Advancing Health and Resilience in the Gulf of Mexico Region: A Roadmap for Progress (2023)
Chapter: Appendix C: Commissioned Paper: Current State of Health, Community Resilience, and Cohesion in the Gulf of Mexico Region
C
Commissioned Paper
Current State of Health, Community Resilience, and Cohesion in the Gulf of Mexico Region
Commissioned Report
July 29, 2022
Kelsey Gleason, ScD
Maryann Makosiej, MPH
Current Health and Well-Being in the Gulf of Mexico Region
TABLE C-1 Health Outcomes in the United States and Gulf Region
TABLE C-2 Indigenous and Indian American Health
TABLE C-3 Demographic Composition of the United States and Gulf of Mexico Region
Stressors and Environmental Conditions
TABLE C-5 Health Behaviors and Beliefs
Social Determinants and Health Outcomes in the United States and Gulf of Mexico Region
TABLE C-6 U.S. Health Outcomes and Social Determinants
TABLE C-7 Alabama Health Outcomes and Social Determinants
TABLE C-8 Mississippi Health Outcomes and Social Determinants
TABLE C-9 Louisiana Health Outcomes and Social Determinants
TABLE C-10 Florida Health Outcomes and Social Determinants
TABLE C-11 Texas Health Outcomes and Social Determinants
Underlying Contextual Determinants in the Gulf
TABLE C-12 2020 State Physician Profile
TABLE C-13 New Voter Restriction Laws Since the 2020 Election
TABLE C-14 Gerrymandering by State
TABLE C-15 Regional Government Expenditures Per Capita, 2019
TABLE C-16 State and Local General Revenue per Capita, 2019
Appendix Table 1: Self-Reported Health and Behavior Profiles of High School Students
INTRODUCTION
Since the inception of public health as a profession in the 19th and early 20th centuries, public health professionals have recognized the need for including a social framework in reducing health inequities and building community health resilience. Yet disparities in health resilience and outcomes remain pervasive. These disparities are particularly concerning in regions of the United States with underlying sociopolitical and historical contexts that lay bare systemic issues in equity, equality, and access, both within and outside of the health care system. The Gulf States—Alabama, Mississippi, Louisiana, Texas, and Florida—are no exception and face the added burden of specific environmental and natural hazard–related disasters. Understanding and addressing the social determinants of health in the Gulf Region are important for reducing long-standing disparities and improving health resilience and outcomes.
The National Academy of Sciences (NAS) defines resilience as “the ability to prepare and plan for, absorb, recover from and more successfully adapt to adverse events” (NRC, 2012, p. 1). Measuring a community’s resilience is essential for planning public health measures that seek to bolster its capacity to respond to various stressors, including social determinants of health. Implicit in the NAS definition of resilience is the nature of its fluidity. Resilience, be it measured on a community scale or in a health outcome, is an ability. The myriad of factors that make up resilience and their relation to one another emphasizes this dynamic nature and necessitates the consideration of social determinants of health.
Broadly defined, social determinants of health are “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (CDC, 2022). These include economic stability, education access and quality, health care access and quality, the neighborhood and built environment, and social and community context. However, these factors often do not foster resilience equitably and can lead to significant disparities among vulnerable subgroups. The association between social determinants of health and health outcomes is clear, although unanswered questions remain surrounding the exact mechanisms that explain these relationships (Palmer et al., 2019). Understanding these mechanisms is critical in planning and executing effective public health measures to improve health outcomes and reduce health disparities among the most vulnerable communities.
The need to identify the mechanisms behind social determinants of health and health disparities is particularly urgent in areas impacted by disasters, especially in the context of climate change. As with social determinants of health, decades of research have demonstrated the negative health consequences of disasters, with the most severe impacts among already disadvantaged communities (Weden et al., 2021). The disproportionate
impacts resulting from disasters widen the divide of social stratification of communities, creating accumulating disadvantages for vulnerable groups. This accumulation of disadvantages sets into motion an increase in adverse social determinants of health and manifests in poor health outcomes. This is particularly true in the Gulf Region, where the geographic distribution of environmental hazards has been shown to both activate and exacerbate existing social and spatial stratifications of health (Weden et al., 2021).
This report reviews the current state of health and community resilience in the Gulf Region to support the Committee on Progress Toward Human Health and Community Resilience in the Gulf of Mexico Region.
CURRENT HEALTH AND WELL-BEING IN THE GULF OF MEXICO REGION
An overview of leading health indicators in the United States and Gulf States is shown in Table C-1. An overview of health and well-being indicators for high school students in the United States and Gulf States is shown in the Appendix Table 1. A range of health indicators were selected to provide an overview of health and well-being in the Gulf of Mexico Region represented by indicators of mortality, morbidity, and overall well-being.
Mortality
All 10 indicators of mortality were found to be, on average, higher in the Gulf States as compared to the rest of the United States. Of note, the death rate per 100,000 people was observed to be significantly higher on average in the Gulf States (886.8 deaths per 100,000 people) as compared to the rest of the United States (802.1 deaths per 100,000 people).
For the diseases selected for this report, mortality rates from disease are higher in the Gulf States as compared to the rest of the United States. Rates of death from cancer, COVID-19, heart disease, and diabetes in the Gulf States were all higher than those in the United States, on average. The largest disparities were seen for deaths from heart disease and COVID-19, which were found to be higher across all Gulf States except for Florida and Texas, respectively.
Maternal mortality rates were higher in the Gulf States on average, and specifically in Alabama, Louisiana, and Texas, as compared to the U.S. average. Notably, maternal mortality in Louisiana was observed to be more than double the national average.
Morbidity
Of the selected indicators of morbidity, five out of eight indicators were worse for the Gulf States as compared to the United States. Of these indicators, diabetes rates across all five Gulf States are higher than the U.S. average,
while the prevalence of obesity and incidence of cancer are higher in all Gulf States except for Florida and Texas, respectively. High school students in the Gulf States were also more likely to report having obesity, as compared to their peers across the United States (see Appendix Table 1).
Notably, while the diagnosis of cardiovascular disease is lower in the Gulf States as compared to the United States, death from heart disease is higher in the Gulf States, highlighting potential health disparities in health care access.
Though the rates of children with confirmed elevated blood lead levels (BLLs) were observed to be lower in the Gulf States as compared to the United States, these results should be interpreted with caution. As noted in Table C-2, the percentage of children tested for lead in each of the Gulf States is lower than across the United States. This indicates a disparity in access to lead testing in the Gulf States, and measures of BLLs may not be representative of the population at greatest risk.
Rates of cardiovascular disease were observed to be higher among Indigenous populations in the Gulf States and the United States (Table C-2), as compared to all racial/ethnicity groups combined (see Table C-1).
Well-Being
Five measures of health were included as indicators of well-being: life expectancy, food insecurity, mental illness, suicide ideation, and illicit drug use. Of the indicators considered in this report, only life expectancy and food insecurity were found to be greater in the Gulf States, on average, as compared to the United States. The average life expectancy at birth in the Gulf States is more than 2 years shorter than the life expectancy at birth in the United States, ranging from 74.4 years in Mississippi to 79 years in Florida. Food insecurity was found to be highest in the states of Alabama (14%), Mississippi (11.8%), Louisiana (14.8%), and Texas (13.3%), while rates of food insecurity in Florida (10.1%) are on par with the national average (10.5%).
Mental illness, suicide ideation, and illicit drug use were all found to be lower on average in the Gulf States as compared to the United States, though rates varied widely between the Gulf States.
Similarly, high school students in the Gulf States were less likely to report suicide attempts, binge drinking, drinking, or marijuana use as compared to students in the United States. However, high school students in the Gulf States were more likely to report feeling sad or hopeless and smoking cigarettes as compared to students across the United States (Appendix Table 1).
Life expectancy of American Indians/Indigenous groups was observed to be greater (Table C-2) as compared to all race/ethnicity groups combined (Table C-1).
