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Policy Points Social policies might not only improve economic well-being, but also health. Health policy experts have therefore advocated for investments in social policies both to improve population health and potentially reduce health system costs. Since the 1960s, a large number of social policies have been experimentally evaluated in the United States. Some of these experiments include health outcomes, providing a unique opportunity to inform evidence-based policymaking. Our comprehensive review and meta-analysis of these experiments find suggestive evidence of health benefits associated with investments in early life, income support, and health insurance interventions. However, most studies were underpowered to detect health outcomes., Context: Insurers and health care providers are investing heavily in nonmedical social interventions in an effort to improve health and potentially reduce health care costs., Methods: We performed a systematic review and meta-analysis of all known randomized social experiments in the United States that included health outcomes. We reviewed 5,880 papers, reports, and data sources, ultimately including 61 publications from 38 randomized social experiments. After synthesizing the main findings narratively, we conducted risk of bias analyses, power analyses, and random-effects meta-analyses where possible. Finally, we used multivariate regressions to determine which study characteristics were associated with statistically significant improvements in health outcomes., Findings: The risk of bias was low in 17 studies, moderate in 11, and high in 33. Of the 451 parameter estimates reported, 77% were underpowered to detect health outcomes. Among adequately powered parameters, 49% demonstrated a significant health improvement, 44% had no effect on health, and 7% were associated with significant worsening of health. In meta-analyses, early life and education interventions were associated with a reduction in smoking (odds ratio [OR] = 0.92, 95% confidence interval [CI] 0.86-0.99). Income maintenance and health insurance interventions were associated with significant improvements in self-rated health (OR = 1.20, 95% CI 1.06-1.36, and OR = 1.38, 95% CI 1.10-1.73, respectively), whereas some welfare-to-work interventions had a negative impact on self-rated health (OR = 0.77, 95% CI 0.66-0.90). Housing and neighborhood trials had no effect on the outcomes included in the meta-analyses. A positive effect of the trial on its primary socioeconomic outcome was associated with higher odds of reporting health improvements. We found evidence of publication bias for studies with null findings., Conclusions: Early life, income, and health insurance interventions have the potential to improve health. However, many of the included studies were underpowered to detect health effects and were at high or moderate risk of bias. Future social policy experiments should be better designed to measure the association between interventions and health outcomes., (© 2020 The Authors. The Milbank Quarterly published by Wiley Periodicals LLC on behalf of The Millbank Memorial Fund.)

The objective of this study is to attempt to understand predictors of health among adult migrants from Myanmar to Thailand and predictors of development among their children. EQ5D5L scores and sociodemographic data were obtained among adult household members of children from two schools on the Thai/Myanmar border. Children were administered Ages and Stages questionnaires (ASQs). OLS and logistic regressions were used to examine predictors (e.g., witnessing gunfire) of various outcome measures (e.g., ASQ scores among children). In logistic regression analyses, maternal literacy proved to be a very strong predictor of the child's ASQ communication [17 ASQ points out of 60; 95% confidence interval (CI) 3, 31 points], problem solving (25 points; 95% CI 4, 45 points), and social skills (12 points; 95 % CI 1, 23 points) scores. A lower number of habitants/room predicted significantly better dentition among children [odds ratio (OR) 1.08, 95% CI 1.01, 1.67] and better social skills on the child's ASQ (12 points; 95% CI 1, 23 points). Appliance ownership was a weak predictor of adult health, with those who own a refrigerator having about an 8% higher score on the EQ5D5L (1.08; 95% CI 1.01, 1.16). Finally, parents who witnessed gunfire tended to have children with ASQ scores that were 14 points lower than average in problem solving (95% CI -24, -4). Maternal education programs may have a very large impact on the development of their children. However, identifying those households at greatest need of resources is not a simple task, and will require a more complete census of communities at risk.

