As income inequality rises, researchers are noting a related trend. While those in higher income brackets have seen life expectancy increase significantly in a generation, those on the lower end of the economic spectrum have not. In some counties, life expectancy has actually dropped in certain demographics. A number of factors are involved, including higher rates of smoking, inadequate access to health care, and higher levels of stress. We explore how health care reform and policies to address income inequality might affect the longevity gap.

Guests

  • Lisa Dubay Senior fellow, Health Policy Center, Urban Institute
  • David Kindig Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences, University of Wisconsin-Madison’s School of Medicine; Co-Chair of the Institute of Medicine Roundtable on Population Health Improvement.
  • Annie Lowrey Reporter, New York Times

A Look At Life Expectancy In Our Region

This chart shows how life expectancy has grown in Washington, D.C., Fairfax, Va., and nationally, between 1989 and 2009.

Male Life Expectancy Across the U.S., 2010. Courtesy of the Institute for Health Metrics and Evaluation at the University of Washington

Female Life Expectancy Across the U.S., 2010. Courtesy of the Institute for Health Metrics and Evaluation at the University of Washington.

Transcript

  • 12:22:34

    MR. KOJO NNAMDIWelcome back. As the gap between rich and poor continues to grow across the U.S., researchers are noting a related issue. While those in higher income brackets have seen life expectancy increase significantly in a generation, those on the lower end of the economic spectrum have not. In some cases life expectancy has actually decreased, something almost unprecedented in wealthy industrialized countries. So what's shortening the lives of America's poor? Less access to health care for one but there are other factors as well.

  • 12:23:05

    MR. KOJO NNAMDIJoining us to talk about the longevity gap and what might be done about it is Annie Lowrey. She is a reporter with the New York Times. Annie Lowrey joins us in studio. Welcome.

  • 12:23:14

    MS. ANNIE LOWREYThank you.

  • 12:23:15

    NNAMDIAlso with us is Lisa Dubay who is a senior fellow in the Health Policy Center at the Urban Institute. Lisa Dubay, thank you for joining us.

  • 12:23:24

    MS. LISA DUBAYIt's nice to be here.

  • 12:23:25

    NNAMDIAnd joining us from studios at Wisconsin Public Radio is David Kindig, emeritus professor of population health sciences and emeritus vice-chancellor for health sciences at the University of Wisconsin-Madison's School of Medicine and co-chair of the Institute of Medicine Roundtable on population health improvement. David Kindig, thank you for joining us.

  • 12:23:45

    DR. DAVID KINDIGNice to be here.

  • 12:23:46

    NNAMDIFor those of you who would like to join the conversation, the number's 800-433-8850. Do you think health care reform will help address the growing longevity gap, 800-433-8850? You can shoot us a Tweet @kojoshow or email to kojo@wamu.org. Annie Lowrey, you recently wrote an article titled Income Gap Meet the Longevity Gap, in which you compared two counties. Tell us a little bit about how you chose those two locations and about the income disparities that you found.

  • 12:24:17

    LOWREYWell, the two counties that I chose are, in many ways, extreme examples. So we visited some counties in a southern area of West Virginia and the Appalachians that are both very poor. And the population tends to be very sick by all sorts of metrics, whether it's smoking rates, obesity rates, diabetes rates. And it's a remote and rural area. That also matters too. There is a hospital there, a state-run hospital. There are health clinics, there are doctors. But it's a very underserved population. And there's no interstate that goes there. That's part of the big problem. It's hard to get out.

  • 12:24:52

    LOWREYAnd then I looked at Fairfax County, Va., which is one of the...

  • 12:24:55

    NNAMDIRight down the road.

  • 12:24:56

    LOWREYYeah, right down the road, one of the richest counties in the entire United States. Also one of the healthiest, one of the longest living low smoking rates, low obesity rates and just a tremendous amount -- tremendous concentration of social services, of hospitals, of jobs. And so then we wanted to look at these really extreme cases and think about how their diverging economic fortunes might have influenced their also diverging health and longevity fortunes, if that makes sense.

  • 12:25:28

    NNAMDIAnd tell us what you discovered in terms of life expectancy because on the one hand people are flocking to Fairfax and on the other, people seem to be flocking out of McDowell County in West Virginia.

