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August 2001, Vol 91, No. 8 | American Journal of Public Health 1209-1213
© 2001 American Public Health Association

RESEARCH

Changing to the 2000 Standard Million: Are Declining Racial/Ethnic and Socioeconomic Inequalities in Health Real Progress or Statistical Illusion?

Nancy Krieger, PhD and David R. Williams, PhD, MPH

Nancy Krieger is with the Department of Health and Social Behavior, Harvard School of Public Health, Boston, Mass. David R. Williams is with the Department of Sociology and Institute for Social Research, University of Michigan, Ann Arbor.

Correspondence: Requests for reprints should be sent to Nancy Krieger, PhD, Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 (e-mail: nkrieger{at}hsph.harvard.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 

Objectives. This study determined the effects of changing from the 1940 to the 2000 standard million on monitoring socioeconomic and racial/ethnic inequalities in health.

Methods. Using the 1940, 1970, and 2000 standard million, we calculated and compared age-adjusted rates for selected health outcomes stratified by socioeconomic level.

Results. Changing from the 1940 to the 2000 standard million markedly reduced the age-adjusted relative risks for self-reported fair or poor health status of poor Americans compared with high-income Americans.

Conclusions. Public health researchers and practitioners should give serious consideration to the implications of the change to the 2000 standard million for monitoring social inequalities in health.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
The year 2000 ushered in a major change in the standard million that the US National Center for Health Statistics (NCHS) employs for age-adjusting data. For more than 50 years, the official standard was the 1940 standard million, which was based on the age distribution of the US population in 1940.1 During the past half century, however, life expectancy has increased considerably, leading the Secretary of Health and Human Services in 1998 to approve a change to the 2000 standard million, reflecting the older age distribution of the US population.1

In discussing the impact of the new standard million, several reports have noted that the new standard may attenuate racial/ethnic disparities in health.2–8 The age standard matters for comparing age-adjusted rates, because the age-adjusted rate is a weighted average of the age-specific rates, with the weights determined by the age structure of the age standard. If, say, the age-specific rates for 2 populations differ least among the elderly, then the magnitude of difference in their age-adjusted rates would appear to be smaller if the age standard includes a higher proportion of elderly than younger persons. For example, on the basis of mortality data age-adjusted to the 1940 standard, the relative risk of all-cause mortality in 1995 was 1.6 times higher among African Americans than among White Americans—as it also was in 1950, with the same 1940 age standard used.6,9 If, however, the 2000 standard had been used, the excess risk in 1995 would have been reduced to 1.4, a 12.5% decline.6 While this change may appear small, a true decline to 1.4 would actually have represented a welcome change. This raises the possibility of mistaking a reduction due to a technical change for a true decline representing progress in reducing racial/ethnic disparities in health.2

To alert the public health community, the NCHS has prepared several reports.1,8,10 Apart from these documents, however, there has been remarkably little discussion in public health literature about the impending changes.7 Moreover, although the government documents and some research articles have briefly considered the implications of the new standard for Black–White comparisons,2–8 there has been no discussion of the impact on comparisons involving other social inequalities in health, both with regard to other racial/ethnic groups and with regard to socioeconomic inequalities in health. This is a serious omission, given (a) the growing racial/ethnic diversity of the US population and (b) evidence indicating that socioeconomic inequalities in health often are larger than racial/ethnic inequalities in health.9,11,12

