and equality focuses on nomic status of older women within the context outcomes that demonstrate group differences in of societal inequity, stratifcation, and inter- valued resources, such as pay, wealth, and educa- sectionality; they highlight the importance of tion. But these studies are limited to the extent understanding economic inequality within a that they explain why inequalities persist over time. Accordingly, Takeuchi and colleagues spot- light mechanisms that constrain opportunities ‘More attention should be paid to the for some social groups, and offer approaches interplay between inequality, the for advancing research, policy, and practice to environment, and health.’ address inequity and inequality in our society. A growing body of literature posits that framework that takes into account the intersec- more unequal societies have more polluted and tions of various social identities and the societal degraded environments, perhaps helping to determinants of inequity (e.g., capitalism, rac- explain why more unequal societies are often ism, patriarchy), as it is the societal determinants less healthy. The relationship between environ- that determine the laws, norms, and policies that mental quality and social inequality along the create and maintain inequality over time. Angel axes of income, wealth, political power, race, and and Angel continue this conversation by discuss- ethnicity suggests that more attention should be ing the implications of lifelong income inequality paid to the interplay between inequality, the en for individuals, families, and society. Poor older

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 8 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America adults are expensive. The Angels argue that a quences of incarceration, and how these impact lifetime of low earnings, combined with demo- individuals, families, and communities. graphic shifts and the changing role of fami- Gorman and Oyarvide highlight the diver- lies, has a social cost that results in an increased sity among older adults in the United States burden to states for Medicaid support and an in an article focused on bisexual older adults. increased need for innovative solutions to long- Their piece reveals heterogeneity among LGBT term care for poor elders. older adults and identifes a socioeconomic pro- The economy of the United States becomes fle among older bisexual men and women that more robust as the health and well-being of is less positive than those of gay, lesbian, or het- its citizens improve. Improving the health of erosexual older adults. In doing so, the authors all Americans can directly result in economic encourage us to consider how socioeconomic sta- growth, partly because more people are more tus differences shape the health and aging tra- productive in the labor force. However, racism jectories of sexual minority older adults and the and discrimination hamper access to oppor- implications for their fnancial security and long- tunity. Studies consistently show that racism term care. has deleterious consequences for health. How- Finally, Nguyen highlights the historically ever, bias based upon race results in an income important role of the African American church gap that costs the United States $1.9 trillion per for flling the gap left by limited access to formal year, signifcantly slashing the country’s wealth. mental health services by socially and economi- Addressing factors such as healthcare inequities, cally marginalized groups. Empirical evidence unjustifed incarceration disparities, and fewer shows that individuals with higher socioeco- employment and education opportunities would nomic positions have lower prevalence of mental generate 12 percent more annual U.S. earnings. health disorders due to the protective nature of America’s changing demographics highlight the income, education (Gaines, 2007), and employ- urgency of addressing bias based upon race, gen- ment (Lincoln and Chae, 2010; Lincoln et al., der, and sexual orientation and its impact on 2011). If the causal order is reversed, studies people’s health, wealth, and our nation’s eco- show that mental health disorders predict edu- nomic growth. cational attainment, labor force participation, The next set of articles explores the unequal income, and earnings. impact of mass incarceration, and the impli- For example, persons with psychiatric dis- cations of racial discrimination and economic orders are more likely to have difficulty fnding inequality upon health and aging among racial, a job, retaining a job, and have reduced earn- ethnic, and sexual minorities. Cox encourages ings while employed (Kessler et al., 2008). Thus, us to think about racial health disparities and social resources that can mitigate the relation- aging within the context of mass incarceration. ship between mental health and fnancial inse- Criminal justice policies and practices result in curity are crucial for individuals who might the unequal impact of mass incarceration that otherwise be disadvantaged due to their social disadvantages individuals based on race, ethnic- position. Nguyen’s article highlights the expo- ity, and class. African American men make up sure of African Americans to racial discrimi- 40 percent of the prison population compared to nation and the toll this exposure can take on 6 percent of the population of the United States. older adults’ well-being. In lieu of access to for- Thus, health, aging, and wealth in this popula- mal mental health services among older Afri- tion and others disproportionately represented can Americans, the author demonstrates the role among those incarcerated cannot be fully under- of the church for providing informal sources of stood without considering the causes and conse- support that can protect congregants from seri-

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 9 GENERATIONS – Journal of the American Society on Aging ous mental illness associated with exposure to pathways toward economic mobility, which can social stressors like racial discrimination. lessen economic disparities across the life course and reduce economic inequality in later life. Introduction of Program Spots Low health literacy is linked to a wide range of Economic inequality is tied to societal and social poor health-related outcomes, including low use of determinants indexed by inequalities in economic preventive medical services, uncontrolled chronic stability, neighborhood resources, hazardous health conditions, delays in accessing or forego- toxic exposures, and opportunity structures. ing needed care, difficulty fnding a provider, lack Thus, efforts to end economic inequality require of a usual source of care, and mortality (Berkman disruptive, life-course interventions at the indi- et al., 2011). Thus, health literacy—an individual’s vidual, community, and policy levels. The fnal set of articles follows a “program spot” format Programs that increase health literacy that serves to highlight four initiatives designed to address economic, social, and environmental can help close the gap between inequity in ways that can affect outcomes across economic insecurity and health the life course, while also generating knowledge disparities. and policy ideas of local and national importance. These shorter pieces provide examples of ability to access, process, and understand basic how to address social and economic inequality health information and services needed to make with programs that build economic assets during appropriate health decisions—is an important childhood, increase health literacy and commu- determinant of health inequities across groups. nity engagement among African Americans in Health literacy is determined by individual urban neighborhoods, and increase our knowl- and community-level socioeconomic status, and edge about the intersection between race, place, connections with others through work, civic and income to identify important points of policy engagement, and social networks (Rikard et al., interventions at local and national levels. 2016). There is a social and economic gradient The persistent difference in wealth has con- in health literacy such that low health literacy sequences for child outcomes in the United is more prevalent among older adults, racial and States, particularly for the large and growing ethnic minorities, and groups of low socioeco- population of non-white children. Without the nomic status (Rikard et al., 2016). However, the potential buffer that wealth provides in times of benefts of health literacy interventions appear unemployment and emergency expenses, fam- greater for racial and ethnic minorities and indi- ily well-being can suffer. When children grow up viduals with low incomes than for those with in households that have no wealth and face eco- higher incomes (Miller, 2016). nomic insecurity, they may experience signif- Given the link between economic inequality, cant stress and have limited opportunities for health literacy, and poorer health outcomes, pro- upward mobility. grams that increase health literacy among racial In the frst program spot, Shanks describes and ethnic minority and low-income populations different approaches to help low-income, low- can help close the gap between economic insecu- wealth households build assets that could im rity and heath disparities. The next two program prove near-term economic security, and help spots feature academic−community initiatives children succeed academically and achieve designed to help close the health gap. future economic success. The programs and In my program spot article, I share key suc policies described by Shanks have the poten- cesses from an outreach and engagement pro tial to increase fnancial capability and promote gram that I founded at the University of Southern

California. Advocates for African American El RISE explores the “basic tools of opportu- ders (AAAE) was created to increase access to nity,” such as use of and access to transpor- health information and resources to older resi- tation and childcare and associated costs to dents in South Los Angeles, a community that is families in time and money, to demonstrate how underserved, under-resourced, and economically race, ethnicity, and income affect vulnerable disadvantaged relative to other communities in families in practical ways. The goal of RISE is Los Angeles County. AAAE increases health lit- to use the tools of research to impact policies, to eracy for older African Americans and their fam- support the efforts of community-based organi- ilies by partnering with community stakeholders, zations to change public assistance policies, and including organizations, advocates, and residents, to help families and neighborhoods improve to conduct community-partnered participatory their own lives. research, to raise awareness, and to increase knowledge about chronic health conditions, Conclusion mental health disorders, and the available health- The inequalities that shape our opportunities promoting resources in the community. from birth structure our fnal years. Advantages Gluck, Shaw, and Hill describe their unique and disadvantages accumulate over the life university−community partnership that pro- course. In developing policies to address eco- motes brain health among African American nomic inequality and senior poverty, policy mak- older adults in the greater Newark, New Jersey, ers, researchers, analysts, and advocates should area. The African-American Brain Health Initia- better understand the conditions experienced tive combines research, education, and commu- by our country’s most vulnerable older adults nity engagement to increase brain health liter- throughout their lives. Age, race, gender, and acy. African Americans have a disproportionate risk for Alzheimer’s disease, memory loss, and The contexts in which we live other age-related brain health problems. How- ever, less than 5 percent of this population is in powerfully affect our opportunities— cluded in Alzheimer’s disease prevention studies regardless of compositional or clinical trials. Gluck and colleagues offer out- differences in individual resources. reach and engagement strategies that have con- tributed to the success of their educational and place influence economic and social experiences outreach programs, and their engagement of and risks leading up to and in later life. African Americans in research for more than Addressing inequity in aging requires a life- a decade. course approach that includes targeted inter- The fourth program spot by Dearing, McRoy, ventions and policies at various points within and Mulrean features a young, dynamic initia- the life course. The contexts in which we live tive that brings together researchers from Bos- powerfully affect our opportunities—regard- ton College and beyond with practitioners and less of compositional differences in individual policy makers to better address the root causes resources. Thus, policies targeting vulnerable of social, economic, and environmental ineq- elders should consider the role that inequality in uity. To do this, Research in Social, Economic neighborhoods, social networks, and opportuni- and Environmental Equity (RISE) faculty use ties plays in creating, maintaining, and perpetu- research strategies to understand how race, ating economic inequality across the life span. place, and poverty intersect to impact the daily Meeting the challenge of eliminating economic lives of individuals living in disadvantaged inequity requires examining the “root causes”; neighborhoods. focusing on what can be seen as upstream inter-

References Bialik, K., and Cilluffo, A. 2017.6 Lincoln, K. D., and Chae, D. H. Reardon, S., and Bischoff, K. 2011. Facts About Black Americans for 2010. “Stress, Marital Satisfaction, Growth in the Residential Segrega- Black History Month. and Psychological Distress Among tion of Families by Income, 1970– goo.gl/A45Xk5. Retrieved March African Americans.” Journal of 2009. US2010 Project. New York: 3, 2018. Family Issues 31(8): 1081−105. Russell Sage Foundation; Provi- dence, RI: Brown University. Berkman, N. D., et al. 2011. “Low Lincoln, K. D., et al. 2011. “Correlates Health Literacy and Health Out- of Psychological Distress and Major Reardon, S. F., Fox, L., and comes: An Updated Systematic Depressive Disorder Among African Townsend, J. 2015. “Neighborhood Review.” Annals of Internal Medi- American Men.” Research on Social Income Composition by Household cine 155(2): 97–107. Work Practice 21(3): 278–88. Race and Income, 1990–2009.” Annals of the American Academy of Cubanski, J., et al. 2018. How Many Logan, J. R. 2011. Separate and Political and Social Science 660(1): Seniors Are Living in Poverty? Unequal: The Neighborhood Gap 78–97. National and State Estimates Under for Blacks, Hispanics and Asians the Official and Supplemental Pov- in Metropolitan America. US2010 Rikard, R. V., et al. 2016. “Examin- erty Measures in 2016. Menlo Park, Project. New York: Russell Sage ing Health Literacy Disparities in CA: Kaiser Family Foundation. Foundation; Providence, RI: Brown the United States: A Third Look at University. the National Assessment of Adult Gaines, J. S. 2007. “Social Cor- Literacy (NAAL).” BMC Public relates of Psychological Distress Miller, T. A. 2016. “Health Literacy Health 16(1): 975. Among Adult African American and Adherence to Medical Treat- Males.” Journal of Black Studies ment in Chronic and Acute Illness: Sullivan, L., and Meschede, T. 37(6): 827–58. A Meta-analysis.” Patient Educa- 2016. “Race, Gender, and Senior tion and Counseling 99(7): 1079−86. Economic Well-being: How Finan- Gittleman, M., and Wolff, E. N. cial Vulnerability Over the Life 2004. “Racial Differences in Pat- Pew Research Center. 2016. On Course Shapes Retirement for terns of Wealth Accumulation.” Views of Race and Inequality, Blacks Older Women of Color.” Public Pol- The Journal of Human Resources and Whites Are Worlds Apart. icy & Aging Report 26(2,1): 58–62. 39(1): 193–227. goo.gl/Tew33h. Retrieved December 6, 2017. Watson, T. 2009. “Inequality and Jacobson, G., et al. 2017. Income the Measurement of Residential and Assets of Medicare Beneficia- Piketty, T., Saez, E., and Zucman, Segregation by Income in Ameri- ries, 2016−2035. Menlo Park, CA: G. 2018. “Distributional National can Neighborhoods.” Review of Kaiser Family Foundation. Accounts: Methods and Estimates Income and Wealth 55(3): 820−44. goo.gl/HjXVSQ. Retrieved for the United States.” The Quar- January 26, 2018. terly Journal of Economics 133(2): Zaw, K., et al. 2017. Women, Race, 553−609. and Wealth. Durham, NC: Samuel Kessler, R. C., et al. 2008. “Indi- DuBois Cook Center on Social vidual and Societal Effects of Men- Race Matters Institute. 2014. Equity and Insight Center for Com- tal Disorders on Earnings in the “Racial Equality or Racial Equity? munity Economic Development. United States: Results from the The Difference it Makes—Advanc- National Comorbidity Survey Rep- ing Racial Equity.” Baltimore, MD: lication.” American Journal of Psy- Race Matters Institute. chiatry 165(6): 703–11. goo.gl/9hJYr2. Retrieved October 16, 2017.

Equality and Equity: Expanding Opportunities to Remedy Disadvantage

By David T. Takeuchi, Tiziana C. Dearing, Of social inequality and inequity in American Melissa W. Bartholomew, society—and a model program that might foster and Ruth G. McRoy social change.

e have been watching a competition The foregoing example is exaggerated to il Wbetween two runners—one race per day lustrate equality versus equity. This article con- over the past week. It is the eighth day as we wait siders these two constructs, focuses on equity for the next contest. One runner always dresses in as compatible with fairness and social justice, a purple jersey and the second in orange. Purple argues how equity can shape our understand- wins each race by at least ten yards. We decide to ing of available opportunities, and provides an go to the start to see how Purple manages to tri- example of a program that intends to change umph so consistently over Orange. Does Purple inequities in some situations. have an initial burst of speed, a late surge, or is it a steady pace over the entire course? Or is Orange Defining Equality a slow and ineffective runner? We arrive a few The two terms, especially equality, frequently moments before the next race takes place. We take on the prescriptive quality of an ideal and notice that these races are unusual because are used as a rhetorical device to show unity there is no official starting line—only a fnish line. when there is disagreement (Westen, 1990). A Orange is prepping for the race ten yards behind classic example appears in the Declaration of Purple. We notify the race official who then Independence, “We hold these truths to be self- moves Orange ten yards forward. The official evident: That all men are created equal; that decides to provide the same treatment to both they are endowed by their creator with certain runners and advances Purple ten yards. The race unalienable rights; that among these are life, lib begins. Purple wins another race. erty and the pursuit of happiness . . . ” It is dif-

abstract Over time, equality has changed in meaning to refer to the similarity of treatment of individuals and groups. Equity has emerged as an alternative construct linked to social justice, especially in the fields of health and education. Equity invokes a search for the social, economic, and political causes of inequality and for remedies that consider context and circumstances of disparate outcomes. This article discusses how a focus on opportunities could advance research, policy, and practice to enhance the quality of life of people disadvantaged by their position in society. | key words: equality, equity, opportunity hoarding, exploitation

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 13 GENERATIONS – Journal of the American Society on Aging fcult to disagree with these assertions because same starting point. Equality became associated they prescribe an ideal, equality, in which we with assimilation into the dominant male, white, should all believe. However, at the time of its or middle-class norms (Gosepath, 2011). writing, women, Native Americans, blacks, and people who owned no property were excluded Defining Equity from opportunities and privileges open to prop- Equity emerged as an alternative and prominent erty-owning white men. While debate persists construct linked to social justice, especially in over whether Jefferson intentionally excluded the felds of health and education. Equity invokes groups from this statement, or if he offered the a search for the social, economic, and political statement as an aspirational goal, the reference causes of an inequality, and for remedies that con- to equality masks the debate and the reality sider the context and circumstances of disparate that groups were excluded from the parameters outcomes. In the example given at the beginning of the document at the founding of the United of the article, equal treatment advances both run- States (Curry, Riley, and Battisoni, 2003). ners the same distance regardless of their starting Equality, however, is more than a rhetorical point. Equity, on the other hand, moves only the device and has substantive roots in philosophical disadvantaged runner, Orange, to the same start- writings and arguments. There is much debate ing point as the second runner. The second run- on what people are advocating for, or critiqu- ner, Purple, is not moved from the original spot. ing, when they discuss equality (Dworkin, 2000). In a more concrete example, equality would At a minimum, the concept of equality involves give families a $5,000 tax credit for college responses to two related questions: Equal to, and tuition, while equity would give the credit only on, what? Equality involves a reference to some to families earning below a certain income object that may be a normative standard, a per- threshold. While the concept of equity has its son, a group, or another unit by which some- critics, especially around providing certain thing is described. It infers a comparison of groups with special treatment, it is aligned with research evidence that points to the social and ‘Equality became associated with structural causes of social, economic, education, and health problems such as poverty and racism assimilation into the dominant male, (Burton and Welsh, 2015; Link and Phelan, 1995). white, or middle-class norms.’ The evidence supports solutions that advance the runner who is structurally disadvantaged by one of those groups on a topic such as health, a poor starting position. wealth, income, or other forms of social status. The scholarship on equity (and equality) has The concept has gone through different itera- tended to focus on outcomes that assess group tions and has led some to conclude that it has differences in some valued resources such as no unifed meaning. Accordingly, it may be best gender disparities in pay, racial differences in to see equality as a multifaceted construct that wealth, and nativity gaps in access to health provides a moral compass for addressing dispa- insurance. While this emphasis has documented rate positions and outcomes in society (Rae et al., the scope and magnitude of inequalities, the 1982; Rawls, 1971; Williams, 1973). research in this area has been less successful The nuances and multifaceted dimensions about why inequalities persist over time. of equality have morphed over time into a short- hand for similarity or sameness of treatment. Exploitation and opportunity hoarding The concept has been critiqued for its inability to The persistence of unequal outcomes has led convey the reality that not all people begin at the to calls to examine the opportunities that pro-

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 14 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America duce dissimilar ends (Burton and Welsh, 2015). pects. Matched teams of black men and white Exploitation and opportunity hoarding are two men applied for low-wage jobs, using identical mechanisms that constrain opportunities for resumes except for their race and criminal back- some social groups (Tilly, 1998). Exploitation or ground (the treatment conditions). Applicants discrimination occurs when the dominant group were less likely to have positive employment out- restricts other groups from achieving full value comes, with the effect much larger for blacks. for their efforts. Black men with the same history of incarcera- One concrete example is the wage gap tion were less likely than white men to be invited between blacks and whites. This wage gap is for job interviews. larger today than it was in 1979. While this dis- A recent meta-analysis of twenty-eight simi- crepancy has not been linear and has fluctuated lar feld experiments shows that the basic fndings about hiring discrimination in the U.S. The wage gap between whites and labor market endure (Quillian et al., 2017). In the review of twenty-four studies since 1989, whites blacks is larger today than it was received 36 percent and 24 percent more call- in 1979. backs than did blacks and Latinos, respectively. Since 1989, discrimination in the labor market over time, it has increased since 2000. By 2015, did not change for blacks; for Latinos, there was controlling for different correlates of wages, black a slight decrease in discrimination (Quillian et men made 22 percent less than white men on av al., 2017). erage hourly wages; black women made 34 percent less than white men and 12 percent less than Othering and boundary maintenance white women (Wilson and Rogers, 2016). Even at While exploitation and opportunity hoarding are the same education levels, black men and women two mechanisms that help explain inequities in are paid less than their white counterparts. opportunity, two social-psychological processes Fryer, Pager, and Spenkuch (2011), in their exemplify their power and effects over long peri- analysis of the wage gap, found that one-third of ods of time. Othering occurs when status groups the discrepancies in wages can be attributed to create or reproduce inequities by casting mem- discrimination against blacks. Blacks may expe- bers of certain groups (e.g., by race, ethnicity, na rience a lower return on their education in the tivity, gender, sexual orientation) as intellectu- marketplace, and, consequently, may not receive ally, morally, socially, or culturally inferior (Prus, the same wages for their accomplishments. The 1987). Groups defned as inferior become distinct consequences of the wage gap go far beyond in from the “in” group, or from “us.” They instead come. Less pay can mean fewer and restricted become and maintain the status as the “out” opportunities for living in a safe neighborhood, group, or the “other.” Once a group is defned as sending children to good schools, purchasing inferior in some dimension, it is difficult to break health insurance and quality healthcare, and out of the label and it becomes ingrained into accumulating wealth. common images and stereotypes. Opportunity hoarding occurs when powerful Negative perceptions can lead to biased and groups directly or indirectly limit access to valu- unfair treatment. Immigrants often come from able or scarce resources. An innovative study countries where the social norms, cultural prac- illustrates how opportunity hoarding works. tices, and languages may differ from those in the Pager, Western, and Sugie (2009) conducted a United States. These differences can be defned feld experiment in New York City to study how as defcits. At its worst, differences are defned race and a prison record influences job pros- as so far apart from the U.S. mainstream as to be

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 15 GENERATIONS – Journal of the American Society on Aging considered deviant or even criminal. A prevail- nent among the UMC: exclusionary zoning in ing stereotype, for example, is that a large pro- residential areas establishes a spatial divide portion of Mexican immigrants are criminal between the UMC and others; college admis- offenders (Bender, 2003). Evidence shows that sions processes that favor the UMC, including immigrants are less likely to commit crimes than legacy preferences, continue the education U.S.-born individuals (National Academy of Sci- advantage of the UMC; and the informal alloca- ences, Engineering, and Medicine, 2015). How- tion of internships that ensures UMC children ever, it is easy to see how these stereotypes can have the social networks that lead to high-paying shape interactions, especially in meaningful jobs (Reeves, 2017). These activities prevent oth- activities such as fnding a job or getting paid ers from obtaining UMC status and lower the the same wage as other groups. risk for the UMC to slip out of their status Boundary maintenance refers to the domi- (Putnam, 2015). nant group’s actions that intend to, directly or indirectly, preserve symbolic, status, interac- Interventions Can Address Inequities tional, and spatial territories between them- Legal and policy interventions will have the selves and subordinate groups (Schwalbe et al., most substantive and far-reaching impact to 2000). Boundaries are created and maintained to deal with disadvantages linked to existing social institutions. Civil rights (including voter rights), ICW students have a rare skill and earned income tax credits, and the Affordable Care Act (ACA) are some of the examples of legal provide information, guidance, and and policy remedies that address inequities in support to wealthier clients who lack opportunities in different areas. It is unlikely that skill. that the current political environment will produce progressive measures to reduce disadvan- limit access to social and cultural capital such as tage and to increase equity on a wide range of knowledge, social networks, skills, and informa- issues. Instead, there are active attempts to scale tion that may be helpful in fnding a job, securing back or eliminate remedies designed to provide a loan, getting into good schools and neighbor- more equitable conditions for people; these in hoods, buying a house, or participating in a good clude the voter fraud commission, multiple at investment. For example, adolescents from poor tempts to repeal the ACA, and environmental neighborhoods, who have the requisite scholastic protections meant to reduce toxic pollutants in qualifcations and achievements, may not have disadvantaged geographic areas. the appropriate socialization on how to apply for Accordingly, it may be instructive to provide college or scholarships, which limits opportuni- an example of a program that works in a small ties for mobility. space but addresses inequities. This program Reeves (2017) expands on the boundary main- description is not an endorsement or an evalu- tenance feature of opportunity hoarding by fo ation, but a heuristic means to highlight how cusing on upper middle-class families (UMC) equity may be achieved on a small scale. It may or the top 20 percent with the highest income, also offer insights for other programs and poli- rather than on the super wealthy elite. He argues cies that eventually lead to a larger impact. that inequality persists because the UMC have Dorchester is the largest neighborhood in the education, skills, wealth, and high standard Boston and has a rich social history, making it of living, and they engage in activities that main- known as the Boston center of civil rights activ- tain their class standing for themselves and their ism in the 1950s. It is home to more than 114,000 children. Three activities are especially promi- residents and has a diverse racial and ethnic com