  • 12:25:41

    LOWREYRight. So this is one of the real problems with these estimates of longevity that we have, is they're often based on place and people move. And very often people who are higher income or healthier, it's easier for them to move and they go to places like Fairfax, Va. because there's all these great jobs, all these great services, these great schools. And maybe they leave places like McDowell, which is, you know, very low income.

  • 12:26:06

    LOWREYBut even if you look at studies, like one by the Social Security Administration that's looking at men at retirement age, it still finds a growing longevity cap. And that isn't confounded by any of the saving factors. And There's other similar studies that have done the same thing. So this isn't just a matter of people moving place to place. That might be compounding the effects. But it seems that it's also true -- it's true at birth, it's true when you're looking at people at age 60 or 65 and it seems to be true just about everywhere.

  • 12:26:37

    NNAMDIDavid, in your work you rate the health of all U.S. counties and it seems life expectancies in the U.S. are essentially diverging. Can you talk about that?

  • 12:26:47

    KINDIGI'm happy to, and thanks to you for focusing on this important issue and for Annie for her great writing that she's been doing on this. Yes, that is the case. And that's been surprising and shocking to all of us. And even though Annie focused on those two counties, you know, and we look at all the counties in the country in a paper we published two years ago, actually a $9,000 increase in per capita income is associated with 13 percent reduction in mortality rates or reduction in life expectancy. That's even higher in low-income counties than that average.

  • 12:27:25

    KINDIGAnd when we look at the cause -- it's hard to establish cause of factors in this kind of work but income always comes up as a significant factor along with smoking rates and education rates and other factors in this, both not only in the existing thing but associated with the declines that we're seeing in some places, particularly in female life expectancy.

  • 12:27:47

    NNAMDIThat's what I was going to get to next, David, because in wealthy industrialized countries like ours we would expect to see life expectancy increase overtime. But you're talking about a decline in some counties, and in particular among women. Can you talk about that?

  • 12:28:03

    KINDIGWell, I'd be happy to. And that was a paper we published last year. It was shocking to us -- I mean, it's almost true at country level and at state level in the states we always see live expectancy increasing. But when you dig down into -- at the county level, you know, in smaller populations, you know, more variation gets revealed. Having said that, we were shocked at the large number of counties that were actually having falling mortality rates, particularly falling female mortality rates.

  • 12:28:34

    KINDIGAnd, well, we don't exactly know the reason for that. We teased out some of the factors -- income is one of those -- exactly why it was more for women than for men. Smoking rates perhaps in women, but that was not entirely clear. One very interesting thing we did find though is in those falling counties, after controlling for all the things like education and income and smoking rates, we still found regional differences with more of those counties in the south and west than other parts of the country, even after controlling for this. And that means there's probably other factors at work as well.

  • 12:29:12

    NNAMDIAnnie Lowrey, you found this in McDowell County also. What does the picture look like for women there?

  • 12:29:19

    LOWREYSo over the past 30 years with the decline of the coal industry, life expectancy for women has declined in McDowell County. And life expectancy for men hasn't declined but it's very low. Sort of if you compare McDowell with other countries where someplace like Fairfax looks a lot like a country like Sweden, someplace like McDowell looks like a middle income or a low income country even. You know, one country that had very similar mortality rates is Iraq, of all countries.

  • 12:29:50

    LOWREYAnd so what's happening in McDowell is that you see this great economic decline. There were actually a lot of really high-paying coal mining jobs back 10, 20, 30 years ago but those have eroded. And the industries that are in McDowell, so timber, there's a railroad which requires a lot of people for maintenance, that kind of thing. There's also, you know, some shops and social services there that employ people, a lot of nonprofit employment, actually school employment. But it's not much.

  • 12:30:18

    LOWREYAnd you've actually seen real incomes, so incomes adjusted for inflation decline there. And along with that decline, a lot of people have left. And those who have stayed have seemed to get sicker proportionately. So a lot of that -- at just that one county probably a lot of it is explained by who is there. But at the same time, life has gotten harder there. People in a lot of ways are poorer. The county has gotten depopulated so there's less services for them. It's really complicated but it seems that all of these things may be leading to a sicker population among the folks in McDowell.