Rendering this issue even more of concern is that the Healthy People 2010 objectives specifically state the goal of eliminating racial/ethnic disparities in health for 6 conditions.13 Additionally, 30% of the 467 objectives include baseline socioeconomic data, allowing for possibilities of assessing changes in socioeconomic disparities in health over time. It therefore is useful to consider the possible impact of the new age standard on monitoring social inequalities in health.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
We calculated age-adjusted rates separately with the 1940, 1970, and 2000 standard million.6,14(p360) We first calculated and compared rates adjusted to the different age standards for a hypothetical example modeled after current US all-cause mortality rates, stratified by income level. We then calculated and compared rates for 2 outcomes included in the 1998 Socioeconomic Status and Health Chartbook12 prepared by the NCHS. To calculate these age-adjusted rates, we used agespecific rates not published in the chartbook but provided to us by NCHS staff; the overall age range was the same as that presented in the chartbook. Similarly, using the same socioeconomic categories employed for each selected outcome as presented in the chartbook, we categorized income as follows: poor (annual household income below the US poverty line, which equaled $15 569 for a family of 4 in 1995), near poor (annual household income 100%–199% of the poverty line), middle income (annual household income 200% or more of the poverty line and less than $50 000), and high income (annual household income 200% or more of the poverty line and $50 000 or higher)12(pp138–139); education is categorized as less than 12 years, 12 years, and 13 years or more of school.12 We likewise employed the same racial/ethnic categories used in the chartbook: "all racial/ethnic groups combined" for one outcome and 3 groups—White non-Hispanic, Black nonHispanic, and Hispanic—for the other.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
Table 1Go presents the age distribution for the 1940, 1970, and 2000 US standard million. The most notable change, from 1940 to 2000, is a reduction in the young population (aged 34 and younger) and a marked increase in the older population (especially 65 years and older). Table 2Go, in turn, provides data on the projected age distribution for 2000 for different racial/ethnic populations in the United States,15 and it illustrates how the standard million (equivalent to percent weights in the "total population" column) is driven by the age distribution of the White non-Hispanic population, which comprises 71.8% of the total population.


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  		TABLE 1— US Standard Million Population for 1940, 1970, and 2000
 

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  		TABLE 2— Projections of the US Resident Population (in Thousands) for 2000 by Age, Race/Ethnicity, and Hispanic Origin
 
Table 3Go presents a hypothetical example, using all-cause mortality stratified by income level, for the full age distribution of the population (younger than 1 year to 85 years and older). As expected, use of the 2000 standard million increased the magnitude of the age-adjusted mortality rate for each income stratum. The relative increase, however, varied by income level; the increase ranged from a low of 58% among the poor to 100% among the middle–high income stratum. The net effect was that when age-adjusted death rates among the poor were compared with those for middle–high income groups, the calculated relative risk was reduced from 2.9 to 2.3.


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  		TABLE 3— Hypothetical Outcome: Age-Specific and Age-Adjusted All-Cause Mortality Rates by Income Level, and Age-Adjusted Socioeconomic Gradients, by Using the 1940, 1970, and 2000 Standard Million
 
Table 4Go provides empiric data for chronic disease mortality rates among adults aged 25 to 64 years, stratified by education; Table 5Go provides empiric data for the proportion of adults 45 years and older who report having fair or poor health, stratified by income. For chronic disease mortality rates, use of the different age standards had little effect on the magnitude of the age-adjusted rates, and thus on age-adjusted relative risks, for either women or men, given the relatively limited age categories included in these analyses. By contrast, for analyses of self-reported health status among persons 45 years and older, use of the different standards resulted in a slight decrease in age-adjusted rates of fair or poor health among the poor but a marked jump in this proportion among high-income adults, for all 3 racial/ethnic groups included in the analyses. The net effect was to decrease the calculated age-adjusted socioeconomic gradient in self-reported fair or poor health based on the 2000 standard million compared with that based on the 1940 standard million. For example, when poor and high-income White non-Hispanic Americans were compared, the relative risk declined from 6.4 to 5.2; for Black Americans, the decline was from 5.2 to 4.5, and for Hispanic Americans, it was from 5.0 to 3.5.


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  		TABLE 4— Chronic Disease Mortality Rates (per 100 000) Among Adults Aged 25 to 64 Years, by Age, Education Level, and Sexa: United States, 1995
 

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  		TABLE 5— Fair or Poor Health Among Adults 45 Years and Older, by Age, Family Income, and Race/Ethnicity: United States, 1995
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
Use of the 2000 standard million poses important challenges to our understanding of trends in social inequalities in health. As our results indicate, the effects of using the new standard can range from minimal to dramatic, depending on both the age groups being compared and the magnitude of age-specific risks within specified age strata.