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 16 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America position, with blacks (42 percent) comprising studied interactional contexts where power and the largest group, followed by non-Hispanic resources are under negotiation and the social whites (22 percent), Latinos (17 percent), and tables are turned. In this case, members of his- Asian Americans (10 percent) (Boston Redevel- torically disempowered groups (e.g., blacks; opment Authority, 2014). While some Dorchester youth; the poor) may be in temporary positions areas have high average incomes, other sections of power relative to higher status or more privi- have child poverty rates above 30 percent. Crime leged others (e.g., white upper-middle-class pro- rates in Dorchester, including violent crimes, are fessionals). In their daily routines, clients with higher than in 80 percent of Boston’s neighbor- high incomes probably would not interact with hoods (Boston Foundation, 2011). people from backgrounds like those of ICW stu- Inner City Weightlifting (ICW) started in dents (Anderson, 2011). 2010 in a gym with an undisclosed location in One could argue that teens from poor back- Dorchester. Most of its enrollees are in gangs, grounds who perform services (such as mow- have associations with gangs, or are former gang ing lawns) in wealthy neighborhoods are similar members. Violent retaliation for past transgres- to ICW student personal trainers. Both are paid sions and conflicts is possible and serious injury for services, perform work in wealthy neigh- and death pose daily threats for its enrollees. borhoods, receive pay for their effort, and have Since ICW aims to create and maintain a safe opportunities to interact with high-income resi- physical and social environment, its exact loca- dents. ICW personal trainers, however, have sev- tion is on a need-to-know basis. ICW works with eral distinguishing characteristics that make students (as ICW enrollees are called) who have their circumstances unique. committed serious offenses, including gun- and First, they need to become certifed to drug-related offenses. administer their skills, which makes their ser- Current students come from poor neighbor- vice scarcer and more valuable in the market- hoods and are mostly black males. ICW works place. This certifcation confers elements of a to develop trust and rapport with students after profession and heightened status for students they enroll in the program. ICW expects that (Jacobs and Bosanac, 2006; Kenschaft, 2008). weightlifting will instill hope and enable stu- The quantity and quality of social interactions dents to resist retaliatory acts to violence, remove will also differ. While service providers such as themselves from criminal behavior and gang life, gardeners or house cleaners may interact with and develop a better future. While weightlift- wealthier clients to some degree, the interaction ing is a primary activity, the main objective is to often is limited to the exchange of service for remove students from the streets and into the payment. ICW students will have more extensive more supportive environment of the gym. and intensive time with their wealthier clients, About 30 percent of the ICW students which provides for more opportunities for one- become certifed instructors who train clients to-one interaction. Finally, ICW students have who work in prestigious positions and earn high a relatively rare skill and provide information, incomes. Training can take place at the Dorches- guidance, and support to wealthier clients who ter gym, at a second ICW gym in Kendall Square lack that skill. (a neighborhood of Cambridge, Massachusetts), A recent study shows that stigmatized groups or in a private business setting. This facet of the can reduce the social distance between them- ICW can influence exploitation and opportu- selves and others by demonstrating an ability nity hoarding by reducing the social distance and skill pertinent to dominant group members and blurring the boundaries between student (Lucas and Phelan, 2012). Social relationships and client. This is especially the case for seldom- become more equitable when the social table is

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 17 GENERATIONS – Journal of the American Society on Aging temporarily turned and the power is switched it involves a commitment to societal transfor- and students become the trainers of clients. As mation through the experiences and insights ICW continues, it will be intriguing to learn how of the oppressed: “Only through comradeship a temporary turning of the social and power with the oppressed can the converts understand tables can have lasting effects in establishing their characteristic ways of living and behaving, social networks between students and clients— which in diverse moments reflect the structure effects that lead to the students having increased of domination” (Freire, 2000). opportunities for social mobility. The working relationship between the stigmatized youth and the advantaged members of Closing the Gap the dominant group can help them to see each ICW provides an illustrative example of how other more clearly, to reduce othering and break a small, community-based program could hold boundaries, and to develop an equitable rela- the components for wide-scale, meaningful indi- tionship that leads to comradeship. Comrade- vidual and social change to promote equity in ship is the foundation for equality and equity, opportunities. ICW moves away from a transac- and it will only manifest within a society that is tional interaction between students and clients transformed through a restructuring of power. (i.e., the exchange of pay for services) to one that It allows for people disadvantaged by their past could build relationships. Relationship-building to share the same starting line with more advan- provides the means to resist the effects of other- taged members. ing and to blur boundaries between its students and the dominant, more powerful groups. A key David T. Takeuchi, Ph.D., is a professor, associate dean component of the relationship between student for Research, and Dorothy Book Scholar at the Boston and client is the fostering of hope. Hope provides College School of Social Work in Chestnut Hill, students with the promise to invest in their own Massachusetts. He can be contacted at takeuchi@ futures and to persevere against the social, eco- bc.edu. Tiziana C. Dearing, M.P.P., is a professor for nomic, and political challenges in their commu- Macro Practice at the Boston College School of Social nities (West, 2004). Hope can enable ICW Work. She can be contacted at [email protected]. students to move beyond the blurring of bound- Melissa W. Bartholomew, M.Div., M.S.W., J.D., is a aries into actively engaging in building bridges doctoral student at the Boston College School of Social between members of the dominant group and Work. She can be contacted at [email protected]. the stigmatized, oppressed group. Ruth G. McRoy, M.S.W., Ph.D., is the Donahue and Freire (2000) contends this bridge-building Difelice Professor of Social Work at the Boston College process is critical to dismantling the structures School of Social Work. She can be contacted at ruth. that create inequality. For the dominant group, [email protected].

References Anderson, E. 2011. The Cosmo- Boston Foundation. 2011. The Mea- Burton, L., and Welsh, L. 2015. politan Canopy: Race and Civility sure of Poverty. Boston: Boston Inequality and Opportunity: The in Everyday Life. New York: W.W. Foundation. Role of Exclusion, Social Capital, Norton & Company. and Generic Social Processes in Boston Redevelopment Author- Upward Mobility. New York: Bender, S. W. 2003. Greasers and ity. 2014. Neighborhood Redistrict- William T. Grant Foundation. Gringos: Latinos, Law, and the ing Profile: 2010 Decennial Census. American Imagination. New York: Boston: Boston Redevelopment New York University Press. Authority. tinyurl.com/y8qo8az5. Retrieved April 24, 2018.

Curry, J. A., Riley, R., and Batti- Lucas, J. W., and Phelan, J. C. 2012. Reeves, R. V. 2017. Dream Hoarders: soni, R. M. 2003. Constitutional “Stigma and Status: The Interrela- How the American Upper Middle Government: An American Expe- tions of Two Theories.” Social Psy- Class Is Leaving Everyone Else in rience (5th ed.). Dubuque, IA: Ken chology Quarterly 75: 310–33. the Dust, Why that Is a Problem, dall/Hunt Publishers. and What to Do About It. Wash National Academy of Sciences, ington, DC: Brookings Institu- Dworkin, R. 2000. Sovereign Vir- Engineering, and Medicine. 2015. tion Press. tue, The Theory and Practice of The Integration of Immigrants into Equality. Cambridge, MA: Harvard American Society. Washington, DC: Schwalbe, M., et al. 2000. “Generic University Press. The National Academies Press. Social Processes in the Reproduc- doi.org/10.17226/21746. tion of Inequality: An Interaction- Freire, P. 2000. Pedagogy of the ist Analysis.” Social Forces 79(2): Oppressed. New York: Bloomsbury Pager, D., Western, B., and Sugie, 419–52. Academic. N. 2009. “Sequencing Disadvan- tage: Barriers to Employment Fac- Tilly, C. 1998. Durable Inequality. Fryer, R., Pager, D., and Spen- ing Young Black and White Men Berkeley, CA: University of Califor- kuch, J. 2011. “Racial Disparities in with Criminal Records.” Annals nia Press. Job-fnding and Offered Wages.” of the American Academy of Politi- National Bureau of Economic West, C. 2004. “Prisoners of cal and Social Science 623(May): Research. NBER Working Paper Hope.” In P. R. Loeb, ed., The 195–213. No. 17462. Washington, DC: NBER. Impossible Will Take a Little While: Prus, R. 1987. “Generic Social Pro- A Citizen’s Guide to Hope in a Time Gosepath, S. 2011. “Equality.” In cess: Maximizing Conceptual of Fear. New York: Basic Books. E. N. Zalta, ed., The Stanford Ency- Development in Ethnographic clopedia of Philosophy (Spring 2011 Westen, P. 1990. Speaking of Equal- Research.” Journal of Contempo- ed.). goo.gl/oji6wS. Retrieved Jan- ity: An Analysis of the Rhetorical rary Ethnography 16(3): 250–93. uary 31, 2018. Force of “Equality” in Moral and Putnam, R. D. 2015. Our Kids. New Legal Discourse. Princeton, NJ: Jacobs, M., and Bosanac, S. E. York: Simon & Schuster. Princeton University Press. 2006. The Professionalization of Work, Whitby, ON: de Sitter Quillian, L., et al. 2017. “Meta-anal- Williams, B., 1973. “The Idea of Publications. ysis of Field Experiments Shows Equality.” In B. Williams, ed., No Change in Racial Discrimina- Problems of the Self. Cambridge, Kenschaft, L. 2008. Professions and tion in Hiring Over Time.” Pro- MA: Cambridge University Press. Professionalization. Oxford, UK: ceedings of the National Academy Oxford, UK: Oxford University Oxford University Press. of Sciences 114(41): 10870–5. Press, 1997. Link, B. G., and Phelan, J. C. 1995. Rae, D., et al., 1981. Equalities. Wilson, V., and Rodgers III, “Social Conditions as Funda- Cambridge, MA: Harvard Uni W. M. 2016. Black−White Wage mental Causes of Disease.” Jour- versity Press. Gaps Expand with Rising Wage nal of Health and Social Behavior Inequality. Washington, DC: 35(Extra Issue): 80–94. Rawls, J. 1971. A Theory of Justice Economic Policy Institute. (Rev. ed., 1999). Cambridge, MA: Harvard University Press.

Unequal Places: The Impacts of Socioeconomic and Race/Ethnic Differences in Neighborhoods

By Jennifer Ailshire and Catherine García Poverty, neighborhood disorder, social cohesion, and air pollution all play a part in older adults’ physical and mental health.

he U.S. population is aging rapidly and many race and ethnicity (Williams and Collins, 2001). Tfactors, from the predicates of policy to the The same political, economic, and social forces assumptions of individuals, are raising expectations that produced race and ethnicity–based residential that older adults will be able to live independent, segregation also often led to social and economic active, and engaged lives in their communities. problems in the neighborhood. Residential segre- Thus, it is increasingly important to determine gation has been linked, with differential exposure, how the environments in which older adults to neighborhood-based social stressors, physi- reside support or hinder optimal living. Equally cal hazards, and community resources (Gee and important, however, is an acknowledgement Payne-Sturgis, 2004). Additionally, low-income that some older adults live in unequal environ- individuals of all race and ethnic backgrounds are ments—where they are more likely to be exposed more likely to live in poor neighborhoods where to adverse economic, social, and physical condi- stressors, hazards, and lack of resources are com- tions—and this can result in social disparities in mon problems. Any examination of inequality, health and well-being at older ages. therefore, must consider both race and socioeco- A fundamental aspect of social and economic nomic differences simultaneously. inequality is the unequal environments to which Poorly resourced and hazardous environ- people of different racial, ethnic, and socioeco- ments can have adverse impacts on health and nomic backgrounds are exposed. The result of a well-being across the life course, but are particu- historical legacy of racial residential segregation of larly harmful in older age, when individuals are U.S. neighborhoods is that the population is largely at greatest risk of declines in health and func- distributed across neighborhoods based on their tioning. The social, economic, and physical envi-

abstract The social, economic, and physical environments in which older adults live play a vital role in healthy, active, and engaged lives. But older adults live in unequal environments. Low-income older adults and older racial-ethnic minorities are more likely to live in neighborhoods characterized by poverty, disorder, lack of social cohesion, and pollution. At all income levels there is a greater proportion of older racial-ethnic minorities in neighborhoods with economic, social, and physical problems. Neighborhood inequality may contribute to disparities in the aging experience. | key words: neighborhoods, older adults, race-ethnicity, poverty, neighborhood disorder, social cohesion, air pollution

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 20 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America ronments in which older adults live play a vital been linked with a range of physical and men- role in fostering opportunities to lead healthy, tal health outcomes in older adults. Based on active, and engaged lives (Berkman et al., 2000; a recent report summarizing research funded Clarke and George, 2005). by the National Institutes on Aging, older resi- A growing body of evidence, for instance, has dents of economically disadvantaged neighbor- drawn connections between the social and phys- hoods have a higher risk for chronic diseases, ical environment and the processes implicit in functional limitations, and mobility issues, cog- disease and disablement, functional and cogni- nitive impairment, and accelerated biologi- tive decline, and general well-being (Clarke and cal aging (Population Reference Bureau, 2017). Nieuwenhuijsen, 2009; Saelens and Papadopou- Research cited in the report found the relation- los, 2008; Yen, Michael, and Perdue, 2009). Older ship between neighborhood economic status adults experiencing declines in physical and and health was independent of the older adult’s cognitive functioning, mobility limitations, and own economic status, which suggests the disad- decline in social activities and contacts may be vantage of living in poor places is not merely a particularly dependent upon resources and ame- byproduct of one’s own economic circumstances. nities in their immediate environment, as well as more vulnerable to stressors and hazards in their The U.S. population is largely residential environment. Exposure to unequal environments can play distributed across neighborhoods a major role in generating and sustaining racial, based on race and ethnicity. ethnic, and socioeconomic disparities in the aging experience. Specifc neighborhood-based Residence in a high-poverty neighborhood exposures that have been identifed as funda- can exacerbate the problems associated with mental to this inequality include poverty, disor- low income, or can subject those with higher in der, social cohesion, and air pollution. comes to adverse environmental conditions not experienced by residents of more affluent com- Neighborhood Inequality munities. The distribution of older adults living Neighborhood economic status, disorder, and in high-poverty neighborhoods by race-ethnicity lack of social cohesion have been linked to a and income is shown in Figure 1 (see page 22). range of negative physical and mental health Not surprisingly, the share of older adults outcomes in older adults. living in high-poverty neighborhoods declines as household income increases. But at every Neighborhood poverty level of income, there are more older Hispan- Economic inequality is most clearly visible in ics and blacks living in high-poverty neighbor the comparison of poor neighborhoods with hoods than whites of similar income. This affluent neighborhoods. Residents of poor neigh- difference is the most stark among older adults borhoods, for instance, are more likely to be ex of lowest income. posed to social stressors, crime, and physical Findings from the Health and Retirement hazards from decaying infrastructure. Further- Study (2010) and 2010 Census tract counts show more, poor neighborhoods tend to lack the social, that only 20 percent of low-income whites live political, and economic resources that beneft in high-poverty neighborhoods, compared with the residents of more affluent neighborhoods. nearly 60 percent of older Hispanics, and about Given the strong correlation with hazard- 66 percent of older blacks. Importantly, the ous living conditions and lack of resources, it is proportion of older Hispanics and blacks with no wonder neighborhood economic status has annual incomes of $75,000 and greater living in

Figure 1. Distribution of Older Adults Living in older adults’ decisions con- High-Poverty Neighborhoods cerning neighborhood-based activities. Older adults who feel safe in their neighborhoods are more likely to engage in outdoor physical activities, such as tak- ing a walk (Tucker-Seeley et al., 2009). In addition to reduced physical activity, older adults exposed to the stress of living in unsafe, deteriorating environments have worse health (Krause, 1996) and increased risk of functional decline (Bal- four and Kaplan, 2002). Source: Data tabulated on adults older than age 50 from the 2010 Health and Some individuals live in Retirement Study, linked with 2010 Census tract counts of population with income neighborhoods where vandal- below the poverty level. Note: A high-poverty neighborhood is defined as a Census tract in which 20 percent ism, graffiti, trash, vacant build- or more of the residents have incomes at or below the Federal Poverty Level. All ings, and fear of victimization numbers are age-standardized and weighted to the U.S. population. are common, while others live in clean and safe neighbor- high-poverty neighborhoods is as high or higher hoods. Older racial and ethnic minorities and (24 percent and 32 percent, respectively) than low-income elders are more likely to live in the the proportion of older whites with incomes former and perceive their neighborhoods as below $20,000 (22 percent). being less safe. The distribution of older adults Income inequality is a major factor in the among neighborhoods characterized as hav- economic segregation of neighborhoods. But ing high levels of disorder by race-ethnicity and neighborhoods are also segregated by race and income is shown in Figure 2 (see page 23). ethnicity. As a result, older blacks and Hispanics Findings on disorder from the Health and are concentrated in the poorest neighborhoods Retirement Study (2010) show that older adults in the United States. Residents of poor neigh- with higher income perceive less disorder in borhoods are more likely to be exposed to haz- their neighborhoods. More of older Hispanics ardous social and physical conditions that can and blacks see signs of disorder in their neighbor- further exacerbate existing inequalities in the hoods at all income levels under $75,000. At the aging experience. Moreover, poor older adults highest income level, a higher proportion of blacks tend to lack the economic resources necessary perceive neighborhood disorder than whites and to move to better neighborhoods and, as a result, Hispanics. A similar share of high-income blacks become stuck residing in poor places. perceives their neighborhoods as having signs of disorder as the lowest income whites. Neighborhood disorder Living in unsafe and unclean places can have Perceptions of neighborhood problems, such as signifcant consequences for older adults. Any lack of safety and signs of criminal activity and factor limiting the mobility and daily activi- neglect can be a signifcant source of psychologi- ties of older adults has the potential to generate cal distress for residents (Steptoe and Feldman, signifcant inequality in the aging experience. 2001). Safety is an important consideration for Lower-income adults are more likely to live in

Figure 2. Distribution of Older Adults Living in on neighbors for assistance may High-Disorder Neighborhoods be less likely to be physically active. Moreover, older adults living in places that lack social cohesion may have fewer positive social interactions on a daily basis and experience more feelings of isolation. Inequal- ity in the aging experience may, therefore, originate in the lack of cohesiveness with others in the neighborhood. The distribution of older adults living in neighborhoods with low cohesion by race-ethnicity and Source: Data tabulated on adults older than age 50 from the 2010 Health and income is shown in Figure 3 Retirement Study. (see page 24). Note: Reports of disorder were based on conditions in the local area defined as every- Findings on social cohesion where within a twenty-minute walk or about a mile of the resident’s home. Residents who reported big problems with vandalism, graffiti, and litter, people being afraid to from the Health and Retire- walk alone after dark, and many vacant houses or storefronts in the area were con- ment Study (2010) show that sidered to live in a high-disorder neighborhood. All numbers are age-standardized the proportion of older adults and weighted to the U.S. population. living in neighborhoods with low social cohesion declines worse neighborhoods, and this means they bear with increasing household income. At every the double burden of their own poverty and the level of income, a larger portion of older His- stress that is associated with exposure to neigh- panics and blacks live in low-cohesion neighborhood-based problems. Older adults living in places lacking Neighborhood social cohesion social cohesion could have fewer Connecting with neighbors is critical for the health and well-being of older adults whose main positive social interactions and more activities and social interaction may be limited to feelings of isolation. their immediate environments. Socializing with neighbors has been linked with improved recov- borhoods than do whites. Differences between ery from severe mobility limitation (Latham, the groups are quite small in the highest in Clarke, and Pavela, 2015). Older adults living come range. About 30 percent of older blacks among neighbors they consider friendly and with income less than $40,000 live in neighbor- trustworthy may feel safer and thus would be hoods they would characterize as being low on more likely to engage in physical activity outside social cohesion. the home. In addition, visiting with neighbors Older minorities and those with low income can be an important source of social interaction are more likely to live in neighborhoods where and support. they may feel isolated from and mistrustful of Conversely, older adults who think people their neighbors. These older adults lack a poten- in their neighborhood cannot be trusted or are tially important resource for maintaining opti- unfriendly, and who do not think they can rely mal health as they age.