Background: The American Heart Association developed the Life's Simple 7 metric for defining cardiovascular health. Little is known about the association of co-occurring social risk factors on ideal cardiovascular health., Methods: Using data on 11,467 adults aged ≥25 years from the National Health and Nutrition Examination Survey 1999-2006, we examined the association between cumulative social risk and ideal cardiovascular health in US adults. A cumulative risk score (range 0 to 3 or 4) was created by summing four social risk factors (low family income, low education level, minority race, and single-living status). Ideal levels for each component in Life's Simple 7 (blood pressure, cholesterol, glucose, BMI, smoking, physical activity, and diet) were used to create an ideal Life's Simple 7 score [0-1 (low), 2, 3, 4, and 5-7 (high)]., Results: Adults with low income (odds ratio [OR]=0.30 [95% CI 0.23-0.39]), low education [0.22 (0.16-0.28)], who are non-white (0.44 [0.36-0.54]) and single-living [0.79 (0.67-0.95)] were less likely to have 5-7 versus 0 ideal Life's Simple 7 scores after adjustment for age and sex. Adults were less likely to attain 5-7 versus 0 ideal Life's Simple 7 scores as exposure to the number of social risk factors increased [OR (95% CI) of 0.58 (0.49-0.68); 0.27 (0.21-0.35); and 0.19 (0.14-0.27) for cumulative social risk scores of 1, 2, and 3 or 4, respectively, each versus 0]., Conclusions: US adults with an increasing number of socially risk factors, were progressively less likely to attain ideal levels of cardiovascular health factors., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Ecological and cross-sectional studies have indicated that conservative political ideology is associated with better health. Longitudinal analyses of mortality are needed because subjective assessments of ideology may confound subjective assessments of health, particularly in cross-sectional analyses., Methods: Data were derived from the 2008 General Social Survey-National Death Index data set. Cox proportional analysis models were used to determine whether political party affiliation or political ideology was associated with time to death. Also, we attempted to identify whether self-reported happiness and self-rated health acted as mediators between political beliefs and time to death., Results: In this analysis of 32,830 participants and a total follow-up time of 498,845 person-years, we find that political party affiliation and political ideology are associated with mortality. However, with the exception of independents (adjusted HR (AHR)=0.93, 95% CI 0.90 to 0.97), political party differences are explained by the participants' underlying sociodemographic characteristics. With respect to ideology, conservatives (AHR=1.06, 95% CI 1.01 to 1.12) and moderates (AHR=1.06, 95% CI 1.01 to 1.11) are at greater risk for mortality during follow-up than liberals., Conclusions: Political party affiliation and political ideology appear to be different predictors of mortality., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Recent research has found that children who attended pre-kindergarten programs in childhood were more likely to be healthy as adults. One intuitive way of improving population health and longevity may therefore be to invest in pre-kindergarten programs. However, much of the research linking pre-kindergarten programs to health is very recent and has not been synthesized. In this paper, I review the mechanisms linking pre-kindergarten programs in childhood to adult longevity, and the experimental evidence backing up these linkages. I conclude with a critical exploration of whether investments in pre-kindergarten programs could also serve as investments in public health., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

During the 1990s reforms to the US welfare system introduced new time limits on people's eligibility to receive public assistance. These limits were developed to encourage welfare recipients to seek employment. Little is known about how such social policy programs may have affected participants' health. We explored whether the Florida Family Transition Program randomized trial, a welfare reform experiment, led to long-term changes in mortality among participants. The Florida program included a 24-36-month time limit for welfare participation, intensive job training, and placement assistance. We linked 3,224 participants from the experiment to 17-18 years of prospective mortality follow-up data and found that participants in the program experienced a 16 percent higher mortality rate than recipients of traditional welfare. If our results are generalizable to national welfare reform efforts, they raise questions about whether the cost savings associated with welfare reform justify the additional loss of life.

We set out to examine the material, psychological, and sociological pathways mediating the income gradient in health and mortality. We used the 2008 General Social Survey-National Death Index dataset (N = 26,870), which contains three decades of social survey data in the US linked to thirty years of mortality follow-up. We grouped a large number of variables into 3 domains: material, psychological, and sociological using factor analysis. We then employed discrete-time hazard models to examine the extent to which these three domains mediated the income-mortality association among men and women. Overall, the gradient was weaker for females than for males. While psychological and material factors explained mortality hazards among females, hazards among males were explained only by social capital. Poor health significantly predicted both income and mortality, particularly among females, suggesting a strong role for reverse causation. We also find that many traditional associations between income and mortality are absent in this dataset, such as perceived social status.

Objectives: We used 37 years of follow-up data from a randomized controlled trial to explore the linkage between an early educational intervention and adult health., Methods: We analyzed data from the High/Scope Perry Preschool Program (PPP), an early school-based intervention in which 123 children were randomized to a prekindergarten education group or a control group. In addition to exploring the effects of the program on health behavioral risk factors and health outcomes, we examined the extent to which educational attainment, income, family environment, and health insurance access mediated the relationship between randomization to PPP and behavioral and health outcomes., Results: The PPP led to improvements in educational attainment, health insurance, income, and family environment Improvements in these domains, in turn, lead to improvements in an array of behavioral risk factors and health (P = .01). However, despite these reductions in behavioral risk factors, participants did not exhibit any overall improvement in physical health outcomes by the age of 40 years., Conclusions: Early education reduces health behavioral risk factors by enhancing educational attainment, health insurance coverage, income, and family environments. Further follow-up will be needed to determine the long-term health effects of PPP.

Income produces health, and sickness negatively affects earnings. These two factors likely explain the income gradient in health, but each has very different policy implications. In this paper, I examine graphical trends in mortality risk between low-income and higher-income people by age and gender. These trends suggest that forward causality (income affecting health) is more important than reverse causality (health affecting income) in the income-health gradient. However, there is some evidence to suggest that reverse causality plays an important role for younger men.