  • 12:30:52

    NNAMDIAnnie Lowrey is a reporter with the New York Times. David Kindig is emeritus professor of population health sciences and emeritus vice-chancellor for health services at the University of Wisconsin-Madison's School of Medicine. He joins us from studios at Wisconsin Public Radio. Lisa Dubay is a senior fellow in the Health Policy Center at the Urban Institute. Lisa, we've seen recent research on another growing gap in smoking rates between rich and poor. Can you talk about that and how it fits into this broader picture?

  • 12:31:22

    DUBAYSure. You know, we see this gradient in health and it's not just the poor versus the rich. It's the poor are worse off than the near poor who are -- I mean, who are worse off than the middle class and who are worse off than the higher income. And for a lot of health outcomes and also a lot of health behaviors you see that same gradient. So it's not just the poor versus everybody else. There's a gradient.

  • 12:31:54

    DUBAYSo a lot of health behaviors are worse. They're more -- poor health behaviors are more prevalent among lower income populations. That's for certain. And I think that happens for two reasons. First of all, poor people have less access to information about how to be healthy. They have less access to medical care that can make them healthy. And they also live in environments that make it harder for them to be healthy.

  • 12:32:24

    DUBAYParticularly with smoking, you know, one of the reasons that people smoke is to reduce their stress. And poor people are under an enormous amount of stress. Where am I going to get my next meal? How am I going to get my child to school? And so that's something that's sort of not always considered sort of the impact of stress on people's behaviors.

  • 12:32:48

    NNAMDI800-433-8850. Do you think it's significant that life expectancy in the U.S. is falling behind Europe and other wealthy countries? Give us a call or send us an email to kojo@wamu.org. You can also go to our website kojoshow.org, ask a question or make a comment there. Annie, you found that education is also a factor and that divide was really stark in the two communities you looked at.

  • 12:33:11

    LOWREYYeah, so there's probably this sense among researchers that money itself isn't making people healthier. And intuitively this makes sense. You know, if I went and I put more money in your bank account, that's not going to have an influence on your health for some amount of time, right. But it seems that money is very -- and income is tightly interlinked with a bunch of behaviors. And that there's all these pathways that move between income and health that relationships are really complicated but they're definitely prevalent. Education is one of these.

  • 12:33:47

    LOWREYIf you are a low-income person you are much less likely to go to or to complete college than a high-income person. And that's going to have a really big effect, it seems, on your health. And so again, the cause of pathways might work both ways. Maybe if you are a sick person it's harder for you to get a well-paying job. And so you're lower income for that reason.

  • 12:34:09

    LOWREYSo I don't -- I certainly want to acknowledge the complexity here but the idea is that all of these socioeconomic factors seem to be diverging at once. And that that is -- you know, income is maybe one of the root causes as one of the effects of the divergence. And I think that education is maybe an underappreciated factor.

  • 12:34:31

    NNAMDILisa Dubay, can we make a relationship between education and information? You pointed out that in poor communities people are likely to have less information, maybe less access for information than in wealthier communities. But does having more education also imply a greater storehouse of information, if you will?

  • 12:34:54

    DUBAYAbsolutely. I mean, I think that having more education -- we get a lot of information every day, lots of different kinds of information. I mean, for a long time, you know, hormone replacement was a good thing. Then it wasn't a good thing. So there's a lot of information being thrown at us all of the time, so I think having a good education allows you to really sift through that information and to think about, you know, what's right and what's not.

  • 12:35:21

    DUBAYAnd, you know, the link between education and income is very complicated. I mean, they're very highly correlated. So you have higher education, you're more likely to have higher income. If you start in a higher income family, you're more likely to end up as an adult having higher education levels. And so these factors are all really very intertwined, although they have their independent effects.

  • 12:35:48

    NNAMDIOn to the telephones. We'll go to Terri in Washington, D.C. Terri, you're on the air. Go ahead, please.

  • 12:35:55

    TERRIHi, Kojo. Thank you so much for taking my call.

  • 12:35:58

    NNAMDIYou're welcome.

