Dennis P. Andrulis, PhD, MPH Senior Research Scientist The Texas Health Institute Austin, Texas

1. Diversity, Poverty and the Shrinking Health Care Safety Net in Suburban America: Who Will Care for the Underserved? Dennis P. Andrulis, PhD, MPHSenior Research Scientist The Texas Health Institute Austin, Texas The Institute for Healthcare Disparities Nassau University Medical Center Hofstra University Hempstead, NY April 28, 2010

2. “America’s suburbs evoke images of dream homes, plush lawns and neighborhood BBQs, not low-wage jobs and houses under foreclosure. Yet for the first time ever, more poor Americans live in the suburbs than in all our cities combined.” [1]

3. Shattering of a myth • In just 10 years, between 1990 and 2000, the population in Metropolitan Statistical Areas outside the 100 largest cities of the U.S. increased by almost 18 percent, approaching twice the urban centers’ rate of growth (9.7%). [2] • By 2000, more than one in four suburban residents were non-white, almost one in ten were foreign born, and one in six spoke a language other than English at home—demographics that are likely to increase in the coming years; and almost one in ten fell below the federal poverty level. • And by 2005 the number of poor living in suburbs—over 12 million—outnumbered those living in cities. Detroit, Los Angeles, Miami and Washington, D.C. now have fewer residents living below the poverty line than their suburbs. [3]

4. “Suburbs saw by far the greatest growth in their poor population and by 2008 had become home to the largest share of the nation’s poor.—a trend that is likely to continue.” American poverty is becoming an increasingly suburban phenomenon.” [4]

5. Dynamics behind the Change in Suburban America • New immigrants bypassing traditional urban centers and settling in suburban communities having concentrations of residents of similar racial/ethnic heritage (according to a 2007 Census Bureau report, 40 percent of immigrants are moving directly to the suburbs) [5] • Gentrification in cities that is forcing previously urban residents to find less expensive places to live; [5] • Employment opportunities, particularly among lower-skill industries such as retail and personal services; [5] • Efforts to improve quality of life (e.g., higher-performing schools, lower crime rates and affordable housing). [5]

6. Historic and growing safety net need • Poor suburbs look like inner cities: higher rates of those without a high school diploma, low birth weight rates, unemployment and violent crime. [6] • African Americans and Latinos who reside in the suburbs are much more likely than suburban whites to live in fiscally stressed jurisdictions with below average public resources and greater than average public service needs. [6]

7. The recent Great Recession, including the housing collapse, led to significant increases in poverty, with suburban growth—5% nationwide—outpacing cities between 2007 and 2008. The NY suburban metropolitan area was among those with significant poverty increases of 2.9% [7] • By 2004, the largest state numbers of uninsured lived in suburban Chicago, and rely on hospital emergency rooms for help as well as free clinics [7]

8. New or significant increases in immigrant, poor and other vulnerable populations raises questions about how well they are connected to safety net services traditional located in cities [7] • Lower density exurbs have been hard hit by unemployment but also lag in food stamps and other safety net services. [7] • Lack of knowledge, access or capacity may also affect the ability of low income residents in these areas to connect to benefits and programs. [7]

9. Growing Challenges of Access in Suburban America 1. Health care market in poor and diverse suburbs • Hospitals making major marketing and growth decisions to expand to rich suburbs, with more desirable areas, greater homogeneity and greater proportions of individuals speaking English. >Into this new century, the wealthiest suburbs represented 26 percent of the population outside their cities had 42%-60% of staffed beds, admissions, inpatient days/outpatient/emergency visits, PET scans (increasing 2000% from 1996 to 2002), trauma center and NICU beds. [8]

10. Case Study: Leaving the Poor Inner City for Greener Suburban Pastures--Riverview Hospital Detroit (Ascension Catholic Health System) • In 2008 Riverview closed the only hospital on the east side of Detroit and built $224 million hospital 30 miles away to serve a wealthy suburban area of the city. • “Ascension’s approach…is an increasingly common strategy among nonprofit hospital systems: Close money-losing facilities in poor [primarily uninsured] areas and build…in affluent places where people have coverage”. [9] • Similar system moves to the suburbs are occurring across the US: Los Angeles, Chicago, Newark, Denver

11. Residual Effects: • Riverview’s maintained only an urgent care center, which cannot accept full emergencies and which charges $50 if you are uninsured • Community doctors are closing up are moving away as well • Of the 42 hospitals in Detroit in 1960, 3 remain