Figure 3. Distribution of Older Adults Living in fne particles can do the fol- Neighborhoods with Low Cohesion lowing: irritate the lungs, causing damage to lung tissues and aggravating pre-existing lung conditions; pass into the body’s circulatory system, leading to increased inflammation and risk of blot clots; and may even traverse the thin lining of epi- thelial cells separating the nasal cavity from the brain, where they can cause damage to the structure and function of the aging brain (Anderson, Thun- diyil, and Stolbach, 2012). Source: Data tabulated on adults older than age 50 from the 2010 Health and What is the extent of in Retirement Study. Note: Reports of social cohesion were based on conditions in the local area defined as equality in exposure to haz- everywhere within a twenty-minute walk or about a mile of the resident’s home. Res- ardous air among older adults? idents who reported not feeling they belong in the area, that people are not friendly A good way to quantify this is and cannot be trusted, and who feel nobody in the area would help if they were in trouble were considered to live in a low-cohesion neighborhood. All numbers are to determine the proportion of age-standardized and weighted to the U.S. population. older adults living in areas with unhealthy levels of air pollu- Air Pollution tion. The U.S. Environmental Inequality also manifests in the air we breathe. Protection Agency (EPA) sets air-quality stan- Neighborhood social and environmental stress- dards for the nation for all criteria of air pol- ors, such as socioeconomic disadvantage and air lutants. This standard is the level at which the pollution, tend to cluster together geographi- accumulated science has determined concentra- cally. The accumulated evidence from decades of tions of an air pollutant create increased risk to research indicates that racial and ethnic minori- human health. Individuals living in areas with ties and individuals of low socioeconomic status annual average PM2.5 concentrations above this live in communities with a higher burden of level are living in high-pollution environments. air pollution exposure (Gee and Payne-Sturgis, The disproportionate burden of air pollution 2004; Hajat et al., 2013). exposure among older adults by race/ethnicity Exposure to polluted air can have serious and income is shown in Figure 4 (see page 25). health implications for older adults. Although Findings from the Health and Retirement several air pollutants have been shown to be Study (2010) and 2010 Census tract estimates of harmful to human health, small-particle air pol- seasonally weighted annual average PM2.5 con- lution, which is largely a byproduct of industrial centrations from the U.S. EPA’s Fused Air Qual- activities and traffic-based emissions, is of par- ity Surface Using Downscaling (FAQSD) (2018) ticular concern to health researchers. Fine par- fles show the following: At every level of income, ticulate matter (PM2.5 ) includes particles that are a larger portion of older blacks live in high- 2.5um (microns) in diameter and smaller; a grain pollution neighborhoods than do whites. Among of fne beach sand is about 90um in diameter. higher-income households, older Hispanics are

PM2.5 is ubiquitous in the air we breathe and also more likely to live in high-pollution neigh- due to the particulates’ small size, once inhaled, borhoods than their white counterparts. This

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 24 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America difference is most pronounced Figure 4. Distribution of Older Adults Living in among those with household High-Pollution Neighborhoods incomes between $40,000 and $75,000; about 10 percent of older whites live in highly polluted places, compared with 17 percent of Hispanics and 19 percent of blacks. Exposure to high concentrations of air pollution declines with rising income, but only among older white adults. Nearly twice as many low-income older whites live in highly polluted areas, compared to those with high income. Household income is Source: Data tabulated on adults older than age 50 from the 2010 Health and not related to pollution burden Retirement Study linked with 2010 census tract estimates of seasonally weighted annual average PM2.5 concentrations from the U.S. EPA’s Fused Air Quality among older blacks and His- Prediction Using Downscaling (FAQSD) files. panics, which suggests that Note: A high-pollution neighborhood is defined as a Census tract with an annual increasing income does not average PM2.5 concentration above the EPA standard of 12 µg/m3. All numbers are confer the same ability to avoid age-standardized and weighted to the U.S. population. living in polluted places for older minorities as it does for older whites. risk of cognitive decline and dementia (Power Environmental inequality can lead to health et al., 2016). Inequality in the aging process and inequality. Older adults, particularly those in outcomes of aging may be rooted in the differen- poor health, are more susceptible to the adverse tial exposure to hazards that results when older effects of both chronic and acute pollution expo- adults live in unequal environments. sure. Older minorities and low-income whites bear a disproportionate burden of air pollu- Conclusion tion in their communities and may, therefore, The expectation and hope of individuals, their be exposed to increased health risks as they families, and policy makers is that older adults age. Furthermore, increasing income does not will age independently in their communities. shield older blacks and Hispanics from neighbor- Their ability to remain healthy and independent, hood pollution as it does for whites. Neighbor- however, depends greatly on whether the neigh- hoods tend to be segregated by race, regardless borhood conditions to which they are exposed of income (Reardon, Fox, and Townsend, 2015), help or hinder healthy aging. and neighborhoods with predominantly non- Efforts to improve aging outcomes, whether white populations are likely to be spatially iso- at the individual or community level, need to lated in more disadvantaged areas where there consider the unequal distribution of older adults are higher air-pollution concentrations (Hajat into neighborhoods. For instance, programs et al., 2013; Jones et al., 2014). designed to promote physical activity or social This inequality in air pollution exposure is engagement among older adults should consider particularly concerning given emerging evidence potential barriers in the residential environment. that older adults living in more polluted areas Regardless of their motivations and intentions to have worse cognitive function and are at greater be physically active and socially involved, older

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Gaps Matter: Environment, Health, and Social Equity

By Manuel Pastor and Rachel Morello-Frosch Social inequality in exposures to environmental hazards erodes environmental conditions for all people.

n recent years, public health advocates and over time (Berg, Ostry, and Zettelmeyer, 2012). Iresearchers have promoted the idea that in Economists looking at metropolitan regions in equality is not just morally distasteful, but also the United States have offered similar fndings potentially damaging to overall health and well- of the relationship between inequality and eco- being. Among the most compelling advocates of nomic performance, suggesting that tackling this position have been Richard Wilkinson and unequal opportunity for some could have broad Kate Pickett, who laid out the scientifc evidence benefts for all (Benner and Pastor, 2015). and policy implications in their book, The Spirit An emerging frontier in this new work Level: Why Greater Equality Makes Societies involves examining the relationship between Stronger. The authors argue that it is not only social inequality and environmental degrada- economic shortfalls such as poverty that impact tion. Specifcally, social inequality in exposures health, but also the degree of inequality in the to environmental hazards can erode overall distribution of income and wealth that affects environmental conditions for everyone. For ex health, particularly in wealthier societies ample, when low-income communities and (Wilkinson and Pickett, 2011). communities of color are disproportionately A parallel argument has evolved in eco- exposed to harmful pollution (in air and water, nomics, a feld long associated with the notion for example), pollution can be viewed by those of an efficiency-equity trade-off rather than not in that community as someone else’s prob- an efficiency-equity complementarity. Econo- lem. This then can result in a decline in the pub- mists at the International Monetary Fund have lic and political will to implement environmental found that initial disparity in the distribution of policies that reduce overall pollution exposure income and assets is the factor most signifcantly levels and protect community health (Boyce et associated with the inability to sustain growth al., 1999). While still nascent, this new research

abstract Environmental justice often is seen as an issue of righting disparities in the exposures of low-income communities and communities of color to toxic hazards, air pollution, and other disamenities. An intriguing new wave of research finds that when environmental costs and benefits are unequally distributed, this can diminish the collective will to address the commons and hence worsen environmental conditions overall. While more studies are needed, this suggests that centering equity can be beneficial to policies and movements for sustainability. | key words: environmental justice, climate change, public health, social movements, racial generation gap

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 28 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America suggests that environmental inequality can suggests that inequalities are not merely a func- reduce environmental quality. tion of market forces or of wealth, but also are due to structural racism and its interaction with What Is Environmental Inequality? power over processes of permitting decisions Environmental inequality refers to the tendency and the siting of toxic facilities (Hamilton, 1995; for environmental disamenities to be dispropor- Pulido, 2000; Ringquist, 2005). tionately located in low-income communities of These deeply embedded environmental color. This long-standing concern gained national inequalities have adverse impacts on health, and traction because of 1982 protests against the much of the research has validated the concerns placement of a hazardous waste landfll in War- of community organizers worried about local ren County, North Carolina, one of the poorest environmental health issues (Morello-Frosch counties with the greatest proportion of African and Jesdale, 2006; Pastor, Sadd, and Morello- American residents in the state (McGurty, 2000). Frosch, 2004). Vibrant campaigns have sought to The protests prompted the frst nationwide study pressure decision makers to address the health of environmental disparities in the location of effects on local residents of large industrial facil- treatment storage and disposal facilities, which in turn led to a new wave of research by govern- ‘New research suggests that ment agencies and academic scholars (United Church of Christ Commission for Racial Justice environmental inequality can 1987; U.S. General Accounting Office, 1983). reduce environmental quality.’ By 1994, President Bill Clinton signed an executive order mandating that federal govern- ities—such as refneries, chemical plants, and ment agencies (including the U.S. Environmental traffic and truck-related air pollution—and the Protection Agency [EPA], the National Institutes risks associated with living near landflls and of Health, and the departments of Interior and hazardous waste processors (Cole and Foster, Energy) consider the potential disparate environ- 2001; Matsuoka et al., 2011). Advocates also have mental burdens of their programs and enforce- broadened their demands to include not just ment activities on low-income communities and relief from environmental “bads” but also equal people of color (Bullard, 1996). access to environmental “goods,” such as green Despite methodological challenges raised in space, fresh food, and better, affordable public response to some of the earliest research demon- transit (Pastor, Auer, and Wander, 2012). strating disparities (Anderton et al., 1994; Mohai This mobilization for environmental jus- and Saha, 2006), the weight of the evidence and tice, however, can be seen as a special-interest improvements in statistical and spatial tech- demand, one focused on addressing disparities niques indicate patterns of environmental ineq- rather than on improving overall environmental uities by race, income, and other socioeconomic quality. Environmental justice concerns about factors (including measures of civic participa- California’s cap-and-trade system to reduce tion). The patterns of race- and class-based dis- greenhouse gas emissions were dismissed as a parities in exposures to environmental hazards sideshow from the main task of addressing cli- are something we might expect given the nature mate change (London et al., 2013). Yet, climate of localized sources of pollution and the per- change policies to reduce greenhouse gas (GHG) sistence of residential segregation by race and emissions can yield signifcant public health ben- income. However, it is important to note that the efts by also reducing emissions of hazardous pattern of environmental disparity seems more co-pollutants, such as air toxics and particulate pronounced by race than by income, a trend that matter. Socioeconomically disadvantaged com-

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 29 GENERATIONS – Journal of the American Society on Aging munities are typically disproportionately exposed average exposures associated with ambient to these air pollutants, and therefore climate pol- emissions for all population subgroups, includ- icy could also potentially reduce these environ- ing for whites. mental inequities. Other research has found similar links For that reason, some economists and envi- between social inequality and environmen- ronmental justice advocates argue that effi- tal quality measures that can affect health and cient climate regulation requires deeper GHG well-being, particularly in U.S. metropolitan reductions in areas where the health benefts areas. These studies include positive associa- of reducing co-pollutants are likely to be great- tions between racial residential segregation and est, and that this objective cannot be accom- higher exposures to cancer-causing ambient air toxics (Morello-Frosch and Jesdale, 2006) and ‘It is important to be clear about noise exposure (Casey et al., 2017a); and the relationship between neighborhood poverty which constituencies will be willing concentration and lack of green space (Casey to fight hardest for change.’ et al., 2017b). While the reasons are not entirely clear, this plished with the geographically unrestricted work generally echoes our political will argu- trading characteristic of cap-and-trade, in which ment above: more unequal metropolitan regions all GHG reductions are treated equally, regard- may experience a diminished collective public less of location. In this case, revising specifc will to regulate and reduce pollution emissions policies to alleviate environmental burdens on overall, or to invest in improving green infra- disproportionately affected groups can address structure, like urban forestry, parks, and other climate change goals and enhance short-term green spaces. public health benefts. So while the equity case One intriguing experiment tried to directly is strong, social movement and policy advocacy explore the role of social cohesion in public will frames to address injustice can also be embed- to address common environmental challenges. ded in a broader set of concerns. Participants were asked to play a game in which they started off with different sums of money Does Inequality Make a Difference? and were asked to contribute to a public fund to So what is the relationship between environ- prevent climate change. As it turns out, inequali- mental inequality and environmental quality? ties in the initial endowments of money did not Just as the need to articulate this has become impede collective action on climate change if more pressing in the environmental justice advo- it was thought that everyone would be affected cacy space, a new wave of research is offering by climate change. However, when told that the an interesting analog to earlier research on the risks of harm from climate disaster were greater relationship between inequality and economic for low-income participants, wealthier partici- growth or public health. In one article, “Is pants in the game became less willing to part Environmental Justice Good for White Folks?” with their cash and more willing to let the planet economist Michael Ash and colleagues look at warm (Burton-Chellew, May, and West, 2013). the modeled distribution of risks from facilities required to report annual pollutant emissions Evidence and Public Will to the EPA (Ash et al., 2012). Looking at met- While a recent review suggests that environmen- ropolitan areas, they found that those regions tal inequality does have some impact on envi- where average exposures are distributed more ronmental quality—the research is just emerging unequally by race or ethnicity also have higher and there are clear caveats to overgeneralization

(Cushing et al., 2015). For example, the negative also demographically, which can affect public impact of social and environmental disparities will around policy change. The “racial genera- on environmental conditions is more consistent tion gap”—the difference between the percent- in “within-country” studies than in research age of older adults who are non-Hispanic white comparing across countries, perhaps because it versus the percentage of young people who are is too hard to control for differing political (and non-Hispanic white—has been shown to have data collection) systems. In addition, the direc- an impact on collective investments in public tion of causality—perhaps the higher overall education: the bigger the gap (controlling for all pollution levels drive the disparities rather than other factors that explain levels of local spending the other way around—is not entirely settled on education), the lower the per-student invest- by much of this ecological and cross-sectional ment (Pastor, Scoggins, and Treuhaft, 2017). empirical work. According to projections, the racial genera- Still, continuing to explore the relationship tion gap is now at a peak in the United States, between environmental inequality and over- perhaps explaining some of our polarized all environmental conditions could enhance national politics, including around the accep- tance (and lack thereof) about the reality of climate change. Interestingly, one state where the ‘Toxic inequality hurts our economy, racial generation gap long ago peaked (in the our environment, and our well-being.’ 1990s) and has since been shrinking—Califor- nia—is also leading the nation on addressing our understanding about the causal relation- sustainability and environmental justice. How- ship between social inequality and environmen- ever, with the evidence of global warming being tal health. While more research is necessary, the increasingly obvious, our nation cannot wait for mounting evidence that inequality has a drag- demographic change to steer it toward a com- ging effect on public health, the economy, and mon understanding of environmental challenges. the environment suggests that policy advocates A bigger and broader movement must be built— and others have ample reason to be bold about one that can forge ties across groups, genera- emphasizing equity concerns. tions, and geographies; to do this, America needs There is another reason to push concerns to wed the concerns of climate change and cli- about environmental justice: while the general mate justice. Solid research on the linkage has stereotype is that whites who tend to be more a role to play. well off may be more concerned about the environment than other groups, polling in California Making Change Happen suggests that African Americans, Latinos, and As researchers, we have been documenting envi- Asians are more positively inclined to see cli- ronmental disparities since the early 1990s—one mate change as a serious issue and want author- of us as an intrepid and focused graduate student ities to address it (Baldassare et al., 2015). For and the other as, frankly, a less directly inter- those wanting stronger action on the environ- ested and somewhat scattered professor. For the ment, it is important to be clear about which latter, the path to studying environmental justice constituencies will be willing to fght hardest was not particularly intentional; a few under- for change. graduate assistants wanted to work on the topic Research and policy advocacy could beneft and produced a solid paper that, with some guid- from a dimension of central concern to the read- ance, landed in one of the best journals in the ers of this journal: age. Older adults are mark- feld (Boer et al., 1997). Immediately tagged as edly different than the young, not just in age, but an expert, the professor soon attracted the atten-

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Intersectionality and Stratification in the Labor Market

By Kyle K. Moore and Teresa Ghilarducci Older women workers, viewed through the lenses of intersectionality and stratification, are economically disadvantaged, which anticipates their precarious retirement.

lder women and women of color age in an Stratifcation economics combines economics OAmerican economy that separates and strati- with sociology and social psychology to explain fes people according to group-based identities. economic inequality. The stratifcation frame- Analyzing data from the Health and Retirement work posits that identity-based inequality is the Study (HRS)—a nationally representative panel rational outcome of a market economy that does study of Americans older than age 50—this article not work against it. Powerful social identity describes how older working women’s health, groups vie to maintain and improve their rela- work status, and retirement have changed from tive position in society, “stratifying” it through 1992 to 2014 within the framework of intersec- the development of laws, norms, and institu- tionality. tions so that inequality between groups persists Stratifcation and the intersection of identi- over time (Darity, Hamilton, and Stewart, 2014). ties are two different phenomena and together Stratifcation economics explains social and eco- signifcantly affect a person’s chances to age nomic inequality in a way that shifts research with dignity, health, and economic security. The and policy focus away from individual and cul- intersectionality research framework posits that tural defciencies. our social identities (race, gender, class, age, sex- uality, nationality) affect us in multiple ways: How Women and Men Face Different our identities exist as more than the sum of their Aging Landscapes parts. Understanding the social position of older “Patriarchy” is gender-based stratifcation in black women requires more than adding “the which men dominate norms, create institutions, black experience” to “a woman’s experience.” and develop laws to maintain social and eco-

abstract Since the 1990s, women have made gains in education and work, but gender and racial stratification in health, work, and retirement create disparities in aging. This article explores the changing social and economic status of mature men, women, and women of color through a review of the health and aging literature, and analysis of the Health and Retirement Study. The article analyzes the ways women—black women in particular—are disadvantaged by racialized patriarchy, leading to strong dependence on government old-age programs. | key words: stratification economics, racialized patriarchy, retirement income, older women of color, Health and Retirement Study

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 34 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America nomic power over women (Fraser, 2012). Patri (Ross, Masters, and Hummer, 2012). In the 2014 archy takes many forms; its latest iteration ap wave of the HRS, 32 percent of older men (ages pears as “patriarchal capitalism” (Folbre, 2012). 55 to 64) with a high school education or less Patriarchal capitalism supports a market and rated their health as “fair or poor,” compared to non-market division of labor based on gender—a 34 percent of women with a high school educa- system that distinguishes “women’s” work from tion or less. More education helped women more “men’s” work. A gendered division of labor limits than men: 17 percent of college-educated men women’s employment in high-paying jobs, and rated their health as “fair or poor,” compared to allows frms to pay women less than men in the 15 percent of college-educated women. same jobs. Male roles assign dominance, success, and stoicism that can lead to poor health in labor Gendered work dynamics markets where male wages and jobs are eroding. Women’s work prospects changed throughout Patriarchal capitalism makes the labor market the latter half of the twentieth century, and con- experiences of most women and men worse, tinue to change. Cha and Weeden (2014) show while beneftting a small, mostly male, group the convergence in women’s and men’s wages at the top. slowed after the 1990s and stalled in the 2000s, despite women’s increasing labor force participa- ‘Stratification economics combines tion and educational attainment. They attribute the slowdown in gender wage convergence to economics with sociology and social men’s “overwork”—defned as work exceeding psychology to explain economic ffty hours per week. Because men are better inequality.’ able to “overwork” because they have a partner (often a woman) at home performing the neces- Patriarchal capitalism has weakened as more sary domestic labor and care work, organizations women work, obtain education, and move into that support and reward overwork reinforce pa previously male-dominated jobs. Weakening gen- triarchy and gender inequality. dered work and closing pay gaps affect the life Dwyer (2013) provides a macro-oriented per- course of men and women and the health, work, spective on care work in the U.S. economy, argu- and retirement status of older women and men. ing the increase in the share of jobs requiring elements of care—ranging from surgeons to home Gendered health dynamics health workers—accounts for a signifcant portion Women live longer than men, but their morbidity of job and wage polarization between the 1980s (incidence of disease and disability) plays a sig- and late 2000s. Because women are dispropor- nifcant role in women’s lives as they age. Crim- tionately employed in care work jobs—from doc- mins and Beltrán-Sánchez (2010), between 1998 tors and nurses to personal care aides—this could and 2008, found signifcant increases in disease lead to increasing income polarization among and mobility-functioning loss for women. They women workers. However, women and racial also found morbidity is not limited to the fnal minority groups have historically been concen- years of life—people with longer lives have higher trated in lower-paid care-work occupations. risks of poor and declining health. Long-term HRS data confrm convergence between care plays a more important role in women’s older women’s and men’s labor market experi- lives compared to men’s. ences over the past twenty years. Between 1992 Women’s self-reported health status varies and 2014, the share of older women (ages 55 to more with education than men’s, and more edu- 64) working full time (at least thirty hours per cation boosts women’s health more than men’s week and forty weeks per year) rose from 41 per

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 35 GENERATIONS – Journal of the American Society on Aging cent to 45 percent, while the share of older men change in retirement planning over time is working full time fell from 66 percent to 59 perdue to increased educational attainment, more cent. Full-time earnings converged as well, marital disruption, and women having fewer though, as is the case with convergence in labor children (all signs of declining patriarchal force participation rates, this is due in part to capitalism), but also is due to increased debt falling annual earnings among men. Between and fnancial fragility (a measure of whether 1992 and 2014, older women’s median full-time one could come up with $2,000 in thirty days). earnings (in 2014 dollars) rose from $30,382 to Duberly, Carmichael, and Szmigin (2014) ex $36,750, while men’s median full-time earnings plore the differences between women’s and fell from $48,101 to $47,000, which may reflect men’s career paths and experiences with retire- the loss of unions and other sources of bargain- ment, noting women’s reasons for continuing ing power (Madland and Rowell, 2017). work or deciding to retire often are more rela- Jobs have become less physically intensive tional than are men’s, as women consider the overall for both older women and men. In 1992, needs of family members and other dependents. 38 percent of women and 41 percent of men re They also emphasize that the role of early disad- ported their jobs required physical effort all or vantage (such as low pay and underemployment) most of the time. By 2014, 31 percent of women in the labor market affects how older women ap and 34 percent of men reported their jobs required proach retirement (Duberly, Carmichael, and physical effort. However, stooping, crouching, Szmigin, 2014). and kneeling actions often are required in care Access to a retirement plan at work, the type of retirement plan at work, and retirement sav- ‘Women need sources of retirement ings balances have undergone major changes for women over the past twenty years. As women’s income that will guarantee security participation in the labor force has increased, through to their final years.’ so has their access to pensions at work; in 1992, 29 percent of older women had a workplace re and service occupations. In 1992, 23 percent of tirement plan, whereas by 2014, that number women reported needing to perform these had increased to almost 38 percent. Much of actions at work, while 30 percent of men did so. this change is attributable to the rise in defned By 2014, these statistics had largely converged, contribution retirement plans, and their grad- with women reporting needing to stoop, crouch, ual replacement of more secure defned ben- and kneel 25 percent of the time, compared to eft plans that characterized earlier periods of men’s 27 percent. If certain aspects of jobs are patriarchal capitalism. Of the older women who becoming more physically intensive, then it may had access to pensions in 1992, 36 percent had be more difficult for older workers to continue to a defned contribution plan as their sole source work, making the option to retire more impor- of workplace retirement savings. By 2014, that tant than ever. number had increased to 57 percent. The increase in defned contribution plan Gendered retirement dynamics coverage translated into an increase in defned Women’s retirement prospects are affected by contribution account balances for both women their long lives, their higher morbidity, their and for men, though men still have larger bal- familial position, and their experience in the ances than women. In 1992, the median sums labor market. Lusardi and Mitchell (2016) show of all defned contribution plan balances for that, compared to 1992, more recent cohorts women and men (in 2014 dollars) were $10,000 of women plan on delaying retirement. This and $40,500 respectively. By 2014, those bal-

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 36 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America ances had increased to $40,000 for women, working conditions for many white Americans and $70,000 for men. Women need sources of by keeping wages low. retirement income that will guarantee security Intersectional analysis directs us to look for through to their fnal years. the ways in which white racism transforms black The slow decline of patriarchal capitalism has women’s experiences within the patriarchy, allowed women to attain increased economic such that they are distinct from white women’s prosperity and independence in some cases, experiences, and for the ways white racism and though the disruption of existing systems has the patriarchy reinforce one another (Brewer, left some groups of women in economic insecu- Conrad, and King, 2002). In the following sections, this article describes how health, work, ‘Neither black women nor white and retirement outcomes differ between black women and white women. women have enough saved at older ages, but older black women are in Racialized dynamics for women: health a more precarious position.’ Race and gender intersect, causing signifcant health challenges for black women as they age, rity. This is clear when examining differential including distinct challenges from the burdens outcomes among women by race. Analyses using of morbidity women generally face at older ages. intersectionality and stratifcation lenses bring Being black is associated with higher morbidity this polarization of outcomes among women into at older ages across gender, leading to a longer stark relief. period of end-of-life morbidity for black women as compared to white women. Jeffries (2012) Aging Experiences of Black Women documents how “co-morbidities”—multiple and White Women health issues that develop together—impact black While all women live experiencing the conse- women in particular, and how they develop as a quences of gender-based stratifcation under result of various economic and social factors. patriarchy, black women in the United States Jefferies highlights obesity and mental health face the further burden of racial stratifcation issues as being exacerbated by the mass incarcer- under systemic white racism. White racism, ation of black men, and the attendant decrease of though it is a younger system of social and eco- resources and increase in stress levels that may nomic stratifcation than patriarchy, is no less come from family disruption. Warner and Brown life-altering for those living within its bounds. (2011) use an intersectionality approach, with an Just as patriarchy refers to a system that subor- analysis of HRS, to examine the development of dinates women to men, white racism establishes disability across the life course for older Ameri- a racial hierarchy which subordinates all other cans. While they fnd that disability levels follow racial categories to those designated as white a predictable pattern, with white men having (Saunders and Darity, 2003). the lowest levels and black women and Hispanic Though there is no longer a formal legal sys- women having the highest, black women are tem of racial stratifcation as there was in the found to have increasing levels of disablement United States up until the 1960s, its vestiges throughout old age. remain persistent in their effects on blacks and Older black women are indeed sicker than other racial minorities across the life course. their white counterparts, irrespective of college While white racism serves its purpose of main- attendance: forty-three percent of older black taining economic and social distance between women with a high school diploma or less edu- blacks and whites, it also worsens living and cation, and one-fourth of black women who had