  • 12:35:59

    TERRIAnd thank you, Annie Lowrey, for covering this issue. It's really important. I've been following your reporting on it. The comment that I wanted to make was in response to Kojo's question about whether the Affordable Care Act might be some help in countering the trend toward lower life spans, especially for lower-income women. My interest is in the lower-income women. I think it will.

  • 12:36:22

    TERRIUnder the Affordable Care Act, insurance companies must cover essential preventive care, the mammograms and cervical cancer screenings and especially birth control, which is an essential part of women's preventive care. So if you have health insurance the Affordable Care Act requires the health insurance companies to cover your birth control. And that's really important.

  • 12:36:44

    NNAMDIThank you very much for making that point, Terri. But, you know, one of the points that Annie makes is that health care is just one piece of this puzzle, if you will. Health is more than what happens in the doctor's office. Can you talk about that?

  • 12:36:59

    LOWREYAbsolutely. So there's this great experiment. We don't quite know how the Medicaid expansion and the expansion of coverage through the subsidies and the Affordable Care Act is going to affect community health. We have some idea. I would note that actually getting insurance coverage in a lot of ways is effectively lifting your household's income, right. It's giving you something that's really valuable for a price that, you know, a lot of folks can't afford. Same thing with Medicaid coverage.

  • 12:37:28

    LOWREYSo that might be actually one pathway it's going to reduce your financial stress possibly. Whether it's going to affect your health behaviors, I'm not sure that we have really great answers to that question yet. And I think that some of the best answers we have come from a study in Oregon where they had a lottery and some folks got Medicaid coverage and others didn't.

  • 12:37:48

    LOWREYAnd it doesn't seem to have affected their health very much, but it does affect their mental health. And it did affect their financial health. And so I think it remains to be seen. The researchers -- it was a really -- an all star team of researchers who did this study. They only looked at a couple health indicators. They couldn't look at the whole universe. And so I think -- and they also only looked for a couple years. They couldn't look 10, 20, 30 years down the road obviously. So I think that it's just this great question mark. And surely there's going to be some effect but I don't think that we know what and I don't think we know how.

  • 12:38:21

    NNAMDILisa, environment can also play a significant role in this, can it not?

  • 12:38:26

    DUBAYAbsolutely. So one of the links between income and your health is that you get to choose -- the higher income you have the greater choices of environments that you have to live. And so you can live in a neighborhood that has high quality housing, a great school system, great daycare, a park to run in that's safe to play in, lots of options for healthy food. So absolutely the environment that you live in makes a huge difference.

  • 12:39:01

    DUBAYBut I also want to go back to what Annie was saying about the Oregon experiment. I think that oftentimes there's a rush to understand the impacts of these programs. And I think some of the studies that have been done are not looking at sort of the long range impacts. So what we know is that over time diabetes can be controlled, hypertension can be controlled in populations with those conditions. And I think they're not easy -- it's not necessary an immediate fix but I think we need to be cautious about some of the Oregon results that suggest that there weren't health impacts. Because they really did take a very short run look.

  • 12:39:46

    DUBAYIt was a fabulous study but there were -- you know, there's some challenges to that. And, you know, I think everybody wants to know what works immediately. And sometimes things take a while to change. It takes a while to change people's behavior. It takes a while to change people's ways. These are not immediate fixes.

  • 12:40:08

    NNAMDIAnd, David Kindig, you make the point that it's not necessarily medical spending that is making the difference.

  • 12:40:14

    MR. DAVID KINDIGRight. Thanks for asking about that. Of course you have to have health insurance in order to get the benefits of our medical care system. And the Affordable Care Act will be important in that regard. But it's not the only factor. I mean most of us believe it's not the most important factor. And that's the importance of this show and Annie's work.

  • 12:40:37

    MR. DAVID KINDIGBecause there's still -- most Americans believe that medical care is the most important thing and that these other things don't matter. And that's, in part, why we spend, you know, much more than many other countries and get poorer outcome. So the importance of this conversation is to say of course we need everybody to have health insurance for immunizations, and their appendectomy when they need it and their eye care. But it is not the whole story and we need a much more balanced investment approach.

  • 12:41:06

    NNAMDIWe're going to take a short break, then we'll return to this conversation about the longevity gap. But you can still call right now, at 800-433-8850. What do you think we should do about the growing gap between rich and poor? 800-433-8850 or send us an email to kojo@wamu.org. I'm Kojo Nnamdi.

