New research shows that life expectancy for those in the bottom income quartile, where you live in the U.S. impacts how long you live.

New research shows that life expectancy for those in the bottom income quartile, where you live in the U.S. impacts how long you live.

Wealthy people typically live longer than poor people: this idea has long been studied and supported by research. But new work is deepening our understanding of differences in life expectancy across the U.S. A study published yesterday tells us not only that the gap in lifespan between the rich and poor has increased notably in recent years, but that for poor Americans, where you live in the U.S. plays a key role in determining how long you live. And new work from The Washington Post adds another layer, pointing to decaying health and earlier death for white women in particular. Life expectancy in America: how it’s linked to income, location and gender.

Guests

  • Dr. Susan J. Blumenthal senior fellow, Health Policy Program at New America; served as the country's first deputy assistant secretary for women's health; former assistant surgeon general of the United States; senior policy and medical advisor, amfAR
  • Neil Irwin senior economics correspondent, The New York Times
  • Laudy Aron senior fellow, the Urban Institute’s Center on Labor, Human Services, and Population
  • Joel Achenbach science and politics reporter, The Washington Post

Transcript

  • 10:06:53

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. The life spans of the wealthy are mostly consistent across the U.S. Those of the poor, very dramatically. That's a key finding of new research that came out this week. It tells us a poor person is likely to live longer in San Francisco than in Cincinnati, for instance. New reporting also tells us women, in particular, are dying prematurely at an alarming rate and closing the gap in life expectancy between women and men.

  • 10:07:30

    MS. DIANE REHMHere for a look at the latest research, Dr. Susan Blumenthal, public health expert and former assistant surgeon general of the U.S., Neil Irwin of the New York Times, Laudy Aron of the Urban Institute and Joel Achenbach of The Washington Post. Do join us, questions, comments, 800-433-8850. Send an email to drshow@wamu.org. Follow us on Facebook or send us a tweet. And welcome to all of you.

  • 10:08:07

    MR. JOEL ACHENBACHGood morning, Diane.

  • 10:08:08

    MS. LAUDY ARONGood morning.

  • 10:08:09

    MR. NEIL IRWINThank you

  • 10:08:09

    DR. SUSAN J. BLUMENTHALGreat to be here, Diane. Thank you.

  • 10:08:10

    REHMGood to see you all. Neil Irwin, I'll start with you. The link between income and life expectancy is certainly something we've know about for a while. Tell us what we do know.

  • 10:08:26

    IRWINRight. So the surprising thing is not that there's a relationship between how much money a person makes and how long they live. Research goes back hundreds of years on that basic idea. What this new research does is help us understand how that's playing out in the United States in the 21st century and at a very granular level by different cities, different regions of the country.

  • 10:08:49

    IRWINAnd what it shows is that, A, the story is getting worse between 2001 and 2014, the gap -- the rich are living about three years longer over that span. The poor have seen no gain in life span and that there's big, big differences between different parts of the country and how those dynamics are playing out.

  • 10:09:06

    REHMTell me where this data is coming from.

  • 10:09:09

    IRWINSo it's a comparison slip -- it's generated by Raj Chetty of Stanford and a group of seven economists and public health experts. It's combining 1.3 billion tax records on income with Social Security death records. So it's matching up, at a very granular level, using, again, more than a billion records what the relationship is between income and life span.

  • 10:09:32

    REHMAnd what about men and women?

  • 10:09:38

    IRWINSo women, in general, live longer than men. That's widely understood. That's widely known. The gap between rich and poor is a little different between men and women. With men, it's a 15-year gap between the life span of the top 1 percent and the bottom 1 percent. That's only 10 years with women.

  • 10:09:54

    REHMSo to you, Laudy Aron, how do you think this changes the picture as we have known it?

  • 10:10:04

    ARONWell, it really adds to the picture. There have been cross national studies that show that the U.S. compared to other high income nations, other wealthy democracies around the world suffers from what we call a U.S. health disadvantage. This disadvantage shows up at all ages, men and women, all racial and ethnic groups. And so this new study really brings down to within the U.S. this more granular level that Neil just described and really shows the importance of place when it comes to our health and survival and that place can be defined as what country you live in, what city you live in or even what neighborhood or metro stop you live nearby. We see life differences along those lines.

  • 10:10:49

    REHMAnd that's the kind of work of The Washington Post has found, Joel Achenbach. Tell us what you did and what you found.

  • 10:11:01

    ACHENBACHSo we looked at every death in America for the last 25 years. Went through the...

  • 10:11:05

    REHMEvery death.

  • 10:11:06

    ACHENBACHWe looked at all the deaths and we broke it down by race, by gender. And importantly, we did it geographically, so where are people dying? And this followed up the much publicized research last year from the Princeton economist who said there's a rising death rate among midlife white Americans. We were looking at, well, where are they dying? We saw very clear signal, a very clear pattern that there's a divide between urban and rural Americans.

