Walking uphill both ways

by Allan Joseph and Emily Flower

Sometimes, good data visualization just has a way of grabbing your attention. That’s what the Providence Plan, a data-focused organization here in Rhode Island, was able to do last week with this stark map (click to see a larger version):

Current Busing Policy Maps

Some background: These maps represent the distances high school students have to walk before qualifying for access to free transportation services through the Providence Public School District (PPSD). Or in layman’s terms, if you live in a green area on your high school’s map, you get a free bus pass. If you live in the red area, you’re on your own. A monthly pass costs $62 a month, and that’s the cheapest option.

Middle school students in PPSD receive transportation services if they live more than 1.5 miles from their school. When students transition to high school (when they can pick their school based on their interests), they get a free bus pass only if they live more than 3 miles away — measured as the crow flies, not in walking distance.

It may be cliché, but more than a handful of students do actually walk uphill, both ways, during their often hour-long commute to and from school each day. The city is built primarily on two hills; it’s difficult to get anywhere here without traversing a highway, waterway, or climbing up or down a hill — often all three in the same walk.

For many students, this daily trek is enough of a reason to not attend school. Between middle school and high school, the transportation requirement doubles. So does the chronic absenteeism rate. The chronic absenteeism rate jumps too. (Edited for miscalculation.) PPSD middle schools see a 26% chronic absenteeism rate, defined by a student missing 18 instructional days (roughly the entire month of November). PPSD high schools reported a 36% chronic absenteeism rate in the 2012-2013 school year. Obviously that’s not exclusively due to the transportation issue, but it doesn’t seem like a stretch to say that buses are a major factor — especially since absence rates are sky-high in the winter, even compared to neighboring districts.

But this isn’t just about chronic absenteeism, nor is it limited to education policy. Schools are some of the most important forces for health in the life of poor children — and with 83% of students in PPSD qualifying for subsidized lunch (family income below 185% of the federal poverty level), the majority of students in PPSD are poor or near-poor. In the short term, many students depend on subsidized lunch for food security. Their most familiar and important healthcare provider? The school nurse. Their easiest access to health resources? The school nurse, again. When they don’t go to school, they’re cut off from all of those resources. That’s not to mention that if they do decide to walk to school from nearly 3 miles away as the crow flies, they could be placing their health at risk, as frostbite, heatstroke, and violence are all real risks at various times of the year.

Long-term, there’s a relationship between educational attainment and health outcomes. Though the literature isn’t clear on how much of that is causal, we think it’s a fair bet that students who do better in school (by attending more often) will have a better chance at attaining better health. (Here’s some tentative evidence.)

But there’s some movement towards changing the policy. Recently-introduced House Bill 7012 aims to change the policy in order to bring PPSD’s policy in line with the other school districts in the state: a 2-mile walk zone. That’s far from ideal, but it’s certainly an important step: about 2,100 students would gain access to busing, and it stands to reason that those are the students who would most benefit from expanded busing, as they live the farthest away. Here’s what the new maps would look like (again, click to enlarge):

New Policy Maps

As you can see, that one mile covers quite a bit of the city. But H.B. 7012 isn’t an easy sell, not by a long shot. For one, the policy would cost the city $1.35 million at a time of strict belt-tightening in the Ocean State. But look at it another way: Gov. Lincoln Chafee’s latest budget proposed a large cut to Medicaid — to $819 million in state spending, or $1.9 billion when federal matching funds are added. The policy would cost just 0.1% of the Rhode Island Medicaid program’s annual budget. And therein lies the key to understanding the problem.

Targeted, “low-hanging fruit” interventions on the social-service side can help promote health outcomes at relatively low cost. We can, and should, pursue those interventions — and it shouldn’t take a well-made map to draw our attention to them.

We’re not arguing that Rhode Island’s Medicaid program should pay for the busing solution, of course. That would be an admittedly silly ad hoc way to make policy. What we’re trying to say is that healthcare and medical care are not synonyms. What we talk about in “health policy” is often more properly termed “medical care” — how to finance health insurance, the difficulties of narrow networks, how to manage our medical-care costs as a country, etc. But health is affected by more than medical care — and it’s definitely affected by social services, school transportation included. Yet we’ve separated the ways we pay for social services and medical-care services in ways that don’t always make sense. Moreover, bad health limits the ability of poor Rhode Islanders — and Americans — to take advantage of social services designed to give them a leg up, while limited social services can make pursuing health a Herculean task.

Talk about climbing uphill both ways.

*Much more on this topic coming soon: a review of The American Health Care Paradox, a new book by Elizabeth H. Bradley and Lauren A. Taylor.


Allan is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

Emily works in civic education in Providence, Rhode Island. She graduated from The Ohio State University with a degree in Public Affairs. You can follow her on twitter @emilygflower.


One thought on “Walking uphill both ways

  1. This is a very insightful and meaningful analysis. Let’s hope Rhode Islanders–and others around the country–read this, think about its implications, and change policy so that health care for children is easier to access and not based on one’s proximity to school.

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