12. Market actions leave less financially lucrative, more diverse poor suburbs with significantly fewer health care resources, especially for intensive, specialty and trauma care >High poverty suburbs, which represented 44 % of the population in these areas accounted for only 17%-22 % of staffed beds, admissions, inpatient days, and outpatient/emergency visits, PET scans, and trauma centers and 34% of NICU beds >Suburban hospitals being affected by increasing numbers of for-profit suburban ambulatory diagnostic and treatment centers-in essence “cherry-picking” profitable patients, leaving behind vulnerable populations

13. Greater diffusion of especially poorer populations over broader geographic areas may encumber efforts by hospital systems to attract a “critical mass” of profitable patients in a desirable catchment area. • Health insurance reform may lessen financial barriers to access but open to question are incentives or available funds to invest in new or extended sites for poor suburbs and needed support services such as trained interpreters

14. 2. Suburban social determinants affecting health care decisions and ability to access care. Overall poor community conditions and lack of service support infrastructure (e.g., transportation) may further discourage investment

15. Dispersed Health Services and Resources--a growing spatial gap between health services and where people live. • “Public hospitals, nutrition assistance programs…are still overwhelmingly urban. You see small-scale operations in suburbs getting inundated. They just can’t deal with the demand.” [10] • In suburbs surrounding cities like Houston and Phoenix, for example, Level 1 trauma care is concentrated in downtown locations and ambulances are often backed up due to long commutes. [11] • In suburbs surrounding Chicago, immigrant children without access to primary care physicians are increasingly going without dental checkups and vaccinations. [12]

16. Research documents consequences: only 43 percent of Hispanics in primarily suburban “new growth” communities lived within 5 miles of a community health center and about 50 percent lived within 10 miles of a hospital; nearly one in five Latino parents reported transportation as a problem in accessing health care for their children. [13]

17. Lack of other critical sources affecting health and quality of life • Grocery stores with fresh produce are greatly dispersed, requiring suburbanites to travel considerable distances • Parks, walking areas, bike trails and other opportunities to support healthy behavior tend to be limited • Social services and other supports such as advocacy programs also tend to be confined to urban cores, with few outreach efforts or resources for suburban dwellers, particularly those with limited English proficiency • Transportation as a major access barrier is a recurrent theme in many suburban areas. Getting to most places requires a car, and frequently very limited public transportation is available

18. 3. Specific concerns around meeting the needs of increasingly diverse suburban communities • As suburbs continue to grow in diversity, efforts to expand access to health care will require addressing barriers related to race, culture and language. • While urban cores tend to be better prepared to address the needs of diverse patients and their languages, many “new-growth” suburban communities have far few services or practitioners with experience caring for these populations • Given a significantly lower proportion of hospitals generally and the losses in suburban public hospitals, lack of access to emergency, trauma and specialty care present especially difficult problems

19. Actions to Improve Access to Care • Supporting a suburban health care safety net • The need to develop, maintain and sustain a health care safety net through public and other hospitals will remain critical in these areas. • Experience in addressing needs of diverse and low income populations—patients who are likely remain unattractive to the broader health care marketplace

20. Familiarity with meeting service needs of diverse patients--interpreter services and culturally competent care that are more likely to be found in safety net settings. • Legal and especially undocumented immigrants in suburbs may be reluctant to participate in mainstream care. • And in the context of health care debates: health care reform will not cover undocumented immigrants and leave others without coverage. The presence of a viable safety net can work to assure they are not left out of care.

21. 2. Building regional alliances to coordinate levels of care • “Regionalization aims to concentrate limited or expensive health care services locally within an area while dispersing primary and secondary care more broadly.” [14] • Many suburban areas with populations in small towns or dispersed across expanses may benefit significantly by bridging to other suburban areas to take advantage of collective resources and build networks.

22. Example: • Suburban towns in Camden County, New Jersey, faced with new, including poor, diverse residents, created the First Suburbs Network to: >support and enhance infrastructure, improve quality of life and improve neighborhoods. Such regional efforts >address health care as a priority, by identifying and developing critical health care infrastructure needs for the region, such as: “…[establishing] efficient referral and pre-hospital care (emergency medical services) patterns…[improving] indigent health care reimbursement, [developing] strategies to disperse primary and secondary care… and [maintaining] timely access to centralized tertiary services in urban areas. [15]

23. 3. Support and models for collaborating with cities to tap experience and resources. • Suburban areas with major economic and demographic changes can benefit significantly from developing constructive alliances with their urban counterparts. • Cities have greater experience in addressing the needs of low income and diverse residents, and in tackling emerging issues affecting health and access such as unemployment and crime.