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 37 GENERATIONS – Journal of the American Society on Aging attended some college rated their health as “fair disparities did exist. In 1992, half of all older or poor” in 2014. A signifcantly smaller share of black women reported having to exert physical older white women reported bad health: thirty- effort at work all or most of the time, compared two percent of older high school−educated white to 37 percent of older white women. By 2014, women and 14 percent of college-educated wo 44 percent of women needed to exert physical men. Education was more protective of white effort on the job, compared to 30 percent of older than black women: more education reduced black white women. Stooping, kneeling, and crouch- older women’s likelihood to rate themselves as ing actions on the job increased for white women having poor health by 43 percent, but for white between 1992 and 2014, rising from 22 percent women, the improvement was 57 percent. to 25 percent, while black women’s incidence of stooping, kneeling, and crouching barely changed Racialized dynamics for women: work and remains 15 percent higher than white wom- Older black women face unique challenges in the en’s. Black women still are disadvantaged in the workplace at the intersection of white racism labor market, and face a higher risk of exposure and patriarchy. The health effects of changing to working conditions that harm health. industry distribution fall heaviest upon black women, who already face a high risk of old age Racialized dynamics for women: retirement morbidity and higher mortality as compared to Low career earnings and higher risk of work- white women. Goh, Pfeffer, and Zenios (2015) related morbidity both diminish black women’s show exposure to harmful workplace condi- prospects for retirement, including their abil- tions accounts for a larger share of life expec- ity to accumulate adequate retirement savings. tancy reduction for black women, as compared Brown (2011) uses the HRS to analyze older to white women or white men, particularly for black women’s wealth trajectories, and fnds those with a high school diploma or less edu- their low levels of net worth during middle and cation. Duffy (2005) complicates traditional late life are the result of living under racialized notions of care work, showing women of color patriarchy—discrimination, state policy, and often are stratifed into those care-work occupa- residential segregation all affect black women’s tions with the lowest pay and fewest opportuni- wealth in retirement. Angel, Prickett, and Angel ties for advancement. (2014) confrm that women of color are at higher While older women have improved economi- risk of retirement insecurity, reap fewer eco- cally relative to men over the past twenty years, nomic gains from marriage, and will have to rely closer inspection reveals increases in earnings upon Social Security and other assistance pro- and labor force participation have gone dispro- grams as they age. portionately to white women. While 40 percent HRS data reveal that older black women are of both older black women and white women less fnancially secure in retirement compared were employed full time in 1992, by 2014, white to older white women, and are becoming less women’s participation rose beyond black wom- secure. We analyze women’s pension wealth sep- en’s to 46 percent, compared to 39 percent. In arately from their husbands’. Married women addition, the racial earnings gap between older may be able to beneft from some of their hus- women grew—older white women earned 6 per- bands’ pensions, but marriage is a fluid state: a cent more in 1992 than older black women and woman’s claim to her husband’s pension is vul- 20 percent more in 2014. nerable if she becomes single or divorced. Older white women and black women were While the share of older white women with required to do less physical effort in the work- retirement plans at work rose from 35 percent place in 2014 than they did in 1992, though racial to 42 percent between 1992 and 2014, the share

Figure 1. Defined Contribution (DC) especially black women—are at risk. For racial and Account Balances ethnic minorities, relatively lower life chances for high socioeconomic status, safe jobs, and low Older Women have Less Saved in DC Accounts than Older Men; Black Women have Less Saved than White Women rates of old-age morbidity (Crystal and Shea, 1990) produce relatively more reliance upon the state. $80,000 $70,000 $70,000 $60,000 An intersectional approach to describing the $45,000 $50,000 $40,000 $40,000 health, work, and retirement of older Americans $30,000 $21,000 $20,000 helps us understand the social and economic $10,000 $- Women Men Black Women White Women inequalities that leave all women, and especially DC Account Balance 2014 women of color, disadvantaged in old age. Source: RAND HRS Data, Version P., 2016. Depicts sum across This article focused on and analyzed the defined contribution plans at work for full-time workers ages ways in which older women, particularly older 55 to 64. black women, are disadvantaged by racialized of older black women with workplace retire- patriarchy. There are more dynamics in the ment plans fell from 31 percent to 28 percent. political economy of aging in the United States Among women with pensions, the share of older that we have not explored. Hispanic and Asian black women who only have a defned contribu- ethnic identifcation also shape the aging pro- tion plan more than doubled, from 26 percent to cess, and each requires separate analysis. Strati- 57 percent, while the share of white women hav- fcation in the labor market not only maintains ing only defned contribution plans rose from 37 a relative position for dominant social identity percent to 59 percent. (Defned contribution— groups, but also serves the greater purpose of 401(k)−type plans—are more risky than tradi- lowering wages for all workers to the beneft of tional workplace retirement plans, and employers the capitalist class. Class is no less an impor- are not mandated to provide 401k savings.) tant identity than is race or gender; that said, Though both black women and white women we leave the class benefciaries of stratifcation have some individual retirement savings, black to further research. women’s balances lag far behind men’s and white The government can mitigate the harm done women’s. Black women’s median total defned to disadvantaged groups and the inequity caused contribution wealth in 1992 was only $6,329 and by racialized patriarchy. Government programs rose in 2014 to $21,000, while white women’s and policy should aim to provide access to affor defned contribution wealth grew from $11,533 dable long-term healthcare and secure vehi cles to $45,000. Most Americans are not prepared for retirement savings for all Americans (Ghilar- for retirement (Ghilarducci, Papadopoulos, and ducci and James, 2018), so that older women are Webb, 2017). Neither black women nor white able to retain the option of a secure retirement women have enough saved at older ages, but older after a lifetime of work; this would promote black women are in a more precarious position. healthier retirements and more options in the labor market. Political Economy of Race and Gender Workplace and household patriarchy have created Kyle K. Moore is a doctoral student in economics at a gendered dependency of older people, in their The New School for Social Research in New York City. older age, upon the state. Social Security, Medi- He can be contacted at [email protected]. care, and Medicaid are especially important to Teresa Ghilarducci, Ph.D., is the Bernard L. and Irene benefciaries who will live a long time and who Schwartz Professor of Economics and director of the were lifelong low-wage workers in physically de Schwartz Center for Economic Policy Analysis at The manding jobs—a situation for which women— New School for Social Research.

References Angel, J. L., Prickett, K. C., and Duberley, J., Carmichael, F., and Lusardi, A., and Mitchell, O. Angel, R. J. 2014. “Retirement Szmigin, I. 2013. “Exploring Wom- 2016. Older Women’s Labor Mar- Security for Black, Non-Hispanic en’s Retirement: Continuity, Con- ket Attachment, Retirement Plan- White, and Mexican-origin text and Career Transition.” Gender, ning, and Household Debt (Rep. No. Women: The Changing Roles of Work & Organization 21(1): 71–90. 22606). Cambridge, MA: National Marriage and Work.” Journal of Bureau of Economic Research. Duffy, M. 2005. “Reproducing Women, Politics & Policy 35(3): Labor Inequalities.” Gender & Madland, D., and Rowell, A. 2017. 222–41. Society 19(1): 66–82. How State and Local Governments Brewer, R. M., Conrad, C. A., and Can Strengthen Worker Power and Dwyer, R. E. 2013. “The Care Econ- King, M. C. 2002. “The Complexi- Raise Wages. Washington, DC: omy? Gender, Economic Restruc- ties and Potential of Theorizing Center for American Progress turing, and Job Polarization in the Gender, Caste, Race, and Class.” Fund. goo.gl/qzQJVp. Retrieved U.S. Labor Market.” American Soci- Feminist Economics 8(2): 3–17. March 2, 2018. ological Review 78(3): 390–416. Brown, T. 2011. “The Intersection RAND HRS Data, Version P. 2016. Folbre, N. 2012. The Rise and and Accumulation of Racial and Produced by the RAND Center Decline of Patriarchal Capitalism Gender Inequality: Black Women’s for the Study of Aging, with fund- (Working paper No. 298). Amherst, Wealth Trajectories.” The Review ing from the National Institute MA: University of Massachu- of Black Political Economy 39(2): on Aging and the Social Security setts Amherst Political Economy 239–58. Administration. Santa Monica, CA: Research Institute. RAND Corporation. Cha, Y., and Weeden, K. A. 2014. Fraser, N. 2012. Feminism, Capi “Overwork and the Slow Con- Ross, C. E., Masters, R. K., and talism, and the Cunning of History: vergence in the Gender Gap in Hummer, R. A. 2012. “Education An Introduction. Paris, France: Wages.” American Sociological and the Gender Gaps in Health Fondation Maison des Sciences de Review 79(3): 457–84. and Mortality.” Demography 49(4): l’Homme. 1157–83. Crimmins, E. M., and Beltrán- Ghilarducci, T., and James, T. 2018. Sánchez, H. 2010. “Mortality Saunders, L., and Darity, W. 2003. Rescuing Retirement. New York: and Morbidity Trends: Is There “Feminist Theory and Racial Eco- Columbia University Press. Compression of Morbidity?” The nomic Inequality.” In M. A. Fer- Journals of Gerontology, Series B: Ghilarducci, T., Papadopoulos, M., ber and J. A. Nelson, eds., Feminist Psychological Sciences and Social and Webb, A. 2017. “Inadequate Economics Today: Beyond Economic Sciences 66B(1): 75–86. Retirement Savings for Workers Man. Chicago: The University of Nearing Retirement.” Policy Note. Chicago Press. Crystal, S., and Shea, D. 1990. Schwartz Center for Economic “Cumulative Advantage, Cumula- Warner, D. F., and Brown, T. H. Policy Analysis and Department tive Disadvantage, and Inequality 2011. “Understanding How Race/ of Economics, The New School Among Elderly People.” The Geron- Ethnicity and Gender Defne Age- for Social Research, Policy Note tologist 30(4): 437–43. trajectories of Disability: An Inter- Series. sectionality Approach.” Social Sci- Darity, W. A., Hamilton, D., and Goh, J., Pfeffer, J., and Zenios, S. ence & Medicine 72(8): 1236–48. Stewart, J. B. 2014. “A Tour de 2015. “Exposure to Harmful Work- Force in Understanding Inter- place Practices Could Account for group Inequality: An Introduction Inequality in Life Spans Across to Stratifcation Economics.” The Different Demographic Groups.” Review of Black Political Economy Health Affairs 34(10): 1761–8. 42(1−2): 1–6. Jeffries, T. Y. 2012. “Co-morbidity and Other Complexities Affect- ing Black Women’s Health.” The Review of Black Political Economy 39(3): 335–40.

The Public Cost of Low Earnings Across the Life Course

By Jacqueline L. Angel and Ronald J. Angel Lifelong economic disadvantage disproportionately affects Hispanics and African Americans, and can translate into a Medicaid cost burden in California and Texas.

ncome inequality in the United States has Hispanics, but different Medicaid policies. As a Igrown dramatically in recent decades, even as result of low average levels of education and low aggregate wealth has increased (Mather and lifetime earnings, the Mexican-origin popula- Jarosz, 2014). Greater productivity benefts have tions of both states face a greatly elevated risk of not been distributed equally, and as has been inadequate retirement savings. The combination well-documented, those who have beneftted least of inadequate savings and the longer life expec- are racial and ethnic minorities (Brown, 2011; tancy of this population when compared to non- Crystal, Shea, and Reyes, 2016). In this article, we Hispanic whites means that many are at high address an issue that has important implications risk of old-age poverty and dependency on Med- for individuals, families, and society at large, and icaid for long-term care (Angel and Angel, 2015). which is a direct outcome of lifelong income disadvantage among minority Americans. Specif- The Financial Challenge for the Sunshine cally, we focus on the social costs of poverty in and Lone Star States later life, and on the increasing burden to states of Increasing life spans and low levels of retirement Medicaid support for the community and insti savings create a double-edged fnancial challenge tutional care of growing impoverished and frail for states because Medicaid, which is jointly fi older populations who are living longer with seri- nanced by the federal and state governments, is ous health and functional limitations. the major source of long-term care for impover- The focus is on California and Texas, two ished and infrm older adults (The Pew Chari- states with similar population profles, which table Trusts, 2014). Although the majority of include large proportions of Mexican-origin Medicaid recipients are children, the majority of

abstract This article discusses implications for frail Hispanic and African American elders of how California and Texas might reform Medicaid, paying particular attention to the consequences for His- panic elders, who make up a large fraction of both states’ older populations. Hispanics have longer life expectancies than non-Hispanic whites, but worse health and functional limitations in later life. Their families may struggle to care for them at home. African American and Hispanic elders will likely have to turn to Medicaid to pay for long-term care, further straining state budgets. | key words: Hispanic, African American, state Medicaid expenditures, California, Texas

Medicaid expenditures support people with dis- retirement savings (Morrissey, 2016). The issues abilities and older adults (Hearne and Topoleski, raised in this article, then, may be particularly 2013; The Pew Charitable Trusts, 2014). serious for minority Americans, but apply more Medicaid pays for 62 percent of all nursing broadly. The almost inevitable attempts to con- home care (Henry J. Kaiser Family Foundation, trol Medicaid expenditures that states will be 2017b). Although the federal government pays forced to consider could place many older Ameri- for at least half of the cost of Medicaid (50 per- cans, particularly minority group elders, at risk cent in California and 56.9 percent in Texas in of inadequate medical and long-term care. 2018), states are responsible for the remainder (Henry J. Kaiser Family Foundation, 2017a). The Economic Insecurity of African As a consequence, debates over Medicaid eligi- Americans and Hispanics bility, regulation, and funding can be politically Other statistics reveal the unique vulnerabilities charged in state legislatures. of African Americans and Hispanics. Although The magnitude of the problem for states is Social Security and Medicare have greatly im readily apparent—California and Texas in par- proved the lot of most older Americans, serious poverty continues to plague minority groups. In ‘Medicaid pays for 62 percent of all 2013, 7 percent of non-Hispanic whites, 19 per- nursing home care.’ cent of Hispanics, and 18 percent of African Americans ages 65 and older had incomes below ticular. In 2010, 18.9 percent of total state expen- the poverty line (Johnson, Mudrazija, and Wang, ditures in California went to Medicaid. In that 2013). Poverty rates are higher for women than same year, Texas spent 24.6 percent of its total for men among all racial and ethnic groups expenditures on Medicaid (National Association (Morrissey, 2016). of State Budget Officers, 2011). By 2017, that per- The late-life vulnerability of African Amer- centage had risen to 33.3 percent in California icans and Hispanics largely reflects dramatic and 31.7 percent in Texas (National Association lifetime earnings differentials. Projections of of State Budget Officers, 2017). median earnings based on the 2013 Federal Because such a rate of increase is probably Reserve Board’s Survey of Consumer Finances unsustainable, states must act quickly. Although indicate that by age 61, non-Hispanic whites will the problem of low retirement savings and have earned $2 million, while African Ameri- wealth is particularly serious for the African cans will have earned $1.5 million, and Hispan- American− and Mexican-origin populations, ics, $1 million (Urban Institute, 2015). it is important to emphasize that a substantial While these earnings differentials are dra- proportion of other Americans lacks adequate matic, wealth differentials are even more so.

A Long-Term-Care Conundrum: A Comparison of California and Texas The problem of long-term care is compounded by the fact that both California and Texas have sizeable rural populations. In both states, Hispanics account for one-third of the rural population. Older individuals in rural areas often lack access to the acute and long-term-care services they need (Housing Assistance Council, 2012; Mather and Pollard, 2007). The consequences of isolation of Hispanics in rural areas is compounded by the fact that on average, older Hispanics spend half or more of the years they live past age 65 with serious disabilities (Angel, Angel, and Hill, 2015). The situation is especially serious in Texas, in which 15 percent of residents live in rural areas, and many are concentrated in counties along the Texas–Mexico border—areas that have been offi- cially designated as medically underserved (Texas Health and Human Services Commission, 2014).

Wealth consists of cash, real property, stocks 14 percent is from private pensions, and 13 per- and bonds, housing equity, and the total value cent is from assets (Angel and Mudrazija, 2015). of all other assets, minus debt. For most Amer- The greater reliance of African Americans icans, their major asset is a home, and differ- and Hispanics upon Social Security reflects an ences in total wealth largely reflect differential additional problem. Their average Social Secu- earnings and savings over the life course. In rity stipend is lower than that of non-Hispanic 2013, non-Hispanic white households had seven whites, who on average receive $14,939 per year, times the median wealth ($134,230) of African while African Americans receive on average American families ($16,686) and six times the $12,320, and Hispanics receive $11,459 (Waid, wealth of Hispanic families ($13,730) (Urban 2014). This fact means that African Americans Institute, 2015). and Hispanics are more likely than non-Hispanic Not only are these differentials in wealth whites to have to continue working full time past large, but also they are growing (Urban Institute, age 65 (Baer, 2015). 2015). From 2010 to 2013, the median wealth of non-Hispanic white households increased What Dangers Lie Ahead? Medicaid by $1,195. During that same period, the wealth Financing Reform of African American and Hispanic households As a candidate, President Trump vowed not decreased. For African Americans, median to cut spending on Social Security, Medicare, household wealth dropped $5,656, and for His- or Medicaid (Angel, 2016). But after assum- panics, it declined $2,705 (Urban Institute, 2015). ing office, the newly elected president and the Once again, we must note that although the Republican-dominated Congress proposed the situation of African Americans and Hispan- American Health Care Act (AHCA) to replace ics is particularly serious, the problem of inad- President Obama’s Affordable Care Act. This equate retirement savings affects all groups, if to legislation would have capped the federal con- lesser degrees. In the 2013 Survey of Consumer tribution (Rudowitz, 2017). Currently, federal Finances, 23 percent of respondents between matching funding to states is guaranteed with ages 45 and 59 reported that they had no retirement savings or pension (Board of Governors of Fifteen percent of people ages 60 and the Federal Reserve System, 2014). What is most disturbing is that 15 percent of those ages 60 older, including those already retired, and older, including those already retired, had had no savings. no savings. African Americans’ and Hispanics’ fnancial no cap and rises depending on program needs situations in later life also are negatively affected (Artiga et al., 2017). The proposed legislation by the fact that they have fewer sources of in would have limited the growth in funding to the come and are more reliant upon Social Security growth rate of the medical care component of than are non-Hispanic whites. For non-Hispanic the Consumer Price Index, plus an additional whites, Social Security provides 37 percent of 1 percent for older adults and disabled Medicaid their total personal income, private pensions enrollees. The legislation posed serious threats provide 23 percent, and assets provide 31 per- to states like California and Texas that have cent. By contrast, 49 percent of African Ameri- growing low-income older adult populations cans’ total income comes from Social Security, (McConnell and Chernew, 2017). 21 percent comes from private pensions, and 10 Were the AHCA or similar legislation to percent comes from assets. For Hispanics, 54 pass, states would be faced with difficult deci- percent of total income is from Social Security, sions. The three big drivers of Medicaid spend-

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 43 GENERATIONS – Journal of the American Society on Aging ing are eligibility, benefts covered, and provider for these waiver programs (MedicaidWaiver.org, payment rates. Having to work within the con- 2018). Were Congress to cap Medicaid funding, straints of a block grant would mean states those lists would in all likelihood only increase. would cover fewer people, cut benefts, reduce Clearly, California and Texas have different provider payments (which already are low), or political cultures, yet both have constitutional raise taxes to make up for limitations in the fed- requirements for balanced budgets (National eral contribution—all politically and socially Conference of State Legislatures, 2010). Texas, unpalatable prospects (Rudowitz, 2017). however, has no state income tax to provide Reductions in federal funding would invari- additional revenue for balancing budgets in eco- ably increase out-of-pocket costs for frail elders nomic downturns, while California does. and people with disabilities. What is certain is that proposals to replace the current matching Conclusion: Implications of Changes system with a fxed allocation of federal dollars in Medicaid paid through block grants or other caps would California and Texas, like all other states, face have signifcant consequences. While these pro- rapidly growing Medicaid expenditures as their posals would provide states greater flexibil- populations live longer, often with seriously ity than the current Medicaid funding model, compromised health and autonomy. Before the the potential cost-saving is unknown due to the latter half of the twentieth century, most indi- fact that most spending is driven by the needs of viduals died at younger ages than is the case high-cost older enrollees and people with dis- today, and they remained in their own home (or abilities (Bachrach, Mann, and Karl, 2017). one of their children’s homes) until their death. Texas presents a number of unique fscal and Few older individuals looked to federal or state political challenges, most notably its historically governments for support. low investment in Medicaid relative to other Since Social Security was introduced, and states, and its relatively low spending per enrollee certainly since the introduction of Medicare and (The Commonwealth Fund, 2016). Texas’ eli- Medicaid, the fnancial support of older adults gibility levels are set at the federal minimum has been increasingly “de-familized,” a term (Bachrach et al., 2017). Texas spends a smaller meaning that responsibility for the support of fraction of its Medicaid budget on older adult older adults, and especially of seriously infrm benefciaries than does California (Kaiser Family elders, has been transferred from the family to Foundation, 2014). This reflects state differences the state. Families continue to provide a great in the mix of community and institutional care deal of support and assistance to aging parents, that each state funds (Angel, Caldera, and Angel, and non-governmental and faith-based organi- 2017; Kaiser Family Foundation, 2014). zations do as well, but the modern welfare state Texas has kept spending on long-term ser- has created the general expectation that the poor vices and supports relatively low by prioritiz- are largely the responsibility of the state. ing less costly home- and community-based We have focused on the consequences for services over institutional care (Angel et al., state governments of rapidly aging populations 2017). Because community services are formally with low incomes and few assets. Although the optional, limitations in federal funding could problem of inadequate retirement savings is a result in a serious reduction in those services general problem, it is particularly serious for (Solomon and Schubel, 2017). Unlike Califor- minority Americans. As the result of lifelong nia, in which there are no waiting lists for home- earnings and savings disadvantages, older Afri- and community-based services, approximately can Americans and Hispanics are at elevated 150,000 Texans are on “interest” or waiting lists risk of poverty and dependency on Medicaid in

