Overview of Idaho

Idaho Map.png

Idaho is a large western state with impressive mountain ranges, large areas of high desert and massive expanses of forested terrain.  Geography and distance impact both the demographic characteristics and social determinants of health within Idaho.

 

Demographics

Idaho is ranked 38th of the 50 United States for total population and 14th for geographic size. The 2020 census population for Idaho was 1,839,106 and, because of its large size and relatively small population, Idaho remains one of the most rural states in the nation. With approximately 22.3 people per square mile, Idaho ranks 44th of the 50 states in population density. The national average population density is 93.8 people per square mile, a four-fold greater density than Idaho. Thirty-five of Idaho’s 44 counties are rural, with 16 of these considered frontier, which means those counties have fewer than six people per square mile.

The 2020 census diversity index shows that racial and ethnic diversity has increased in Idaho over the past decade. In 2020 the diversity index from Idaho was 35.9 percent, up from 28.2 percent in 2010. A diversity index of 0 percent would mean that everyone in the population has the same racial and ethnic characteristics, while a value close to 100 percent indicates that everyone in the population has different racial and ethnic characteristics. The diversity index for the United States was 61.1 percent in 2020, up from 54.9 percent in 2010.

The racial groups that comprised Idaho’s population in 2020 were:

  • White alone, not Hispanic or Latino, 78.9 percent

  • Black or African American alone, not Hispanic or Latino, 0.8 percent

  • American Indian and Alaska Native alone, not Hispanic or Latino, 1 percent

  • Asian alone, not Hispanic or Latino, 1.4 percent

  • Native Hawaiian or Pacific Islander alone, not Hispanic or Latino, 0.2 percent

  • Some Other Race alone, not Hispanic or Latino 0.4 percent

  • Two or More Races, not Hispanic or Latino 4.2 percent

 

Persons of Hispanic or Latino origin comprised 13 percent of Idaho’s total 2020 population and could be of any racial group. Idaho is home to six federally recognized tribes: Coeur d’Alene Tribe, Kootenai Tribe of Idaho, Nez Perce Tribe, Shoshone-Bannock Tribes of the Fort Hall Reservation, the Northwestern Band of the Shoshone Nation and the Shoshone-Paiute Tribes of the Duck Valley Reservation. Idaho also has two refugee centers located in southwest Idaho (Ada County) and south-central Idaho (Twin Falls County).

Social Determinants and other Demographics

The conditions in which people are born, live, learn, work and play have a substantial impact on health outcomes and quality of life. Also known as the social determinants of health (SDOH), these conditions and the policies and systems that shape them, are the underlying, contributing factors of health inequities that result in differences in health outcomes for some populations.  SDOH factors include income, education, housing, safe environment, access to healthy food, quality health care, social support, discrimination, and other factors that influence health choices, behaviors, and opportunities.

Multitudes of research conclude one of the clearest predictors of health disparities is geography – where people live - finding zip code to be a greater predictor of health and longevity than genetic code. Social, economic, and environmental factors and their influence on health can vary greatly depending on where one lives, as each neighborhood has differing levels of access to affordable housing, good jobs, healthy food, education and healthcare. In Idaho, mapping life expectancy by census tract shows a difference of as much as 20 years of life between the highest and lowest tracts, and many of these gaps occur in the same community.

SDOH graphic.png

Economic Stability


Poverty is a strong predictor of poor health. According to the 2019 American Community 5-Year Survey (ACS), the median household income was $55,785 in Idaho compared to $62,843 nationally.[i] Similarly, per capita income was less in Idaho at $27,970, compared to $34,103 nationally. All racial and ethnic groups measured in the ACS had lower household and per capita incomes in Idaho than their counterparts nationally. Despite lower incomes, Idaho’s poverty level of 13.1 percent aligns with the national average of 13.4 percent.[i] This alignment with national trends largely holds true across sex, age, education level, and racial and ethnic groups. However, increased poverty of 18.7 percent is felt by young adults between the ages of 18 and 34, compared to 16.3 percent for this age group nationally.[i] Within Idaho, greater levels of poverty are experienced by certain demographic groups and within certain areas. For instance, 20.7 percent of Idaho’s Hispanic or Latino population lives at or below the poverty level in comparison to 11.5 percent of the white population who do not identify as Hispanic or Latino. Poverty measured at the county level ranges from 30.9 percent in Madison County to 4.5 percent in Teton County.[i]

Idaho is an important agricultural state, producing nearly one-third of the potatoes grown in the United States. Wheat, sugar beets and alfalfa hay are also major crops. Other industries contributing to Idaho’s economy include information technology, mining, lumber, tourism, and manufacturing. The United for ALICE Report, 2018, reveals two key characteristics of Idaho’s labor force:

  1. Idaho has a “large (and growing) number of workers paid hourly.” These workers are more likely to have disruptions in income due to schedule changes and variability in hours worked, “they are less likely to receive benefits such as health insurance, paid time off, family leave, or retirement benefits.”
  2. Idaho has a “historically high number of workers out of the labor force” whether due to retirement, school, health issues or family caregiving needs.