TABLE C-1 Health Outcomes in the United States and Gulf Region
| United States | Gulf State Average | Alabama | Mississippi | Louisiana | Florida | Texas | |
|---|---|---|---|---|---|---|---|
| Mortality | |||||||
| Death rate (per 100,000)a | 802.1 | 886.84 | 966 | 991.7 | 946.1 | 722.1 | 808.3 |
| Firearm deaths (per 100,000)b | 13.73 | 20.878 | 23.18 | 27.57 | 25.47 | 13.99 | 14.18 |
| Cancer mortality (per 100,000)a | 144.1 | 154.72 | 161.6 | 176 | 159.9 | 136.3 | 139.8 |
| COVID-19 deaths (per 100,000; age adjusted) | 306 | 370.8 | 403 | 421 | 375 | 355 | 300 |
| Diabetes deaths (per 100,000)a | 24.8 | 29.44 | 23.6 | 41 | 33.1 | 22.8 | 26.7 |
| Drug overdose deaths (per 100,000)a | 13.9 | 14.2 | 13.1 | 11.2 | 18.1 | 18.1 | 10.5 |
| Infant mortality (per 1000 births)c | 5.6 | 7.16 | 7.7 | 8.7 | 8 | 6.1 | 5.5 |
| Mortality, children 1–4 yrs (per 100,000)a | 22.7 | 39.72 | 39.3 | 47.3 | 44.3 | 33.3 | 34.4 |
| Suicide (per 100,000)b | 14 | 14.864 | 18.9 | 13.82 | 13.82 | 14.42 | 13.36 |
| Heart disease deaths (per 100,000)a | 168.2 | 204.32 | 237.5 | 245.6 | 221.5 | 143.1 | 173.9 |
| Maternal mortality (per 100,000 live births)d | 23.8 | 34.4 | 36.4 | 20.8 | 58.1 | 22.3 | 34.5 |
| Morbidity | |||||||
| Adults who are obese (% of pop)e | 31.5%5 | 35.56% | 38.70% | 39.80% | 37% | 27.90% | 34.40% |
| Disabilityf | 12.80% | 14.90% | 16.20% | 17% | 16% | 13.70% | 11.60% |
| Cancer incidence rate (age adjusted, 2014–2018)f | 448.6 | 455.8 | 450.8 | 474.4 | 482.4 | 460.2 | 411.2 |
| COVID-19 cases (per 100,000)h | 27,023 | 27,844 | 28,189 | 28,523 | 26,877 | 30,740 | 24,893 |
| Children with blood lead levels (BLLs) ≥5 μg/dLi | 2.60% | 2.42% | 1.70% | 2% | 5.80% | 1% | 1.60% |
| Children with BLLs ≥10 μg/dLi | 0.41% | 0.28% | 0.28% | 0.24% | 0.58% | 0.10% | 0.22% |
| Diabetes (adult)j | 12.10% | 15.24% | 16.70% | 17.20% | 16% | 13% | 13.30% |
| Cardiovascular disease (adult)j | 7.50% | 9.06% | 10.10% | 9.90% | 9.60% | 9% | 6.70% |
| Well-Being | |||||||
| Life expectancy at birth (years)k | 78.8 | 76.58 | 75.2 | 74.4 | 75.7 | 79 | 78.6 |
| Food insecurity (household level)l | 10.5% | 13% | 14% | 11.80% | 14.80% | 10.10% | 13.30% |
| Mental illness (adults)m | 21% | 19% | 21% | 19.47% | 18.92% | 16.60% | 16.70% |
| Adult suicide ideationm | 4.9 | 4.552 | 4.83 | 5.31 | 4.72 | 4.04 | 3.86 |
| Illicit drug use (aged 12+)n | 2.9 | 2.68 | 3.2 | 2.4 | 3 | 2.7 | 2.1 |
b CDC, n.d.
TABLE C-2 Indigenous and Indian American Health
| United States | Gulf State Average | Alabama | Mississippi | Louisiana | Florida | Texas | |
|---|---|---|---|---|---|---|---|
| Mortality | |||||||
| Death rate (per 100,000)a | 790.8 | 376.82 | 319 | 241.9 | 387.2 | 116 | 820 |
| Firearm deaths (per 100,000)b | — | — | — | — | — | — | — |
| Cancer mortality (per 100,000)a | 34.1 | 52.16 | 49.3 | 84.7 | 57.7 | 49.8 | 19.3 |
| COVID-19 deaths (per 100,000; age adjusted)c | 160.4 | — | — | — | — | — | — |
| Diabetes deaths (per 100,000)a | 49 | — | — | — | — | — | — |
| Drug overdose deaths (per 100,000)a | — | 376.82 | 319 | 820 | 387.2 | 241.9 | 116 |
| Infant deaths per 100,000 live births | — | 379.74 | 282.4 | 1122.4 | 258.8 | 156.2 | 78.9 |
| Mortality, children 1–4 yrs (per 100,000)a | — | — | — | — | — | — | — |
| Suicide (per 100,000)d | 22.3 | — | — | — | — | — | — |
| Heart disease deaths (per 100,000)c | 139.8 | — | — | — | — | — | — |
| Morbidity | |||||||
| Adults who are obese (% of pop)e | 37.1% | 43.5% | 48.8% | 39.9% | 41.8% | — | — |
| Disabilityf | 18.20% | 21.80% | 28.40% | 21% | 17.40% | 20.70% | 21.50% |
| Cancer incidence rate (age adjusted, 2014–2018)g | 285.8 | 185.56 | 120.2 | 306.4 | 144.8 | 174 | 182.4 |
| COVID-19 cases (per 100,000)h | — | — | — | — | — | — | — |
| Children with blood lead levels (BLLs) ≥5 μg/dLi | — | — | — | — | — | — | — |
| Children with BLLs ≥ 10 μg/dLi | — | — | — | — | — | — | — |
| Diabetes (adult)j | 19.5% | — | — | — | — | — | — |
| Cardiovascular disease (adult)j | 9.50% | 25.20% | 19.60% | 30.80% | — | — | — |
THE CURRENT STATE OF DEMOGRAPHICS, HEALTH CONTRIBUTORS, AND DETERMINANTS OF HEALTH AND WELL-BEING IN THE GULF OF MEXICO
Select social determinants, stressors and environmental conditions, and health behaviors and resources indicators are summarized for the United States and all five Gulf States in Tables C-3, C-4 and C-5. No state-specific data on adverse childhood experiences (ACEs) were available.
Demographics
The demographic profiles of the states that make up the Gulf Region are similar to average U.S. demographic profiles, except for the proportion of Black or African Americans, which is higher in the Gulf region (Table C-3).
TABLE C-3 Demographic Composition of the United States and Gulf of Mexico Region
| United States | Gulf State Average | Alabama | Mississippi | Louisiana | Florida | Texas | |
|---|---|---|---|---|---|---|---|
| Demographics | |||||||
| Age (% of population)a | |||||||
| < 5 years | 6 | 6.2 | 6 | 6.2 | 6.5 | 5.3 | 7 |
| < 18 years | 22.4 | 23.04 | 22.3 | 23.7 | 23.5 | 19.9 | 25.8 |
| > 18 years | 77.6 | 76.96 | 77.7 | 76.3 | 76.5 | 80.1 | 74.2 |
| > 65 years | 16 | 16.24 | 16.9 | 15.9 | 15.4 | 20.5 | 12.5 |
| Median agea | 38.2 | 38.22 | 39.2 | 37.7 | 37.2 | 42.2 | 34.8 |
| Race/ethnicitya | |||||||
| Black or African American | 12.20% | 24.38% | 26.60% | 36.60% | 31.40% | 15.10% | 12.2% |
| Hispanic or Latino | 18.20% | 16.12% | 4.40% | 3.50% | 6.90% | 26.50% | 39.3% |
| White | 60.10% | 53.98% | 67.50% | 55.40% | 55.80% | 51.50% | 39.7% |
| Average family size | 3.21 | 3.262 | 3.16 | 3.21 | 3.27 | 3.23 | 3.44 |
| Average household size | 2.6 | 2.632 | 2.53 | 2.59 | 2.59 | 2.62 | 2.83 |
Social Determinants
Overall, the Gulf Region has a higher prevalence of adverse social determinants of health as compared to the rest of the United States (Table C-4): on average the total poverty is higher, and the median earnings for both males and females are lower across all five Gulf States. Moreover, employment rates are lower in the Gulf States on average, although Texas has a higher employment rate as compared to the average U.S. state.
Though no reliable indicator for the quality of housing was available, median gross rent was lower across all Gulf States (except for Florida) and homeownership rates were higher (with the exception of Texas) as compared to the average United States. However, the percentage of the population without internet access was found to be significantly worse in the Gulf States on average and particularly Alabama, Mississippi, and Louisiana, as compared to the U.S. average.
Stressors and Environmental Conditions
All indicators of environmental hazards and conditions were found to be similar, on average, in the Gulf States as compared to the United States, including proximity to point pollutant sources and air quality indicators. Heat stress hospitalizations, an indicator of extreme heat, were observed to be higher in available Gulf State data as compared to the United States.
Health Behaviors and Beliefs
A summary of findings on health behaviors and beliefs in the Gulf of Mexico and the United States is reported in Table C-5. “Self-reported health status of adults” was used to represent knowledge of health status. Overwhelmingly, respondents in all five Gulf States were more likely to indicate their health status as “poor” or “fair” as compared to the rest of the United States, with lower proportions indicating “very good” or “excellent” in the Gulf Region.
In addition, health resource indicators were chosen to provide an overview of the quality of and access to care, including health insurance coverage, physician utilization, and hospital bed availability. Overall, health insurance coverage is lower on average in the Gulf Region (87.96%) and across all Gulf States as compared to the United States (91.3%) (although Louisiana reports the same percentage coverage as the U.S. average). Differences in type of coverage exist between the Gulf Region and the rest of the United States, whereby the Gulf States are all more likely to have a lower proportion of private health coverage. In addition, male, Black, and Hispanic Gulf residents were less likely to be insured as compared to these populations in the United States.