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 44 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America later life. Although Hispanics tend not to enter required to accept Medicaid clients, most nurs- nursing homes, social and demographic changes, ing home operators, and especially nonproft including smaller families, children’s migration operators, are motivated by a mission to serve away from their parent’s communities, divorce, the less fortunate and feel compelled to take in the need for women to work, and more are under low-income elders. mining families’ ability to provide for all of an As a result, though, many of these operators infrm aging parent’s needs. have to serve private-pay patients and provide Given the fact that Hispanics have longer life other services (e.g., home health, independent liv- expectancies than non-Hispanic whites, many ing, assisted living, etc.) to supplement the short- will live into their 80s, 90s, and even longer. In fall. In Texas, some for-proft providers have the future, a growing number of Hispanics may homes in states with higher Medicaid reimburse- fnd they have no choice but to turn to Medicaid, ment rates so they can use that money to help off- a situation that portends ever-increasing pres- set the losses to the homes in Texas. Nationwide, sures on state budgets. Attempts to control the most providers have to pay close attention to the growing fscal pressures associated with both payor mix and the fnancial reality means that acute and long-term care for low-income popu- many nursing homes have reduced their number lations may result in cost containment measures of licensed Medicaid beds. that could seriously undermine the support that both minority and non-minority elders need. Because resources are not infnite, changes On average, older adult Hispanics are inevitable, and the core question becomes spend half or more of the years they what might be the most equitable way of control- live past the age of 65 with serious ling Medicaid costs? As noted earlier, nursing home care has traditionally represented the most disabilities. expensive means of providing long-term care, and states are inevitably looking for savings. As the populations in need grow, budgetary Although state Medicaid programs are required pressures may force states to decrease Medicaid to cover nursing home care, they retain some nursing home reimbursement rates even further. control over expenditures. For example, they Although they may be inevitable, Medicaid cuts can set eligibility criteria for participation and could have a serious impact on access to acute, as decide how much to pay facilities and providers well as to long-term care for low-income and (Reaves and Musumeci, 2015). These amounts minority Americans. As previously mentioned, can be rather low. On average, state governments rural areas, especially counties along the U.S.– reimburse nursing home providers 89.4 percent Mexico border, are poor and medically under- of their total costs for providing care to Medicaid served. Providers along the Texas–Mexico bor- recipients (Eljay, 2016). Nursing homes in Texas der are particularly sensitive to potential cuts in lose approximately $30 to $60 per day, per per- Medicaid reimbursement rates. Medicaid serves son, when Medicaid is the primary payor. only the poorest and sickest older adults but, Why would nursing homes accept any Med- under budgetary pressure, states could introduce icaid clients if they lose money and are forced more restrictive health- and income-qualifcation to make up the loss from other paying resi- criteria, reducing access to many sick older indi- dents? First, nursing home operators who are viduals who have limited resources. licensed to receive Medicaid are required to It is still too soon to predict the fate of Medi reserve a certain number of beds for Medicaid caid, but it is obvious that cutting benefts and recipients. Second, even though they are not increasing out-of-pocket spending by nursing

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Mass Incarceration, Racial Disparities in Health, and Successful Aging

By Robynn Cox An analysis of the impacts of mass incarceration on the African American community and on the cohort’s long-term health consequences.

ver the past forty years, the United States in imprisonment rates between blacks, Hispan- Ohas taken part in an experiment in mass ics, and whites: the imprisonment rate is 5.6 and incarceration. Incarceration rates up until the 2.6 times the white imprisonment rate for blacks mid-1970s were relatively stable, after which and Hispanics, respectively. This also is shown they began to increase exponentially (see Figure in Figure 3 (on page 51) by looking at the lifetime 1, on page 49) due to an increase in the demand likelihood of going to prison over time, which for more punitive (versus rehabilitative) crimi- increased from 13.4 percent for a black male nal justice policies. Over this same time period, born in 1974 to 32.2 percent for a black male there has been a surge in the number of individ- born in 2001; for Hispanics, it increased from uals with criminal records (it is estimated that 4 percent to 17.2 percent during the same time more than 100 million individuals in the United period, with a much less pronounced change States have a criminal record), longer prison sen- for whites. tences, and, ultimately, greater rates of incar- Comparing prison admission rates of blacks ceration. This article explores the impact that and whites from 1926–1993 (see Figure 4 on page mass incarceration might have on successful 52), it is clear that imprisonment has always had aging and racial disparities in aging outcomes. a disproportionate impact on the lives of Afri- Although Americans (influenced by policy can Americans compared to whites: the propor- makers) demanded harsher punishments for tion of African Americans admitted to prison criminal offenses, these policies clearly have relative to their proportion in the population has had a differential impact by race. Figure 2 (on been increasing over time, while that for whites page 50) shows the imprisonment rate by race has been decreasing. It is also clear from Figure and ethnicity. It confrms substantial disparities 4 that, coinciding with the era of mass incarcera-

abstract This article analyzes racial health disparities and aging in the context of mass incarceration. It reviews what we know about the impacts of incarceration on individuals, families, and communities, and discusses how mass incarceration might impact racial disparities in health and aging. Given the role of the criminal justice system in the lives of minorities, and the deleterious effects of this contact, racial disparities in aging and health cannot be completely understood without fully understanding the consequences of concentrated mass incarceration in minority communities. | key words: mass incarceration, health disparities, aging

Figure 1. Rate of Imprisonment in The impacts of incarceration are not re State or Federal Correctional Facilities, stricted to the imprisoned individual. A pleth- 1925–2011 ora of research has identifed the deleterious effects of incarceration on the mental and physical health and fnances of loved ones exposed to a relative’s incarceration. The well-being of children is particularly vulnerable to an exposure to parental incarceration and leads to intergenera- tional effects (Cox and Wallace, 2016; Johnson, 2009). There also is evidence that incarceration negatively impacts the identity, stability (Charles and Luoh, 2010; Clear, 2008; Petersilia, 2000), public health (Johnson and Raphael, 2009), civic engagement (Petersilia, 2000), and economic well-being of communities (Clear, 2008; Lynch and Sabol, 2004) having concentrated incarcera-

Source: Author’s calculation from Minor-Harper, 1986; Carson tion rates. and Mulako-Wangota, 2013. Incarceration has consequences at the individual, family, and community levels; and these tion, after 1975, the unequal impact of imprison- are disproportionately borne by communities of ment among African Americans increased ex color (Wildeman, 2014). Society can no longer ponentially. While the threat of exposure to an address issues of poverty and racial inequality incarceration has always been greater for Afri- without also addressing the deleterious effects can Americans, this threat has greatly increased of incarceration. within the last forty years. The U.S. experiment in mass incarceration ‘Between 1993 and 2013, the size has led scholars from across disciplines to investigate the impact of these policy choices on the of the ages 55 and older state lives of all Americans, and in particular Afri- prison population has increased by can Americans. These scholars have noted that 400 percent.’ incarceration has a negative effect on labor- market outcomes through stigma, deteriora- While there has been substantial research tion of human capital, decreasing access to social investigating the economic consequences of capital, and labor-market barriers to employ- incarceration, less research has focused on iso- ment (Cox, 2010). lating its effects on health and aging, specifcally Spending extended periods in confnement in the context of prisoner re-entry, even though hinders individuals from building social capi- the prison population has become older over tal, which would otherwise enhance legitimate time (Carson and Sabol, 2016). Between 1993 employment prospects (Cox, 2010). Moreover, and 2013, the size of the ages 55 and older state confnement may favor developing negative prison population has increased by 400 percent. behaviors essential to survival during incar- Moreover, 48 percent of state prisoners released ceration, but disruptive to economic stability are ages 35 and older. on release. These behaviors can further disrupt When it comes to aging, most research has social networks, and could lead to the inability to focused on aging while in prison; but 95 per- obtain and maintain meaningful employment. cent of prisoners are eventually released from

Figure 2. Imprisonment Rate of detained individuals. It is important to note that Sentenced Prisoners by Race the quantity and quality of these services can vary depending on whether an individual is confned in a jail or a prison, the location of the jail or prison, and by the gender of the individuals housed in the facility. The protective hypothesis suggests that in carceration may help to stabilize the health of confned individuals, and possibly even prolong life. Evidence supporting the protective hypothesis has been found by researchers who have documented individuals’ higher rates of mortality directly after release from prison due to homicide, suicide, disease, and cancer (Rosen, Schoenbach, and Wohl, 2008; Binswanger et al., Source: Author’s calculation from Minor-Harper, 1986; Carson 2007). Once individuals are released from con- and Mulako-Wangota, 2013. fnement, they may have difficulty accessing prison. Although aging may create unique chal- required medication, or they may fnd it harder lenges for re-entry, there is a paucity of research to comply with treatment regimens. on this topic, particularly on the effect of incarceration on racial disparities in health and aging Behaviors essential to survival during outcomes. This article explores prisoner re-entry in the context of aging by frst discussing the incarceration are disruptive to relationship between health and incarceration economic stability back home. and then discussing how this relationship might impact aging outcomes. According to Patterson (2010), these benefts may go beyond being protective, to actu- The Direct and Indirect Effects ally improving the health of imprisoned African of Incarceration on Health American men. She fnds that the mortality rate Theoretically, mass incarceration may directly of African American males during incarcera- and indirectly place a strain on the immedi- tion approaches that of white males who are not ate family unit and relatives (Cox and Wallace, incarcerated, even after controlling for death 2016), as well as the community at large. It is dif- from homicide and motor vehicles. Even so, she fcult to isolate the direct effect of incarceration fnds a negative impact of incarceration on the on health because those exposed to incarcera- mortality rates of women and whites, suggesting tion typically come from vulnerable populations, that this effect is specifc to African American which tend to have higher rates of chronic ill- males (Patterson, 2010). nesses and communicable diseases than the gen- Studies also have documented the negative eral population (see Figure 5, on page 53). Even effects of incarceration. Using administrative if one could control for this selection bias, the data to measure the dose response of an incar- impact of incarceration on health is ambiguous: ceration on the life expectancy of New York while confnement often is a traumatic, highly State parolees, Patterson (2013) fnds that for stressful experience, there are opportunities every year in prison, the odds of death increased for confned individuals to make human capital by 15.6 percent for parolees, which was equiva- investments through social services offered to lent to a two-year decrease in life expectancy for

Figure 3. Male Lifetime Likelihood post-release, all of which are associated with of Going to State or Federal Prison by poorer health outcomes. Incarceration affects Race, 1974–2001 labor market outcomes through producing negative stigmas, deterioration of human capital, and decreasing access to social capital (Cox, 2010). As a result, offenders often are unable to obtain relevant work experience and build pro- social networks that would otherwise enhance legitimate employment prospects. Moreover, behaviors essential to survival during incarceration are disruptive to economic stability after incarceration (Cox, 2010; Petersilia, 2000). Ulti- mately, incarceration may lead to the deterioration of social bonds and the development of negative social networks, which could give rise to poorer health because of limited economic Source: Figure by author; data from Bonczar, 2003. resources and a worsening of psychological well- each additional year in prison. The risk is great- being post-incarceration. For African Americans, est immediately following release from prison incarceration could bring about greater levels and diminishes over time. While Patterson does of psychological distress if this potentially trau- not investigate the mechanisms leading to higher matic experience causes a deterioration in famil- mortality rates, prior research suggests (as stated ial relationships and more negative interactions above) that this could be due to an elevated risk among family members, as well as greater fnan- of death from suicide, chronic disease, and can- cial strain (Lincoln, Chatters, and Taylor, 2005). cer immediately following release. Other studies using quasi-experimental designs have found that the formerly incarcer- One cannot discuss racial health ated have inferior health outcomes when com- disparities without considering the pared to observationally similar individuals impact of the criminal justice system. who have not been exposed to an incarceration. These studies fnd that individuals exposed to As previously mentioned, incarceration not an incarceration have greater health limitations only impacts the health of the exposed individ- (Schnittker and John, 2007), an increased likeli- ual, but also has an effect on the health of family, hood of having an infectious disease, and stress- relatives, and children. As in the case of the indi- related illnesses (Massoglia, 2008a); in addition, vidual, the effect of incarceration on the health incarceration may exacerbate racial health dis- of family members is ambiguous because on the parities (Massoglia, 2008b). one hand, incarceration may remove a negative Incarceration not only worsens health out- family member and free up additional house- comes, but also it may lead to additional stigma, hold resources. On the other hand, incarceration stress, and a deterioration of other forms of hu might remove a positive contributing member of man capital (e.g., on-the-job training, motiva- the family, which could lead to depleted house- tion, self-esteem) and social capital (e.g., social hold resources and social supports for the family networks, familial support), which could lead to members left behind. declines in economic resources and social sup- Lee and Wildeman (2013) hypothesize mech port, in turn causing prolonged levels of stress anisms through which mass imprisonment may

Figure 4. Ratio of Proportion Admitted contact with an incarcerated family member, to Prison to Share of Population by and incarceration disrupted social ties and Race, 1926–1993 familial relationships. Most of the families surveyed lost income due to a family member’s confnement, and two out of three families could not afford their day-to-day basic needs. Finally, 83 percent of those left behind were women, and many family members reported negative health problems, such as PTSD, nightmares, anxiety, and chronic stress, due to a loved one’s incarceration (deVuono-powell et al., 2015). Charles and Luoh (2010) fnd that high levels

Source: Cox, 2015. of incarceration lower the number of men freely interacting in society, leading to lower mar- increase hypertension, diabetes, and obesity riage rates and economic well-being, specifcally among non-incarcerated African American wo among African American women. Moreover, Lee men. They highlight the ways through which et al. (2014) fnd that women with incarcerated social bonds to incarcerated men can compro- relatives have statistically signifcant increased mise the health of African American women, odds of cardiovascular risk factors and disease as and assert that incarceration diminishes socio- measured by obesity, experiencing a heart attack economic status, compromises family function- or stroke, and self-reports of fair or poor health, ing, and adversely affects stress levels and mental presumably stemming from the added stress of health (Lee and Wildeman, 2013). Incarceration having an incarcerated family member. reduces a man’s potential to earn and damages There also has been a plethora of research a woman’s socioeconomic resources by desta documenting the negative effects of parental in bilizing existing relationships. Stated differ- carceration on children. Incarcerated children ently, incarceration acts as an economic shock face increased economic (Wildeman, 2014; Cox to the household, with potential long-term and Wallace, 2016) and residential insecurity effects through diminished earnings and in (Wildeman, 2014), as well as developmental and creased debt. behavioral problems that lead to intergenera- Grinstead et al. (2001) fnd evidence that tional transmissions of incarceration (Wildeman prison is an economic shock to the household, and Western, 2010; Johnson, 2009). especially to low-income families. They fnd that While some research fnds that incarcera- to remain in contact with incarcerated African tion has a negative effect on communities and American men, women in the study sample spend families, other research has found that the con- roughly $292 per month in 1998, the equivalent fnement of an unstable family member might of $440 per month in today’s dollars, or between improve the well-being of affected family mem- 9 percent and 26 percent of their income. bers (Finlay and Neumark, 2010) and the com- A more recent study by the Ella Baker Center munity at large (Clear, 2008; Lynch and Sabol, for Human Rights fnds that families lose income 2004). Nonetheless, while removing problem when a loved one is incarcerated, and often in atic members from a community through in cur, on average, almost $14,000 in debt paying carceration may initially lead to benefts, concen- for court-related costs and fnes (deVuono-powell trated levels of incarceration are destabilizing to et al., 2015). The study also fnds that one in three the community (Clear, 2008; Lynch and Sabol, families surveyed went into debt to maintain 2004), and may lead to an array of social prob-

Figure 5. Prevalence of Chronic and impossible to completely understand racial dif- Infectious Health Conditions Among ferences in aging without incorporating how pol- the General Population and State and icies and institutions, such as mass incarceration Federal Prisoners and the criminal justice system, impact minority health and racial disparities in health. Non-communicable, generally preventable diseases such as cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes are the leading causes of death across the world. This is true for the United States: even though largely avoidable, chronic illnesses continue to be widespread and very costly to society; they also are the leading causes of death among Afri- can Americans. While there is some overlap in Source: Figure by author; calculations by Maruschak, Berzofsky, and Unangst, 2015. the ranking of these diseases across racial and ethnic groups, minorities tend to experience lems such as higher crime rates (Clear, 2008) and greater morbidity and mortality from chronic greater public health concerns (see Johnson and illnesses than do non-Hispanic whites (Shuey Raphael, 2009, for a discussion on the impact of and Willson, 2008). male incarceration rates on racial disparities in Prior research has focused on three main HI V/A IDS). explanations of racial health disparities: 1) biological; 2) race as a proxy for socioeconomic sta- Racial Disparities in Health, Incarceration, tus; and 3) race and socioeconomic status as and Aging separate constructs (Kawachi, Daniels, and Rob- In 2015, the National Institute of Aging proposed inson, 2010). The belief that racial disparities a new framework to research health disparities. result from biological differences is largely dis- Criminalization was included in this framework credited. There is, however, some debate about as one of the environmental factors to be consid- whether racial health disparities are solely at ered by health disparities researchers (Hill et al., tributable to class, or if race is actually a separate 2015). However, there has been little research construct from socioeconomic status. investigating the role of the criminal justice sys- Nonetheless, research demonstrates that tem and criminal justice policies on health, aging, racial health disparities cannot be explained by and racial disparities in aging. Most research class alone, and therefore race should be consid- has focused on the role of other environmental, ered a separate construct from class (Kawachi, socioeconomic, sociocultural, behavioral, and Daniels, and Robinson, 2010; Brondolo, Gallo, biological factors in racial health disparities. and Myers, 2009; Shuey and Willson, 2008). One This research has provided insight into some of hypothesized mechanism through which race the possible mechanisms of racial disparities in affects health outcomes is through the psychoso- aging. There is, however, a paucity of literature cial stressors resulting from cultural, structural, focusing on the relationship between aging, the or interpersonal discrimination. Psychosocial criminal justice system, and prisoner re-entry stressors also are associated with greater eco- (see Williams and Abraldes, 2007, for a brief dis- nomic barriers and changes in behavior and psy- cussion of aging and re-entry). chobiological processes, which could impact But, given the pervasiveness of the crimi- future generations (Brondolo, Gallo, and Myers, nal justice system in the lives of minorities, it is 2009). For example, while certain minorities may

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Sexual Orientation, Socioeconomic Status, and Healthy Aging

By Bridget K. Gorman and Zelma Oyarvide Sexual orientation relates to socioeconomic status, and the differences in this status directly impact the health and healthy aging trajectories of LGBT elders.

he older adult population in the United States economic status (SES) among older adults, and the Tis more diverse than ever before—including importance of SES differences for the health sta- diversity based on sexual and gender minority tus and healthy aging trajectories of selected sex- status. Recent studies indicate that there are more ual minority (lesbian, gay, and bisexual) adults. than 2.4 million lesbian, gay, bisexual, and transgender (LGBT) adults ages 50 and older in the Socioeconomic Status, Sexual Orientation, United States, and that this population will grow and Health to more than 5 million by the year 2030 (Fredrik- While healthy aging relates to a variety of fac- sen-Goldsen et al., 2014). In recent years, LGBT tors, socioeconomic resources loom large. Schol- older adults have been the focus of a small but arship has frmly established the fundamental growing body of research examining the charac- role of socioeconomic status for health (Link teristics and circumstances associated with their and Phelan, 1995). Socioeconomic differences in health and healthy aging (Institute of Medicine health impairment accumulate across the life [IOM], 2011). course, and education is an especially important These studies paint a picture of a population cause of healthy aging due to its key role in the that, on average, faces a variety of health chal- acquisition of material assets (e.g., good jobs, lenges, including stigma, discrimination, and re health insurance, income, and wealth), as well as lated stressors; barriers to receiving formal and the development of health-related habits, skills, informal healthcare services; and fnancial insta- and abilities (Ross and Mirowsky, 2010). While bility (Choi and Meyer, 2016). In this article, we education acts as an intrinsic resource that helps discuss how sexual orientation relates to socio- delay the onset of chronic health conditions and

abstract The socioeconomic profile of older adults is crucial to shaping their likelihood of living a long life relatively free from disease and impairment. Compared to heterosexual and gay or lesbian older adults, bisexual elders have the lowest rates of completed schooling and live in lower-income households, which strongly contributes to their poorer health reports. Older gay men and lesbians have a more positive socioeconomic profile, including higher levels of completed schooling than heterosexual older adults—however, their annual household income is more similar to heterosexuals, especially for older gay men. | key words: socioeconomic status, sexual orientation, bisexual, health, aging

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 56 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America functional limitations, income Table 1. Education and Income Profile of Older U.S. operates more as a coping Adults, by Gender, Sexual Orientation, and Age resource that helps slow the Completed Annual progression of health prob- Schooling Household Income lems after they occur (Herd, % Less than % College % Less than % $75,000 Goesling, and House, 2007). High School Degree $25,000 and higher Considered together, the educa- OLDER WOMEN tion and income profle of older Heterosexual adults is a crucial factor shap- 50–64 10.1 30.1 24.5 33.8 ing their likelihood of living 65–79 12.6 22.0 35.2 15.3 a long life relatively free from 80+ 16.4 18.1 50.8 8.9 disease and impairment. Lesbians Due to the fundamental role 50–64 2.3 48.3 23.8 45.0 of education, income, and other 65–79 6.6 45.7 27.8 28.1 aspects of socioeconomic sta- 80+ 15.0 38.9 38.2 6.3 tus for healthy aging, the wide Bisexual disparities seen in SES across 50–64 15.8 31.8 35.5 28.0 sociodemographic groups is 65–79 22.4 33.0 53.9 12.7 troubling, especially for older 80+ 17.1 13.2 50.7 6.1 adults. To illustrate, we calcu- OLDER MEN lated estimates for SES by gen- Heterosexual der, sexual orientation, and age 50–64 12.7 30.8 21.8 38.4 using data from the 2011–2015 65–79 14.5 28.4 24.6 24.4 80+ 18.9 24.6 33.1 18.5 waves of the Behavioral Risk Factor Surveillance System. Gay 50–64 5.4 41.3 28.5 37.9 Table 1 (opposite) shows how 65–79 7.9 50.9 23.1 24.9 low education (less than a high 80+ 23.0 35.1 34.9 19.4 school diploma) and high edu- Bisexual cation (college degree or more), 50–64 18.8 34.7 46.6 25.7 as well as low annual house- 65-79 12.6 25.4 48.4 17.2 hold income (less than $25,000) 80+ 42.8 20.4 62.8 14.7 and higher income ($75,000 or Source: Calculated by the authors based on Behavioral Risk Factor Surveillance more) differ by sexual orienta- System (BRFSS) data from 2011–2015 waves for the following 40 U.S. states (various tion and gender among older years by state): AK, AZ, CA, CO, CT, DE, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, adults in three age cohorts: MD, MA, MI, MN, MO, MT, NV, NM, NY, NC, ND, OH, OR, PA, RI, TX, UT, VT, VA, WA, WV, WI, and WY. ages 50 to 64, ages 65 to 79, and ages 80 and older. Overall, it shows that across of completed schooling, and they live in lower- groups, completed schooling and household income households than do heterosexual, gay, income decline with increasing age. or lesbian older adults. While the percentages of their disadvantage vary by gender and age Socioeconomic and Health Status cohort, SES disparities can be quite high. For ex of Bisexual Older Adults ample, among older women ages 65 to 70, 22.4 Table 1 also highlights the socioeconomic dis- percent of bisexual women did not complete high advantages of bisexual older adults. Across age school—this compares to 12.6 percent of hetero- groups, bisexual elders have the lowest rates sexual women, and just 6.6 percent of lesbians.