  • 10:11:35

    ACHENBACHIf you look at the more rural areas, anything from a small city to a small town to, like, a very remote area, the death rate among white Americans, and particularly among women, is going up dramatically. It has for 25 years. What you see in some groups, say, you know, 40 to 45 year old white women, a 50 percent increase almost in their death rate, their mortality rate. So something is going on in this country that's very profound and this is a signal. And Laudy just talked about, you know, the health disadvantage in America.

  • 10:12:13

    ACHENBACHThis is a signal that this is a broad problem that affects lots of people and our map of where people are dying is really a map of America. It's happening a lot of places, just not in the big cities.

  • 10:12:25

    REHMAll right. And to you, Susan Blumenthal, what's your reaction to all this?

  • 10:12:31

    BLUMENTHALWell, I think what these studies have underscored is something that Ralph Waldo Emerson once said. The first wealth is health and it shows really the intertwining of income and education, which, as we've known for a long time, in determining our health status. But what's been added to it is the granularity of the zip code and also looking at the differences in sex and racial and ethnic status.

  • 10:12:57

    BLUMENTHALYou know, recent studies have shown that sex matters. It matters at the molecular level, at the cellular level, at the environmental level and the way we interact with the environment. And I think what we're learning is that there are some important sex differences and that the protective effect of being a woman has been shrinking over the past decades. For example, in 1970, women had almost an eight-year greater survival advantage than did men. Life expectancy advantage, which has shrunk in recent years to about five years.

  • 10:13:32

    BLUMENTHALAnd the big questions are why. And again, we're seeing significant differences between urban women and rural women.

  • 10:13:39

    REHMSusan Blumenthal, she is senior fellow in the health policy program at New America. She was the country's first deputy assistant secretary for women's health and former assistant surgeon general of the U.S. You can join us, 800-433-8850. Send your email to drshow@wamu.org. So Neil, let's look at geography. Where are these changes most pronounced?

  • 10:14:22

    IRWINSo the first observation is this is a very different story geographically between rich and poor. So among the rich, it almost doesn't matter where you life. If you're in Detroit, if you're in a rural place, if you're in an urban place, you live longer.

  • 10:14:34

    REHMBecause health is the first wealth.

  • 10:14:36

    IRWINIt is. Among the poor, there's vast differences, tremendous differences between cities where poor Americans are doing well and where they're not. The cities that do well, we've already mentioned some of them, New York, San Francisco. And the cities that are not doing as well, there are some large cities in there. Detroit has very bad results. But it is a lot of these areas that stretch through the middle of the country that, you know, involve all kinds of economic challenges, all kinds of public health problems more generally, obesity, high smoking rates.

  • 10:15:09

    IRWINThis isn't a simple story of income and wealth. It's also a story of kind of broader sense of economic despair and people not living in ways that are going to allow them to live long lives.

  • 10:15:21

    REHMSo Laudy, the cities that are faring so much better, can we tell why?

  • 10:15:31

    ARONYou know, I think the evidence is mounting and if we just kind of think about it, it make sense that a poor person that's living in a vibrant community, a large city with jobs and culture and, you know, economic activity is going to fare better than a poor child that is in a community that's suffering and is not going anywhere. That poor child may be doing his homework alongside and immigrant child and that immigrant child may be perfecting his or her English alongside the poor American child.

  • 10:16:08

    ARONThere are just -- there are more pathways toward opportunity and success in these larger more vibrant cities.

  • 10:16:16

    REHMBut what about access to healthcare?

  • 10:16:20

    ACHENBACHThat's a huge issue. In the rural areas, it's hard to find a doctor. So our story came out Sunday in The Washington Post online and we've been -- gotten thousands of comments from people, many saying it's hard to find a doctor...

  • 10:16:36

    REHMOf course.

  • 10:16:36

    ACHENBACH...a specialist where I live. So one of the great things about your show, Diane, is, you know, you heard all across the country. You have listeners who, I'm sure, will call in and tell us, you know, what life is like where they live and what we're seeing in America and what we did at The Post where we sent some reporters to Alabama, to Oklahoma, to California, is we've looked at specific families and people who are suffering through opioid addiction, heavy drinking, cirrhosis of the liver, is taken out of a lot of these midlife women, where there's a spike in suicide.

  • 10:17:14

    ACHENBACHSo this country is not as healthy as it should be, as these other health experts here can attest, that, you know, our reporting shows sort of two Americas. Neither is as healthy as it ought to be, but one is sicker than the other and that's the more rural America.

  • 10:17:35

    REHMJoel Achenbach, he's science and politics reporter for The Washington Post. His latest article co-authored with Dan Keating is titled "A New Divide In American Death." Short break and your calls, your comments when we come back. Stay with us.