Moreover, the proportion of adults who report not seeing a doctor in the past 12 months because of cost was found to be substantially higher on average (11.98%) and across all five Gulf States than in the rest of the United States on average (9.7%).
| Social Determinants | |||||||
|---|---|---|---|---|---|---|---|
| United States | Gulf State Average | Alabama | Mississippi | Louisiana | Florida | Texas | |
| Incomea | |||||||
| Median household income (dollars) | 64,994 | 54,175 | 52,035 | 46,511 | 50,800 | 57,703 | 63,826 |
| Median earnings for male full-time, year-round workers (dollars) | 54,323 | 47,467 | 50,823 | 45,599 | 52,911 | 45,980 | 42,024 |
| Median earnings for female full-time, year-round workers (dollars) | 44,220 | 35,754 | 37,425 | 34,304 | 37,701 | 39,451 | 29,887 |
| Total povertya | 12.80% | 16% | 16% | 20% | 18.60% | 13.30% | 14.20% |
| Poverty by age (%)a | |||||||
| < 18 years | 17.50% | 23.06% | 22.70% | 27.60% | 26.30% | 18.70% | 20% |
| 18–64 years | 12.10% | 15.14% | 15.10% | 18.20% | 17.40% | 12.50% | 12.50% |
| 65+ years | 9.30% | 11.22% | 10.20% | 12.80% | 11.90% | 10.50% | 10.70% |
| Educationa | |||||||
| High school or equivalent degree | 26.70% | 29.32% | 30.30% | 30.10% | 33.30% | 28.20% | 24.70% |
| Some college, no degree | 20.30% | 21.26% | 21.60% | 22.20% | 21.20% | 19.80% | 21.50% |
| Associates degree | 8.60% | 8.56% | 8.70% | 10.20% | 6.50% | 10% | 7.40% |
| Bachelor’s degree | 20.20% | 17.04% | 16.30% | 13.80% | 15.90% | 19.30% | 19.90% |
| Graduate or professional degree | 12.70% | 9.96% | 9.90% | 8.90% | 8.90% | 11.30% | 10.80% |
| Employment ratea | 59.60% | 56% | 54% | 52.70% | 54.90% | 55% | 61% |
| Housinga | |||||||
| Median gross rent | $1,096 | $955 | $811 | $789 | $876 | $1,218 | $1,082 |
| Home ownership rate | 64.40% | 66.62% | 69.20 | 68.80 | 66.60% | 66.20% | 62.30% |
| % pop without internet accessa | 14.5 | 18.66 | 19.7 | 23.9 | 20.7 | 14.3 | 14.7 |
| Environmental Hazards | |||||||
| Num. billion-dollar disasters (2018–2021)b | 56 (total US) | 19.4 | 18 | 18 | 12 | 19 | 30 |
| Cost of billion-dollar disasters (2018–2021)b | 315.2 (total US) | — | 500 M-1.0 B | 2 B-5 B | 5 B-10 B | 50 B-100 B | 20 B-50 B |
| Heat stress hospitalization (per 100,000)c | 1.9 | — | 4.2 | 4.6 | — | — | |
| % of children tested for lead < 72 months of aged | 17.60% | 11.64% | 12.00% | 16.50% | 3.10% | 13.90% | 12.70% |
| Particulate matter 2.5 (μ/m3)e | 8.74 | 8.896 | 8.9 | 9.15 | 9.22 | 7.64 | 9.57 |
| Ozone (ppb)e | 42.6 | 37.36 | 39.1 | 37.8 | 37.2 | 32.7 | 40 |
| Diesel particulate matter (μg/m3)e | 0.295 | 0.243 | 0.216 | 0.149 | 0.298 | 0.338 | 0.214 |
| Air toxics cancer risk (lifetime risk per million)e | 29 | 33.2 | 34 | 32 | 41 | 28 | 31 |
| Air toxics respiratory hazard indexe | 0.36 | 0.412 | 0.47 | 0.42 | 0.45 | 0.36 | 0.36 |
| Traffic proximity (traffic count/distance)e | 710 | 414 | 230 | 140 | 560 | 630 | 510 |
| Lead paint (% pre-1960 Housing)e | 0.28 | 0.158 | 0.18 | 0.15 | 0.2 | 0.11 | 0.15 |
| Superfund proximity (site count/km)e | 0.13 | 0.0836 | 0.054 | 0.064 | 0.086 | 0.13 | 0.084 |
| Risk-management plan facility proximity (facility count/km)e | 0.75 | 0.714 | 0.41 | 0.54 | 0.91 | 0.79 | 0.92 |
| Hazardous waste proximity (facility count/km)e | 2.2 | 0.752 | 0.83 | 0.31 | 1.4 | 0.5 | 0.72 |
TABLE C-5 Health Behaviors and Beliefs
| United States | Alabama | Mississippi | Louisiana | Florida | Texas | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Selected Characteristics of Health Care Coverage in the United Statesa | ||||||||||||
| % | % | % | % | % | % | % | % | % | % | % | % | |
| Insured | Uninsured | Insured | Uninsured | Insured | Uninsured | Insured | Uninsured | Insured | Uninsured | Insured | Uninsured | |
| Age | ||||||||||||
| < 6 years | 95.7 | 4.3 | 97.4 | 2.6 | 96.1 | 3.9 | 96.8 | 3.2 | 94.7 | 5.3 | 91.6 | 8.4 |
| 6–18 years | 94.4 | 5.6 | 96.6 | 3.4 | 94.4 | 5.6 | 96 | 4 | 92 | 8 | 87.6 | 12.4 |
| 19–25 years | 85.7 | 14.3 | 81.6 | 18.4 | 76 | 24 | 85.7 | 14.3 | 78.6 | 21.4 | 71 | 29 |
| 26–34 years | 84.5 | 15.5 | 80.6 | 19.4 | 76.9 | 23.1 | 83.4 | 16.6 | 76.2 | 23.8 | 72.3 | 27.7 |
| 35–44 years | 86.6 | 13.4 | 84.7 | 15.3 | 81.2 | 18.8 | 85.8 | 14.2 | 80 | 20 | 75.4 | 24.6 |
| 45–54 years | 89.2 | 10.8 | 87.4 | 12.6 | 84.1 | 15.9 | 88.7 | 11.3 | 83 | 17 | 79.7 | 20.3 |
| 55–64 years | 92 | 8 | 90.9 | 9.1 | 88.7 | 11.3 | 91.5 | 8.5 | 86.9 | 13.1 | 84.6 | 15.4 |
| 65–74 years | 99 | 1 | 99.5 | 0.5 | 99.6 | 0.4 | 99.4 | 0.6 | 98.5 | 1.5 | 97.9 | 2.1 |
| 75+ years | 99.5 | 0.5 | 99.7 | 0.3 | 99.8 | 0.2 | 99.6 | 0.4 | 99.2 | 0.8 | 98.6 | 1.4 |
| Sex | ||||||||||||
| Male | 90.3 | 9.7 | 89.4 | 10.6 | 86.7 | 13.3 | 89.7 | 10.3 | 86 | 14 | 81.9 | 18.1 |
| Female | 92.2 | 7.8 | 91.5 | 8.5 | 89.2 | 10.8 | 92.8 | 7.2 | 88.6 | 11.4 | 83.5 | 16.5 |
| Race | ||||||||||||
| White | 94.1 | 5.9 | 92.3 | 7.7 | 90.1 | 9.9 | 93.4 | 6.6 | 90.7 | 9.3 | 90.1 | 9.9 |
| Black | 90.1 | 9.9 | 89.1 | 10.1 | 86.3 | 13.7 | 90.8 | 90.8 | 85.1 | 14.9 | 85 | 15 |
| Hispanic/Latino | 82.3 | 17.7 | 73.3 | 26.7 | 70.8 | 29.2 | 72.1 | 27.9 | 81.4 | 18.6 | 73.2 | 26.8 |
| Education | ||||||||||||
| < high school | 78.7 | 21.3 | 79.1 | 20.9 | 77.9 | 22.1 | 82.8 | 17.2 | 75.5 | 24.5 | 62.1 | 37.9 |
| High school graduate | 88 | 12 | 86.9 | 13.1 | 83.6 | 16.4 | 88 | 12 | 82.7 | 17.3 | 76 | 24 |
| Some college/assoc. | 91.7 | 8.3 | 90.4 | 9.6 | 88.1 | 11.9 | 91.5 | 8.5 | 87.9 | 12.1 | 84.7 | 15.3 |
| > bachelor’s degree | 96.2 | 3.8 | 96.4 | 3.6 | 95.5 | 4.5 | 95.7 | 4.3 | 93.3 | 6.7 | 93.4 | 6.6 |
| Household income | ||||||||||||
| < $25,000 | 86.7 | 13.3 | 83.4 | 16.6 | 81.5 | 18.5 | 88 | 12 | 82.4 | 17.6 | 73.9 | 26.1 |
| $25,000–$49,999 | 86.8 | 13.2 | 87.6 | 12.4 | 84.6 | 15.4 | 88.6 | 11.4 | 83.4 | 16.6 | 74.8 | 25.2 |
| $50,000–$74,999 | 89.3 | 10.7 | 90.5 | 9.5 | 88.7 | 11.3 | 90.3 | 9.7 | 85.5 | 14.5 | 79.4 | 20.6 |
| $75,000–$99,9999 | 92 | 8 | 93.3 | 6.7 | 91.3 | 8.7 | 92.3 | 7.7 | 88.6 | 11.4 | 84.2 | 15.8 |
| $100,000+ | 95.5 | 4.5 | 96.2 | 3.8 | 95 | 5 | 95.8 | 4.2 | 92.9 | 7.1 | 91.4 | 8.6 |
| Adults Who Report Fair or Poor Health Statusb | ||||||||||||
| All adults | 14.70% | 21.10% | 21.80% | 19.40% | 15.30% | 15.90% | ||||||
| Race | ||||||||||||
| White | 13.40% | 18.90% | 18.20% | 16.50% | 14.20% | 13.40% | ||||||
| Black | 19.10% | 27.70% | 27.50% | 27.10% | 14.60% | 17.70% | ||||||
| Hispanic | 20.00% | NSD | NSD | 19.50% | 19.00% | 21.30% | ||||||
| Sex | ||||||||||||
| Male | 13.70% | 19.80% | 19.90% | 17.90% | 14.00% | 14.90% | ||||||
| Female | 15.70% | 22.00% | 23.20% | 20.70% | 16.50% | 16.90% | ||||||
| United States | Alabama | Mississippi | Louisiana | Florida | Texas | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Adults Reporting Not Seeing a Doctor in the Past 12 Months Because of Cost by Race/Ethnicity, 2020b | ||||||||||||
| All adults | 9.70% | 11.20% | 12.20% | 9.80% | 12.40% | 14.30% | ||||||
| Race | ||||||||||||
| White | 7.70% | 9.40% | 10.20% | 8.20% | 9.40% | 10.90% | ||||||
| Black | 12.70% | 15.30% | 15.20% | 12.80% | 17.70% | 15.60% | ||||||
| Hispanic | 16.70% | 13.50% | NSD | 11.20% | 16.90% | 21.10% | ||||||
SOCIAL DETERMINANTS AND HEALTH OUTCOMES IN THE UNITED STATES AND GULF OF MEXICO REGION
As health outcomes and social determinants of health vary between the United States and Gulf States, so do the intersection between social determinants of health and health outcomes. This intersectionality of disadvantaged social categorizations creates compounding, overlapping, and interdependent systems of discrimination or disadvantage.