  • 12:43:11

    NNAMDIWelcome back to our conversation about the longevity gap. We're talking with David Kindig. He is co-chair of the Institute of Medicine Roundtable on Population Health Improvement and emeritus professor of population health sciences at the University of Wisconsin, Madison School of Medicine. Lisa Dubay is a senior fellow in the Health Policy Center at the Urban Institute. And Annie Lowrey is a reporter with the New York Times.

  • 12:43:36

    NNAMDIWe got an email from Jessica, in Silver Springs, since we were talking about the extent to which healthcare will help to improve life expectancy. Jessica writes, "I remember reading a New Yorker article a few years ago about how the communities in and around McAllen, Texas, a very low-income community near the border, have the highest per person Medicaid spending in the country. Does that get to your guest's point about how spending doesn't necessarily improve health or improve longevity in its own right?" David Kindig?

  • 12:44:09

    KINDIGWell, yeah, and that was a great piece by Atul Gawande that a lot of people should read. It just -- it's true. The evidence is clear that the most extremes in medical care spending, the places that spend the most do not necessarily have the best outcomes. I mean, you need to have a certain level. But I think most of us believe when you get into these higher levels that there's a lot of waste.

  • 12:44:36

    KINDIGThe Institute of Medicine has estimated perhaps a quarter or 30 percent of what we spend, you know, could be wasted, and in some of those communities that's what we're seeing.

  • 12:44:46

    NNAMDIDavid, we've been talking about comparisons between rich and poor counties in the U.S., but the U.S. is also falling farther behind other industrialized nations in life expectancy. Can you talk about that and how significant it might be?

  • 12:45:01

    KINDIGRight. Well, I mean that's the other frame of reference. You know, sometimes the comparisons to other countries people glaze over because they know that we're, you know, different than Sweden or whatever the comparison is. And we have plenty of gaps in our own country, but -- as we've been talking about. But as cross-nationally, we are far behind.

  • 12:45:20

    KINDIGActually, I saw in just the New York Times this morning a new sort of a social index report that said that we actually were ranking 50th in some of the health outcomes. But that's been consistent over years, particularly with the other developed countries. And we spend maybe a third more than some of them. So, yes, we're spending more and not doing as well.

  • 12:45:46

    NNAMDIThere also seems, David, to be a connection between poverty and shorter lives. But proving that the growing income gap is what is leading to the longevity gap, with the county-level information we have, is difficult. Is it not?

  • 12:46:02

    KINDIGWell, that's correct. In social science it's really hard to establish these causal relationships. And sociologists and economists use the best tools they can on epidemiologists to tease these relationships apart. It's really -- I think it's now clear that these relationships are correct. That the effect of education and income and social support is a very important factor.

  • 12:46:29

    KINDIGTeasing out exactly like where the next dollar should go, is the next best investment in smoking or in Obamacare or in earned income tax credits. I mean that's the part where teasing apart these causal relationships is important. And we need a lot more research on that to guide policy makers who have to carefully choose where they put their next dollar.

  • 12:46:53

    NNAMDIOn the other hand, Lisa, that there is a link between poverty and health seems pretty intuitive. Does research back that up?

  • 12:47:02

    DUBAYAbsolutely. I mean there's certainly a correlation between having higher incomes and having better health. I mean I think this gets to what Dave was saying, which is that, you know, we can't -- we don't randomly assign people high incomes and low incomes. So there's probably some reverse causality in there. We know that there is. For example, if you become disabled your income is going to decline.

  • 12:47:33

    DUBAYAt the same time, I think people pretty much believe that most of the causal pathway is from having higher income produces better health. And it does that both because it gives you better economic security, and better job opportunities and less hazardous job opportunities, but it also allows you to purchase health in lots of ways, through the environments that you live in. And in terms of environmental exposures, in terms of access to the ability to live a healthy life.

  • 12:48:07

    NNAMDIAnnie Lowrey?

  • 12:48:08

    LOWREYSo when I was reporting this story I talked to a lot of health economists. And I would kind of ask them, you know, if I snapped my fingers and we became a socialist country and redistributed all income evenly, so, you know, every family was getting the exact same amount of income, would we be healthier? Basically saying, you know, how much is inequality the issue here, as opposed to income, the level of income nationally -- if that makes sense.