As another example, Table 1 shows that an indicate that fnancial stress may be especially nual household income varies strongly among high among bisexuals in later life. the oldest men; while about one-third of hetero- This fnding about fnancial stress more gener- sexual and gay men ages 80 and older report an ally reflects a growing body of research document- annual income of less than $25,000, this rate is ing substantial fnancial and other health-related almost double among bisexual men (62.8 per- risks among bisexuals. Scholarship focused upon cent). As recent assessments have concluded adults in general has shown that, compared to het- (Fredriksen-Goldsen and Muraco 2010; IOM, erosexual and gay or lesbian adults, those who 2011), previous research on older adults has dis- identify as bisexual report poorer socioeconomic proportionately focused on gay men and lesbi- circumstances, higher participation in health- ans, while bisexuals and other sexual minority damaging behaviors like smoking and heavy groups rarely were examined. Yet the data pat- alcohol use, and poorer mental and physical terns in Table 1 illustrate the risks associated health status (Conron, Mimiaga, and Landers, with only considering gay or lesbian adults (or 2010; Gorman et al., 2015; Veenstra, 2011). Bisexuals also report lower averages of life Bisexual elders have the lowest rates satisfaction and less emotional support than either gay or lesbian or heterosexual adults of completed schooling and live in (Gorman et al., 2015). Additionally, Fredriksen- lower-income households. Goldsen and colleagues (2016) show that older bisexual adults report more internalized stigma lumping together subgroups into an umbrella as well as a lower sense of community belong- “sexual minority” category). Doing so would ing and perceived social supports than their gay obscure or ignore the poorer socioeconomic or lesbian peers. This study also showed a lower standing of bisexual older adults relative to their rate of sexual identity disclosure among bisex- heterosexual and gay or lesbian peers—a key uals—a fnding that applies not only to friends, factor shaping health disparities across the life family, and co-workers, but also to medical care course that are based on sexual orientation. providers (see also IOM, 2011). A recent study by Fredriksen-Goldsen and col- Considered together, these studies indicate leagues (2016) concluded that the poorer socioeco- that a variety of health-related risks—includ- nomic standing of bisexual older adults operated ing economic vulnerability, participation in un as a strong explanatory mechanism for their healthy behaviors (e.g., smoking), stress, and poorer health reports, compared to heterosexual lower levels of social support—may be elevated and gay or lesbian older adults. Recent reviews among bisexual older adults. Furthermore, the of LGBT aging issues have discussed how fnan- lower rate of sexual identity disclosure to medi- cial instability is a major concern for many sexual cal professionals among bisexuals is worrisome, minority older adults (e.g., Movement Advance- because research on the medical experiences of ment Project [MAP] and Sage, 2010). sexual minorities highlights the importance of As summarized by Choi and Meyer (2016): sexual identity disclosure for a positive medical “Lifetime disparities in earnings, employment, encounter (Daley, 2012; Sherman et al., 2014). and opportunities to build savings, as well as discriminatory access to legal and social programs Analyzing SES Similarities that are traditionally established to support aging Looking again at Table 1, it also shows more adults, put LGBT older adults at greater fnancial positive socioeconomic profles for gay men risk than their non-LGBT peers.” The fndings and lesbian older adults relative to same-age shown in Table 1 and from previous scholarship heterosexuals. Depending upon the contrast,

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 58 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America gay men and lesbians often report similar or adults ages 50 and older report higher levels of better levels of completed schooling and annual education, but fairly equivalent rates of poverty in household income. This is seen most strongly comparison to similar-age heterosexuals—a pat- for education: with just one exception (among tern they attribute to discrimination and blocked men ages 80 and older), gay men and lesbians opportunities across the life course, which lim- report higher levels of completed schooling, on ited the ability of sexual minorities to fully capi- average, than their heterosexual peers. This talize on the economic benefts associated with educational advantage is especially stark when their educational achievement. That we see this we look at the percentage with a college degree, more strongly among older gay men than among where the proportion with a college degree is lesbians (in Table 1) may relate to elevated expe- markedly higher among gay men and lesbians. riences with stigma and discrimination among For example, among adults ages 50 to 64, 48.3 gay men. Herek (2002) has documented that U.S. percent of lesbians have a college degree, com- adults (especially heterosexual men) hold more pared to 30.1 percent of heterosexual women. negative attitudes toward gay men than they do Among men ages 50 to 64, 41.3 percent of gay toward lesbians, and gay men experience sub- men have at least a college degree, compared to stantially higher rates of harassment, verbal 30.8 percent of heterosexual men. abuse, violence, and property crimes than either Looking at annual household income among lesbians or bisexuals (Herek, 2009). older women, we see a more muted but generally similar pattern. The proportion of older women Healthy Aging Among Sexual Minorities reporting a household income below $25,000 is As detailed in Healthy People 2020, improving lower among lesbians than heterosexuals in each the health and well-being of sexual minorities is an important public health goal for the United U.S. adults (especially heterosexual States (U.S. Department of Health and Human Services, 2010). Existing health disparities re men) hold more negative attitudes search provides a framework for understanding toward gay men than lesbians. how SES contributes to sexual orientation differences in health status, because SES often is age group, and (with the exception of women implicated as one of the strongest contributors ages 80 and older) a higher proportion also re to health stratifcation (Link and Phelan, 1995). port a household income of $75,000 or above. Overall, the poor health standing of bisexuals Among older men, however, the proportion in documented across an increasing number of either income group is very similar between gay studies may be due in large part to their lower and heterosexual men in most age groups. The socioeconomic standing, on average, than mem- biggest difference occurs among men ages 50 to bers of other sexual orientation groups. 64, where a higher proportion of gay men (28.5 In particular, our understanding of how edu- percent) report an annual household income of cation and income relate to disease onset and less than $25,000, compared to 21.8 percent of progression is important, because the poorer heterosexual men. socioeconomic profle of bisexual older adults Previous studies also have found higher levels suggests that they may face particular hardships of educational achievement among gay men and in navigating the health challenges associated lesbians in comparison to comparably aged het- with aging. Older sexual minority adults are erosexual adults (IOM, 2011). Additionally, work more likely to be single, living alone, and with- by Fredriksen-Goldsen and colleagues (2013) out children than heterosexual elders, and they found a similar pattern wherein gay and lesbian rely more on partners and friends to provide

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African American Elders, Mental Health, and the Role of the Church

By Ann W. Nguyen How might churches play a role in ameliorating congregants’ discrimination-based generalized anxiety disorder?

ased on national surveys and polls, African many of the communities it serves (Lincoln and BAmericans have the highest levels of reli- Mamiya, 1990). African American churches gious involvement in the United States (Chatters, offer a wide range of community programs and Nguyen, and Taylor, 2014). Among older African services, such as anti-poverty and material aid Americans, religion is particularly important. programs, programs for older adults and their Compared to younger African Americans and caregivers, counseling and intervention pro- older whites, older African Americans are more grams, and educational and awareness pro- likely to attend religious services, participate in grams (Taylor et al., 2000). Moreover, African congregational activities, and read religious mate- American churches’ offerings of programs and rials (Taylor, Chatters, and Brown, 2014; Taylor, services are more extensive than those of white Chatters, and Jackson, 2007). Older African Amer churches (Taylor et al., 2000). These services icans also are more likely than older whites to and programs emerged partly from African consume religious media (i.e., books, television, Americans’ difficulties with accessing these pri- and radio), engage in private prayer, use religion vate and public services due to social and eco- to cope with stress, consider religion to be impor- nomic marginalization. tant, and consider themselves religious (Taylor, Given the prominence of religion and the Chatters, and Jackson, 2007). church in the lives of older African Americans, At the institutional level, the church has his- congregants are important social network mem- torically played a major role in African Amer- bers for this population. In fact, some African ican communities. Not only is it a religious Americans, particularly those who do not live institution, but also is a social, civic, politi- near family, or who are estranged from fam- cal, educational, and economic institution in ily, consider church members to be their surro-

abstract The African American church has played a major role in African American communities, and church relationships represent an important stress-coping resource for older African Americans. African Americans rely on the church and church members for assistance, in part because of difficulties accessing formal resources due to social and economic marginalization. Church can buffer against the negative effects of discrimination upon generalized anxiety disorder among older African Americans. Interventions that focus on the use of church members for support capitalize on a major strength among older African Americans. | key words: African American, older adults, discrimination, church, stress-coping resource, generalized anxiety disorder

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 61 GENERATIONS – Journal of the American Society on Aging gate family (Taylor, Chatters, and Levin, 2004). African Americans reported experiencing mul- Church members are a critical source of social tiple types of individual and interpersonal dis- support for this population. The most common crimination, such as racial slurs and insensitive types of support exchanged among African or offensive comments about their race. This sur- American congregants are advice and encour- vey’s results clearly document the extensiveness agement, companionship, assistance during ill- of discrimination in African Americans’ lives. ness, prayers, and fnancial aid (Taylor, Chatters, Discriminatory events, especially day-to-day and Levin, 2004). unfair treatment such as being followed in stores Church relationships are an important or receiving worse service than others are par- stress-coping resource and are linked to bet- ticularly pernicious forms of chronic stress, as ter mental health. Some studies have found they often are unpredictable and uncontrollable; that church support, contact with church mem- experiencing these can lead to feelings of lack bers, and subjective closeness to church members protect against psychological distress and Church relationships are a stress- depressive symptoms among African Americans (Chatters et al., 2018). The function of church coping resource and linked to better relationships as a stress-coping resource is crit- mental health. ically important to consider among African Americans, given that this population is par- of control and self-efficacy and can contribute ticularly susceptible to discrimination, a type of to poor mental and physical health. Research on chronic stressor that is prevalent among popu- discrimination has unequivocally indicated that lations of color and other marginalized groups, it is linked to a range of mental health problems, such as older adults. such as depression (Williams and Williams- Morris, 2000) and psychological distress. Discrimination and Mental Health In particular, discrimination is associated A recent national survey indicates that discrimi- with anxiety and anxiety disorders (Gee et al., nation is pervasive in African Americans’ lives 2007; McLaughlin, Hatzenbuehler, and Keyes, (National Public Radio, Robert Wood Johnson 2010; Soto, Dawson-Andoh, and BeLue, 2011). For Foundation, and Harvard T.H. Chan School of instance, Mouzon et al. (2016) found that older Public Health, 2017). Ninety two percent of Afri- African Americans who were exposed to more can American adults (ages 18 and older) in this frequent experiences of discrimination were survey reported that they believed that discrimi- more likely to have an anxiety disorder than nation against African Americans exists in the older African Americans who were exposed to United States today. When asked about personal less frequent experiences of discrimination. experiences with discrimination, at least one out Soto and colleagues (2011) have demon- of two African Americans reported experienc- strated in a national probability sample of ing racial discrimination in the workplace or in African Americans that racial discrimination interactions with law enforcement, which were is predictive of generalized anxiety disorder the most prevalent discriminatory experiences (GAD), which is characterized by excessive documented in this study. anxiety and worry. Further, McLaughlin, Hat- Housing discrimination was the third most zenbuehler, and Keyes (2010) found that dis- prevalent discrimination issue reported, with crimination predicted a wide range of anxiety 45 percent of African Americans surveyed indi- disorders, including post-traumatic stress dis- cating that they have personally experienced this order (characterized by intense and disturbing type of discrimination. Moreover, a majority of thoughts and feelings following exposure to one

Discrimination and GAD Among Older Although there has been a fair amount of African Americans research on discrimination and its mental health GAD is the most prevalent anxiety disorder in the effects among adults, there is little research on United States, affecting approximately 2.1 percent discrimination in older adults. I used data from to 3.1 percent of Americans in any given twelve- the National Survey of American Life: Coping month period (Revicki et al., 2012). The lifetime with Stress in the 21st Century (NSAL) to estimate prevalence of GAD in the general U.S. population the association between everyday discrimina- ranges from 4.1 percent to 9 percent (American tion and age among African American adults. Psychiatric Association, 2013). Among African The NSAL has a national probability sample Americans, the twelve-month prevalence is 1.37 based on 6,082 face-to-face interviews with indi- percent, and the lifetime prevalence ranges from viduals ages 18 or older, including 3,570 African 3 percent to 4.9 percent (Himle et al., 2009). Americans, 891 non-Hispanic whites, and 1,621 GAD is highly comorbid with other psychi- Caribbean blacks. The data were collected by atric disorders, with other anxiety disorders and the Program for Research on Black Americans at depression being the most prevalent comorbid the University of Michigan’s Institute for Social disorders (Revicki et al., 2012). A wide range of Research. As illustrated in Figure 1 (see above), impairments and high levels of social and occu- perceptions of everyday discrimination (i.e., pational disability are associated with GAD day-to-day unfair treatment) decrease with age (Revicki et al., 2012). Individuals with GAD ex among African Americans. perience substantial impairments in role func- There have been very few investigations into tioning, especially in the social and occupational why this inverse relationship between discrimi- domains (Hoffman, Dukes, and Wittchen, 2008; nation and age exists. Some speculate that this Revicki et al., 2012). This disorder accounts for pattern may reflect a cohort effect in which older 110 million disability days annually in the United African Americans were socialized to expect States (American Psychiatric Association, 2013). and tolerate higher levels of discrimination and Moreover, GAD is associated with diminished more overt forms of discrimination than younger mental health–related quality of life (Hoffman, African Americans (Kessler, Mickelson, and Wil- Dukes, and Wittchen, 2008), life satisfaction liams, 1999). Despite this, older African Ameri- (Revicki et al., 2012), overall well-being, and sat- cans are nevertheless adversely affected by these isfaction with family life (Hoffman, Dukes, and experiences. Among older African Americans, Wittchen, 2008). increases in experiences of everyday discrimina-

Figure 2. The Discrimination− tion, but only in relatively older adults (i.e., older GAD Association adults who experienced fnancial strain reported lower life satisfaction). However, for relatively older adults who experienced fnancial strain and had high levels of support from family and friends, the negative association between fnancial strain and life satisfaction was substantially weaker, indicating that social support can offset the harmful effects of fnancial strain, a chronic stressor, on subjective well-being. Most studies on the stress-buffering effects of social relationships among older adults do

Source: National Survey of American Life, author’s calculations. not focus on church relationships, despite the heightened importance of religion in the lives tion are associated with increases in the prob- of older adults and particularly in older African ability of meeting criteria for lifetime GAD, as Americans’ lives. One study that has examined shown in Figure 2 (see above). the stress-buffering effects of church relationships found that church support offset the nega- Stress-Buffering Effects of tive effects of fnancial strain on self-rated health Church Relationships for older African Americans, but not older whites Numerous studies have documented the protec- (Krause, 2006). This suggests that church mem- tive effects of social relationships against mental bers may be an effective stress-coping resource illness among older adults, protecting against for older African Americans when they are con- numerous psychiatric disorders, depression, fronted with discrimination, and could offset its social anxiety disorder, and GAD (Krause and effect on mental illnesses, including GAD. Hayward, 2015). Yet the mechanism by which social support and social relationships pro- ‘Church support offset the negative tect against mental illness is less understood. Emerging evidence suggests that particular as effects of financial strain on self- pects of social relationships can buffer against rated health for older African the harmful effects of stress. A study of older Americans.’ Korean women found that social support buf fered against the effects of discrimination upon I used a subsample of older African Americans depression (Lee and Kim, 2016). Older Korean (N = 670; ages 55 and older) from the NSAL to test women who reported more frequent experi- the stress-buffering effects of several aspects of ences of discrimination reported higher levels of church relationships in the discrimination−GAD stress, which, in turn, was predictive of depres- association. Frequency of contact with church sion. However, respondents who reported higher members and subjective closeness to church levels of support had lower stress levels and con- members buffered against the impact of every- sequently were less likely to have depression. day discrimination on lifetime GAD. Figures 3 Krause’s (2005) investigation of the stress- and 4 (see page 65) illustrate that for older African buffering function of social support among older Americans who had low levels of contact with and adults found that family and friendship support subjective closeness to church members, more acts as a stress-buffer in the negative associa- discriminatory experiences were associated with tion between fnancial strain and life satisfac- greater risk for lifetime GAD. On the other hand,

Figure 3. Contact Frequency and Figure 4. Subjective Closeness and Lifetime GAD Probability Lifetime GAD Probability

Source: National Survey of American Life, author’s calculations. Source: National Survey of American Life, author’s calculations.

discriminatory experiences were not associated health services has indicated that prior to mental with lifetime GAD for older African Americans health service use, African American adults have who reported high levels of contact with and sub- more positive attitudes toward mental health ser- jective closeness to church members. This dem- vices than whites (Diala et al., 2000). onstrates that contact with church members and However, after receiving mental health subjective closeness to church members can offset care, African Americans have less positive atti- the detrimental effects of discrimination on GAD tudes toward mental health services than do among older African Americans. whites. This suggests that the mental health care received by African Americans may not be Conclusion culturally competent or may be of lower qual- Given the importance of religion among older ity (Alegría et al., 2008). Among those who seek African Americans and the relatively high lev- mental health care, African Americans are less els of church involvement in this population, likely than non-Hispanic whites to receive qual- church members are particularly meaningful ity care and care adhering to official practice and relevant social partners for these older adults guidelines (Alegría et al., 2008). An additional and represent possible stress-coping resources barrier to accessing mental health care for Afri- for older African Americans dealing with dis- can Americans is the perception of discrimina- crimination. As a growing body of research has tion. When experiences of discrimination are documented the deleterious consequences of dis- accounted for, African Americans are just as crimination, a more complete understanding of likely as their white counterparts to seek help factors and processes that can mitigate the effects for psychiatric problems (Woodward, 2011). of discrimination on mental illness is paramount Similarly, among older adults, experiences of to developing interventions that can bolster the discrimination explain why older African Amer- roles of such factors and facilitate effective cop- icans are less likely to receive help than older ing resources in the lives of vulnerable older Afri- whites (Woodward et al., 2010). Given this racial can Americans. This is particularly important, disparity in mental health care access, church considering the fact that African Americans face members are important and effective stress- a number of barriers to formal mental health ser- coping resources that older African Americans vices and are less likely to access mental health can mobilize when facing discrimination. How- services than non-Hispanic whites (Alegría et ever, this is not to suggest that church members al., 2008). Research on attitudes toward mental should supersede professional mental health

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Himle, J. A., et al. 2009. “Anxiety McLaughlin, K. A., Hatzenbuehler, Taylor, R. J., Chatters, L. M., and Disorders Among African Ameri- M. L., and Keyes, K. M. 2010. Brown, R. K. 2014. “African Amer- cans, Blacks of Caribbean Descent, “Responses to Discrimination ican Religious Participation.” and Non-Hispanic Whites in the and Psychiatric Disorders Among Review of Religious Research 56(4): United States.” Journal of Anxiety Black, Hispanic, Female, and Les- 513–38. Disorders 23(5): 578–90. bian, Gay, and Bisexual Individu- Taylor, R. J., Chatters, L. M., and als.” American Journal of Public Hoffman, D. L., Dukes, E. M., and Jackson, J. S. 2007. “Religious and Health 100(8): 1477–84. Wittchen, H. U. 2008. “Human and Spiritual Involvement Among Older Economic Burden of Generalized Mouzon, D. M., et al. 2016. “Dis- African Americans, Caribbean Anxiety Disorder.” Depression and crimination and Psychiatric Disor- Blacks, and Non-Hispanic Whites: Anxiety 25(1): 72–90. ders Among Older African Amer- Findings from the National Survey icans.” International Journal of of American Life.” The Journals of Kessler, R. C., Mickelson, K. D., and Geriatric Psychiatry 32(2): 175–82. Gerontology, Series B: Psychological Williams, D. R. 1999. “The Preva- Sciences and Social Sciences 62(4): lence, Distribution, and Mental National Public Radio, Robert S238–50. Health Correlates of Perceived Dis- Wood Johnson Foundation, and crimination in the United States.” Harvard T.H. Chan School of Pub- Taylor, R. J., Chatters, L. M., and Journal of Health and Social Behav- lic Health. 2017. Discrimination in Levin, J. 2004. Religion in the Lives ior 40(3): 208–30. America: Experiences and Views of of African Americans: Social, Psy- African Americans. tinyurl.com/ chological, and Health Perspectives. Krause, N. 2005. “Exploring Age ybgmcja9. Retrieved April 27, 2018. Thousand Oaks, CA: Sage. Differences in the Stress-buffering Function of Social Support.” Psy- Nguyen, A. W., Taylor, R. J., and Taylor, R. J., et al. 2000. “Men- chology and Aging 20(4): 714–17. Chatters, L. M. 2016. “Church- tal Health Services in Faith Com- based Social Support Among munities: The Role of Clergy in Krause, N. 2006. “Exploring the Caribbean Blacks in the United Black Churches.” Social Work 45(1): Stress-buffering Effects of Church- States.” Review of Religious 73–87. based and Secular Social Support Research 58(3): 385–406. on Self-rated Health in Late Life.” Williams, D. R., and Williams- The Journals of Gerontology, Series Pew Research Center. 2015. Ameri- Morris, R. 2000. “Racism and B: Psychological Sciences and Social ca’s Changing Religious Landscape. Mental Health: The African Amer- Sciences 61(1): S35–43. tinyurl.com/ldnxabw. Retrieved ican Experience.” Ethnicity and April 27, 2018. Health 5(3-4): 243–68. Krause, N., and Hayward, D. R. 2015. “Social Perspectives: Sup- Revicki, D. A., et al. 2012. “Human- Woodward, A. T. 2011. “Discrimi- port, Social Relations, and Well- istic and Economic Burden of Gen- nation and Help-seeking: Use of being.” In P. A. Lichtenberg et al., eralized Anxiety Disorder in North Professional Services and Informal eds., APA Handbook of Clinical America and Europe.” Journal of Support Among African Ameri- Geropsychology (Vol. 1). Washing- Affective Disorders140(2): 103–12. cans, Black Caribbeans, and Non- ton, DC: American Psychological Hispanic Whites with a Mental Soto, J. A., Dawson-Andoh, N. A., Association Publishing. Disorder.” Race and Social Prob- and BeLue, R. 2011. “The Relation- lems 3(3): 146–59. Lee, H. S., and Kim, C. 2016. ship Between Perceived Discrimi- “Structural Equation Modeling nation and Generalized Anxiety Woodward, A. T., et al. 2010. “Dif- to Assess Discrimination, Stress, Disorder Among African Ameri- ferences in Professional and Infor- Social Support, and Depres- cans, Afro Caribbeans and Non- mal Help-seeking Among Older sion Among the Elderly Women Hispanic Whites.” Journal of Anxi- African Americans, Black Carib- in South Korea.” Asian Nursing ety Disorders 25(2): 258–65. beans, and Non-Hispanic Whites.” Research 10(3): 182–8. Journal of the Society for Social Work and Research 1(3): 124. Lincoln, C. E., and Mamiya, L. H. 1990. The Black Church in the Afri- can American Experience. Durham, NC: Duke University Press.

Can Economic Interventions for Children Reduce Economic Inequality in Adulthood?