Limitations in the availability and consistency of data exist, both across indicators and states. Comprehensive data across all five Gulf States on social determinants of health and health outcomes were only available for suicide, disability, and gun mortality.
Mortality
All-cause mortality rates for Black Americans were found to be higher across each Gulf state and the United States as compared to White and Hispanic or Latino Americans (Tables C-6 through C-11). Notably, however, the death rate for Black Americans in each of the Gulf states is lower than the average death rate for Black Americans in the United States.
Across the United States, Black Americans have higher death rates from all indicators considered, except for suicide, which is more common among White Americans (Table C-6). Disparities in death rates between White and Black Americans in each of the Gulf states are particularly evident for infant deaths, as well as deaths attributed to guns, diabetes, and police-related deaths, which are all significantly higher for Black and Latino individuals. Importantly, males were found to have significantly higher death rates for all mortality indicators across all Gulf states (Tables C-6 through C-11).
Limited data were available on the distribution of health outcomes by age.
Morbidity
Rates of obesity and diabetes were found to be higher for Black Americans across the United States and all five Gulf states. As compared to Black Americans across the United States, rates of disability and cardiovascular disease were found to be higher for Black Americans in Alabama, Mississippi, and Louisiana. Following the trends observed for mortality from heart disease and diabetes, where males were observed to have higher rates as compared to females across the United States and all Gulf states, men were also observed to have higher rates of diagnosis from these diseases across the Gulf states. Females were more likely to be obese or have a disability in all Gulf states as compared to the United States.
Wellness
Across all five Gulf States and the average United States, Black Americans were observed to have lower life expectancies as compared to White Americans.
TABLE C-6 U.S. Health Outcomes and Social Determinants
| Race | Age* | Sex | |||||
|---|---|---|---|---|---|---|---|
| White | Hispanic or Latino | Non-Hispanic Black | < 30 Years | > 30 Years | Female | Male | |
| Mortality | |||||||
| Death rate (per 100,000) | 844.05a | 734(1) | 1152.1(1) | 693.4(2) | 834(2) | 689.2a | 990.5a |
| Drug overdose deaths (per 100,000) | 33.1b | — | 35.8b | 22c | 19.6c | 81.2 | 76.2 |
| Heart disease deaths (per 100,000) | 170.1d | 122.7d | 228.6d | 164e | 147e | 76.4 | 68.8 |
| Gun mortality (per 100,000)f | 12.4 | 8.69 | 32.37 | 3.19 | 17.01 | 12.92 | 14.45 |
| Diabetes deaths (per 100,000)g | 21.1 | 30.9 | 46.8 | — | — | 19.5 | 31.2 |
| Infant mortality (per 1,000 births) | 4.5g | 5g | 10.5g | 5.44h | 6.55h | 5.06 | 6.08 |
| Mortality, children 1–4 yrs (per 100,000)g | — | — | — | — | — | — | — |
| Suicidei | 17.81 | 7.98 | 7.83 | 13.1 | 19.2 | 8.97 | 17.26 |
| Cancer mortality (per 100,000) j | 160.2 | 110.8 | 182.5 | — | — | — | — |
| Police-related deaths per 1 million people between 2013 and 2022 (as of July 13)k | 22 | 29 | 62 | 6.2 | 8.7 | — | — |
| Maternal mortality (per 100,00 live births)l | 19.1 | 18.2 | 63.1 | ||||
| Morbidity | |||||||
| Obesity (adult) | 30.2% | 35.9% | 42.4% | — | — | 31.9% | 31.1% |
| Disabilitym | 14.2% | 9.1% | 14.3% | — | — | 12.9% | 12.7% |
| Diabetes (adult)n | 11.5% | 12.8% | 17.4% | — | — | 15.2% | 18.7% |
| Cardiovascular disease (adult)n | 8.4% | 4.7% | 6.6% | — | — | 5.8% | 9.3% |
| Wellness | |||||||
| Life expectancyo (years) | 78.6 | 81.8 | 74.7 | 81.2 | 76.2 | ||
*Because different sources of information were used, categories were created from the data to represent two distinct age categories for comparison between indicators.
TABLE C-7 Alabama Health Outcomes and Social Determinants
| Race | Age* | Sex | |||||
|---|---|---|---|---|---|---|---|
| White | Hispanic or Latino | Non-Hispanic Black | < 30 Years | > 30 Years | Female | Male | |
| Mortality | |||||||
| Death rate (per 100,000)a | 930.4 | 460.2 | 1077.6 | — | — | 810.3 | 1163.5 |
| Drug overdose deaths (per 100,000)b | — | — | — | — | — | 10.1 | 16.2 |
| Heart disease deaths (per 100,000)a | 233.2 | 75.2 | 270 | — | — | 7.1 | 41.2 |
| Gun mortality (per 100,000)c | 18.6 | NSD | 37 | 21.9 | 24.49 | — | — |
| Diabetes deaths (per 100,000)a | 19.1 | NSD | 40.8 | — | — | 17.8 | 30.7 |
| Infant mortality (per 1000 births)a | 5.8 | 7.5 | 11.6 | — | — | — | — |
| Mortality, children 1–4 yrs (per 100,000)a | 33.4 | — | 51.7 | — | — | 33 | 45.4 |
| Suicidec | 5.94 | — | 1.05 | 12.33 | 23 | 1.81 | 7.07 |
| Cancer mortality (per 100,000)a | 163.6 | 61.5 | 169.1 | — | — | 132.1 | 201.4 |
| Police-related deaths per 1 million people between 2013 and 2022 (as of July 13)d | 33 | 7.6 | 55 | — | — | — | — |
| Maternal mortality (per 100,00 live births)e | 14.7 | 11.8 | 37.1 | ||||
| Morbidity | |||||||
| Obesity (adult) | 35.3%f | 36.6%f | 50.5%f | — | — | 39.9%g | 37.3%g |
| Disability | 17%h | 7.8%h | 15.8%h | — | — | 16.4%i | 16%i |
| Diabetes (adult)j | 15.4% | — | 20.8% | — | — | 15.2% | 18.7% |
| Cardiovascular disease (adult)j | 10.5% | — | 8% | — | — | 8% | 13% |
| Wellness | |||||||
| Life expectancyk | 76 | — | 72.9 | — | — | 78.2 | 72.2 |
*Because different sources of information were used, categories were created from the data to represent two distinct age categories for comparison between indicators.
TABLE C-8 Mississippi Health Outcomes and Social Determinants
| Race | Age* | Sex | |||||
|---|---|---|---|---|---|---|---|
| White | Hispanic or Latino | Non-Hispanic Black | < 30 Years | > 30 Years | Female | Male | |
| Mortality | |||||||
| Death rate (per 100,000)a | 935.4 | — | 1108.4 | — | — | 823.9 | 1207.5 |
| Drug overdose deaths (per 100,000)b | — | — | — | — | — | 8.7 | 13.8 |
| Heart disease deaths (per 100,000)a | 229.3 | 112.4 | 285.3 | — | — | — | — |
| Gun mortality (per 100,000)c | 20.15 | — | 41.12 | 27.82 | 28.23 | 8.61 | 49.81 |
| Diabetes deaths (per 100,000)a | 26.9 | — | 73.2 | — | — | 33.1 | 50.7 |
| Infant mortality (per 1000 births)a | 6.8 | — | 11.4 | — | — | — | — |
| Mortality, children 1–4 yrs (per 100,000)a | 39 | — | 57.4 | — | — | 42.3 | 52.1 |
| Suicidec | 19.27 | — | 6.47 | 9.13 | 17.29 | 3.98 | 24.31 |
| Cancer Mortality (per 100,000)a | 169.3 | 197.9 | 62.3 | — | — | 147.9 | 214.7 |
| Police-related deaths per 1 million people between 2013-2022 (as of July 13)d | 38 | 9.5 | 53 | — | — | — | — |
| Maternal mortality (per 100,00 live births)e | 18.9 | — | 51.9 | ||||
| Morbidity | |||||||
| Obesity (adult) | 33.5%f | 41.3%f | 50.4%f | — | — | 41.9%g | 37.2%g |
| Disability | 17.7%h | 9.4%h | 16.8%h | — | — | 17.1%i | 16.9% |
| Diabetes (adult)j | 14.9% | — | 21.3% | — | — | 16.9% | 17.7% |
| Cardiovascular Disease (adult)j | 11.6% | — | 6.9% | — | — | 7.6% | 13% |
| Wellness | |||||||
| Life expectancyk | 76 | — | 72.6 | — | — | 77.6 | 71.2 |
*Because different sources of information were used, categories were created from the data to represent two distinct age categories for comparison between indicators.