  • 10:20:02

    REHMAnd welcome back here as we talk about new studies indicating changes in America's health across the country, new revelations about shorter life spans for those, even white women, not just women as a whole, but white women shortening the span between men and women's life spans. Here in the studio, Neil Irwin of The New York Times, Laudy Aron, she's at the Urban Institute, Joel Achenbach of The Washington Post, and Dr. Susan Blumenthal, former assistant surgeon general of the U.S.

  • 10:20:58

    REHMJoel Achenbach, Alabama was one of the places The Washington Post looked at carefully. Tell me what you found generally about access to health care and the stats that came out of that.

  • 10:21:16

    ACHENBACHSure. So we looked at Alabama as a state and also looked at it at the county level. We sent a reporter there, one of our ace reporters, who went to a rural county in northern Alabama where 80 percent of the arrests there are drug-related arrests. They have an opioid epidemic there, a lot of addiction. It's the classic story of a town where the jobs have been disappearing. It's a coal-mining region and the jobs have vanished and you have a culture in crisis there. And that's rural Alabama.

  • 10:21:50

    ACHENBACHIn the state on the whole, it's really important for everyone to remember that, although the white women have seen this big uptick in their death rate, they still outlive white men, they still outlive African Americans of both sexes. So, in a sense, what's happening is the goal of health equity, which is an important goal for a lot of people -- you know, let's get rid of these disadvantages...

  • 10:22:14

    REHMRight.

  • 10:22:14

    ACHENBACH...you know, by race and ethnicity, this was a long-term goal -- no one wanted that to be achieved by having lots more white women die. I mean, that was not the idea, right? In Alabama, you see a real closing of the gap there. But it's because of something going on in these rural, largely white communities where you have the drug addiction and the alcohol abuse.

  • 10:22:40

    REHMAnd, Neil, tell me about Birmingham, Alabama. What's going on there?

  • 10:22:45

    IRWINYes. That was an interesting result in this research by geography, which is that, you know, although some of the places with the most improvement are large coastal cities, there are exceptions, Birmingham being one of them. There was almost a three-year gain in life span for the poorest quarter of residents in that area. You know, a number of things seem to be driving that. There -- it is a stronger local economy than many parts of the Deep South. So you do have foundations, you have better, you know, public hospitals and public health and -- than some places in that part of the country.

  • 10:23:17

    IRWINI think part of it seems to be, you know, they're doing some things to try and encourage healthy behaviors. There are some...

  • 10:23:22

    REHMSuch as?

  • 10:23:22

    IRWINClinics in poor neighborhoods that provide primary care for low cost. They've -- this is probably too recent to affect this new data, but they have a stronger anti-smoking laws than many parts of Alabama, you know, restaurants, hotels, things like that. So, you know, I think there is an optimistic message in here. You know, you don't have to be a very wealthy urban place like San Francisco to have good health outcomes. There are ways that you can have progress that...

  • 10:23:46

    REHMHmm.

  • 10:23:47

    IRWIN...may not -- maybe you don't get to where New York or San Francisco is, but people can live longer with the right steps.

  • 10:23:52

    REHMAnd Susan Blumenthal, here's a tweet from Hallie -- and we've received several like this -- on the mortality gap between men and women, is the change just because women are less healthy or are men more healthy?

  • 10:24:14

    BLUMENTHALWell, I think what we're seeing is women adopting some of the same health-damaging behaviors that men have over the years. Remember, in 1930, women didn't get lung cancer or chronic pulmonary disease. They were targeted to start smoking by tobacco companies and with messages like, you know, it was sort of an equal opportunity. And so women's lung cancer rates went up. Women were not the subject for many years of research studies, for example, on lung cancer or heart disease. Prevention programs didn't target their unique needs. So women's lung cancer and COPD rates went up. Men's started to come down. Today, more than 70,000 women die of lung cancer every year, as compared to 40,000 of breast cancer.

  • 10:24:57

    REHMSo...

  • 10:24:58

    BLUMENTHALBut we don't know. So, again, women -- obesity, opioid crisis, drugs, alcohol -- all of these behaviors women now are engaging in. And they have different -- and they may have differential effects. We need to better report on these sex differences and make sure that, you know, women are included in the research studies and that prevention programs target their unique needs. Education -- women with a high school education or less and with lower incomes are more vulnerable.

  • 10:25:26

    REHMAnd, Laudy, here's a tweet from Wendy. She says stress is a factor tying all these groups together, resulting in poorer health. Would you agree with that?

  • 10:25:41

    ARONI couldn't agree more. I think it's really important to understand that all of the kinds of health behaviors that we're talking about -- smoking, drug use, food behaviors -- don't happen in isolation. It's not just a bunch of individuals deciding on each and every one of those things. They occur in a context. And communities are affected, the forces that are at play in that community, whether, you know, mothers have nurturing and child-care environments to bring their children up in, jobs, schools, after-school activities, all of these things affect a family and a community's ability to lead a healthy life.