We urge that public health researchers and practitioners give serious consideration to the implications of the change to the 2000 standard million for our work. We further recommend that any analyses regarding trends in social inequalities in health use a consistent age standard for all comparisons and that scrupulous attention be paid to the age standard used in comparisons of rates obtained from different published reports of age-adjusted data. These same caveats apply when comparing US age-adjusted rates with rates for other countries adjusted to other standard millions.4,7,16 Additionally, public health departments, both state and local, and the NCHS should either present "bridge" data allowing comparisons of contemporary rates adjusted to the 1940 and 2000 standard or else should reissue older data readjusted to the 2000 standard. Finally, efforts to evaluate progress toward reducing racial/ethnic and socioeconomic inequalities in health, along with progress in meeting the 2010 goals, should not mistake reductions due to a change in the age standard for true declines marking the desired objective of eliminating social inequalities in health.


   Acknowledgments
 
Thanks go to Elsie Pamuk, PhD, acting director, Division of Epidemiology, National Center for Health Statistics, Hyattsville, Md, for sharing age-specific rates used for the Health United States 1998 Socioeconomic Status and Health Chartbook.


   Footnotes
 
N. Krieger initiated the study and, together with D. R. Williams, planned the data analysis (which N. Krieger conducted), interpreted the data, and wrote the paper.

Peer Reviewed

Accepted for publication October 28, 2000.


   References
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. Anderson RN, Rosenberg HM. Report of the second workshop on age adjustment. Vital Health Stat 4. 1998;No. 30.

2. Patterson JE. Age adjustment in National Center for Health Statistics mortality data: implications of a change in procedures. Vital Health Stat 4. 1992;No. 29:71–72.

3. Rosenberg HM, Curtin LR, Maurer J, Offutt K. Choosing a standard population: some statistical considerations.Vital Health Stat 4. 1992;No. 29:29–45.

4. Rothenberg R, Hahn R. The choice of the standard for age adjustment. Vital Health Stat 4. 1992;No. 29:49–59.

5. Maurer J. Age-specific weights of age-specific percent changes assumed in the computation of percent changes based on age-adjusted death rates. Vital Health Stat 4. 1992;No. 29:79–83.

6. Anderson RN, Rosenberg HM. Age standardization of death rates: implementation of the year 2000 standard. Natl Vital Stat Rep. 1998;37(3).

7. Sorlie PD, Thom JT, Manolio T, Rosenberg HM, Anderson RN, Burke GL. Age-adjusted death rates: consequences of the year 2000 standard. Ann Epidemiol.1999;9:93–100.[Medline]

8. New population standard for age-adjusting death rates. MMWR Morb Mortal Wkly Rep.1999;48:126–127.[Medline]

9. Williams DR. Race, socioeconomic status, and health: the added effects of racism and discrimination. Ann N Y Acad Sci.1999;896:173–188.[Abstract/Free Full Text]

10. Feinleib M. A reconsideration of age adjustment. Vital Health Stat 4. 1992;No. 29:3–7.

11. Krieger N, Rowley DL, Herman AA, Avery B, Phillips MT. Racism, sexism, and social class: implications for studies of health, disease, and well-being. Am J Prev Med.1993;9(suppl):82–122.[Medline]

12. Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Socioeconomic Status and Health Chartbook. Health, United States, 1998. Hyattsville, Md: National Center for Health Statistics; 1998.

13. Healthy People 2010. Conference ed, 2 vol. Washington, DC: US Dept of Health and Human Services; January 2000. Available at: http://www.health.gov/healthypeople. Accessed June 30, 2000.

14. Devessa S, Grauman DJ, Blot WJ, Pennell GA, Hoover RN, Fraumeni JF Jr. Atlas of Cancer Mortality in the United States, 1950–94. Bethesda, Md: National Cancer Institute; 1999. NIH publication 99-4564.

15. US Census Bureau. Current Population Reports P25-1130. Population projections of the United States by age, sex, race, and Hispanic origin: 1995–2050. Last Available at: http:/www.census.gov/prod/1/pop/p25-1130. Accessed September 5, 2000.

16. Feinleib M, Zarate AO, eds. Reconsidering age adjustment procedures: workshop proceedings. Vital Health Stat 4. 1992;No. 29.




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