CASINO REVENUE AND AMERICAN INDIAN HEALTH

Transcription

1 CASINO REVENUE AND AMERICAN INDIAN HEALTH The Link Between Tribal Gaming and the Health Status and Behaviors of American Indians Barbara Wolfe Jessica Jakubowski Robert Haveman Hannah Goble Marissa Courey University of Wisconsin-Madison

2 Background: Income and Health Many studies have linked income and health Yet, the nature of this relationship remains elusive. Most research plagued by issues of: Reverse causality Endogeneity - unobserved factors influencing both income and health Here view operation of gaming casinos by American Indian tribes as a natural experiment which provides an opportunity to estimate the relationship between an exogenous income shock and health of a vulnerable group-- American Indians Gaming is defined as class III gaming (Casino) Includes Slot Machines, Black Jack, Craps, Roulette

3 American Indian Health 3.1 million American Indians Self Assessed Health Poor or Fair 12.1% compared to 8.6% among Whites (18+) Binge Alcohol use (5+ drinks one sitting) 32.8% vs. 23.4% Whites (12+) Limitation in Activity 18.4% compared to 11.4% Whites (18+) Any tobacco use 41.7% compared to 31.2% Whites (12+)

4 Infant Mortality Rates per 1,000 Live Births by Detailed Race and Hispanic Origin of Mother: U.S., Infant Mortality Rate per 1,000 Live Births All Races White Non-Hispanic White African American Non-Hispanic African American American Indian/Alaska Native Asian/Pacific Islander Hispanic Mexican Puerto Rican Cuban Central & South American Other & Unknown Hispanic/Latino

5 Age-Adjusted Death Rates per 100,000 Persons by Race and Hispanic Origin for Diabetes: U.S., 2005 Age-Adjusted Death Rate per 100,000 Persons All Races White African American 41.5 American Indian/Alaska Native 16.6 Asian/Pacific Islander 33.6 Hispanic

6 Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin for Chronic Liver Disease & Cirrhosis: U.S., 2005 Age-Adjusted Death Rate per 100,000 Persons All Races White African American 22.6 American Indian/Alaska Native 3.6 Asian/Pacific Islander 13.9 Hispanic

7 Age-Adjusted Death Rates per 100,000 Persons by Race and Hispanic Origin for All Causes: U.S., 2005 AI disparity in health now limited to particular diseases. Age-Adjusted Death Rate per 100,000 Persons All Races White African American American Indian/Alaska Native Asian/Pacific Islander Hispanic

8 How Widespread is Gaming? In 2005, 202 out of 562 federally recognized tribes (FRT) had established gaming compacts. Approximately one third of AI living on a reservation were part of a FRT with a gaming compact

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10 Is there evidence of selectivity in location of casinos? Poverty rate, Median family income, Percent Native American, Unemployment rate, State conservatism rank *** Number of religious adherents /1, Constant ** N 342 Pseudo R-Squared.09

11 Study Questions 1. Did the income of American Indians increase as a result of tribal gaming? 2. Did American Indians experience better health as a result of tribal gaming? 3. Did American Indians experience better health as a result of income increases tied to tribal gaming?

12 Multi-level Data Structure Behavioral Risk Factors Surveillance System Tribal Gaming Data County Geocode Area Resource File 1990 Merged individual-level data file

13 Multi-level Data Structure Tribal Gaming Data Behavioral Risk Factors Surveillance System Casino-style gaming Date casino opened Tribal affiliation County Geocode Area Resource File 1990 Merged individual-level data file

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16 Multi-level Data Structure Behavioral Risk Factors Surveillance System Individual-level outcomes: Tribal Gaming Income Data Health conditions Risk Behaviors Access to care Individual-level controls Demographic characteristics County Geocode Merged individual-level data file Area Resource File 1990

17 Multi-level Data Structure County level environmental controls: Poverty Employment Per capita income Tribal Gaming Data Behavioral Risk Factors Surveillance System County Geocode Area Resource File 1990 Merged individual-level data file

18 Multi-level Data Structure Tribal Gaming Data Behavioral Risk Factors Surveillance System County Geocode 24,000 American Indian adults Pooled cross sections Allows a With Gaming v. Without Gaming comparison among American Indians Allows a before-after Area comparison among Resource American Indians File 1990 Not limited to reservation pop or IHS Merged individual-level data file

19 When we talk of a tribe having a gaming facility, this means they had a facility for at least two years Two samples Full sample (N=24,079): all American Indians included in BRFSS Before-after sample (N=8,973): All AI respondents linked to a tribe that operated a Class III gaming facility at any point during the period of observation

20 Models Y = αdind + βx + γc + θr + μ Where Y = income, DinD = [Casino ever=1*casino=1], X=individual variables, C: community variables, R=casino ever=1 H =δdind + θy +ξx + ψc + φr + η (H is vector of health outcomes) Note: ESTIMATED MODELS RUN ON INDIVIDUALS BUT ADJUSTED FOR COUNTY OF RESIDENCE USING CLUSTER ADJUSTMENT OF SE

