Survey Examines Health and Education Conditions in the Eighth District’s LMI Communities

The biennial Community Development Outlook Survey (CDOS) was administered by the St. Louis Fed in October 2023 to assess the economic conditions of low- and moderate-income (LMI) communities and the organizations serving them. Respondents included 604 stakeholders, such as nonprofits, community-based organizations, government and education entities, and financial institutions, from the Eighth Federal Reserve District states.Eighth District states are Arkansas, Illinois, Indiana, Kentucky, Mississippi, Missouri and Tennessee.

A previous blog post highlighted CDOS results that examined economic mobility within the Eighth District’s LMI communities through the lens of employment and housing conditions. This post delves into two other important factors that can help contribute to labor market participation and to better economic outcomes:

• Conditions in prekindergarten (pre-K) to 12th grade education, for which survey respondents reported optimistic expectations for 2024
• Conditions in health care, for which survey respondents reported a mixed outlook for 2024 in terms of overall health conditions and access to health care

Optimism for 2024 in Education

Education provides a key path to higher income: Workers’ earnings increase and their unemployment rates decrease as educational attainment rises. CDOS findings revealed optimism for 2024, with almost 40% of respondents indicating that they expected overall conditions in pre-K to 12th grade education to improve this year for those in the LMI community. According to survey respondents, three factors contributed to this positive outlook:

• Improved availability of early childhood education: This can enhance children’s school readiness (PDF) and is linked to higher test scores throughout primary education.
• Expanded access to internet and technology: This contributes to student learning and building digital and technological skills, which provide tools for further learning and future use in the workplace.
• Increased availability of programs and counselors to support students: Providing critical social, emotional and academic assistance can promote student academic success.

Yet pre-K to 12th grade education faces several changes. School funding and teacher hiring and retention were raised in the survey as top concerns. Educator shortages in grades pre-K to 12 have been a common theme lately across the country. However, the shortage of educators was present even prior to the COVID-19 pandemic, according to the National Association of Educators. While teachers leaving the profession is a major driver of the current educator shortfall, job openings have been outpacing hires since 2017. Furthermore, research by consulting firm McKinsey shows that while nearly a third of U.S. pre-K to 12th grade educators are considering quitting their jobs, teacher departures would disproportionately affect low-income families and students of color.

Student home life was raised in the survey as another major concern, with 25% of respondents indicating it was the main factor negatively affecting education in grades pre-K to 12. Children pay attention and learn best when they go to school in a good physical and mental state (PDF). Stress can lead to worry, anxiety, unhappiness and behavior problems, all of which can adversely affect children’s ability to learn.

On the other hand, the availability of programs and counselors to support students (academically and emotionally) was considered one of the top factors positively affecting education conditions in Eighth District LMI communities, according to respondents. As part of a school support team, school counselors provide critical social, emotional and academic support, which promotes success and achievement for students.

The figure below shows that several states in the Eighth District have a better student-to-counselor ratio than the U.S. average. However, no District state met the ratio of 250 students to 1 counselor that is recommended by the American School Counselor Association. This suggests that many Eighth District students do not have appropriate access to counseling, which is particularly beneficial to students of color and students from low-income families.

Student-to-School Counselor Ratio, 2022-23

SOURCES: American School Counselor Association and author’s calculations.

Continued efforts towards increasing access to counselors can improve the chances that students graduate from high school and attend a four-year college (PDF).

Survey Highlights Poor Overall Health and Access to Care in 2023

According to the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health Promotion, residents of impoverished communities are at increased risk for mental illness, chronic disease, higher mortality and lower life expectancy. Unmet social needs and environmental factors can contribute to worse health outcomes.

Health issues and access to care can also create additional challenges for LMI families. For example, large expenses related to treatment cost, distance to care and time spent in obtaining care can interfere with work schedules. Alternatively, the lack of treatment can reduce labor force participation.

The CDOS findings revealed that 63% of respondents assessed their LMI communities’ health conditions to be poor or very poor in 2023; most of these respondents did not expect conditions to improve in 2024 because of high rates of untreated chronic diseases, mental health issues and lack of access to care.

High rates of untreated chronic diseases were among the top adverse factors affecting health conditions, according to survey respondents. While almost 30% of U.S. adults had to skip or delay care in 2022 (PDF) because they could not afford it, others received the care and went into medical debt. According to a report by health policy nonprofit KFF, 57% of U.S. adults with household income under $40,000 said they had medical debt. High levels of medical debt can then reduce the ability of households to receive further needed treatment, contributing to the cycle of poor health outcomes and low income.

Respondents indicated that mental health needs were by far the most concerning challenge in health care. “People are massively stressed out and burdened by generational trauma that they don’t have time or money to address,” one respondent noted.Intergenerational trauma is a response to a devastating event resulting in adverse physical and emotional outcomes passed down between generations. Some examples include racial discrimination, substance abuse and domestic violence. While the rates of mental illness in the Eighth District are close to the average national level, access to treatment in District states is lower relative to the rest of the country.

A Majority of Survey Respondents Rated 2023 Health Conditions and Access to Health Care to Be Poor or Very Poor for LMI People in the Communities That They Serve

SOURCES: 2023 Community Development Outlook Survey and author’s calculations.

NOTES: Of the 33 respondents answering the “access to health care” question, no one responded with “very good.” Of the 40 respondents answering the “health conditions” question, no one responded with "good." The number of observations differs because respondents selected questions according to their area of work.

Additionally, more than half of respondents indicated poor or very poor access to physical or mental health care, with the main challenges including the cost of care, insurance coverage, and distance or transportation to medical appointments. During 2023, survey findings showed some positive trend, with almost 30% of respondents indicating that access had improved between 2022 and 2023; 22% expected further improvements in 2024. Telehealth options, insurance coverage and the availability of free or low-cost clinics have contributed to this upward trend. As one of the respondents noted: “There are more federally funded clinics to assist with health care access.”

Nevertheless, the end of Medicaid’s continuous enrollment provision—which required states to provide continuous coverage to Medicaid enrollees through March 31, 2023—may reverse some of the recent improvement in access to health care. The figure below shows that net Medicaid enrollment declined by at least 10% from a 2023 baseline in six of the seven Eighth District states, according to the latest data available to KFF on May 10, 2024.KFF calculated baseline enrollment as enrollment in the month before a state resumed disenrollments, which varied by state. See KFF’s data on the District states, whose most recent Medicaid data ranged from February to April 2024. Special attention to health care access in Arkansas may be needed, given the state’s 23% fall in net Medicaid enrollment.

The Percent Change in Net Medicaid Enrollment since Disenrollments Began in 2023

SOURCES: KFF’s Medicaid Enrollment and Unwinding Tracker and author’s calculations.

NOTE: The percent change is based on the difference between the state’s most recent data available to KFF as of May 10, 2024, and its 2023 baseline enrollment, i.e., enrollment in the month before a state resumed disenrollments, which varied by state.

Investments that expand health care access and educational support in LMI neighborhoods could help improve economic outcomes for this population. This may allow for enhanced economic security and economic mobility in the longer term.

Notes

1. Eighth District states are Arkansas, Illinois, Indiana, Kentucky, Mississippi, Missouri and Tennessee.
2. Intergenerational trauma is a response to a devastating event resulting in adverse physical and emotional outcomes passed down between generations. Some examples include racial discrimination, substance abuse and domestic violence.
3. KFF calculated baseline enrollment as enrollment in the month before a state resumed disenrollments, which varied by state. See KFF’s data on the District states, whose most recent Medicaid data ranged from February to April 2024.