Objectives: We examined whether stress related to negative body image perception and the desire to lose weight explained some of the body mass index-health gradient., Methods: We used 2003 Behavioral Risk Factor Surveillance System data to examine the impact of desired body weight, independent of actual body mass index, on the amount of physically and mentally unhealthy days by race, ethnicity, and gender., Results: The difference between actual and desired body weight was a stronger predictor than was body mass index (BMI) of mental and physical health. When we controlled for BMI and age, men who wished to lose 1%, 10%, and 20% of their body weight respectively suffered a net increase of 0.1, 0.9, and 2.7 unhealthy days per month relative to those who were happy with their weight. For women, the corresponding numbers were 0.1, 1.6, and 4.3 unhealthy days per month. The desire to lose weight was more predictive of unhealthy days among women than among men and among Whites than among Blacks or Hispanics., Conclusions: Our results raise the possibility that some of the health effects of the obesity epidemic are related to the way we see our bodies.

Objectives: We estimated the costs associated with reducing class sizes in kindergarten through grade 3 as well as the effects of small class sizes on selected outcomes such as quality-adjusted life-years and future earnings., Methods: We used multiple data sets to predict changes in the outcomes assessed according to level of educational attainment. We then used a Markov model to estimate future costs and benefits incurred and quality-adjusted life-years gained per additional high school graduate produced over time., Results: From a societal perspective (incorporating earnings and health outcomes), class-size reductions would generate a net cost savings of approximately $168,000 and a net gain of 1.7 quality-adjusted life-years for each high school graduate produced by small classes. When targeted to low-income students, the estimated savings would increase to $196,000 per additional graduate. From a governmental perspective (incorporating public expenditures and revenues), the results of reducing class sizes ranged from savings in costs to an additional cost of $15000 per quality-adjusted life-year gained., Conclusions: Reducing class sizes may be more cost-effective than most public health and medical interventions.

Background: This paper examines hospital utilization, estimated hospital costs, and mortality rates for U.S.-born, foreign-born, and Puerto Rican-born persons residing in New York City., Methods: We conducted a multivariate regression analysis using New York City neighborhoods as the unit of analysis. We utilized data from the Statewide Planning and Research Cooperative System data set and from the 1997 Housing and Vacancy Survey. We also examined mortality rates using 1990 death certificate data and decennial census data., Results: The foreign-born are much less likely to be hospitalized for most major categories of illness and have lower mortality rates than either U.S.-born or Puerto Rican-born New Yorkers. The life expectancy at 1 year of age of the foreign-born is 4 years longer than for U.S.-born persons and 6 years longer than Puerto Rican-born persons. We estimate that the overall cost of providing hospital-based care to the foreign-born was $611 million US dollars less than the cost of providing hospital-based care to an equivalent number of U.S.-born persons in 1996., Conclusion: The foreign-born in New York City appear to be healthier and consume fewer hospital resources than U.S.-born populations. It is possible that the cost of hospital utilization would be lower still if the foreign-born population had better access to ambulatory and preventive services.

Background: Although educational attainment is a well-recognized covariate of health status, it is rarely thought of as a tool to be used to improve health. Since fewer than 40% of U.S. citizens have a college degree, it may be possible for the government to improve the health status of the population by assuming a larger burden of the cost of postsecondary education. This paper examines the costs and health effects of a government subsidy for public postsecondary education institutions., Methods: All high school graduates in 1997 were included in a decision analysis model as a hypothetical cohort. Data from the U.S. Department of Education, the World Health Organization, and the National Center for Health Statistics were used as model inputs. Results. Relative to the present educational system, a federal subsidy for public and private colleges equal to the amount now paid by students for tuition and living expenses would save $6,176 and avert 0.0018 of a disability-adjusted life-year (DALY) per person annually if enrollment increased 5%. The overall savings among 1997 high school graduates would be $17.1 billion and 4,992 DALYs would be averted per year relative to the present educational system. If enrollment increased by just 3%, $3,743 would be saved and 0.0011 DALYs would be averted per person. An enrollment increase of 7% would lead to savings of $8,610 and 0.0025 DALYs would be averted per person relative to the present educational system., Conclusions: If the government were to offer a full subsidy for college tuition at public universities, both lives and money would be saved, so long as enrollment levels increased. Providing a free postsecondary education for students attending public schools may be more cost-effective than most health investments., (Copyright 2001 American Health Foundation and Academic Press.)

Background: The quality-adjusted life year (QALY) is an attractive outcome measure because it captures both health-related quality of life (HRQL) and life expectancy in a single metric. We present a method for calculating QALYs that is simple, utilizes data that are free of charge, and may improve consistency in burden-of-disease investigations., Methods: For purposes of illustration, we calculated the burden of disease due to stroke using two abridged life tables, each adjusted for HRQL. The first life table was generated using all-cause mortality and morbidity data (a reference cohort) and the second was generated using all diseases except stroke (a stroke-free cohort). The difference in total QALYs and in quality-adjusted life expectancy (QALE) was determined by subtraction., Results: Approximately 61,328 (95% CI=60,272, 62,383) QALYs were lost to stroke in the life-table cohort. Stroke is responsible for a decrement of 0.03 years of life expectancy and 0.61 years of QALE in the United States., Conclusions: The "years of health life"measure affords a rapid, inexpensive, and sensitive means for estimating the burden of disease for local health priorities and may assist research efforts in including QALYs as an outcome measure.