21 Multiple Regression Analysis: Income Dependent Variable Household Income (self report) midpoints of brackets (and 1.5* times highest bracket) Key Independent Variable DinD (Casino ever*casino) County-level Controls % unemployed 1990 % poverty 1990 Per capita income 1990 MDs per capita Individual-level Controls Age Gender Education Marital Status Employment Year

22 Results: Income Mean annual household income of ~$33,000 (year 2000 dollars) At median estimate of effect of DinD (Gaming) on Income and ln income (OLS) Income ln income DinD 2451 (7.4%)*** 1283 (3.9%)***

23 Results: Income Mean annual household income of ~$33,000 (year 2000 dollars) At median estimate of effect of DinD (Gaming) on Income and ln income (OLS) Income ln income DinD 2451 (7.4%)*** 1283 (3.9%)*** Sensitivity tests Pre-Post 2647*** 1450*** Interval DinD 1941*** 1544*** No Added controls 2659*** 1732***

24 Health Outcomes Health Indicators 1. Poor/fair health 2. Hypertension 3. High cholesterol 4. Asthma 5. Disability 6. Obesity 7. Diabetes Access to Care 1. Health Coverage 2. Foregone Care Risk behaviors 1. Smoking 2. Binge drinking (days) Mental Health (days) 1. Poor mental health 2. Depression 3. Anxiety

25 Results: Direct Effect of Gaming DinD Health Indicators [-] Poor/fair health [-] Hypertension [+] High cholesterol [-] Asthma [-] Disability [-] Obesity [-] Diabetes Access to Care [+] Health Coverage [-] Forgone Care Risk behaviors [-] Smoking [-] Binge drinking (days) Mental Health (days) [+] Poor mental health [+] Depression [+] Anxiety

26 Results: Direct Effect of Gaming DinD Health Indicators [-] Poor/fair health [-] Hypertension [+] High cholesterol [-] Asthma [-] Disability [-] Obesity [-] Diabetes Access to Care [+] Health Coverage [-] Forgone Care Risk behaviors [-] Smoking [-] Binge drinking (days) Mental Health (days) [+] Poor mental health [+] Depression [+] Anxiety

27 Results: Total Effect of Gaming (Direct+indirect effect through change in income) Core Results Health Indicators Poor/fair health ( %) Hypertension (-4.1%) High cholesterol (.3%)ns Asthma (-2.7%) Disability (-10.1%) Obesity (-1.7%) Diabetes (-7.8%)

28 Core results continued Risk behaviors Smoking (-5.3%) Binge drinking (days) (-.4) Mental Health (days) Poor mental health ( %) Depression ( %) Anxiety ( %)* *LN specification has negative results. Both Statistically significant.

29 Core Results - 3 Access to Care Health Coverage ( %) Forgone Care (-3 3.5%)

30 Sensitivity Results: Specification with DinD, income and with Casino dummy only [NO ADDED CONTROLS] Before Gaming vs. After Gaming Restricted sample of American Indians living in counties that have gaming tribes by 2003 Recall Positive, statistically significant association between income and gaming

31 Sensitivity Results: Total Effect of Gaming (Direct+indirect effect through change in income) Health Status Health Indicators No added controls Poor/fair health -10.5% Hypertension -4.7% High cholesterol -3% Asthma -18% Disability -27% Obesity +10% Diabetes +6%

32 Sensitivity results continued Health indicator No added controls Smoking -10% Binge drinking (days) -10.6% Days of Poor mental health -13% Depression -32% Anxiety -20.5% Access to Care Health Coverage -1.9% Forgone Care -18%

33 Sensitivity Results: Total Effect of Gaming (Direct+indirect effect through change in income) Health Status Health Indicators Before-after sample Core Poor/fair health -1.6% -1.5% Hypertension -4% -4% High cholesterol -.4ns.3% Asthma -8% -3% Disability -10% -10% Obesity -1.7% -1.7% Diabetes -8% -8%

34 Sensitivity results continued Health indicator Before-after Core Smoking -5.5% -5.3% Binge drinking (days) +2.5% -.4% Days of Poor mental health 2.5% 2.7% Depression 6% 1.2% Anxiety 1.2% % Access to Care Health Coverage 2.4% 1.3% Forgone Care -3.3% -3.3%

35 Conclusions Strong evidence that gaming is associated with income increases for American Indians Gaming is associated with better health outcomes, access, and less risk taking behaviors both in terms of full effect (direct and indirect) and through income increases (indirect). Gaming has unexpected positive associations with measures of mental health (though association with indirect effect via income is to reduce days with poor mental health, depression and anxiety.)

36 Limitations/Future Work Limitations Associations likely underestimated due to: Measurement error Tribal affiliation Casino income National Aggregate BRFSS 11.9% of AIAN households are phoneless compared to 2.4% of all households ( 2000 Census) Cross-sectional Future Work: Non-AI comparisons, regional variation