TABLE C-9 Louisiana Health Outcomes and Social Determinants
| Race | Age* | Sex | |||||
|---|---|---|---|---|---|---|---|
| White | Hispanic or Latino | Non-Hispanic Black | < 30 | > 30 | Female | Male | |
| Mortality | |||||||
| Death rate (per 100,000)a | 882.7 | — | 1097.1 | — | — | 794.3 | 1134.6 |
| Drug overdose deaths (per 100,000)b | — | — | — | — | — | 12.3 | 24.1 |
| Heart disease deaths (per 100,000)a | 212.8 | 93.8 | 261.5 | — | — | — | — |
| Gun mortality (per 100,000)c | 15.9 | 7.1 | 46.84 | 29.3 | 23.06 | 7.31 | 45.62 |
| Diabetes deaths (per 100,000)a | 23.3 | 15.6 | 61.4 | — | — | 27.7 | 39.6 |
| Infant mortality (per 1000 births)a | 5.8 | 7.4 | 11.3 | — | — | — | — |
| Mortality, children 1–4 yrs (per 100,000)a | 33.1 | 60.4 | — | — | 38.8 | 49.5 | |
| Suicidec | 18.87 | 8.52 | 6.13 | 8.83 | 17.15 | 5.17 | 23.07 |
| Cancer mortality (per 100,000)a | 154.4 | 77 | 188 | — | — | 133 | 196.3 |
| Police-related deaths per 1 million people between 2013 and 2022 (as of July 13)d | 25 | 28 | 73 | — | — | — | — |
| Maternal mortality (per 100,00 live births)e | 47.9 | 44.5 | 111.2 | ||||
| Morbidity | |||||||
| Obesity (adult, % of pop) | 33.9%f | 33.6%f | 46.7%f | — | — | 38%g | 36%g |
| Disability | 16.5%h | 9.4%h | 16.5%h | — | — | 16.2%i | 15.7%i |
| Diabetes (adult)j | 14.3% | 12.2% | 22.2% | — | — | 15.9% | 16.2% |
| Cardiovascular Disease (adult)j | 9.9% | — | 8.4% | — | — | 8.2% | 11.2% |
| Wellness | |||||||
| Life expectancyk | 77.1 | — | 73.1 | — | — | 78.6 | 72.8 |
*Because different sources of information were used, categories were created from the data to represent two distinct age categories for comparison between indicators.
TABLE C-10 Florida Health Outcomes and Social Determinants
| Race | Age* | Sex | |||||
|---|---|---|---|---|---|---|---|
| White | Hispanic or Latino | Non-Hispanic Black | < 30 Years | > 30 Years | Female | Male | |
| Mortality | |||||||
| Death rate (per 100,000)a | 703.1 | — | 841.2 | — | — | 600.8 | 862.3 |
| Drug overdose deaths (per 100,000)b | — | — | — | — | — | 12.5 | 23.8 |
| Heart disease deaths (per 100,000)a | 146.4 | 117.2 | 187.5 | — | — | — | — |
| Gun mortality (per 100,000)c | 7.06 | — | 25.41 | 12.85 | 14.69 | 4.28 | 23.32 |
| Diabetes deaths (per 100,000)a | 19.6 | 22.9 | 48.2 | — | — | 16.9 | 29.7 |
| Infant mortality (per 1000 births)a | 4.6 | 4.9 | 10.7 | — | — | — | — |
| Mortality, children 1–4 yrs (per 100,000)a | 29 | — | 46.3 | — | — | 28.3 | 38.1 |
| Suicidec | 20.8 | 7.93 | 5.59 | 7.99 | 17.86 | 6.02 | 20.68 |
| Cancer mortality (per 100,000)a | 146.4 | 102.1 | 147.6 | — | — | 117.4 | 159.7 |
| Police-related deaths per 1 million people between 2013 and 2022 (as of July 13)d | 27 | 18 | 70 | — | — | — | — |
| Maternal mortality (per 100,00 live births)e | 12.9 | 10.6 | 32 | ||||
| Morbidity | |||||||
| Obesity (adult, % of pop) | 27.8%f | 28.4%f | 36% | — | — | 27.9%g | 27.9%g |
| Disability | 16.4%h | 10.1%h | 12.2%h | — | — | 13.8%i | 13.6%i |
| Diabetes (adult)j | 13.4% | 11.5% | 18% | — | — | 13% | 13% |
| Cardiovascular Disease (adult)j | 11.1% | 4.9% | 5.2% | — | — | 6.6% | 11.4% |
| Wellness | |||||||
| Life expectancyk | 79.9 | — | 76.1 | — | — | 81.8 | 76.3 |
*Because different sources of information were used, categories were created from the data to represent two distinct age categories for comparison between indicators.
TABLE C-11 Texas Health Outcomes and Social Determinants
| Race | Age* | Sex | |||||
|---|---|---|---|---|---|---|---|
| White | Hispanic or Latino | Non-Hispanic Black | < 30 Years | > 30 Years | Female | Male | |
| Mortality | |||||||
| Death rate (per 100,000)a | 787.2 | — | 972.9 | — | — | 686.7 | 955.5 |
| Drug overdose deaths (per 100,000)b | 10.8 | — | — | — | — | 7.7 | 13.3 |
| Heart disease deaths (per 100,000)a | 183.5 | 142.8 | 233.2 | — | — | — | — |
| Gun mortality (per 100,000)c | 16.72 | 9.51 | 26.22 | 12.75 | 15.4 | 4.41 | 24.16 |
| Diabetes deaths (per 100,000)a | 20.1 | 38.1 | 44.3 | — | — | — | — |
| Infant mortality (per 1000 births)a | 4.4 | 5.2 | 9.8 | — | — | — | — |
| Mortality, children 1–4 yrs (per 100,000)a | 29.1 | — | 43.6 | — | — | 27.9 | 34.3 |
| Suicidec | 20.53 | 8.65 | 8.14 | 9.43 | 16.45 | 5.35 | 21.68 |
| Cancer mortality (per 100,000)a | 151.4 | 110.8 | 171.8 | — | — | 132.1 | 201.4 |
| Police-related deaths per 1 million people between 2013 and 2022 (as of July 13)d | 29 | 27 | 62 | — | — | — | — |
| Maternal mortality (per 100,00 live births)e | 40.6 | 26.6 | 93.1 | ||||
| Morbidity | |||||||
| Obesity (adult) | 31.9%f | 39.6%f | 40.4%f | — | — | 35.4%g | 33.5%g |
| Disability | 13.8%h | 9.5%h | 13.3%h | — | — | 11.6%i | 11.5%i |
| Diabetes (adult)j | 11.6% | 16.1% | 15.4% | — | — | 12.2% | 14.5% |
| Cardiovascular Disease (adult)j | 8.5 | 4.6% | 4.2% | — | — | 4.5% | 8.9% |
| Wellness | |||||||
| Life expectancyk | 78.5 | — | 74.2 | — | — | 81 | 76.1 |
*Because different sources of information were used, categories were created from the data to represent two distinct age categories for comparison between indicators.
UNDERLYING CONTEXTUAL DETERMINANTS IN THE GULF
Understanding the interplay of the social determinants of health in the U.S. Gulf Region necessitates a historical framework for the sociopolitical context underlying the current state of health in the Gulf Region. The Gulf Coast of the United States was first settled by the French and Spanish in the late 18th and early 19th centuries. Growing shipping lanes and trade routes to the Gulf Coast coalesced with national efforts to expand westward. Supported by slavery, sugar and cotton production boomed, and by the 19th century, New Orleans was the fourth-largest city in the country (CUNY Open Education Resources, n.d.). However, that prosperity changed in the wake of both the Civil War and the Galveston Hurricane.
The Civil War depressed the Southern economy and upended previously held cultural norms tied inextricably to economic activity, slavery, and social engagement. At the cessation of the war, millions of former slaves throughout the South faced the question of freedom. While the 13th, 14th, and 15th amendments sought to codify the nuances of freedom for African Americans, Southern states individually passed laws, rooted in racism, that restricted or granted rights by race. Many states, including Alabama, Louisiana, Mississippi, Texas, and Florida, adopted Jim Crow laws, Black Codes, and other legislation that encouraged racial segregation and voter suppression. The landmark 1896 Supreme Court case Plessy v. Ferguson, which upheld a law passed in Louisiana, federally codified the statute of “separate but equal” and sanctioned physical and social segregation (Plessy v. Ferguson, n.d.). Outside of the legislatures, social White supremacist organizations (e.g., the Ku Klux Klan) sought to terrorize Black communities and individuals (The National Geographic Society, 2022). With cooperation and even encouragement from law enforcement, these groups used violence and intimidation to frame a new social order (The National Geographic Society, 2022).
Against the backdrop of a changing Gulf Region came the Galveston Hurricane of 1900. At the time, Galveston was thriving: more than 70 percent of the entire cotton crop of the United States passed through the port of Galveston, and approximately 1,000 ships called on the port each year (Galveston County News, 2014). As the deadliest natural disaster in the history of the United States, the hurricane depressed the local economy and greatly halted investment along the Gulf Coast (Rohr, 2016). It was the first major hurricane to strike the newly developed U.S. Gulf Region and signaled a new era of weather volatility that continues today (see Box C-1).
Following the Galveston Hurricane, the residential and spatial segregationist policies that were formed in the wake of the Civil War were exacerbated and added to the basis of the sociopolitical context of the South. In the U.S. Gulf Region especially, the movement of White families away from heterogeneous communities and into less environmentally hazardous, more economically advantaged areas precipitated the division of the social determinants of health for certain communities over others (Weden et al., 2021). Incremental changes and historical differences in the physical and sociopolitical environment in which Gulf Region residents worked and lived set the stage for many of the health disparities seen today. These policies set specific subgroups of the Gulf Region population apart from others—by race, education, or otherwise—and therefore created inequities in access to health care, education, and economic stability. In addition, racism impacts health in other ubiquitous ways, including the stress of racism and discrimination both within and outside of health care that leads to physiologic, psychologic, and epigenetic changes that impact health.
These pillars frame the social determinants of health, which are the basis of a community’s capacity for resilience in times of adversity.