Idaho’s low wages coupled with rising costs of living across the state has resulted in many wage-earners struggling to get out of poverty. The economic impact of COVID-19 on Idaho’s economy and people is still being realized.

ALICE - Access Limited Income Constrained Employed – in Idaho

ALICE identifies and defines those households who fall within the “gap” – though they have income above the Federal Poverty Level (FPL), they are ineligible for state or Federal benefits programs and struggle to make enough to support their families. According to UnitedforALICE.org, ALICE families are often forced to make difficult decisions when they don’t have enough income to afford basic needs - housing, food, transportation, childcare, and health care. These decisions mean a family must decide between paying the rent or paying their childcare provider, or between buying groceries and filling a prescription. In 2018, the most recent ALICE data available, 12 percent of Idahoans fell under the FPL, while 28 percent were ALICE. As Idaho’s cost of living rises, driven by the skyrocketing growth in housing prices outpacing growth in wages, more households are finding their financial stability jeopardized.[ii]

Note: The latest ALICE report for Idaho was released in 2020, however, it analyzed data collected in 2018. Thus, the true effects of the COVID-19 pandemic on Idaho’s ALICE population won’t be known until the 2020 report is released in 2022.

[i]. U.S. Census Bureau. American Community Survey. 2015-2019 American Community Survey 5-year Estimates Subject Tables. Retrieved from: https://data.census.gov/cedsci/

[ii]. Alice In Idaho: A Financial Hardship Study. 2020 Idaho Report. United Ways of the Pacific Northwest. Retrieved from: https://www.unitedforalice.org/idaho




Education


Education and income go hand-in-hand. “A quality education is the best predictor of professional and financial success in the U.S., and the earliest years of a child’s education lay a critical foundation for this success.”(ALICE) Quality early education increases the likelihood of children who are prepared for kindergarten, graduate from high school, achieve higher education degrees and future career success. Additionally, people with more education tend to have higher incomes and better health outcomes. College graduates are often able to secure better paying jobs with fewer safety hazards and income from these jobs can be used on higher quality housing as well as other health enhancing resources.[ii]

A greater percentage of Idahoans over the age of 25 have graduated from high school (90.8 percent) than the national average of 88.0 percent.[i] Yet, the rate for those who go on to higher levels of education are lower in Idaho across almost all demographic groups. Nationally, 32.1 percent of the population over the age of 25 hold a bachelor’s degree or higher, while only 27.6 percent do in Idaho. Educational attainment disparities are also seen among various racial and ethnic groups. For Idaho’s Hispanic and Latino population, the high school graduation rate is 64.6 percent while this group has a graduation rate of 68.7 percent nationally.[i] Also, 9.9 percent of Idaho’s Hispanic and Latino population holds a bachelor’s degree or higher compared to 16.4 percent across the U.S. Within Idaho’s rural and frontier counties a smaller percentage of adults over the age of 25 have gone on to receive at least some post-secondary education than those living in urban counties, 54.5 percent compared to 66.7 percent.[i]


Quality and affordable early childhood education is a vital component necessary to support a child’s lifelong educational attainment and future earnings. In turn, access to affordable childcare supports a healthy economy as it allows parents to go to work and earn a better living. The most recent United for ALICE report, released by the United Way in 2020, reports the rise in the cost of child care in Idaho, noting an increase of “almost 20 percent for a family with two children in just one year (between 2017 and 2018).” Further compounding the issue, “Idaho is also one of four states without state-funded preschool, making it even more difficult for families to find quality, affordable preschool.”[iii]

[i]. U.S. Census Bureau. American Community Survey. 2015-2019 American Community Survey 5-year Estimates Subject Tables. Retrieved from: https://data.census.gov/cedsci/

[ii]. Alice In Idaho: A Financial Hardship Study. 2020 Idaho Report. United Ways of the Pacific Northwest. Retrieved from: https://www.unitedforalice.org/idaho

[iii]. Zajacova, Anna and Lawrence, Elizabeth, The Relationship Between Education and Health: Reducing Disparities Through a Contextual Approach, Annual Review of Public Health, Vol. 39: 273-289, April 2018.