  • 10:26:25

    BLUMENTHALI want to underscore that. I mean, 68 percent of Americans -- women are overweight. The average American woman has gained 30 pounds since 1960. You know, we think of one person -- you're obese, you need to lose weight -- but really all the factors in a community -- food marketing, lack of healthy foods, food deserts -- all of these behave -- and the fact that healthy foods cost more, all these factors impact on an individual person's ability to stay healthy. And prevention, as Hippocrates says, is preferable to cure.

  • 10:26:56

    REHMExactly.

  • 10:26:56

    BLUMENTHALAnd that, I think, is one of the key issues.

  • 10:26:58

    REHMAnd, of course, the access to doctors. Let's go back to that and talk about that urban-rural divide, Joel.

  • 10:27:10

    ACHENBACHSo if you look at our story that went online on Sunday, the comments are fascinating from people, saying that where we live there is this high rate of obesity and people who are really suffering. And you can't get good health care. And people talk about insurance problems they have, the difficulties, even if they have insurance, of finding a specialist. They -- if you're a doctor, you're going to typically want to be in a big city. I mean, that's where the money is.

  • 10:27:41

    REHMOf course.

  • 10:27:41

    ACHENBACHAnd so rural health is a big issue. And we have not explored that in depth. Some of our other guests here probably can speak to that. But this is a slow-motion crisis happening in America that is -- it's hard to disentangle all the factors, but geography is clearly something that we need to look at as a major cause of this divide.

  • 10:28:06

    REHMLaudy.

  • 10:28:07

    ARONAnd I just want to add that, when we talk about health care, we're not just talking about primary care doctors and hospitals. We are also talking about mental health providers, substance-abuse treatment providers, specialists who are informed in trauma care. There are a lot of other types of care that we tend to forget when we think about health care and health care needs.

  • 10:28:30

    REHMI must say, "60 Minutes" recently did a piece on a traveling health care truck that went through the rural areas and people would just line up to have an opportunity, because they have no other opportunity. Here's a tweet from Coleen, who wants to know how we are defining rich in this conversation. Did any of the studies break down rich versus poor?

  • 10:29:07

    IRWINYeah, so this is in the JAMA paper that's out this week...

  • 10:29:12

    REHMJournal of the American Medical Association.

  • 10:29:14

    IRWINThank you. They break it down by, it's called vintiles, each 5 percent. So we can get up to even the top 1 percent, which gets into several hundred thousand dollars a year. So what's interesting is, at those higher levels -- even, you know, you might think, once you get income over $100,000 or something like that, that it might level off, that you might say, well, once you have a certain level of income and health insurance and access to all these things, you would expect life expectancy to level off -- in fact, it keeps rising as you get closer and closer to the upper 1 percent.

  • 10:29:42

    IRWINSo even as you go from $100,000 income to $200,000, to $300,000 to $500,000, you still see -- they're small -- but you still see increases in life expectancy. That's actually a surprising result.

  • 10:29:52

    REHMSurprising result, indeed. And a tweet from Al. What about educational level? What are the granules there, Laudy?

  • 10:30:04

    ARONSo, you know, it's interesting, because obviously this recent study in JAMA was focused on income. But really, advantage and disadvantage, as we're describing it here, could have just as easily been measured by education or a host of other indicators. The story is largely the same. And we see this gradient between income-education advantage and a variety of health outcomes at every step along the way.

  • 10:30:31

    REHMAll right. We have some callers. Let's go first to Chris in West Bloomfield, Mich. You're on the air.

  • 10:30:40

    CHRISGood morning, Diane.

  • 10:30:41

    REHMHi.

  • 10:30:41

    CHRISThank you so much for having this panel on today.

  • 10:30:43

    REHMGood.

  • 10:30:45

    CHRISSo, I am in a lot of doctors' offices. I do software support. So not being a medical professional and just having some anecdotal experience. And, you know, I went to a water park in southern Indiana -- and, again, I'm from a suburban area -- and I was shocked by how many people -- how much obesity there seemed to be. And where, there, like my whole family was sort of shocked by it. And then I went to a doctor's office doing some support in Indiana, and the doctor had one consistent message to all of his patients, and it was, cut out sugar. And, you know, he was a primary care physician. And, you know, he did regular primary care.

  • 10:31:26

    CHRISAnd yet, at the same time, he thought that so many of their problems, of his patients' health problems were related to sugar intake and nutritional decisions. And I know, where I'm from, nutrition is a big deal. And a lot -- there's a real focus on making healthy decisions when it comes to food selection. But, you know, one of your guests said something important, and that was women were targeted to start smoking. And, you know, where profit was put over, you know, the profit of a few was put over the health decisions of a greater community. And I really feel like that's what's happening with our nutritional system here in America.

