This will be complicated – and potenitally quite controversal. It is not at all meant to be a political commentary but where you live may directly impact your health. As the role of social determinants in one’s well-being are better measured and understood, there is the promise that they can be better managed. An analysis of the patchwork of differing state regulations, government priorities, economic conditions, and local norms and cultures shows fascinating patterns which provides commentaries on the state of health by state. Geography may be one of the most influential determinants of one’s health.
Undeniably the level of economic disperity across the country has increased dramatically, punctuated by the emergence of highly concentrated pockets of exceptional wealth. The Economic Development Group and its Distressed Communities Index (below) highlights the level of this fragmentation. Their analysis determined that three of every four new jobs were created in only 40% of U.S. zip codes, and that more than half of the communities determined to be distressed have seen a net job loss since 2000. Of most importance, life expectancy for people in those communities was a full five years shorter. As communities become more economically distressed, investments in public health infrastructure naturally become further impaired.
Last month the Brookings Institution’s Metropolitan Policy Program published research comparing the economic conditions of the top 100 cities in the U.S. with the 182 smallest (which had populations between 50,000 and 215,000) and the results were startling. Employment levels grew twice as fast in the largest cities while income levels grew 50% faster. Economic dislocation and disruption, most notably from automation and foreign trade, appear to disproportionately impact smaller cities. The resiliency of larger metropolises is attributed to the aggregation of human and financial capital leading to greater levels of innovation. The cities of New York, Los Angeles and Chicago alone accounted for 17% of the national GDP last year. Not lost on any of us, in the recent presidential election 57% of cities with a population of less than 250,000 voted for the Republican candidate while only 38% voted for Secretary Clinton.
Certainly, large cities are not the panacea for all of a community’s ills. The New York State Technical and Education Assistance Center recently published a sobering analysis on the condition of New York City schools, finding that 10% of the students are homeless. These students demonstrated markedly worse academic performance, often testing at levels 50% that of the other students. One-third of homeless students missed at least one month of schooling and 62% of them were deemed “chronically absent.” Obviously being raised in those conditions will directly impact one’s health and well-being.
Furthermore, while an individual’s “investment” in healthcare comes in several forms, it is perhaps best reflected in the level of out-of-pocket expenses incurred. Interestingly, the JP Morgan Chase Institute recently compared annual out-of-pocket expenses as a percent of take-home pay for 2.3 million customers in 23 states. While generalizations are very difficult to make without further and more complete study, the data strongly suggest that more affluent states spend less as a percent of income on out-of-pocket expenses (healthcare costs are relatively less burdensome perhaps), making quality care more affordable and therefore, attainable. States with less of a healthcare cost burden have fewer distressed communities. Undoubtedly, though, differences by state have as much to do with specific insurance plan designs and local provider costs, which are often influenced by local regulations and how competitive a given market is.
Obviously, there are many factors which influence levels of obesity in any given region; quality of the healthcare system, access to healthy food, cultural considerations and weather to name just a very few. The Body Mass Index map below developed by the Behavioral Risk Factor Surveillance System is even more provocative in light of the map above as states exhibiting greater levels of distress neatly coincide with those that tend to be more obese. As wealth continues to aggregate in fewer distinct regions of the country, many of which are on the coasts, the general well-being of many states in the middle of the country become of greater concern. Somewhat antithetical to that concern are the residents of Colorado who spend a lot on healthcare and appear to be in the best shape of all of us; my namesake of Greeley, CO (“go west”) looks to be particularly relaxed and healthy.
Just to jump to the conclusion, arguably of most importance are relative mortality rates. How much does a social determinant like geography account for the tremendous variability observed in average lifespans? Here again the map is provocative, and perhaps even suggestive. The average annual mortality rate across the country between the years of 1999 – 2015 was 786 people per 100,000; the deep magenta counties were over 200 people more than that average. Are there healthy and less healthy regions of the country? Quiet clearly, yes.
Intermountain Health recently stated that “zip code determines health more than genetic code” when presenting data of two nearby Utah towns with very different demographics. In one town, the average household income was $77,000 with 5% living below the poverty line, and a life expectancy of 85 years. In the other town the average household income was $40,000 with 24% below the poverty line, but tragically the life expectancy plummeted to 76 years.
Shockingly the next map looks quite similar to the others when looking at something as disturbing as murder rates by state. A large swath of the country, which happens to correlate to areas of greater levels of distress, suffers with annual murder rates between 4 – 10 people per 100,000, which in some cases may be 5x the rate experienced in other states.
Just about two years ago I studied the Social Security Administration’s “Life Expectancy Calculator” and learned that I had 10,877 days left, which is now closer to 10,000 days. This is quite sobering and causes me to consider a relocation to Greeley, Colorado, which is nestled in something called the “Front Range Urban Corridor” (sounds enticing) and was determined by Forbes to be #5 of the ten best “Top Small Cities for Jobs” – although being a small city may now be somewhat problematic.