Neighborhood and Built Environment


Community design and the quality of our built environments directly affect human health. The built environment refers to the physical spaces where we live, recreate and work. It is comprised of our homes, businesses, cultural institutions, parks, public spaces, roads, environmental conditions, utilities, and other infrastructure. These neighborhood or community attributes have a profound impact on our health by promoting or restricting access to physical activity, transportation options, healthy foods, safe housing, and even social interactions.

Research has shown that people living in more affluent neighborhoods tend to have better access to health promoting attributes like parks and safe connected sidewalks and pathways that are buffered from automobile traffic.[i] In contrast, people living in lower income neighborhoods tend to be exposed to unhealthy attributes such as higher levels of pollution from nearby freeways or industrial land uses. Emerging climate research also shows that residents living in lower income urban neighborhoods are exposed to higher summertime temperatures due to built environment conditions that include greater expanses of asphalt and concrete with fewer trees or green spaces.[ii] Get Healthy Idaho aims to improve conditions so that all Idahoans have access to health promoting attributes in their communities.


Food Security

Prior to COVID-19, Idaho was seeing improvements in the number of food insecure households. Data from Feeding America reported 10 percent of Idaho’s population faced food insecurity in 2019.[iii] According to the Idaho Food Bank and Idaho’s Map the Meal Gap report, released in May 2021, the pandemic and other economic changes had an immediate effect on the number of food insecure households, reporting a projected 11.3 percent of Idahoans will be impacted in 2021. This equates to more than 200,000 Idahoans, including over 57,000 children.

Among children enrolled in Idaho public schools during the 2020-2021 school year, 36.1 percent were eligible for free or reduced-price lunch.[iv] Idaho’s most rural counties tend to experience higher rates of food insecurity and limited access to healthy foods.4 Shoshone County is estimated to have the highest food insecurity rate, with 19.6 percent overall, and 28.2 percent among children in the county. As a comparison of the disparity among counties, Teton County had the lowest food insecurity rate, at 7.3 percent. The counties with the highest rates of food insecurity also tend to have higher rates of obesity and diabetes. Adults with obesity are at increased risk for many diseases and health conditions including type 2 diabetes, stroke, and heart disease.

Transportation and Access to Physical Activity Opportunity

Maintaining a robust transportation system with safe options for all people regardless of age, income, or ability to drive improves health. Transportation connects people to employment, healthcare, food, recreation, and all the other places people need to access to live full and healthy lives. Without reliable and safe transportation, people are less likely to receive preventative healthcare and less able to participate in health promoting activities like healthy eating and physical activity.[v],[vi]

While only 3.9 percent of Idaho households do not have access to vehicles, 27.4 percent of households only have access to one vehicle, thereby increasing their reliance on alternative modes of transportation.7 Many Idahoans also face difficulties paying maintenance costs for the vehicles that they own, and others drive less as they age. Although rural areas have different needs than urban areas, an equitable and health promoting transportation system that works for all Idahoans would include safe and ADA accessible walking routes, safe and connected bicycle infrastructure, street connectivity, public transportation or shuttle options, and diverse land uses so people have the opportunity to live within walking distance to key destinations.

In 2019, approximately 35 percent of Idaho adults making less than $25,000 per year reported no physical activity outside of work, compared to 13.5 percent of those who make more than $75,000 per year.[vii] Neighborhood design may help to explain this discrepancy, as people who live in neighborhoods where it is safe and enjoyable to walk or bike are more likely to participate in these activities. At a national level, the 2021 Dangerous by Design report by Smart Growth America, found that people walking in low-income communities are approximately three times more likely to be killed by drivers than those walking in high income areas.[viii] Communities that invest in active transportation options like sidewalks, protected bike lanes and public transportation not only help to protect the environment, but they also increase transportation equity and improve health.15

Housing

Purchase prices for homes in the state have increased 91.8 percent over the past 5 years.[ix] Statewide, the cost of renting a 2-bedroom apartment has reportedly increased 58.0 percent from May 2020 to May 2021.[x] This rapid increase in the cost of housing without a significant increase in income has resulted in many households struggling to meet living expenses. Many studies have shown that housing instability contributes to poor health and, as a result, increased healthcare costs.