  • 10:32:00

    CHRISI mean you have profit in the processed food put, you know, over nutritional value. And then if you look at how much we spend on diabetes and how much it costs our nation as a whole and when you have somebody like Ted Cruz running on, I'm going to put hamburgers back in the cafeteria, you know, when there's that much sentiment working against people...

  • 10:32:19

    REHMAll right. Joel Achenbach.

  • 10:32:22

    ACHENBACHWell, just to echo something that Dr. Blumenthal said a minute ago, the average American woman now weighs as much as the average American man did in the early 1960s. We've, you know, we've all collectively gained all this weight. And obesity is comorbid, as they say, with other things like alcohol abuse. If you look at the amount of alcohol that Americans consume now -- there's been a closing of the gap between men and women. Men tend...

  • 10:32:52

    REHMOn alcohol.

  • 10:32:54

    ACHENBACHOn alcohol. Men tend to still drink more than women do. But our research -- when we talked to experts at NIH -- say that the women can have a telescoping of the negative effects, such as diseases associated with alcohol abuse and dying. And if they -- if they're obese, you know, drinking heavily can really be a lethal combination.

  • 10:33:20

    REHMAnd you're listening to "The Diane Rehm Show." Susan Blumenthal.

  • 10:33:27

    BLUMENTHALAlso, obesity affects every single organ system. We used to think that the fat cell was inert but, in fact, it secretes chemicals that cause problems with, you know, gout. It causes liver disease, as does alcohol. And this is -- there's been a spike in liver disease among white women of midlife. And I think that, you know, we need to really prevent obesity and tobacco. Tobacco is still the leading cause of death in America. Almost one out of five deaths are linked to tobacco today. But we can create a culture of change. We've seen that. I mean, since the first Surgeon General's Report was released in 1964, over 50 percent of Americans smoked. This has been reduced with a combination of approaches. And I think that this can be done with obesity.

  • 10:34:15

    BLUMENTHALBut once a person is obese, you know, we've missed that opportunity for prevention.

  • 10:34:20

    REHMVery hard. Laudy.

  • 10:34:22

    ARONI also just wanted to quickly add in the context of our conversation about obesity, is that obesity goes hand in hand with food insecurity. And food insecurity and hunger in this country is real, it's widespread, there is a whole other map, by place, that we could be looking at that reflects these differential levels of food insecurity. So we need to understand that's part and parcel of this conversation.

  • 10:34:46

    REHMThere also, it seems to me, would have to be better education about food choices, Neil.

  • 10:34:54

    IRWINYeah, I think that's right. I would add one thing to all of this that kind of is the backdrop. You know, I -- my day job, I'm an economics writer -- and I think there's something that's happened where, you know, in the last few years there was a recession, there was a crisis, all these things. And we tend to -- people who do what I do and write about economics tended to focus on that. I think it -- that masked a little bit what is a much longer term problem. You know, if you look at this data we're talking about on life span, it goes back decades. This isn't a new thing in the last few years.

  • 10:35:18

    REHMRight. Right.

  • 10:35:20

    IRWINThis is a story of places where the underlying economic situation, the ability of people to get health insurance, to earn good wages, to afford healthy foods, to, you know, afford, you know, exercise can -- requires time. If you're working, you know, two jobs, it's hard to exercise. So, you know, there's this broader economic backdrop that I think is true in a lot of the country, that is not just a story of the last few years. It's something that's been building for decades.

  • 10:35:46

    REHMAll right. To Ken in Pittsburg, PA. Hi, you're on the air.

  • 10:35:52

    KENGood morning. Thank you very much. You know, when I heard the disparity or the change in the -- or the increase in the gap between women and men life expectancy, one of the first things that came to mind was, you know, in the last few decades, women's education levels have been going up and consequently their employment rates have been going up. And I've been wondering if your people on the panel or -- that does any study look into the increasing presence of women in the workforce and the stresses and things that are related to that concerning life expectancy?

  • 10:36:30

    REHMSusan Blumenthal.

  • 10:36:31

    BLUMENTHALI think stress is a key factor. But actually women who have higher education levels and have a job have higher income levels, do better. And they have lower smoking and obesity rates and alcohol and so forth. So I think these are generally protective factors.

  • 10:36:47

    REHMAnd the more you know, the better you are able to take care of yourself through education, through employment. So I don't think we can look at employment as a cause.

  • 10:37:03

    BLUMENTHALI think that, you know, in the past, we've neglected important sex differences. And I think that if we had studied women more, we would be able to give answers for men as well, to improve their health.