By Trina R. Shanks Child Development Accounts offer economic support early in life that can institutionalize greater financial health.

conomic inequality in wealth and income has All of these experiences come at negative costs Ebeen increasing in the United States over the to young people, as well as to society as a whole last third of a century. Households at the top (Holzer et al., 2008; Williams Shanks and Rob- income distribution have experienced rapid inson, 2013; McLoyd et al., 2009). Although the growth, while households at the bottom have United States is generally described as a place of stagnated (Henly et al., 2018; Grusky, Mattingly, opportunity, since the 1940s, absolute mobility and Varner, 2016; Saez and Zucman, 2016). Eco- has declined and, for the frst time, current gen- nomic inequities are even more stark when erations of young people are not expected to earn viewed through the lens of both race and ethnic- more than their parents (Chetty et al., 2016). ity, with households of color faring worse than national averages. Economic Disparities by Race, Ethnicity, Such inequalities have implications for future and Gender Persist generations. Children growing up in low-income, Income inequality has increased for everyone low-wealth households (especially when this since the 1970s, although it increased somewhat poverty occurs in early childhood and contin- less among people ages 60 and older (Bosworth, ues across multiple years) experience worse Burtless, and Zhang, 2016). However, economic educational and health outcomes, higher lev- disparities by race, ethnicity, and gender that are els of stress, greater involvement in crime, and found in households with children persist into lower earnings and lower wealth in adulthood. old age. Older African Americans and Latinos are

abstract American economic inequality often starts early in life and persists through adulthood and retirement. The disparities are starker when viewed through the lens of race, ethnicity, and gender. A promising policy recommendation to help lessen economic inequality is institutionalizing greater financial health through a structured matched savings account or asset-building program. One well- researched example is the Child Development Account (CDA), of which there are both long-standing and newly emerging examples. Using such accounts to build wealth could lead to less economic disparity in old age. | key words: inequality, wealth, financial health, asset-building, Child Development Accounts, life course

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 68 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America more than twice as likely to be poor, have lower pay for child-related expenses; an Edusave life expectancies, and be more dependent upon scheme with an annual contribution and incen Social Security income than older non-Hispanic tives for children between the ages of 7 and 16 whites. to maximize educational enrichment; a Post- Older women are more likely to be poor secondary Education account scheme that than men (Mather, Jacobsen, and Pollard, 2015; matches family savings to help pay for approved Olshansky et al., 2012). Older African Ameri- college and post-secondary expenses; and a cans have lower lifetime earnings, less wealth, Medisave account with a lump-sum grant for less retirement savings, and are insecure across a health-related expenses through age 21. Left- range of indicators that lead to greater economic over money in any of these accounts follows strain (Williams Shanks and Leigh, 2015). the individual across their lifetime through If I were to recommend a policy response to the Central Provident Fund mandatory retire- lessen economic disparities across the life ment savings system (for specifc details on course—a response that also would reduce eco- Singapore, see Loke and Sherraden, 2015). nomic inequality in old age—it would be some- Whether four separate accounts, as proposed thing similar to Aspen’s Savings for Life model by Aspen, or a lifelong account that offers pro- (goo.gl/m28Ho6). This approach recommends gressive incentives at key life stages as suggested four subsidized accounts at key life stages: Child by Sherraden (1991), the potential benefts would Accounts, Home Accounts, Individual Retire- be similar. ment Accounts, and Annuities (Mensah et al., 2007). Asset-Building Tools for Children’s For the Child Accounts, the government Brighter Futures would provide all children a beginning endow- Child Development Accounts (CDA; also some- ment to open an investment account, giving every times called Child Savings Accounts) are one child a chance to build fnancial literacy. The well-researched example that set a precedent Home Accounts would provide a government for providing real opportunity and structured match for low- and moderate-income families economic support across a major life milestone— transition to adulthood—usually with an emphasis on post-secondary education. Such accounts Since the 1940s, absolute mobility are a way to institutionalize fnancial well-being has declined in the United States. that includes everyone, not just those born into households at the upper end of income and on savings toward a house down payment. The wealth distributions. There is research on the Individual Retirement Accounts would also ben- best design features for CDAs, as well theoretical eft from a government match for low- and mod- and empirical evidence on how they might influ- erate-income Americans who have no access to ence child outcomes (Clancy and Beverly, 2017; retirement plans at work. And the Security “Plus” Grinstein-Weiss, Williams Shanks, and Beverly, Annuities would provide additional guaranteed 2014; Elliott and Sherraden, 2013). income as a complement to Social Security. The Saving for Education, Entrepreneur- Although this might seem like a radical pol- ship and Downpayment (SEED) initiative was icy proposal in the U.S. context, a similar gov- a national policy and practice demonstration to ernment-sponsored savings program exists in test asset-building accounts for children, funded Singapore. Singapore has a Baby Bonus scheme by a dozen foundations. It ran from 2003 to 2008 that offers an unrestricted cash gift and match- and piloted CDA programs in twelve commu- ing funds for children from birth to age 12 to nities across the country, partnering with local

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 69 GENERATIONS – Journal of the American Society on Aging organizations, including preschools, schools, school graduation. As part of this initiative, 495 nonprofts, and a foster-care program. Head Start students were enrolled in a Michigan A 2010 report synthesizes fndings across all 529 college savings account and given an initial the sites and offers lessons learned from these deposit of $800, which came from partnering efforts (Sherraden and Stevens, 2010). Build- foundations and which then made most families ing upon SEED, a few foundations also funded a eligible for a $200 state match. statewide CDA experiment with a random selec- The program also offered MI-SEED house- tion of newborns, a program that was launched holds a dollar-for-dollar match of up to $1,200 in 2007 in Oklahoma. Called SEED for Okla- for any additional money saved. As the formal homa Kids (or SEED-OK), the experimental de program ended in December 2008, the median sign tests policy features and demonstrates the balance in the accounts was $1,131 (mean $1,483). feasibility of scaling programming at the state By December 2015, the median balance had level without going through community partners grown to $1,337 (mean $2,017). Although the country went through the ‘Automatic enrollment, automatic Great Recession soon after the program started (2007–2009), and many families faced severe initial deposits, and a progressive economic hardships, less than 10 percent with- savings subsidy favor disadvantaged drew funds from these MI-SEED accounts. children.’ Caregivers (most respondents were mothers, but also grandparents and other caregivers) (Zager et al., 2010). saw the money as an investment in their child’s A promising result from SEED-OK is that future. Although $1,300 may seem an insignif- automatic enrollment, automatic initial deposits, cant amount given the increasing cost of college and a progressive savings subsidy favor disad- tuition, there is evidence that even small dol- vantaged children (Beverly, Clancy, and Sher- lar amounts in child savings can increase the raden, 2016). Such features help assure a CDA likelihood of college enrollment and comple- policy that reduces inequalities, rather than tion—particularly for children in low-income reproducing them. households (Elliott, 2013). Initial fnancial, parental, and child outcomes Between 2014 and 2015, my research team of the SEED-OK program (Clancy et al., 2016; contacted ffty MI-SEED families to conduct in- Beverly, Clancy, and Sherraden, 2016; Sherraden depth interviews with caregivers and youth. A et al., 2015) have piqued interest in other states summary report on MI-SEED, with longitudi- and municipalities. New programs are starting nal outcomes and these qualitative fndings, will throughout the country, but children participat- be released by the end of 2018. To offer a quick ing in these emerging programs are still fairly update, most families were still excited about young, so research evidence is limited (Prosper- the MI-SEED account ten years later, and some ity Now, 2018; Shanks, 2014). were having concrete conversations about how I was a researcher with the quasi-experiment they would use the money to fund their child’s set up in Michigan as part of the original SEED post-secondary education. MI-SEED partici- demonstration that is now one of the longest pants are expected to graduate from high school running CSA programs in the United States. As between 2017 and 2019. The fnal research task a site that enrolled Head Start students in 2004 will be collecting data to examine who gradu- and 2005, results coming from Michigan SEED ated from high school and went on to enroll in (MI-SEED) provide longitudinal data on a CDA college and whether having this CDA account program from early childhood through high influenced post-secondary outcomes.

Prioritizing Young People: A Path investment vehicles that take advantage of com- to Financial Health pound interest, establishing a foundation for fi The Consumer Financial Protection Bureau nancial capability through one’s working years (CFPB, 2015) defnes fnancial well-being as “a and into retirement. state of being wherein a person can fully meet CDAs (or any well-run asset-building pro- current and ongoing fnancial obligations, can gram) are not a panacea for all economic disparity. feel secure in their fnancial future, and is able However, they are a way to offer economic sup- to make choices that allow enjoyment of life.” Financial well-being is not tightly aligned with Relatively small amounts, like liquid income, but having greater liquid savings and the ability to cover an unexpected expense are both assets of $2,000, can provide a associated with greater fnancial well-being. Rel minimum floor to assure financial health. atively small amounts, such as liquid assets of $2,000, can provide a minimum floor to assure port early in life that effectively institutionalizes fnancial health (CFPB, 2017). greater fnancial health. If such accounts are intro- Prioritizing such fnancial health frst among duced as part of a larger economic strategy that young people through child accounts and then follows individuals over a lifetime, there is less across the life span could lead to less economic danger of anyone facing severe economic strain disparity overall and greater fnancial well-being in old age. Rather than being known as a society in older age and retirement. For example, CDAs with extreme economic inequality where dispari- and similar age- and stage-appropriate accounts ties start at birth and persist through death, Child could promote investment that leads to greater Accounts can model how strategic investment at educational attainment via post-secondary train- transformative moments make it possible to gener- ing; greater fnancial cushion as fewer house- ate pathways of prosperity for all. holds experience zero and negative net worth; more options for employment and self-employ- Trina R. Shanks, Ph.D., is an associate professor at the ment, including business start-ups; and more University of Michigan School of Social Work in Ann opportunity to engage in saving and long-term Arbor. She can be contacted at [email protected].

References Beverly, S. G., Clancy, M. M., and Chetty, R., et al. 2016. “The Fading Clancy, M. M., et al. 2016. “Test- Sherraden, M. 2016. Universal American Dream: Trends in Abso- ing Universal Child Development Accounts at Birth: Results from lute Income Mobility Since 1940” Accounts: Financial Effects in a SEED for Oklahoma Kids (CSD (NBER Working Paper 22910). Large Social Experiment.” Social Research Summary No. 16-07). goo.gl/xsZ6Gt. Retrieved February Service Review 90(4): 683–708. goo.gl/BbP7Na. Retrieved Febru- 12, 2018. Consumer Financial Protection ary 12, 2018. Clancy, M. M., and Beverly, S. G. Bureau (CFPB). 2015. Financial Bosworth, B., Burtless, G., and 2017. Statewide Child Development Well-Being: The Goal of Financial Zhang, K. 2016. Later Retirement, Account Policies: Key Design Ele- Education. Washington, DC: CFPB. Inequality in Old Age, and the ments (CSD Policy Report 17–30). CFPB. 2017. Financial Well-Being in Growing Gap in Longevity Between goo.gl/FHaHtw. Retrieved Febru- America. Washington, DC: CFPB. Rich and Poor. Washington, DC: ary 12, 2018. Brookings Institution.

Elliott, W. 2013. “Small-dollar McLoyd, V. C., et al. 2009. “Poverty Sherraden, M., and Stevens, J., Children’s Savings Accounts and and Socioeconomic Disadvantage eds. 2010. Lessons from SEED: A Children’s College Outcomes.” in Adolescence.” In R. M. Lerner National Demonstration of Child Children and Youth Services Review and L. Steinberg, eds., Handbook Development Accounts. St. Louis, 35(3): 572–85. of Adolescent Psychology (Vol. 2). MO: Washington University, Cen- Hoboken, NJ: Wiley. ter for Social Development. Elliott, W., and Sherraden, M. 2013. “Assets and Educational Mensah, L., et al. 2007. Savings Sherraden, M., et al. 2015. “Uni- Achievement: Theory and for Life: A Pathway to Financial versal Accounts at Birth: Build- Evidence.” Economics and Security for all Americans. ing Knowledge to Inform Policy.” Education Review 33(3): 1–7. bit.ly/2JYjb9x. Retrieved Journal of the Society for Social January 22, 2018. Work and Research 6(4): 541–64. Grinstein-Weiss, M., Williams Shanks, T. R., and Beverly, S. 2014. Olshansky, S. J., et al. 2012. “Dif- Williams Shanks, T. R., and Leigh, “Family Assets and Child Out- ferences in Life Expectancy Due to W. A. 2015. “Assets and Older Afri- comes: Evidence and Directions.” Race and Educational Differences can Americans.” In N. Morrow- Future of Children 24(1): 147–70. Are Widening, and Many May Not Howell and M. S. Sherraden, eds., Catch Up.” Health Affairs31(8): Financial Capability and Asset Grusky, D. B., Mattingly, M. J., and 1803–13. Holding in Later Life: A Life Course Varner, C. E. 2016. The Poverty and Perspective. New York: Oxford Inequality Report. goo.gl/tQhsCu. Prosperity Now. 2018. “Find a University Press. Retrieved January 22, 2018. Children’s Savings Program.” goo.gl/YsybLW. Retrieved Williams Shanks, T. R., and Rob- Henly, J., et al. 2018. “Reduce February 16, 2018. inson, C. 2013. “Assets, Economic Extreme Economic Inequality.” Opportunity and Toxic Stress: A In R. Fong., J. E. Lubben, and R. P. Saez, E., and Zucman, G. 2016. Framework for Understanding Barth, eds., Grand Challenges for “Wealth Inequality in the United Child and Educational Outcomes.” Social Work and Society. New York: States Since 1913: Evidence from Economics of Education Review 33: Oxford University Press. Capitalized Income Tax Data.” 154–170. The Quarterly Journal of Economics Holzer, H. J., et al. 2008. “The Eco- 131(2): 519–78. Zager, R., et al. 2010. The SEED for nomic Cost of Childhood Poverty Oklahoma Kids Experiment: Initial in the United States.” Journal of Shanks, T. R. 2014. “The Promise of Account Opening and Savings (CSD Children and Poverty 14(1): 41–61. Child Development Accounts: Cur- Research Report 10-14). rent Evidence and Future Direc- Loke, V., and Sherraden, M. goo.gl/WqSGVG. Retrieved tions.” Community Investments 2015. Building Children’s Assets in February 16, 2018. 26(2): 12–15. San Francisco: Federal Singapore: The Beginning of a Life- Reserve Bank of San Francisco. long Policy (CSD Policy Brief No. 15-51). goo.gl/fuJxj3. Retrieved Sherraden, M. 1991. Assets and the January 25, 2018. Poor: A New American Welfare Pol- icy. Armonk, NY: M. E. Sharpe, Inc. Mather, M., Jacobsen, L. A., and Pollard, K. M. 2015. “Aging in the United States.” Population Bulletin 70(2). Washington, DC: Population Reference Bureau.

Advocates for African American Elders: Engaging Our Older Adults in Education and Research

By Karen D. Lincoln An outreach program provides culturally competent health education for older African Americans in Los Angeles County.

os Angeles County (LAC), California, is the Founded in 2012 to address racial disparities in Llargest county in the nation. It contains Cali- health outcomes, AAAE partners with commu- fornia’s biggest population of older adults, the nity-based agencies, governmental organiza- majority of which are racial and ethnic minorities tions, and health plans to address the persistent (Department of Finance, 2017). Due to LAC’s size, and growing needs of older African Americans. it is divided into eight Service Planning Areas AAAE educates and disseminates informa- (SPA) (County of Los Angeles, 2018). These dis- tion about healthcare policies and resources tinct geographic regions allow the Department through fact sheets, educational forums, and the of Public Health to develop and provide relevant AAAE website. It also collaborates with local public health and clinical services to the specifc healthcare providers to improve outreach, edu- health needs of residents in these different areas. cation, and care, assessing service needs and re sources via surveys in LAC. The program also A Model Program Responds engages in community-partnered participa- to Racial Health Disparities tory research to provide real-world solutions for Advocates for African American Elders (AAAE) improving health outcomes and to build commu- is an outreach and engagement program at the nity research capacity. University of Southern California (USC) that AAAE selected SPA 6 (South Los Angeles) as provides culturally competent health education its primary service area because of its social and for older African Americans throughout LAC. economic disparities. A demographic snapshot of

abstract Advocates for African American Elders (AAAE) is an outreach and engagement program at the University of Southern California, Suzanne Dworak-Peck School of Social Work. Founded by Associ- ate Professor Karen Lincoln, AAAE comprises community advocates and graduate students who have since 2012 provided culturally competent health education for older African Americans throughout Los Angeles County. AAAE partners with community-based agencies, governmental organizations, and health plans to conduct community-partnered participatory research, raise awareness, increase knowledge and access to healthcare resources, and improve health outcomes for older African Americans and their families. | key words: Advocates for African American Elders, Los Angeles County, healthcare access

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 73 GENERATIONS – Journal of the American Society on Aging communities in SPA 6 shows that African Ameri- Americans’ knowledge about Alzheimer’s dis- cans constitute more than 28 percent of the pop ease and attitudes toward clinical research, and ulation, the largest concentration of African a randomized, comparative effectiveness trial Americans in LAC. Within that African Ameri- to increase knowledge about Alzheimer’s and can population, 36.5 percent are ages 50 to 64 to examine the effects of cultural mistrust and and 48.8 percent are ages 65 or older; these per- racial discrimination upon research attitudes. centages represent the largest population of older adults in LAC (USC Edward R. Roybal Institute The 2014 community survey on Aging, 2015). Residents in SPA 6 have the low- Findings from the 2014 community survey indi- est levels of education and income, and the high- cated that many older African Americans in LAC est poverty rate of all eight SPAs (Los Angeles were healthy, connected, engaged, and received County Department of Public Health, 2017). services that met their needs. However, survey fndings also revealed service needs and gaps for ‘South Los Angeles has the County’s many participants. Moreover, results revealed low computer and health literacy levels across highest rates of hypertension (64 age groups and educational levels, as well as a percent) and obesity (34.1 percent).’ lack of knowledge about services and programs available for older adults. These fndings were About 20 percent of SPA 6’s population that is most prevalent among survey participants who ages 50 or older has diabetes, and 20 percent has a lived alone, had low levels of education, were depression diagnosis. South Los Angeles has the of advanced age, and had poor physical and County’s highest rates of hypertension (64 per- mental health. cent) and obesity (34.1 percent) (Los Angeles In 2014, AAAE released Understanding the County Department of Public Health, 2017), and Service Needs of African American Seniors in Los one of the County’s lowest levels of access to den- Angeles County: Findings from the Advocates for tal care and healthcare. There are eleven licensed African American Elders Community Survey, a dental practitioners and thirty-nine physicians per report of the fndings the 2014 community sur- 100,000 residents in the South Los Angeles area, vey (Lincoln, 2014). The report was disseminated compared to 225 licensed dental practitioners and to more than 500 policy makers and community 1,000 physicians in the West Los Angeles area stakeholders, resulting in numerous tweets, (USC Edward R. Roybal Institute on Aging, 2015). many of which were “favored” and re-tweeted. African Americans make up 5.7 percent of USC also provided access to the report’s recom- the West Los Angeles (SPA 5) population and mendations to inform and be included in the Los non-Hispanic whites comprise 64 percent of the Angeles Department of Aging’s strategic plan. population. Residents in West Los Angeles have A second report from these data, titled New the highest levels of education, the lowest pov- Research Highlights the Benefits of Commu- erty rate (11.9 percent), and the lowest rates of nity Programs for Older African Americans in obesity (10.3 percent), diabetes (4.5 percent), and Los Angeles County (Lincoln, 2015), outlined hypertension (17.1 percent) of all eight SPAs. the benefts of community-based programs for older adults. Findings showed that participation AAAE in Action in and access to quality community-based ser- The range of AAAE research activities include vices resulted in better physical health and over- a community survey of 550 African Americans, all well-being, including better quality of life, a healthcare experience survey of 200 African less depression, less isolation and loneliness, and Americans, a qualitative study to explore African reduced risk of food insufficiency.

Survey findings leverage advocacy, that benefciaries can make informed decisions outreach,and policy about their healthcare and avoid any disrup- I presented the survey fndings as part of my oral tions that passive enrollment into a new health and written testimony to the California State plan might infer. Legislature to emphasize the need for increased AAAE responded to the need for outreach quality, access, and availability of services and and education in African American communities programs for older adults who reside in poor, by developing an innovative and engaging talk segregated, and under-resourced neighborhoods. show format to deliver information about Cal My legislative testimony and recommenda- MediConnect. The talk show has been hosted tions are included in the report, A Shattered Sys- by a variety of African Americans, including a tem: Reforming Long-Term Care in California, professional actress, a licensed clinical social which was published by the Senate Select Com- worker, and the co-director of AAAE. Culturally congruent presenters increase the participants’ ‘The training has been delivered to level of access to information because participants relate to the messengers. The set design more than 250 healthcare and mental is a replica of a talk show set that offers audio health care providers.’ and visual learning via the host, guests, and a PowerPoint presentation (running in the back- mittee on Aging and Long-Term Care (Senate ground rather than being the show’s focus) that Select Committee on Aging and Long-Term Care, highlights the conversation in graphic form. 2014). This widely disseminated report offers AAAE partnered with the fve health plans thirty legislative recommendations in eight participating in the Cal MediConnect program issue areas (state leadership, legislative leader- to extend outreach and education efforts. AAAE ship, system integration, fragmentation/lack of also coauthored an issue brief in collaboration integrated data, infrastructure, workforce, fund- with staff attorneys from Justice in Aging. Titled ing, and federal issues) for immediate action and Thinking Outside the Box: Creative and Culturally provides the frst blueprint for the country to Competent Outreach Strategies in Health Care achieve improved coordination and a high-func- Transitions, the brief describes the AAAE out- tioning, comprehensive long-term-care system. reach and education model, and highlights its One fnding from the AAAE community sur- effectiveness in reaching, engaging, and edu- vey indicated that 81.5 percent of participants cating members of underserved communities were unaware of new legislation authorized (Chen, Lincoln, and Gaines, 2015). by the Affordable Care Act that established the Dual Eligible Demonstration Project in Califor- A focus on training, brain health education, nia called Cal MediConnect. Cal MediConnect and research is a complex healthcare system that combines a AAAE’s dedication to improving healthcare de dual eligible’s healthcare benefts, both Medi- livery to African Americans was the impetus for care and Medicaid services, into one beneft designing the AAAE Cultural Competency Train- package administered by managed care orga- ing. To date, this is the only training of its kind nizations. Although participation in the dem- for service providers focused on African Ameri- onstration project is voluntary, California, like can older adults and mental health. The training many states, passively enrolled dual eligibles has been delivered to more than 250 healthcare into the program. Passive enrollment highlights and mental health care providers, including so the critical need for benefciary outreach and cial workers, medical directors, psychiatrists, education in dual demonstration projects so physicians, and health plan staff, and is cur-

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 75 GENERATIONS – Journal of the American Society on Aging rently being offered by the Los Angeles County Findings from The Wisdom Project were Department of Mental Health (CMUs, CEUs used to develop a curriculum for BrainWorks: A and Certifcates of Completion are available for Comparative Effectiveness Trial to Examine Text participants). Message-Based Alzheimer’s Disease Education for Currently, AAAE is leading efforts at USC to Community-Dwelling African Americans. This increase education and participation in Alzheim- three-pronged, randomized trial used the AAAE er’s disease clinical research among African talk show format to deliver an Alzheimer’s dis- Americans. AAAE’s Brain Health initiative was ease curriculum to a sample of 200 African Amer- created to address the higher risk and greater icans ages 50 and older. Daily text messages were burden of Alzheimer’s among African Ameri- sent to the intervention groups in order to sup- cans, compared to other racial groups (Mayeda port and reinforce the curriculum. The goal of this et al., 2016). The Wisdom Project: Exploring Atti- study was to increase Alzheimer’s disease knowl- tudes and Beliefs about Alzheimer’s Disease and edge and positive attitudes about clinical research (Clay, 2017). Data collection was completed in December 2017 and data analysis has begun. AAAE is leading efforts to increase education and participation in What’s Next for AAAE? Alzheimer’s disease clinical research We will publish our fndings from BrainWorks and apply for funding to expand this study. among African Americans. AAAE will continue to further its mission of enhancing quality of life for African American Clinical Research among African Americans used older adults by leading outreach and engagement focus groups to understand the beliefs, experi- efforts informed by CPPR, growing the research ences, and informational and educational needs capacity of community residents and organiza- related to Alzheimer’s disease, and barriers and tions, providing training and research oppor- facilitators to participation in clinical research tunities for graduate students, increasing the among thirty-two African Americans ages 50 cultural competency of service providers, and and older. Findings revealed that racism and dis- advocating for quality and accessible healthcare crimination were fundamental causes underly- for members of underserved communities. ing previously reported barriers to participation in clinical research, such as mistrust and fear Karen D. Lincoln, Ph.D., M.S.W., M.A., is associate of experimentation (the frst manuscript from professor at the Suzanne Dworak-Peck School of these data has been submitted for publication Social Work at the University of Southern California to The Gerontologist). in Los Angeles.