  • 12:48:34

    LOWREYAnd they said well, yeah, probably. And the reason is because basically if you eradicate poverty you presumably get a really big health effect. Whereas, if you take a lot of money away from higher-income folks you have less of a big health effect. You know, a billionaire is not going to be a 1,000 times healthier or live a 1,000 times longer than, you know, somebody's who's making one-one-thousandth of his income. Right.

  • 12:48:57

    LOWREYBut at the same time, as hard as it is to prove the linkages and pin down the linkages between income and longevity, it's yet harder to do it for inequality and longevity. But I think it's a fascinating mental exercise because income inequality and wealth inequality have increased. And this longevity divergence has happened at the same time. So it's a complicated issue, but I do think that there's evidence that the growing inequality and income is probably having some effect.

  • 12:49:30

    NNAMDIOn to Vicky, in Washington, D.C. Vicky, you're on the air. Go ahead, please.

  • 12:49:34

    VICKYThank you, Kojo, for taking my call. My question relates to a point that was made a few minutes back about the fact that access to health insurance is not going to necessarily, in and of itself, help to address this gap. And I was wondering whether amongst your panel of experts they were aware of studies or ideas about how to possibly incentivize healthier behaviors that could help to address this gap that we've been discussing. Thank you.

  • 12:50:06

    NNAMDIDavid?

  • 12:50:09

    KINDIGYou know, there's a world of public health out there working on everything we can do in the health behavior range, from smoking and diet and exercise. You know, there's no magic bullets on some of that. For me -- so it's a very important thing that we need to do, along with medical care. I think one of the most underappreciated things, though, is that many -- and there is strong evidence that in order to change those behaviors, a lot of that also depends on your social context.

  • 12:50:44

    KINDIGAnd low-income people have -- for obvious reasons -- you know, much more difficulty in actually just kind of making those choices themselves. So in some ways this is all related. Being able to make the healthy choice, is to consider (unintelligible) condition by your income and educational status. So it all kind of works together.

  • 12:51:07

    NNAMDIGo ahead, please, Lisa.

  • 12:51:08

    DUBAYYeah, I just want to be clear. I don't think anybody's saying that medical care isn't important. Medical care is absolutely important. It's important on the prevention side and it's important in many acute circumstances. I think we are having a debate -- we've had a debate in this country about whether or not everybody should have access to health insurance coverage. I think we haven't had the debate in this country about whether or not everybody should have access to health.

  • 12:51:37

    DUBAYAnd health is a -- to sort of give everybody the same opportunity to have health, they need health insurance coverage, they need access to care, but there are many other things that they need a well. And think that's what this conversation is about. And I think that's what Annie's piece really so clearly pointed out.

  • 12:51:55

    NNAMDIOn to Christopher, in Washington, D.C. Christopher, your turn.

  • 12:52:02

    CHRISTOPHERHi, yes. Thanks for having me on, Kojo. I just had a question for your panelists. I was curious as to how important they thought the current debate about minimum wage was in relation to longevity. And it seems to me like the less you get paid the less time you have. I don't think anyone thinks that you can buy happiness. But the more money you have the more free time you have.

  • 12:52:20

    CHRISTOPHERWhen you have to just, you know, spend every day working just to make ends meet -- and a lot of times that involves dealing with employers that aren't giving you your fair share, whether it be not paying overtime or, you know, taking tips out. It seems like that ice-cold beer at the end of the day quickly turns into a habit, as opposed to a reward.

  • 12:52:39

    NNAMDIThe stress factor, Lisa?

  • 12:52:40

    DUBAYYeah, I mean, I think there are a couple of things that go on there. First, I mean, I think we know that stress has an important impact on people's health. So there's that. But I think when we think about increasing the minimum wage or if we think about the EITC tax credit, which, you know, gives money to working families, I think the researchers in us tend to look at, well, what does that do to their incomes and what does that do to their work.