  • 10:37:16

    REHMSusan Blumenthal, former assistant surgeon general of the U.S. Short break here. More of your calls, your conversation, when we come back. Stay with us.

  • 10:40:02

    REHMAnd welcome back. We'll go right back to the phones, to Lucas in Fort Lauderdale, Florida. You're on the air.

  • 10:40:13

    LUCASGood morning, Ms. Rehm. First of all, I just want to say you're a national treasure.

  • 10:40:17

    REHMThanks.

  • 10:40:18

    LUCASI'm so happy to get a chance to participate in the show. One thing that I did as I was thinking as I was listening to the panel discuss, it's come up from a couple callers, is one of the remarkable things this study allows us to do is really focus as a society on the importance of public health interventions inside ameliorating health disparities across the nation, rather than just clinical ones.

  • 10:40:37

    LUCASOf course access to clinical care is important in under-served areas, but I feel that at times we focus too much of our policy efforts and allocate too many of our financial resources and the distribution, increasing the access to medical care, when, as we've seen from a number of studies, medical care only accounts for only roughly 20 percent of the variance in raising mortality of individuals. And so this study does a great job of helping us remember that perhaps there's opportunities to engage in more cost-effective interventions that have higher returns on investment both in terms of health and financial.

  • 10:41:13

    REHMAll right, thanks for your call, Susan.

  • 10:41:14

    BLUMENTHALThank you. Well, I think that, you know, we need to do both. We need to increase access to care, and we need to do better in terms of public health because only three to five percent of the United States, $2.8 trillion health care budget, was spent on prevention. The Affordable Care Act I think will help us achieve some of these goals. First it's reduced -- now 90 percent of Americans have health insurance. And, you know, before the act, women could be charge more for men -- than men for their health insurance.

  • 10:41:47

    BLUMENTHALAnd if you had a pre-existing condition like breast or lung cancer or depression, you could not be covered. But the act also has a very important component, which is to establish a prevention in public health fund, which is to increase access and provide support for community-based prevention programs, to help people stop smoking, to encourage a healthy diet, to be physically active and to prevent alcohol and drug use. And I think this is a very important component.

  • 10:42:16

    BLUMENTHALIt also includes the establishment of a national prevention strategy that mobilizes all agencies of government and the private sector. Remember, and I think to your point, health is -- can no longer be bounded just by the clinic or the hospital, but health requires a health in all policies approach, where you have smart agricultural, transportation, housing policies, as well.

  • 10:42:39

    REHMExactly. All right, here's a tweet from Yasmine. She says, you mentioned white and African-American, what about other minorities, such as Hispanic, Laudy?

  • 10:42:52

    ARONYes, well, demographers and others refer to something called the Hispanic paradox, which is that in fact as a group, Hispanics have better health outcomes than their underlying socioeconomic status might predict. And certainly that's true of recent immigrants to this country, and that might be part of what we're observing in the recent JAMA study with respect to the relatively strong position of New York and San Francisco and other communities that receive recent immigrants.

  • 10:43:26

    REHMAll right, and for you, let's see, could the panel please explain what the opioid belt is and how drug use negatively affects rural health, Joel?

  • 10:43:40

    ACHENBACHWell, the phrase opioid belt, I think if you look at this country, it's not just a belt. I mean, the opioid problem is happening all over the place. We did a map of where the death rates are rising, and it shows, you know, most of the country, actually. I mean, it's not rising in the cities, it's not rising in New York or Washington or San Francisco, but it's particularly severe in places like West Virginia, Kentucky, Tennessee, Arkansas. There's kind of a belt of pain, you might say, running through the middle of the country. Oklahoma has a problem.

  • 10:44:21

    ACHENBACHThis is -- you know, this is a complicated story that we can't boil down to a simple narrative, but it is -- it is true that no other country uses opioids like we do. For some reason, this country got on this, you know, pill kick back in the 1990s, when Oxycodone was approved. And, you know, if you have a friend who's had surgery, they come out of surgery, they've got a prescription for OxyContin, you know, really powerful painkiller. And, you know, these opioids, you can get hooked on them, and some people wind up, you know, turning to heroin because of it.

  • 10:45:01

    ACHENBACHAnd the thing about death rates that makes it such a compelling statistic is that there's no code creep on death. It's unambiguous. I mean, these are people who were not misdiagnosed. They're dead, okay, and it's -- the fact that these death rates are going up says something's going on in this country that's not good.

  • 10:45:22

    REHMAll right, let's go to Birmingham, Alabama. Jim, you're on the air.

  • 10:45:27

    JIMGood morning, Diane. My pleasure.

  • 10:45:27

    REHMHi, good.

  • 10:45:29

    JIMI just wanted to -- the study that they've done also doesn't take into account recent developments here in Alabama. Alabama is one of the states that did not expand their Medicaid program, and recently our legislators cut $85 million out of our Medicaid budget, and that's going to result in the closure of several or more rural hospitals and a reduction in care for things like hospice care and glasses and kidney dialysis for poor patients.