References Chen, D., Lincoln, K. D., and County of Los Angeles. 2018. Lincoln, K. D. 2014. Understand- Gaines, B. F. 2015. Thinking Out- “SPA 6 South Area—LA County ing the Service Needs of African side the Box: Creative and Culturally Department of Public Health.” American Seniors in Los Angeles Competent Outreach Strategies in goo.gl/6T4azK. Retrieved January County: Findings from the Advo- Health Care Transitions. Los Ange- 9, 2018. cates for African American Elders les: Justice in Aging. Community Survey. Los Angeles: Department of Finance. 2017. USC Edward R. Roybal Institute Clay, J. 2017. “Alzheimer’s Educa- “Population Projections (Baseline on Aging, Advocates for African tion Takes a Page from Oprah’s 2016).” goo.gl/2kqMai. Retrieved American Elders. Playbook.” USC News. October 12. January 3, 2018.

Lincoln, K. D. 2015. New Research Mayeda, E. R., et al. 2016. “Ine USC Edward R. Roybal Insti- Highlights the Benefits of Commu- qualities in Dementia Incidence tute on Aging. 2015. The 2015 Los nity Programs for Older African Between Six Racial and Ethnic Angeles Healthy Aging Report. Los Americans in Los Angeles County. Groups Over 14 Years.” Alzheimer’s Angeles: USC Edward R. Roybal Los Angeles: USC Edward R. Roy- and Dementia 12(3): 216–24. Institute on Aging. bal Institute on Aging, Advocates Senate Select Committee on Aging for African American Elders. and Long-Term Care. 2014. A Shat- Los Angeles County Department of tered System: Reforming Long- Public Health. 2017. Key Indicators Term Care in California. Envision- of Health by Service Planning Area. ing and Implementing an IDEAL Los Angeles: Los Angeles County Long-Term Care System in Califor- Department of Public Health. nia. Sacramento, CA: Senate Select Committee on Aging and Long- Term Care.

Recruiting Older African Americans to Brain Health and Aging Research Through Community Engagement

By Mark A. Gluck, Ashlee Shaw, and Lessons from the African-American Brain Health Diane Hill Initiative at Rutgers University−Newark.

he African-American Brain Health Initia- focus future interventional efforts to remediate Ttive (AABHI) at Rutgers University–Newark it. Additionally, African Americans are under- is a unique university−community partnership represented in biomedical research (Shavers- combining community engagement, education and Hornaday et al., 1997; Corbie-Smith et al., 1999; training, and brain health research. Partnering Braunstein et al., 2008). with community-based organizations, we promote However, as a result of community-engaged brain health literacy, Alzheimer’s awareness, brain- outreach efforts, we have enrolled African healthy lifestyle choices, and participation in brain American community members in several research for older African Americans in Greater research studies on aging and Alzheimer’s Newark, New Jersey. Our research and training disease. In 2015, we recruited more than a missions bring together undergraduates, graduate thousand older African Americans of Greater students, postdoctoral fellows, faculty, and clini- Newark to participate in a short health and cians for cross-disciplinary efforts that link neu- lifestyle survey, working in partnership with roscience, neurology, public health, social work, the New Jersey Department of Health’s Office and nursing. of Minority and Multicultural Health. Based African Americans have two to three times on their positive experience with this study— the prevalence of Alzheimer’s disease as com- which, for most, was their frst biomedical or pared to whites (Barnes and Bennett, 2014; Tang health research experience ever—many agreed et al., 2001). We do not fully understand the to participate in additional research studies causes of this health disparity, nor how best to at Rutgers.

abstract The African-American Brain Health Initiative at Rutgers University–Newark is a university– community partnership combining community engagement, education and training, and brain health research. Partnering with community-based organizations, it promotes brain health literacy, Alzheimer’s awareness, brain-healthy lifestyle choices, and participation in brain research for older African Ameri- cans in Greater Newark, New Jersey. Our approach to recruitment relies on building trust through long- term relationships; communicating health knowledge through trusted community leaders; recruiting subjects through targeted efforts; and cultivating research participants as ambassadors. | key words: Rutgers University–Newark, research study recruitment, African American, older men, community partnership, brain health

We have two ongoing research studies within Key to this external outreach has been a the AABHI. One study, funded by the National cross-disciplinary partnership at Rutgers Institutes of Health’s (NIH) National Institute University–Newark with the Office of Uni- on Aging, investigates how variations in life- versity–Community Partnerships, which is style, weight, diet, sleep, and, especially, physi- responsible for, and experienced with, external cal ftness, are correlated with cognitive and community relations. Community participants brain function in older African Americans, recruited to our research have come primar- with the goal of identifying early predictors ily from long-standing partnerships with local of cognitive decline and future conversion to Alzheimer’s disease. ‘African Americans have two to three Our other study, funded by the Federal Office of Minority Health in partnership with times the prevalence of Alzheimer’s the New Jersey Office of Minority and Multi- disease compared to whites.’ cultural Health, asks if participating in a bi- weekly dance-based exercise class, hosted by churches; senior centers; city, county, and state local churches and senior centers, can improve offices for health and aging; as well as from out- memory and brain function in older African reach to public and other low-income housing Americans, reducing known biomarkers for sites. Representatives from many of these part- Alzheimer’s risk. For these two research stud- ner organizations make up the AABHI Commu- ies, we recruit and test about 150 people per year, nity Advisory Board, which meets every other and all are African Americans ages 55 and older. month to guide our activities and provide a The initial testing takes about two and a half bridge to community needs and interests. hours and individuals who are medically and With these partners, the Rutgers University– physically able may return on another day for Newark AABHI hosts several large events optional brain imaging. every year, attracting about 250 older African American community members to each. Also, Research Recruitment Tactics we run around two smaller “Lunch ’n’ Learns” Our approach to research recruitment for both per month at our partner sites, which attract studies relies on extensive community engage- twenty-fve to ffty people per event. All of these ment based on the following four key strategies: health education programs emphasize six key √ Build trust through long-term relation- steps to brain health that our community mem- ships that bring value to the community. bers can and should take, and lifestyles and All of our activities build on trust established habits associated with reducing their risk for from more than a decade of community engage- Alzheimer’s disease: doing regular exercise, ment and service in Greater Newark. We have keeping mentally active, avoiding unproductive implemented a range of outreach and engage- stress, and getting adequate sleep, social sup- ment approaches designed to enhance commu port, and proper nutrition. nity health through brain health education pro Each event also includes a presentation on grams that support older African Americans in the benefts and importance of research partici- adopting healthier lifestyles. Our community- pation by African Americans. Whenever pos engaged approach leverages community partner- sible, these presentations on research participa- ships to develop a culture of trust between Rut- tion are given by African American students at gers and the community (Holland, 2005; Sandy Rutgers University–Newark (often they are stu- and Holland, 2006; Silka and Renault-Caragianes, dents who grew up in Newark) who are working 2006; Post et al., 2016). on our AABHI research studies as part of their

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Volume 42 .Number 2 | 79 GENERATIONS – Journal of the American Society on Aging undergraduate or graduate training. For some brain research (see also Releford, Frencher, and of these events, we also partner with other local Yancey, 2010); hosting an annual classic car show organizations with complementary missions, and men’s brain health fair; supporting a sum- including the American Heart Association, the mer picnic and health fair for older residents American Stroke Association and the Alzheim- of public housing in partnership with the New- er’s Association. ark Housing Authority; partnering with a local √ Communicate health information seniors bowling league; and hiring black men through known and trusted community from the community, including local black grad- leaders. uate students, and black male nurses recruited We hire and train known and trusted com- through the Northern New Jersey Black Nurses munity leaders as health educators to deliver information about brain health and research in ‘All of our activities build on trust formation to community members at the events described above. These Community Brain Health established from more than a decade Educators often are leaders from our partner of community engagement.’ churches and senior centers, including church deacons and pastors, as well as retired teachers, Association, to work as our ambassadors and nurses, and other community advocates. In addi- Community Brain Health Educators for recruit- tion to leading and presenting at our brain health ing men to our research. Through this multi- education events, they assist in nurturing, manag- pronged approach, we are attracting increasing ing, and expanding our relationships with com numbers of men to our studies. munity organizations, while serving as locally The need for additional efforts in recruiting “embedded” brain health experts. men to our programs demonstrates that, even √ Recruit older black men through when working with an underrepresented popu- targeted efforts. lation, additional, more targeted outreach may be Attracting older men to health education and necessary to capture a particular group within research participation has been a challenge; in a population of interest. For example, we have and around Newark, African American women found it useful to develop targeted programs ages 55 and older outnumber men by more than for residents of low-income public and federally two to one, and the ratio is even more extreme subsidized housing. As we become increasingly within the community and church groups from sensitive to the needs and interests of the many which we recruit (the ratio is less extreme in sub-communities within our broader commu- senior public housing). We have developed a nity of older African Americans in Greater New- range of outreach and engagement approaches ark, we have come to appreciate that a range of specifcally designed to enhance recruitment strategies may be required for each. of older black men to our research studies. √ Cultivate research participants as These approaches embody both of the frst ambassadors for brain research. two strategies noted above, but re-focused spe- Once participants have participated in re cifcally on men. These include the following: search, they become AABHI VIPs: Very Impor- supporting the growth of a network of church tant Participants. All VIPs receive regular men’s ministries who offer a monthly “Men’s contact from us via phone and mail through- Health and Wellness Breakfast Club,” led by out the year. By hearing from us and seeing us our Community Brain Health Educators; run- in their churches and community-based orga- ning health education programs for barbers to nizations, participants know they are valued enlist them as ambassadors for brain health and members of an ongoing university−community

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 80 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America partnership, in which Rutgers is committed to All the strategies described herein are read- them, their community, and their health needs ily implementable by other universities and for years to come. All are asked to spread the medical research centers doing aging and brain word about brain health and to encourage friends health research that are interested in working and acquaintances to participate in our research with African Americans and other under- studies. About 25 percent of recent participants represented communities. All require a long- in our studies have come via word-of-mouth term commitment of time and effort to build from other participants, showing that the com- trust and partnerships with local community munity members become engaged not only in the organizations and community members. research, but also in working with us to expand recruitment through their own social networks. Mark A. Gluck, Ph.D., is a professor of Neuroscience and co-director of the African-American Brain Health Initiative at the Center for Molecular and Behavioral Additional, targeted outreach may Neuroscience, Rutgers University−Newark, in New be necessary to capture a particular Jersey. He can be contacted at [email protected]. group within a population of interest. Ashlee Shaw, Ph.D., is a postdoctoral fellow and associate director of the African-American Brain Health Summary Initiative. She can be contacted at a.metshell@ gmail. The AABHI at Rutgers University–Newark com. Diane Hill, Ph.D., is associate chancellor for began in 2006 as an occasional series of commu- University-Community Partnerships and co-director of nity brain health education events co-sponsored the African-American Brain Health Initiative. She can with local churches. Over the last few years, it be contacted at [email protected]. has expanded in scope and impact so that it now integrates all three of our university’s mis- Acknowledgements sions: community engagement, teaching and This work was supported by grants from the training, and research and scholarship. Each NIH/National Institute of Aging (R56-AG053961), of these missions is a key part of the Rutgers the Office of Minority Health at the U.S. Depart- University–Newark AABHI. Community ment of Health and Human Services, through a engagement provides opportunities for Rut- partnership with the New Jersey Department of gers students and postdoctoral fellows to get Health’s Office of Minority and Multicultural interdisciplinary training, while working with Health (MH-STT-15-001), and by support from faculty mentors and community members to the Chancellor’s and Provost’s offices at Rutgers pursue fundamental behavioral and biomedical University–Newark, and the Office of University– research on aging and Alzheimer’s disease. Community Partnerships.

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Holland, B. 2005. “Reflections on Releford, B. J., Frencher, S. K., and Shavers-Hornaday, V. L., et al. Community−Campus Partner- Yancey, A. K. 2010. “Health Pro- 1997. “Why Are African Ameri- ships: What Has Been Learned? motion in Barbershops: Balancing cans Under-represented in Medical What Are the Next Challenges?” Outreach and Research in African Research Studies? Impediments to In P. Pasque et al., eds. Higher Edu- American Communities.” Ethnicity Participation.” Ethnicity & Health cation Collaboratives for Commu- & Disease 20(2): 185–8. 2(1–2): 31–45. nity Engagement & Improvement. Sandy, M., and Holland, B. 2006. Silka, L., and Renault-Caragianes, Ann Arbor, MI: National Forum “Different Worlds and Common P. 2006. “Community−University on Higher Education for the Pub- Ground: Community Partner Per- Research Partnerships: Devising lic Good. spectives on Campus−Community a Model for Ethical Engagement.” Post, M. A., et al. 2016. Publicly Partnerships.” Michigan Journal Journal of Higher Education Out- Engaged Scholars: Next-Genera- of Community Service Learning reach and Engagement 11(2): 171. tion Engagement and the Future 13(1): 30–43. Tang, M. X., et al. 2001. “Inci- of Higher Education. Sterling, VA: dence of AD in African-Americans, Stylus Publishing. Caribbean Hispanics, and Cauca sians in Northern Manhattan.” Neurology 56: 49–56.

Family Matters: Older Adults Caring for Others and Each Other Mercedes Bern-Klug, Guest Editor

The topic for the Fall 2018 issue is caregiving, but with a slightly different twist. When the words “older adults” and “caregiving” are used in the same sentence, most people assume that the older adults being referred to are on the receiving end of the caregiving stick. Of- ten (and more increasingly), however, older adults are the ones who are assuming the caregiver role and doing the work of caregiving.

This issue of Generations focuses on older adults as caregivers to family members and friends, and aims to sensitize readers to situations in which older adults are continuing the role of caregiver (perhaps for an adult child or a sibling with a disability) or are newly arrived to the caregiving role (perhaps for an ill spouse or a friend with a debilitat- ing injury). Nearly two dozen articles will discuss issues that can COMING UP IN impact older adult caregivers, such as retirement, legacy and estate planning, caring for children with a disability and-or problems with Fall 2018 substance abuse, guardianship, family conflict, debt, and more. Generations

Research in Social, Economic and Environmental Equity (RISE3)

By Tiziana C. Dearing, Ruth McRoy, and A collaborative initiative supports research Tess Mulrean and teaching at the intersection of race, place, and poverty.

esearch in Social, Economic and Environ- research success. These are difficult commitments Rmental Equity (RISE3) was initiated to “re that require building new research strategies and frame challenges and resolve problems around metrics. RISE3 is trying to implement this model social, economic, and environmental equity in as it proceeds in its work, and welcomes a commu- ways that impact local outcomes, while generat- nity of practice striving for the same. ing knowledge and policy of national or global sig- nifcance.” It is a dynamic effort led by faculty The Intersection of Race, Place, and Poverty from multiple disciplines at the Boston College Social scientists understand that the intersec- School of Social Work. The collaboration supports tion of distinctive demographic factors such as research and teaching at the intersection of race, race, gender, or income affect outcomes for those place, and poverty. who experience this intersectionality (Moradi RISE3 is committed to the process and the im and Grzanka, 2017). RISE3’s work recognizes pact of its work. Therefore, RISE3 strives to con- the specifc intersectionality of race, place, and duct empirical studies in close connection with poverty upon outcomes ranging from economic the communities that may be most affected by the well-being to health, to quality of social connec- problem or issue being examined. RISE3 strives, tions (Tung et al., 2017; Putnam, 2015), and to wherever possible, to be physically present in mar- disproportionate environmental impact (Teix- ginalized neighborhoods or with marginalized eira and Krings, 2015). Regarding race, scientists, populations; to actively include vulnerable popu- including geneticists, biologists, and social sci- lations in study design, in research processes, and entists, generally agree that race as a biological in the distribution of fndings; and to use the fnd- construct is an obsolete conceptualization and ings’ impacts on people at the margins to measure lacks empirical support.

abstract Research in Social, Economic and Environmental Equity (RISE3) is a collaborative initiative at the Boston College School of Social Work. Led by faculty from multiple disciplines, the initiative seeks to “reframe challenges and resolve problems around social, economic, and environmental equity in ways that impact local outcomes, while generating knowledge and policy ideas of national or global signifi- cance.” RISE3 engages in research, convenes scholars and practitioners, and supports teaching and student interactions that raise awareness of the intersection and impact of race, place, and poverty. | key words: social equity, economic equity, environmental equity, race, place, poverty

Contemporary social scientists challenge vantages (Stoll, 2008; Charles, 2003; Habraken, genetic and biological notions of race by argu- 2000; Gieryn, 2000). Place matters, especially as it ing that people make attributions about groups concerns race and poverty. based on stereotypes and prejudices that are While other academic institutions focus on tied to physical traits (Winant, 2000; Omi and some combination of race, poverty, and place, Winant, 1994). Nevertheless, race matters. Im RISE3’s founders saw an opportunity to make plicit and explicit images, beliefs, and biases new contributions, for three reasons. First, con- are attached to racial categories that form the sider the extent to which a child’s ZIP code is a foundation and reason for unequal treatment powerful predictor of future mobility and sta- (Takeuchi and Gage, 2003). tus (Popkin, Acs, and Smith, 2009). Boston Col- lege is situated—geographically and with its networks—proximal to a handful of ZIP codes Images, beliefs, and biases that are that, for Boston, have proven particularly per- attached to racial categories form the nicious. The Roxbury-Dorchester-Mattapan corridor, for example, has the highest concen- foundation and reason for unequal tration of people of color, with the highest child treatment. poverty rate and among the lowest levels of adult educational attainment in the city (Kahn Poverty is a persistent and robust correlate and Martin, 2011). of a host of different social, political, and eco- Second, Greater Boston is home to a number nomic outcomes. It is frequently identifed as the of innovations in place-based and anti-poverty causal engine that directs inequalities in soci- work, such as UTEC (formerly the United Teen ety. For example, children who reside in poor Equality Center) in Lowell, and the nationally neighborhoods are more likely to have physical known Dudley Streets Neighborhood Initiative and mental health symptoms, experience social in Boston’s Dudley-Newmarket area. RISE3 fac- developmental delays, live in unsafe neighbor- ulty and other Boston College faculty have rela- hoods, perform poorly in schools, and die prema- tionships with these and a wide range of other turely. Even more striking, in 2015 in the United Massachusetts nonprofts that serve low-income, States, 21 percent of children lived in poverty, but predominantly minority communities. the child poverty rate for African Americans and Third, the intersection of race, place, and Hispanics was 32 percent and 31 percent, respec- poverty poses contemporary challenges that tively (Annie E. Casey Foundation, 2017). Given call for a recommitment to a core social justice wage stagnation and growing income inequality value—the dignity of every person. RISE3 is sit- in the United States (Chetty et al., 2017), poverty uated within Boston College, a Catholic, Jesuit still matters. institution with a strong history of high-quality Debate exists over which factor—poverty or secular thought, creating the potential for trans- race—is more important in explaining social, polit- lational work in social science and human dig- ical, economic, and health outcomes. See, for ex nity that can affect policy and practice. ample, fndings associated with the racial and income achievement gaps in primary school educa- Examples of RISE3 Research and Programs tion (Reardon, 2011). RISE3 asserts that one way to RISE3 is a young initiative, with team members move toward common ground is, as Gieryn (2000) who affiliate for specifc projects. The range of does, to contextualize race and poverty around work to date includes conducting research using “place.” Places, as defned here, create, exacerbate, national data sets; convening on public policy is maintain, or reduce social advantages and disad- sues such as childcare and transportation; edit-

Copyright © 2018 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 84 | Summer 2018 Land of the Unequal? Economic, Social Inequality in an Aging America ing a special issue of the Du Bois Review: Social Work Hours (Hawkins, Dearing, and Takeuchi, Science Research on Race on Race and Environ- 2017), primarily focused on the impact of time mental Equity (Takeuchi et al., 2016); and holding and money on childcare and childcare options. a week-long seminar for young scholars of color The study found that lower-income families and working on RISE3-related research. families of color spend more time transporting children to and from childcare. African Amer- ‘A child’s ZIP code is a powerful ican and Hispanic households spend a larger proportion of their income on childcare than predictor of future mobility white households, and low-income children and status.’ were twice as likely to be in childcare during non-standard hours. In February 2016, the Obama Administra- Overall, the two reports demonstrated that tion’s Office of Science and Technology Policy race−ethnicity and income each had an impact (OSTP) launched an initiative to integrate and on one’s access to and use of transportation and make publicly available a large number of fed- childcare, and the proportion of income spent on eral data sets, in the belief that an “open data” each. These studies represent only a sampling of approach would encourage communities, orga- the work done by RISE3 collaborators. nizations, and businesses to use the data to help RISE3’s initiatives have begun to show prac- vulnerable families and neighborhoods improve tical impact. For example, of the eight young their lives. OSTP invited RISE3 to become its scholars who attended our week-long research frst academic research collaborator on the ini- seminar in 2015, fve are now assistant profes- tiative. With funding from Boston College, RISE3 launched The Opportunity Project. ‘African American and Hispanic 3 In spring 2017, RISE released two reports households spend a larger proportion using multiple federal data sets. Their focus was on the intersection of race−ethnicity and income of their income on childcare.’ on access to basic tools of opportunity. The goal was to determine whether and how the interplay sors and two are in post-doctoral fellowships. of these demographic factors might affect access Further, several nonproft organizations in atten- to, and use of, transportation and childcare, spe- dance at the release of the transportation and cifcally. The frst report produced was called Are childcare reports were able to use the reports’ We There Yet? Race, Poverty and Equity in Neigh- data to support their efforts to change state-level borhood Transportation (Dearing, Hawkins, and public assistance policies. Takeuchi, 2017). The report examined the intersection of race−ethnicity and income, as data What’s Next for RISE3? were not available to examine geography. The In the 2018 academic year, RISE3 will host a study revealed that income levels affect how long series of public symposia that match scholars it takes to get to work, as does race−ethnicity— with community experts on topics related to if one is of low income. Use of public transporta- outcomes across social, economic, and envi- tion is generally associated with race−ethnicity, ronmental equity. After each symposium, the and among families using public transportation, RISE3 collaborators will host a private dinner lower-income families are more likely to use for the panelists with doctoral fellows—cho- the bus. sen across academic disciplines and through The second report, Race and Income Equity an application process—to provide guidance to in Childcare: Examining Time, Costs and Parental the students on their program of research. Pos-

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