24. Cities most often have health care resources not otherwise available in suburban areas such as trauma centers and teaching hospitals that are critical components to delivery of high quality care. [16] • Cities are more likely to have longer standing infrastructures to support, advocate for and guide response to need. [16] • Bottom line: municipalities can connect poor and low income workers with an array of supports including health insurance, child care, and nutrition in ways that reach both suburban and city families. [16]

25. The End

26. References [1] See for example, Duchon, L., Andrulis D., and Reid, H. Measuring Progress in Meeting Healthy People Goals for Low Birth Weight and Infant Mortality among the 100 Largest Cities and Their Suburbs. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 81 (3), 323-339; Andrulis, D., Reid, H. and Duchon, L. (2004). Quality of Life in the Nations’ 100 Largest Cities and Their Suburbs: New and Continuing Challenges for Improving Health and Well-Being. Downstate Medical Center/ Brooklyn; Andrulis, D., Duchon, L., and Reid, H. (2003). Before and After Welfare Reform: the Uncertain Progress for Poor Families and Children in the Nation’s 100 Largest Cities and their Suburbs. Downstate Medical Center/Brooklyn; Andrulis, D., Duchon, L., and Reid, H. (2003). Dynamics in race, culture and key indicators of health in the nation’s 100 largest cities and their suburbs. Downstate Medical Center/Brooklyn; Andrulis, D., Duchon, L., and Reid H. (2002). Healthy Cities, Healthy Suburbs. Progress in Meeting Healthy People Goals in the Nation’s 100 Largest Cities and their Suburbs. Downstate Medical Center, Brooklyn; and Andrulis, D. and Goodman, N. (1999). The Social and Health Landscape of Urban and Suburban America. American Hospital Publishing Inc.: Chicago. [2] The Changing Landscape of Hospital Capacity in Large Cities and Suburbs: Implications for the Safety Net in Metropolitan America. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 84(3), May/June 2007.

27. [3] Andrulis, D., Reid, H., & Duchon, L. (2004). Quality of Life in the Nations’ 100 Largest Cities and their Suburbs: New and Continuing Challenges for Improving Health and Well-being. Brooklyn: Downstate Medical Center. [4] Kneebone, E & E. Garr. The suburbanization of poverty: trends in metropolitan America, 2000 to 2008 Brookings. Washington DC 2010 [5] Institute for the Advancement of Minority and Multicultural Medicine, Martin Luther King Jr. Global Health Equity Symposium Guest Speaker, 2008. [6] Institute on Race and Poverty. Minority Suburbanization and Racial Change. Minneapolis: 2006. [7] Kneebone & Garr; Chicago Tribune, April 10, 2005 [8] The Changing Landscape of Hospital Capacity in Large Cities and Suburbs: Implications for the Safety Net in Metropolitan America. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 84(3), May/June 2007. [9] Gruber, M. The big squeeze—in search of a sustainable future for suburban community hospitals. Healthcare Financial Management, 2006, 60, p57-65.

28. [10] Berube, A. (2007, February 13). The Geography of U.S. Poverty and its Implications. Testimony before the Committee on Ways and Means Subcommittee on Income Security and Family Support. The Brookings Institution. Retrieved September 17, 2008 from http://www.brookings.edu/testimony/2007/0213childrenfamilies_berube.aspx. [11] Roberts, S. (2007, October 17). In shift, 40% of immigrants move directly to suburbs. The New York Times. Retrieved September 17, 2008 from http://www.nytimes.com/2007/10/17/us/17census.html. [12] Andrulis, D. & Duchon, L. (2007). The Changing Landscape of Hospital Capacity in Large Cities and Suburbs: Implications for the Safety Net in Metropolitan America. Journal of Urban Health, 84(3): 400–414. [13], [14] Keuhn, B.M. (2007). Poverty Shift May Burden Health System. Journal of the American Medical Association, 297(10):1047-1048. [15] Savitch, H.V. (2003). How Suburban Sprawl Shapes Human Well-Being. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 80(4); and Millard, W.B. (2007). Suburban sprawl: Where does emergency medicine fit on the map? Annals of Emergency Medicine, 49(1):71-74. [16] Millard, W.B. (2007). Suburban sprawl: Where does emergency medicine fit on the map? Annals of Emergency Medicine, 49(1):71-74.