  • 10:46:06

    REHMNeil, do you want to comment?

  • 10:46:09

    IRWINYeah, I mean, so the data I was looking at...

  • 10:46:11

    REHMThe politics of this all get into how people get health care.

  • 10:46:16

    IRWINRight this -- I mean, the data that I've been talking about, it's from 2014. So that's really just as the Affordable Care Act was being fully implemented. So we're only starting to see the differences between states that did expand Medicaid as part of Obamacare and those that did not. That data is kind of taking place as we speak, and I think there'll be a lot of analysis in the future of what it means if a state does take, you know, efforts to make sure the poor have insurance, to make sure that there's the right resources in place for these people.

  • 10:46:47

    IRWINAnd we can guess direction that data's going to point, but I think that'll be a source for a lot of research in the future.

  • 10:46:52

    REHMHere's an interesting email from Stephanie, who says my mother's generation has an extended life expectancy. More and more people of my generation are expected to be caretakers of their parents. So the extended life expectancy of the generation before me actually is having a detrimental effect on my generation. Caretaking falls primarily on the female children, and the incredible high stress level has contributed to my own health issues. Susan.

  • 10:47:34

    BLUMENTHALWell, I think that this is an increasing problem with the aging of the baby boom generation. Women are both having increased rates of chronic disease, as well as being caretakers themselves. But I think again we need -- we have an urgent problem. We have an Alzheimer's epidemic. Again, women are more likely to get Alzheimer's than men for a number of biological and life expectancy-related issues. You know, we need to address these issues as a society and really come up with solutions.

  • 10:48:11

    REHMLaudy.

  • 10:48:12

    ARONI also want to point out, you know, women are also the primary caretakers of the nation's children, and many women are raising children on their own.

  • 10:48:24

    REHMAnd taking care of parents, as well.

  • 10:48:25

    ARONOften both. And, you know, health is really something that is established early in life. So to the extent that we can get things for children right early on, both from a health perspective but also education, socio-emotional learning, trauma-free, nurturing life starts, that is going to have lifelong implications for that child, that child's family, that child's community.

  • 10:48:50

    REHMThat's such an important point.

  • 10:48:52

    BLUMENTHALAnd can...

  • 10:48:52

    REHMLet's go to Emerald Island, Emerald Isle, North Carolina. You're on the air.

  • 10:49:01

    ROSSHello, how are you?

  • 10:49:02

    REHMHi Ross, I'm fine.

  • 10:49:04

    ROSSWonderful. I just want to make a point, I'm very happy you guys are having this conversation today. I would like to go back to prevention is better than cure, and with education especially among children regarding sugar, I think the sugar industry in America is quite evil, to be honest, and I want -- I would like to have or see a national conversation putting pressure on politicians to really bring this to light.

  • 10:49:30

    ROSSThere's a documentary called "Fed Up" on Netflix, I believe, which really brings to light some of the problems that artificial sweeteners cause to children and adults, and the amount that is used in the cafeterias of schools is really horrendous. And they get an addiction to sugar, just like cocaine. It's actually more addicting, which is quite horrific. And if we could please have more of a conversation, educate the children in the schools and get this food fixed so that when they grow up they're not nostalgic to that awful food, and they know what tastes good, they know about whole foods and vegetables, things that are actually good for them.

  • 10:50:08

    REHMIndeed. Joel?

  • 10:50:12

    ACHENBACHI think that's a great comment, and most people would certainly agree that junk food and kids' nutrition is something we need to look at. I want to just mention something. I feel that in this hour we haven't -- we haven't directly addressed, which is that the economics in this country, you know, does not favor a lot of communities where the jobs have disappeared, the manufacturing has disappeared.

  • 10:50:37

    ACHENBACHThere might be a place where you have, you know, industrialized agriculture, but you don't have any small farms anymore. There's a lot of places in this country that are in crisis, and yes, I agree with the caller entirely that kids shouldn't be marketed junk food and so on, but part of the problem is we've gone through this really dramatic change in how our country is organized economically.

  • 10:51:03

    ACHENBACHGlobalization, technological change and these disruptions have really devastated a lot of communities.

  • 10:51:10

    REHMSo what about the availability of good, wholesome grocery stores in those rural areas? Surely that's part of the problem?

  • 10:51:23

    ARONI think we -- you know, this is -- I mean, there are more food deserts. People -- they're more expensive to -- healthy food is more expensive to buy. And transportation-related issues, as well. I think that, you know, there have been a number of initiatives that have been put in place in recent years to try to address these issues, and the Department of Agriculture, through a rural medicine initiative, has also talked about access to health care as bringing tele-medicine, using tele-health approaches, as well.