Jim Crow laws prevented equal, quality access to health care between White communities and communities of color in the South. For example, a 1915 Alabama law decreed, “No person or corporation shall require any White female nurse to nurse in wards or rooms in hospitals, either public or private, in which negro men are placed” (Pilgrim, 2012). Laws like this promoted discrimination within hospitals and other medical care settings and were not struck down until 1954 (Willoughby, 2004). Yet although these laws were abolished over half a century ago, cultural and systemic racism has remained pervasive in the health care system.
Before 1865, Black students were barred from entering American medical schools in the South and heavily restricted thereafter until 1954. Moreover, the number of Black students in American medical schools was significantly reduced through the Flexner report of 1910, which resulted in the closure of five of seven Black medical schools (including one in the Gulf Region) (Harley, 2006). As a result, historically, the number of certified Black medical professionals lagged far behind those of their White counterparts. This historical framework gives background to similar trends observed today, where large discrepancies are observed in the racial composition of states and practicing physicians, particularly in the Gulf Region (Table B-12).
Historical and current sociopolitical conditions have laid the foundation for discrepancies in social determinants of health and resulting adverse health outcomes, particularly for those in communities of color. A subsequent lack of adequate health care services decreased the average quality of care available and increased wait times for care that is available. Reduced access to care and biased, racist, culturally insensitive care results in community members who are less likely to both seek and receive preventive services for chronic conditions (HHS, n.d.). Inattention to the social determinants of health, such as housing, poverty, and environmental issues can also impede the implementation of recommended health care.
TABLE C-12 2020 State Physician Profile
| State | Black or African American Population | Black or African American Physicians (% of total) |
|---|---|---|
| Alabama | 26.6% | 7.1% |
| Louisiana | 31.4% | 8.3% |
| Texas | 12.2% | 6.3% |
| Mississippi | 36.6% | 10.4% |
| Florida | 15.1% | 5.9% |
SOURCE: Adapted from AAMC, 2021.
Discrimination toward residents of color extended beyond the medical setting and into public health. While the science and practice of public health are meant to promote the welfare and well-being of the entire population, historic federal and state discrimination significantly contributed negatively to the social determinants of health among communities of color. In public hospitals, schools, playgrounds, parks, and other places, segregation remained legal until the 1954 decision in Brown v. Board of Education. That grouping of landmark cases marked a shift toward improved access to social services among some marginalized groups in America, yet discrepancies in access still exist. In 1963, Alabama’s governor George Wallace made an infamous promise of “segregation now, segregation tomorrow, segregation forever.” Historical precedent continues today: as recently as 2018, 90.34 percent of students attending Alabama’s 75 “failing” schools were African American, and 80 percent of Black students in Alabama go to school with other Black students exclusively (Mann and Rogers, 2021).
Moreover, the legacy of policies like redlining, redistricting, and restricting of federal housing loans that followed is that they continued to encourage inequitable silos of race and economic activity. Policies like redlining prevented communities of color from receiving home loans in suburbs and other often majority-White or affluent spaces. Between 1934 and 1962, households of color received just 2 percent of all government-backed mortgages, meaning most families of color could not afford to live in neighborhoods with advantageous school districts and employment (Swope and Hernández, 2019). By relegating certain groups to live and grow up in certain environments, the downstream impact on communities of color is limited to access to fair education and health care, and residential neighborhoods located in environmentally hazardous areas. Unequal distribution of resources ultimately contributes to disparities in health (HHS, n.d.). Even today, two major cities in the Gulf Region—New Orleans and Birmingham—remain in the top 10 of the most segregated cities in the country (Cortright, 2020).
The historical sociopolitical context in the Gulf States has led to pervasive social conditions seen today, with implications for community and health resilience. Expansive public policies, from institutionalized slavery to Jim Crow laws to modern disenfranchisement, have stifled and continue to stifle opportunities for resilience-building and social mobility among marginalized groups (Beech et al., 2021). Despite the progress that has been made, extensive challenges and barriers to health exist. Positing inequitable social and economic conditions among different groups of people continues to create and exacerbate health and community disparities among the most vulnerable. These conditions, in turn, continue to amplify disparities not only in health but also in education quality and access, and in economic stability.
Political Conditions
Since the 2020 election, 2 states (including all five Gulf States) passed a total of 56 new laws restricting access to voting, while 49 states introduced 440 bills with provisions to restrict voting access during the 2021 legislative session (Brennan Center for Justice, 2021). These laws make it more difficult for voters to cast ballots that can be counted toward an election and include barriers to voter registration, mail-in ballots, early voting, election-day voting, and ballot verification. Moreover, there is mounting evidence that more restrictive voting laws have a negative impact on voters of color. People of color are more likely to be impacted disproportionately by restrictive voter ID laws and laws around mail-in voting, as well as laws that restrict Sunday voting (as voters of color are more likely to vote on Sundays) (Brennan Center for Justice, 2022). Overwhelmingly, the sponsoring party of these bills are Republicans, and the probability of a bill passing is dependent on which party controls the legislative chambers, with Democratic-controlled chambers less likely to pass bills that restrict voter access (Mejia and Samuels, 2022). Table C-13 summarizes new voter restriction laws by state, region, and political affiliation.
In addition to voter suppression, gerrymandering is also of significant concern in the United States. Gerrymandering—the process of redrawing the nation’s congressional districts—is common in all states and enacted by both Democrat and Republican leaders. Table C-14 demonstrates the current status of gerrymandering in each state as of June 15, 2022. Two Gulf states—Texas and Florida—are the top most gerrymandered states.
TABLE C-13 New Voter Restriction Laws Since the 2020 Election
| State | Region | New Laws Restricting Voting Rights | New Voting Restrictions | Governor Political Affiliation55 | State Senate Majority Political Affiliation | State House Majority Political Affiliation |
|---|---|---|---|---|---|---|
| United States | 56 | 102 | 28 R; 23 D | 19 D; 31 R | 19 D; 30 R | |
| Alabama | Gulf | 3 | 3 | R | R | R |
| Florida | Gulf | 2 | 10 | R | R | R |
| Louisiana | Gulf | 1 | 1 | D | R | R |
| Mississippi | Gulf | 1 | 1 | R | R | R |
| Texas | Gulf | 5 | 10 | R | R | R |
| Nevada | Far West | 2 | 4 | D | D | D |
| Indiana | Great Lakes | 2 | 4 | R | R | R |
| N. Hampshire | Northeast | 3 | 3 | R | R | R |
| New York | Northeast | 1 | 1 | D | D | D |
| Iowa | Plains | 2 | 6 | R | R | R |
| Kansas | Plains | 2 | 4 | D | R | R |
| Nebraska | Plains | 1 | 1 | R | - | - |
| North Dakota | Plains | 1 | 3 | R | R | R |
| Idaho | Rcky Mnts | 2 | 2 | R | R | R |
| Montana | Rcky Mnts | 5 | 8 | R | R | R |
| Utah | Rcky Mnts | 4 | 6 | R | R | R |
| Wyoming | Rcky Mnts | 1 | 2 | R | R | R |
| Arizona | South | 6 | 8 | R | R | R |
| Arkansas | South | 5 | 10 | R | R | R |
| Georgia | South | 1 | 6 | R | R | R |
| Kentucky | South | 1 | 3 | D | R | R |
| North Carolina | South | 1 | 1 | D | R | R |
| Oklahoma | South | 2 | 2 | R | R | R |
| Virginia | South | 2 | 3 | R | D | R |
| Total Political Affiliation | Republican | 14 | 15 | 16 | ||
| Democrat | 4 | 2 | 1 | |||
*SOURCE: Adapted from Mejia and Samuels, 2022.
TABLE C-14 Gerrymandering by State
| State | Map Enacted by | Extra Seats |
|---|---|---|
| Texas | Republicans | R15.8 |
| Florida | Republicans | R15.7 |
| California | Commission | D12.8 |
| Ohio | Republicans | R12.3 |
| Illinois | Democrats | D12.2 |
| Georgia | Republicans | R12.2 |
| Wisconsin | Court | R12.1 |
| New Jersey | Commission | D11.9 |
| South Carolina | Republicans | R11.7 |
| Iowa | Republicans | R11.7 |
| New York | Court | D11.5 |
| Connecticut | Court | D11.5 |
| Tennessee | Republicans | R11.5 |
| Massachusetts | Both parties | D11.4 |
| New Mexico | Democrats | D11.2 |
| Utah | Republicans | R11.1 |
| Indiana | Republicans | R11.1 |
| Oregon | Democrats | D11.0 |
| New Hampshire | Court | D10.9 |
| Missouri | Republicans | R10.9 |
| Arkansas | Republicans | R10.9 |
| Nevada | Democrats | D10.8 |
| Oklahoma | Republicans | R10.8 |
| Montana | Commission | R10.7 |
| Alabama | Republicans | R10.7 |
| Rhode Island | Democrats | D10.6 |
| Pennsylvania | Court | D10.5 |
| Minnesota | Court | R10.5 |
| Hawaii | Commission | D10.4 |
| Idaho | Commission | R10.4 |
| Kentucky | Republicans | R10.4 |
| Mississippi | Republicans | R10.3 |
| State | Map Enacted by | Extra Seats |
|---|---|---|
| Maryland | Both parties | D10.2 |
| Washington | Commission | D10.2 |
| Arizona | Commission | D10.2 |
| Virginia | Court | D10.2 |
| North Carolina | Court | D10.2 |
| Kansas | Republicans | D10.2 |
| West Virginia | Republicans | R10.2 |
| Nebraska | Republicans | D10.1 |
| Maine | Both parties | R10.1 |
| Colorado | Commission | R10.1 |
| Michigan | Commission | D10.0 |
SOURCE: Adapted from Rakich, 2022.