  • 12:53:06

    DUBAYBut there's not a lot of research, historically, that has looked at, well, what does that do for your health? I mean, but there are a few studies, particularly around the implementation of the earned income tax credit, that actually suggests that when you give people the earned income tax credit that smoking is reduced, their children have better birth outcomes. And so I think there's -- researchers are really trying to tease out some of those effects now. Because this link between income and health is becoming much more, I think, important to public policy and to researchers as well.

  • 12:53:47

    NNAMDIAnnie Lowrey, you compared a rural and more urban, suburban county, but similar income disparities also exist in urban areas, including right here in Washington, D.C., where a recent report by the D.C. Fiscal Policy Institute show that D.C. has one of the highest levels of income inequality of any large city in the country.

  • 12:54:07

    LOWREYThis is, I think, a fascinating effect. So I actually got a couple of emails after my story came out. And they said, well, look, you're comparing a very rural county, very rural, with one that's, as you point out, suburban. And there's all sorts of social services, cradle to grave, in Fairfax. It's basically the best social services you can find anywhere. But if you're looking at just D.C. -- let's look at a really wealthy neighborhood in D.C. versus a very low-income neighborhood in D.C., because we have both.

  • 12:54:38

    LOWREYThe same effect happens. There's also been a divergence, even if you're just looking at urban counties. And so this isn't just a story about, perhaps, access to medical care or changing behaviors in rural areas where it might be, you know, smoking might socially be more prevalent and it might be, you know, harder to exercise, harder to reach good food.

  • 12:54:58

    LOWREYIt's also happening in these urban areas where it's probably a lot easier to get good food, where you probably have a higher concentration of social services. And I think that that's pretty important, you know. It's the same if you look in Baltimore, in New York, in Chicago, in all these other cities where inequality has increased, you've also seen a divergence in health outcomes, too.

  • 12:55:15

    NNAMDIWe also have to think of the issue of violence in urban areas. We got an email from a listener who grew up in Barry Farm, here in Washington, who writes, "I grew up in southeast D.C. back when the city had one of the highest murder rates in the entire country. There were times in my life when it seemed like every week a person my own age, on my block, in my classes, in my neighborhood was getting shot. For us longevity meant living past 21 years old.

  • 12:55:37

    NNAMDI"But for reasons that don't necessarily include the complicated ones about healthcare, access to food and economic opportunity that your guests are discussing right now." Even though I am sure that our guests can tell you that there's probably likely a relationship between the level of poverty and the level of violence in neighborhoods. But, Lisa, I wanted to get back to you because we're running out of time. In our region, what are some of the healthcare access issues and disparities?

  • 12:56:03

    DUBAYWell, I think healthcare, like many other things, is very local, in that, you know, you can take Washington, D.C. and, you know, there are parts of the city that have health professionals shortage areas, where there aren't enough healthcare providers within the city. Whereas, if you come over here, there's like a billion buildings of them. And I think, you know, and then, at large I think, there's going to be an increasing inequality just across the states in the region.

  • 12:56:44

    DUBAYOne of the big things that's going on with the Affordable Care Act is the Medicaid expansion. And both the District of Columbia, the District of Columbia prior to the Affordable Care Act already had expanded their Medicaid program, but Maryland has taken up the option to expand their Medicaid program, and Virginia hasn't. And so that leaves about a quarter of a million poor Virginians with no access to coverage.

  • 12:57:10

    NNAMDIWe only have less than a minute left, David, but what can be done about the growing longevity gap? Do we have to address the income gap before we can address it?

  • 12:57:20

    KINDIGI think we have to address all of these things. That's the complicated story. It is, of course, about medical care and what you just talked about. But it's about these other factors, too, health behaviors, the social environment, the physical environment, education, income. And that's what our round table was trying to address. But it's got to be investments in all of those things if we hope to decrease these differences that we have across the country or with other countries.

  • 12:57:48

    NNAMDIDavid Kindig is emeritus professor of population health sciences and emeritus vice chancellor for health sciences at the University of Wisconsin, Madison School of Medicine. He's also co-chair of the Institute of Medicine Roundtable on Population Health Improvement. Lisa Dubay is a senior fellow in the Health Policy Center, at the Urban Institute. And Annie Lowrey is a reporter with the New York Times. Thank you all for joining us. And thank you all for listening. I'm Kojo Nnamdi.

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