  • 10:51:50

    REHMHere's an interesting email. Could the ability of the wealth to afford intense end-of-life and life-extension care affect significantly the highest life expectancy even slightly for the one percent, Neil?

  • 10:52:13

    IRWINYeah, that's certainly possible. That said, you know, if people who make, you know, many hundreds of thousands of dollars, if they have access to certain cancer treatments that are very expensive or whatever, and that affects the numbers, that's one thing. The big gaps, though, the big gaps between somebody who makes $20,000 a year and somebody who makes $60,000 a year, is -- it's not obvious that that's about access to any kind of exotic treatments. That's about how people are living.

  • 10:52:38

    IRWINAnd the big changes in the relationship between income and life span really seem to have to do less with anything that's really aggressive and more about how you live your life.

  • 10:52:51

    REHMAnd in your piece in the Times, you say there's an optimistic message at the heart of all this new research. What is it?

  • 10:53:02

    IRWINI think the optimistic lesson is improving public health, helping poor Americans live longer, it doesn't have to be a matter of solving this very complicated problem of global inequality. You can -- you know, there -- the fact that there are people who are poor, who do not make a lot of money, who in some cities are living nearly as long as middle-class people, that's a sign that it can be done. This is not an impossible task.

  • 10:53:21

    IRWINThat said, as we've been talking about for the last hour, it's a complex set of challenges that are holding people's lifespans back.

  • 10:53:30

    REHMAnd you're listening to the Diane Rehm Show. Susan, your solutions?

  • 10:53:37

    BLUMENTHALWell, I think as we mentioned before that health really needs a multi-sectoral approach. We've seen this in the decline in the HIV, you know, rates, that it went from a disease that, you know, killed people in the '80s, was a lethal disease in America, to one where for women the rates have dropped by 40 percent over the past decade because of a combination of both medical and public health intervention.

  • 10:54:00

    BLUMENTHALSo we need transportation policies, we need agricultural policies, we need housing. I mean, these are the basic foundations because America has some of the very best medical care in the world, but we have to put more emphasis on building public health infrastructure. Income inequalities and education are profound, as the studies showed, in some areas of our country, particularly rural America.

  • 10:54:25

    IRWINAgain, education and income targeted to high-risk groups are going to be critical in bridging the gaps.

  • 10:54:29

    REHMLaudy?

  • 10:54:31

    ARONI would add to that list that, you know, just the importance of -- we've been talking about how health happens in places and communities. So the importances of involves community members themselves. This is as much about kind of political empowerment of disenfranchised groups of Americans, holding our elected officials accountable, crafting innovative solutions with private-sector entities, civic groups, our public officials and really moving forward together.

  • 10:55:00

    REHMBut the question becomes, given the fact that you've seen in these different areas different outcomes, do we need a greater national conversation to make sure that the whole country becomes really, really aware of what's going on?

  • 10:55:21

    ACHENBACHI think we're seeing a slow-motion crisis. I think the new research that's come out in the last few years, including by Laudy at the Urban Institute and other researchers, the Case Steaden Study out of Princeton, the Robert Wood Johnson Foundation has a new study that came out, this new one that Neil reported on, it's pointing out that -- and there is a conversation burbling right now. This is front-page news.

  • 10:55:48

    REHMBurbling.

  • 10:55:49

    ACHENBACHIt's front-page news. Burbling is probably the wrong word, but...

  • 10:55:52

    REHMNo, it's good.

  • 10:55:53

    ACHENBACHIt's front-page news in the Washington Post and the New York Times and many other places because people realize we've got to do something about this, and it's one person at a time in a way. These are lives on the line.

  • 10:56:04

    REHMAnd could this all, what we've been talking about, be affecting the thinking of voters out there?

  • 10:56:16

    ACHENBACHWell, that's another hour to discuss that. Let's throw in the Trump connection to this. We did find at the Post there was a connection between where Trump's support was greatest and where the death rates were highest. I would not read too much causality in that.

  • 10:56:30

    REHMI don't quite -- yeah, I don't quite understand that.

  • 10:56:31

    ACHENBACHNo, it's a correlation, it doesn't mean there's a causality, but stressed communities that are going through some kind of crisis and where there's a lot of anger seem to be places where Trump has found fertile ground for votes.

  • 10:56:47

    REHMVery interesting. All right, we'll have to leave it at that. Joel Achenbach, Laudy Aron, Neil Irwin, Dr. Susan Blumenthal, thank you all so much.

  • 10:56:57

    BLUMENTHALThank you.

  • 10:56:59

    ARONThank you, Diane.

  • 10:56:59

    ACHENBACHThank you so much.

  • 10:56:59

    IRWINThank you.

  • 10:57:00

    REHMAnd thanks, all, for listening. I'm Diane Rehm.

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