People who rent housing comprise 28.4 percent of Idaho’s population, and of those, 45.7 percent are cost burdened, meaning they pay 30 percent or more of household income toward their rent.7 For homeowners, 23.6 percent are cost burdened.7 According to the 2015-2019 American Community Survey, 11 percent of Idaho households were severely cost burdened, meaning they reported spending 50 percent or more of their household income on housing. Severe housing cost burden differs greatly across the state from 4 percent in Power County to 24 percent in Madison County. Housing cost burdened families are unable to afford other necessities and essential services, leading to poor downstream consequences, such as missed medical or dental check-ups. These decisions are often the determining factor turning acute health issues into costly chronic health conditions.

The US Department of Housing and Urban Development (HUD) estimates that Fair Market Rent for a two-bedroom apartment in Idaho is $903.[xi] To afford this level of rent without paying more than 30 percent of income on housing, a household must earn $3,010 monthly or $17.36 per hour for a 40-hour work week. However, the average wage for those who rent their housing in Idaho is $13.62. People who make the minimum wage would need to work 96 hours per week to afford a two-bedroom rental home. Based on the estimates, certain areas of the state require much higher wages to afford a two-bedroom apartment, $19.27 per hour in Boise and $20.48 per hour in Blaine County.20 As these estimates are based on 2019 data, housing cost burdens are even greater today.

[i]. Do All Children Have Places to Be Active? Disparities in Access to Physical Activity Environments in Racial and Ethnic Minority and Lower-Income Communities. Active Living Research. Research Synthesis November 2011. Accessed September 15, 2021. Retrieved from: https://activelivingresearch.org/sites/activelivingresearch.org/files/Synthesis_Taylor-Lou_Disparities_Nov2011_0.pdf

[ii]. The Effects of Historical Housing Policies on Resident Exposure to Intra-Urban Heat: A Study of 108 US Urban Areas. Climate 2020. Accessed October 14, 2021. Retrieved from: https://www.mdpi.com/2225-1154/8/1/12/htm

[iii]. Feeding America, 2019 Map the Meal Gap Study -Online. Accessed July 13, 2021. Retrieved from: https://map.feedingamerica.org

[iv]. Idaho State Department of Education, CNP Lunch Eligibility Reports, 2020-2021 - Online. Accessed July 13, 2021. Retrieved from: https://apps.sde.idaho.gov/CnpEligibility/Report

[v]. Transportation and the Role of Hospitals. American Hospital Association. November 2017. Accessed October 14, 2021. Retrieved from: http://www.hpoe.org/Reports-HPOE/2017/sdoh-transportation-role-of-hospitals.pdf

[vi]. Healthy Places. Centers for Disease Control and Prevention. Accessed October 21, 2021. Retrieved from: CDC - Healthy Places - Transportation and Health

[vii]. Idaho Behavioral Risk Factor Surveillance System Demographic and Public Health District Results (2019). Retrieved from: https://www.gethealthy.dhw.idaho.gov/idaho-brfss

[viii]. Smart Growth America. Dangerous By Design 2021. Accessed October 21, 2021. Retrieved from: https://smartgrowthamerica.org/wp-content/uploads/2021/03/Dangerous-By-Design-2021-update.pdf

[ix]. Federal Housing Finance Agency House Price Index Quarterly Report, March 2021 – Online. Accessed Jul7 13, 2021. Retrieved from: https://www.fhfa.gov/AboutUs/Reports/ReportDocuments/2021Q1_HPI.pdf

[x]. 2021 Apartment Guide Rent Report, June 2021: The State of the Rental Market – Online. Accessed July 13, 2021. Retrieved from: https://www.apartmentguide.com/blog/apartment-guide-annual-rent-report/

[xi]. National Low-Income Housing Coalition – Out of Reach 2021 Report – Online. Accessed July 16, 2021. Retrieved from: https://nlihc.org/sites/default/files/oor/2021/Out-of-Reach_2021.pdf




Access to Healthcare


Health Professional Shortage

In 2021, 100 percent of Idaho was a federally designated mental health professional shortage area, 95 percent of Idaho was a federally designated shortage area in primary care and 94 percent of Idaho was designated a dental health professional shortage area.[i] In 2021, the Idaho Hospital Association reported 51 hospital members (including facilities in Oregon, Washington, and Wyoming). Twenty-seven of these hospitals are critical access hospitals, located in Idaho. These small, rural hospitals also own primary and specialty care clinics and may be co-located with the hospital or operate as remote clinics.[ii]

In 2018, the first college of osteopathic medicine began operating in Idaho for the purpose of training and developing physicians. The Idaho College of Osteopathic Medicine (ICOM) received pre-accreditation status while it continues working towards establishing full accreditation status from the Commission on Osteopathic College Accreditation. ICOM’s mission is to train competent and caring physicians prepared to serve persons in Idaho, Montana, North and South Dakota, Wyoming, and beyond with an emphasis on rural, underserved areas within this five-state region.