GOVERNMENT EXPENDITURES
Examining funding at a state and regional level is another aspect of framing the context of the conditions in which communities grow, work, and play. Public budgets as they relate to education, public welfare, safety, health and hospitals, highways, and police describe many of the social determinants of health. Per capita expenditures specifically describe, on a supposed individual level, the extent of access to quality education, health care and gleaning the economic stability of an area. Table C-15 describes per capita expenditures of elementary and secondary education, public welfare, health and hospitals, highways, and police across regions of the United States, including the five Gulf states individually and averaged. U.S. regions include the South (Arkansas, Georgia, Kentucky, North Carolina, Oklahoma, South Carolina, Tennessee, Virginia, and West Virginia), the Northeast (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont), the Mideast (Delaware, District of Columbia [DC], Maryland, New Jersey, New York, and Pennsylvania), the Great Lakes (Illinois, Indiana, Michigan, Ohio, and Wisconsin), the Plains (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota), the Rocky Mountains (Colorado, Idaho, Montana, Utah, and Wyoming), the Far West (California, Nevada, Oregon, and Washington), and the nation. Note that the South intentionally excludes the Gulf states to provide a budget comparison.
TABLE C-15 Regional Government Expenditures Per Capita, 2019
| Region | Total | Elemen. & Secondary Education | Higher Education | Public Welfare | Health and Hospitals | Police | All Other | Population (Thousands) |
|---|---|---|---|---|---|---|---|---|
| United States | 10,171 | 2,186 | 948 | 2,265 | 980 | 375 | 2,790 | 328,330 |
| Gulf States | 8,779 | 1,687 | 928 | 1,845 | 1,123 | 325 | 2,261 | 63,023 |
| Alabama | 8,768 | 1,667 | 1,156 | 1,620 | 1,473 | 277 | 1,994 | 4,908 |
| Florida | 8,027 | 1,420 | 563 | 1,341 | 822 | 440 | 2,877 | 21,492 |
| Louisiana | 9,526 | 1,730 | 802 | 2,715 | 820 | 343 | 2,638 | 4,658 |
| Mississippi | 8,923 | 1,577 | 1,010 | 2,123 | 1,546 | 263 | 1,818 | 2,978 |
| Texas | 8,650 | 2,042 | 1,111 | 1,428 | 954 | 302 | 1,978 | 28,987 |
| New England | 10,895 | 2,551 | 781 | 2,680 | 512 | 348 | 3,460 | 14,850 |
| Mideast | 12,855 | 3,167 | 858 | 3,160 | 939 | 464 | 3,535 | 48,893 |
| Great Lakes | 9,501 | 2,080 | 941 | 2,161 | 762 | 342 | 2,641 | 46,904 |
| Plains | 9,738 | 2,174 | 956 | 2,049 | 1,007 | 333 | 2,459 | 21,436 |
| South | 8,570 | 1,752 | 925 | 2,067 | 849 | 288 | 2,142 | 64,315 |
| Rocky Mtns. | 9,491 | 1,900 | 1,117 | 1,618 | 877 | 333 | 2,981 | 12,401 |
| Far West | 12,459 | 2,370 | 1,181 | 3,008 | 1,443 | 479 | 3,405 | 54,359 |
SOURCE: Adapted from the Urban-Brookings Tax Policy Center, 2019.
TABLE C-16 State and Local General Revenue per Capita, 2019
| United States | Alabama | Mississippi | Louisiana | Florida | Texas | |
|---|---|---|---|---|---|---|
| Own source revenue | ||||||
| Total (millions) | 53,059 | 31,609 | 19,071 | 30,655 | 139,568 | 203,174 |
| Per capita (thousands) | 8 | 6 | 6 | 7 | 6 | 7 |
| Rank | — | 41 | 42 | 39 | 40 | 33 |
| Tax collections | ||||||
| Total (millions) | 36,467 | 18,028 | 11,762 | 20,938 | 85,635 | 136,540 |
| Per capita (thousands) | 6 | 4 | 4 | 4 | 4 | 5 |
| Rank | — | 50 | 47 | 38 | 46 | 32 |
SOURCE: Adapted from the Urban-Brookings Tax Policy Center, 2019.
Moreover, state and local revenues per capita are lower in the Gulf States as compared to the United States, with per capita spending lower in all five Gulf States. In addition, “own source revenue” and tax collections are lower in all Gulf States except Florida and Texas, on average (Table B-16).
Adequate access and quality education is a major social determinant of health. The Gulf Region spends an average of $1,687 on elementary and secondary education (as compared to $1,752 for the South region and $2,186 nationally), the lowest of any region. Though the Gulf Region has low early childhood education expenditures, per capita expenditure in higher education for the Gulf States is on par with the national average of $948 per capita (though state-by-state spending varies widely within the Gulf Region, from $1,156 in Alabama to $563 in Florida).
Public welfare is the term for varying tax-supported programs that provide cash assistance or services to individuals and families who are deemed eligible on the basis of their income and assets (Hansan, 2014). In the Gulf Region, per capita expenditure toward public welfare was the second lowest at $1,845, as compared to $2,067 for the South region and $2,265 nationally.
Health care quality and access is another social determinant of health and one with impact on both individual and community levels. In the Gulf Region, per capital health care expenditures varied widely: Alabama, Florida, Louisiana, Mississippi, and Texas per capita expenditures toward health and hospital were $1,473, $822, $820, $1,546, and $954, respectively. This is compared with $1,123 for the Gulf Region, $849 for the South region, and $980 nationally.
REPORT SUMMARY
Significant barriers to health care access and resilience were found within the Gulf Region. Significant changes need to be made at the national, state, local, and health care–administration levels to decrease and dismantle the disparities highlighted in this report. The presence of structural and environmental vulnerabilities requires action to improve resiliency, particularly in the context of limited resources and capacities.
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APPENDIX TABLE 1 Self-Reported Health and Behavior Profiles of High School Students
| United States | Gulf State Average | Alabama | Mississippi | Louisiana | Florida | Texas | |
|---|---|---|---|---|---|---|---|
| High School Students Who Currently Smoked Cigarettes (%) | |||||||
| Sex | |||||||
| Male | 6.9 | 7.7 | 8.4 | 8.7 | 10.8 | 5.2 | 5.8 |
| Female | 4.9 | 4.9 | 5.6 | 4.6 | 6.2 | 4.2 | 3.9 |
| Race | |||||||
| White | 6.7 | 8.9 | 9.3 | 9.7 | 12.8 | 5.9 | 7.2 |
| Black | 3.3 | 2.9 | 3.3 | 3.7 | 3 | 2.7 | 2 |
| Hispanic/Latino | 6 | 6.4 | 6.4 | 10.5 | 6.1 | 5 | 4.4 |
| Grade | |||||||
| 9 | 3.8 | 4.5 | 4.9 | 5.5 | 5.5 | 3.9 | 2.7 |
| 10 | 5.2 | 5.5 | 6.5 | 6.4 | 6.4 | 4.3 | 4.1 |
| 11 | 5.9 | 5.2 | 6.3 | 5.7 | 5.7 | 5.2 | 3.5 |
| 12 | 9 | 9 | 10.8 | 9.4 | 9.4 | 5.6 | 9.8 |
| Sexual identity | |||||||
| Heterosexual | 5.2 | 4.9 | 6.2 | 5.6 | — | 3.7 | 4.3 |
| Gay or lesbian | 8.3 | 11.3 | 9.3 | 18.9 | — | 9.6 | 7.6 |
| Bisexual | 11 | 10.1 | 13.2 | 9.2 | — | 8.9 | 9.2 |
