Association for Public Policy Analysis & Management

Study Design: This study relied on two sources of data from the Oregon Health Insurance Experiment, collected between 2009 and 2011. Outcome measurements of Body Mass Index (BMI), blood pressure, cholesterol, diabetes, tobacco use, and physical activity were collected through in-person health screenings. Data on childhood ACEs, current social connections and neighborhood cohesion were collected via a follow-up survey with study participants. Insurance was evaluated using the public health insurance lottery. 

Population Studied: 20,745 low-income non-elderly uninsured adults who signed up for a 2008 U.S. public health insurance lottery were recruited for in-person clinical interviews. 12,229 individuals participated in the clinical health screenings and were recruited for a follow-up study focused on ACEs. Of those who participated in the health screenings, all were sent follow-up surveys with a response rate of 48% (n=5900).     

Principal Findings: Compared to previous published estimates of ACEs in a clinically-served population, our low-income adults experienced notably higher rates of emotional abuse (37.4% versus 10.6%) and emotional neglect (32% vs. 14.8%) but similar rates of sexual abuse, physical abuse, and physical neglect. Rates of household dysfunction were higher for multiple ACEs including household substance abuse (43.2% vs. 26.9%), mental illness (32% vs. 19.4%), and incarceration (13.6% vs. 4.7%).  ACEs were statistically associated with higher rates of obesity, smoking, hypertension, diabetes, and being less physically active. Individual social support statistically reduced cardiovascular risk across several metrics. Health insurance, social participation, and neighborhood cohesion were not powerful moderators.  

Conclusions: Estimates of the prevalence of ACEs in a clinical population seem to underestimate the prevalence in low-income adults who now meet the criteria for public insurance eligibility in many U.S. states. The exposure, degree of exposure, and type of ACEs are associated with higher rates of cardiovascular risk factors. Gaining public health insurance, participating in social activities, and living in a cohesive neighborhood were not significantly protective, but individual social support was for several metrics. 

Implications for Policy or Practice: Adverse Childhood Experiences have been linked to multiple poor adult health outcomes, including cardiovascular disease. Most of what is known about these relationships comes from a clinically observed population. However, the impacts of ACE’s might be compounded in a low-income uninsured population. As millions of previously uninsured low-income adults gain coverage in the United States, it is important to understand the prevalence of ACEs and subsequent attributable cardiovascular risk and protective factors in this disadvantaged population. Understanding what moderates cardiovascular risk in the presence of childhood adversity could be used to inform public health approaches to chronic disease prevention.