Idaho Medicaid

In SFY 2020, approximately 340,000 Idahoans were enrolled in Medicaid, a 21 percent increase from SFY 2019 average enrollment. The growth in SFY 2020 is due to the Medicaid expansion program.[iii] Medicaid enrollment typically fluctuates depending on the state’s economy: When the economy is strong, more people are working and have access to healthcare coverage through their employers; however, when the economy is not performing well, more Idahoans seek healthcare assistance through Medicaid.

Medicaid serves individuals from birth to end of life, provided they meet eligibility criteria. In SFY 2020, 35 percent of Medicaid Trustee and Benefits expenditures went to children from birth to 18 years of age. Medicaid enrollment varies by county, with the highest number of participants living in counties that include some of Idaho’s largest cities (e.g., Ada County has 70,189 participants).[iii] However, some of the smallest counties have the greatest density of residents receiving Medicaid benefits, with Lewis County at 40 percent, followed by Power County at 28 percent, Shoshone at 27 percent and Cassia, Gooding and Owyhee Counties at 26 percent.[iii]

In November 2018, voters passed a ballot proposition to expand Medicaid in Idaho. The goal of Medicaid expansion is to provide Medicaid coverage to individuals with incomes up to 138 percent of the Federal Poverty Level. “Prior to 2020, there were an estimated 78,000 Idaho residents in the coverage gap – ineligible for subsidies in the exchange and also ineligible for Medicaid.”[iv] The state implemented Medicaid expansion January 1, 2020. Estimates prior to the COVID-19 pandemic expected that an additional 91,000 people would be covered. According to Healthinsurance.org, nearly 109,000 people had enrolled as of June 2021, assuring they now have access to affordable, quality health coverage. The COVID-19 pandemic “has increased Medicaid enrollment nationwide, due to widespread job losses.”[iv]

Idaho Kids Health Coverage

According to a 2021 Idaho Kids Covered report, a project of Idaho Voices for Children, “Idaho had the highest increase in the rate of uninsured children in the entire country between 2017 and 2018.” The report emphasizes the critical importance of prioritizing health coverage for children, as they are “more likely to do better in school and grow up healthy.” As of 2021, 5 percent of children in Idaho are uninsured. This equates to 24,000 kids who do not have health coverage. The report also illustrates disparities that exist across income, age, and geography, confirming that a child’s zip code impacts their health and access to care. Hispanic children are more likely than White children to be without coverage.

Half of Idaho’s children (51 percent) are covered by their families’ employer-sponsored health insurance, while 35 percent are covered by Medicaid/CHIP, another 8 percent are covered through health insurance exchange, and 5 percent are uninsured.

[i]. Rural Health and Underserved Areas Bureau of Rural Health and Primary Care, Division of Public Health, Idaho Department of Health and Welfare. Accessed July 13, 2021. Retrieved from: https://healthandwelfare.idaho.gov/providers/rural-health-and-underserved-areas/rural-health-and-underserved-areas

[ii]. Bureau of Rural Health and Primary Care. Special Request. July 2021.

[iii]. Facts, Figures and Trends: 2020-2021. Idaho Department of Health and Welfare. Accessed July 12, 2021, Retrieved from: https://healthandwelfare.idaho.gov/AboutUs/Facts,FiguresTrends/tabid/1127/Default.aspx

[iv]. Norris, Louise, Health insurance & health reform authority, July 18, 2021. Retrieved from: Idaho and the ACA’s Medicaid expansion - healthinsurance.org





Public Health Districts in Idaho

To facilitate the availability of public health services, the state aggregated contiguous counties into seven local public health districts. The boundaries that separate each of the seven areas include geographic barriers, transportation routes and population centers. Access to healthcare and other services continued to be barriers to improving health outcomes for Idaho residents; however, Idaho's seven local public health districts represent the primary outlets for public health services. Each district responds to local needs to provide services that may vary from district-to-district, ranging from community health nursing and home health nursing to environmental health, dental hygiene and nutrition. Many services that the districts provide are through contracts with the division.