| Gay, lesbian, or bisexual | 10.4 | 10.4 | 11.8 | 12.2 | — | 9.1 | 8.8 |
| Not sure | 7.4 | 9.0 | 5.8 | 12.3 | — | 11 | 7.2 |
| United States | Gulf State Average | Alabama | Mississippi | Louisiana | Florida | Texas | |
|---|---|---|---|---|---|---|---|
| High School Students Who Currently Drink Alcohol (%) | |||||||
| Sex | |||||||
| Male | 26.4 | 23.8 | 20.1 | 25.9 | 25.3 | 23.4 | 24.6 |
| Female | 31.9 | 28.5 | 24.6 | 26 | 32.6 | 28.7 | 30.9 |
| Race | |||||||
| White | 34.2 | 33 | 25 | 34.6 | 37.7 | 31.3 | 36.4 |
| Black | 16.8 | 19.5 | 16.8 | 18.2 | 20.8 | 25.5 | 16.4 |
| Hispanic/Latino | 28.4 | 21.5 | 27.4 | 18.6 | 16.5 | 18.5 | 26.6 |
| Grade | |||||||
| 9 | 19 | 20.5 | 18.9 | 21.7 | 26.3 | 19.5 | 16.1 |
| 10 | 26.7 | 22.6 | 20.1 | 19.1 | 21.3 | 24.6 | 28.1 |
| 11 | 32.3 | 28.6 | 22.8 | 28.8 | 33.4 | 29.5 | 28.6 |
| 12 | 39.9 | 34.8 | 28.3 | 36.4 | 38.4 | 31 | 39.9 |
| Sexual identity | |||||||
| Heterosexual | 28.8 | 24.5 | 22.1 | 24 | — | 25.4 | 26.8 |
| Gay or lesbian | 33.3 | 31.4 | 16.9 | 43.6 | — | 34.1 | 31.1 |
| Bisexual | 34 | 35.3 | 36 | 34.9 | — | 28.9 | 41.7 |
| Gay, lesbian, or bisexual | 33.9 | 33.8 | 28.7 | 37.3 | — | 30.3 | 39.1 |
| Not sure | 25.3 | 26.3 | 22.6 | 41 | — | 25 | 16.6 |
| High School Students Who Currently Binge Drink (%) | |||||||
| Sex | |||||||
| Male | 12.7 | 11.0 | 9.4 | 10.8 | 12.6 | 12 | 10.4 |
| Female | 14.6 | 10.7 | 10.5 | 9.5 | 8.8 | 12.6 | 12.5 |
| Race | |||||||
| White | 17.3 | 16.6 | 13.5 | 16.7 | 18.7 | 16.9 | 17.6 |
| Black | 6.2 | 3.8 | 3.4 | 4.1 | 2.4 | 6.3 | 2.8 |
| Hispanic/Latino | 12.4 | 9.88 | 13.5 | 7.9 | 6.3 | 11.1 | 10.6 |
| Grade | |||||||
| 9 | 7.3 | 6.5 | 7 | 5.4 | 7.5 | 8.3 | 4.4 |
| 10 | 10.6 | 8.8 | 8.2 | 6.1 | 5.2 | 11 | 13.6 |
| 11 | 15.3 | 12.3 | 11.5 | 13.8 | 11.9 | 14.4 | 10.3 |
| 12 | 22.4 | 16.8 | 13.6 | 17 | 19 | 15.8 | 18.6 |
| Sexual identity | |||||||
| Heterosexual | 13.4 | 10.7 | 10.1 | 10 | — | 12 | 10.8 |
| Gay or lesbian | 17.3 | 12.2 | 4.2 | 10 | — | 19.2 | 15.6 |
| Bisexual | 15.1 | 14.4 | 16 | 10.6 | — | 13.4 | 17.8 |
| Gay, lesbian, or bisexual | 15.6 | 13.3 | 11 | 10.4 | — | 14.9 | 17.2 |
| Not sure | 13.1 | 10.6 | 5.8 | 14.9 | — | 15.25 | 6.5 |
| United States | Gulf State Average | Alabama | Mississippi | Louisiana | Florida | Texas | |
|---|---|---|---|---|---|---|---|
| High School Students Who Have Ever Used Marijuana (%) | |||||||
| Sex | |||||||
| Male | 37 | 32.9 | 30.6 | 32.6 | 35.1 | 34.3 | 32.1 |
| Female | 36.5 | 32.7 | 28.5 | 31.7 | 33.6 | 34.8 | 35.1 |
| Race | |||||||
| White | 36.8 | 31.1 | 26.4 | 29.1 | 31.7 | 38.1 | 30.5 |
| Black | 37.5 | 35.1 | 34.8 | 35.4 | 38.1 | 30.8 | 36.7 |
| Hispanic/Latino | 39.2 | 31.3 | 32.2 | 30.6 | 25.4 | 32.8 | 35.8 |
| Grade | |||||||
| 9 | 24.3 | 25.5 | 24.4 | 25.1 | 27.6 | 26.1 | 24.4 |
| 10 | 34.3 | 27.9 | 26.2 | 27.6 | 22.3 | 32.4 | 31.1 |
| 11 | 41.1 | 38.6 | 33.4 | 36.3 | 45.6 | 39.2 | 38.9 |
| 12 | 48.7 | 41.1 | 35.5 | 42.4 | 44.8 | 40.8 | 42.2 |
| Sexual identity | |||||||
| Heterosexual | 36 | 30.5 | 27.5 | 29.4 | — | 33.3 | 31.9 |
| Gay or lesbian | 48.2 | 48.4 | 46.6 | 60.7 | — | 45.3 | 41.3 |
| Bisexual | 50 | 48 | 45.7 | 45.1 | — | 45.8 | 55.4 |
| Gay, lesbian, or bisexual | 49.6 | 48.3 | 46 | 49.9 | — | 45.7 | 51.8 |
| Not sure | 27.5 | 28.9 | 32.3 | 40.6 | — | 25.7 | 17.3 |
| High School Students Who Have Obesity (%) | |||||||
| Sex | |||||||
| Male | 18.9 | 20.18 | 19 | 25.8 | 19.3 | 16.2 | 20.6 |
| Female | 11.9 | 14.92 | 15.3 | 21.1 | 13.6 | 11.6 | 13 |
| Race | |||||||
| White | 13.1 | 14.66 | 13.5 | 20.6 | 13.4 | 12.9 | 12.9 |
| Black | 21.1 | 19.96 | 22.8 | 25.5 | 19 | 14.7 | 17.8 |
| Hispanic/Latino | 19.2 | 19.02 | 15.3 | 28.9 | 17.4 | 14.6 | 18.9 |
| Grade | |||||||
| 9 | 14.8 | 16.94 | 16.8 | 20 | 14.9 | 13.7 | 19.3 |
| 10 | 15.9 | 17.78 | 16.3 | 25.3 | 17.9 | 15 | 14.4 |
| 11 | 15.7 | 18.6 | 16.5 | 25.7 | 19.7 | 13.4 | 17.7 |
| 12 | 15.5 | 17.06 | 18.8 | 23.4 | 12.9 | 13.8 | 16.4 |
| Sexual identity | |||||||
| Heterosexual | 14.4 | 17.025 | 16.7 | 22.4 | — | 13.2 | 15.8 |
| Gay or lesbian | 18.2 | 17.55 | 19.4 | 19.7 | — | 17.3 | 13.8 |
| Bisexual | 21.8 | 22.55 | 20.6 | 27.8 | — | 20 | 21.8 |
| Gay, lesbian, or bisexual | 21 | 21.075 | 20.1 | 25.3 | — | 19.3 | 19.6 |
| Not sure | 18.2 | 25.525 | 18.6 | 35.6 | — | 16.7 | 31.2 |
| United States | Gulf State Average | Alabama | Mississippi | Louisiana | Florida | Texas | |
|---|---|---|---|---|---|---|---|
| High School Students Who Have Seriously Considered Attempting Suicide (%) | |||||||
| Sex | |||||||
| Male | 13.3 | 12.86 | 14.4 | 14.1 | 12.3 | 10.9 | 12.6 |
| Female | 24.1 | 23.6 | 26.8 | 23.2 | 22.5 | 20.2 | 25.3 |
| Race | |||||||
| White | 19.1 | 19.02 | 20.8 | 20 | 15.6 | 17.2 | 21.5 |
| Black | 16.9 | 16.92 | 19.7 | 16.9 | 18.2 | 13.1 | 16.7 |
| Hispanic/Latino | 17.2 | 18.6 | 19.1 | 19.9 | 23 | 14.3 | 16.7 |
| GradeSSSS | |||||||
| 9 | 17.7 | 19.68 | 23.5 | 20.6 | 19.9 | 16.8 | 17.6 |
| 10 | 18.5 | 17.98 | 19.7 | 15 | 20 | 15.6 | 19.6 |
| 11 | 19.3 | 18.08 | 19.4 | 20.2 | 15.8 | 15.6 | 19.4 |
| 12 | 19.6 | 17.3 | 19.1 | 19.6 | 14.7 | 13.8 | 19.3 |
| Sexual identity | |||||||
| Heterosexual | 14.3 | 14.375 | 16.9 | 15 | — | 11.3 | 14.3 |
| Gay or lesbian | 29.8 | 32.1 | 30.7 | 37.1 | — | 30.8 | 29.8 |
| Bisexual | 54.7 | 45.3 | 43.9 | 44.4 | — | 38.2 | 54.7 |
| Gay, lesbian, or bisexual | 48.2 | 41.225 | 38.5 | 42 | — | 36.2 | 48.2 |
| Not sure | 41.9 | 34.6 | 37.2 | 29.3 | — | 30 | 41.9 |
| High School Students Who Have Felt Sad or Hopeless* (%) | |||||||
| Sex | |||||||
| Male | 26.8 | 27.56 | 26.2 | 26.6 | 28.4 | 28.3 | 28.3 |
| Female | 46.6 | 47.14 | 48.6 | 44.4 | 45.5 | 48.6 | 48.6 |
| Race | |||||||
| White | 36 | 37.66 | 36.7 | 38.1 | 38.3 | 34.4 | 40.8 |
| Black | 31.5 | 33.84 | 38.3 | 32.9 | 33.4 | 30.8 | 33.8 |
| Hispanic/Latino | 40 | 38.08 | 37.9 | 38.5 | 42.2 | 33.9 | 37.9 |
| Grade | |||||||
| 9 | 33.2 | 35.54 | 37.5 | 35.2 | 39.3 | 33 | 32.7 |
| 10 | 37 | 37.8 | 36.8 | 35.8 | 43 | 34.6 | 38.8 |
| 11 | 37.9 | 36.74 | 37.8 | 35.6 | 35.9 | 33.7 | 40.7 |
| 12 | 39 | 35.76 | 37.6 | 36.2 | 28.3 | 33.5 | 43.2 |
| Sexual identity | |||||||
| Heterosexual | 32.2 | 32.225 | 33.8 | 31.4 | — | 28.9 | 34.8 |
| Gay or lesbian | 59.6 | 49 | 46.1 | 54.6 | — | 51.4 | 43.9 |
| Bisexual | 68.2 | 65.375 | 61.2 | 66.2 | — | 60.7 | 73.4 |
| Gay, lesbian, or bisexual | 66.3 | 60.4 | 55.2 | 62.4 | — | 58.2 | 65.8 |
| Not sure | 47.4 | 50.3 | 53.3 | 51.7 | — | 48.1 | 48.1 |
* Almost every day for 2 or more weeks in a row so that they stopped doing some usual activities, during the 12 months before the survey.
SOURCE: YBRSS, 2019.
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