Poverty Drags Down Rural Health Rankings

The nation’s smallest counties scored at the bottom of the heap in 18 of 34 measurements used to rank the health of U.S. counties. The suburbs of major cities had the best rankings, according to the annual study.

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The nation’s most rural areas rank dead last in a majority of the measurements used to evaluate the health status of U.S. counties, researchers say.

The findings are part of a study sponsored by the Robert Wood Johnson Foundation that ranks counties by a broad set of health and well-being indicators.

“Noncore” counties, which are located outside metro areas and have no towns of 10,000 residents or more, were last in 18 of 34 measurements used in the study. That’s the worst record of any group of counties when they are sorted by urban-rural status.

The geographic area with the next highest number of last-place rankings was major urban counties (big cities of a million residents and up), with 10. But those counties offset their low marks by ranking first in 14 other categories. 

In contrast, noncore counties ranked best in only two categories. They had less violent crime and fewer housing problems.

The counties with the overall best health rankings were located in “suburban metro” areas, which the study defined as counties located outside large cities.

The rankings’ methodology takes into account the availability of medical resources such as physicians and dentists. It also weighs economic, social and environmental factors such as poverty rates, access to exercise facilities, education levels and unemployment.

 “The one [health criterion] people don’t think of is poverty,” said study director Bridget B. Catlin with the University of Wisconsin Population Health Institute.  “They think of poor inner city communities, and there’s not enough recognition of the role of poverty in affecting the health of people in rural areas.”

Wayne Myers, M.D., a rural health advocate and former director of the federal Office of Rural Health Policy, agreed.

“I don’t think we understand too much about how the day-to-day stress of living takes a toll on the bodies of poor people,” he said. “The stress runs up blood pressure, it makes blood sugars higher. It does take a toll on health.”

University of Wisconsin Population Health Institute/County Health Rankings and Roadmaps
Click chart to enlarge. The chart shows the health ranking of U.S. counties within their respective states by geographic status. Dark blue denotes counties that rank in the first quartile, or the top 25% of healthiest counties. The lightest blue denotes counties that rank in the bottom quartile (or bottom 25%). Noncore counties have the smallest percentage of counties in the healthiest group, and the largest percentage of counties in the least healthy group. Suburbs in major metro areas have the highest percentage of their counties in the healthiest category. (Category definitions are at the bottom of this article.)

The annual study ranks counties within states, not on a national basis. At the request of the Daily Yonder, Wisconsin’s Population Health Institute ran an analysis of how rural counties stack up across the country.

Noncore counties ranked last in all seven of the clinical measurements, such as percentage of population without health insurance and the number of physicians, dentists and mental health professionals available to the county’s population on a per capita basis.

But proximity to medical facilities isn't a good measurement of community health, Dr. Myers said.

“Some of the [least healthy] neighborhoods in the U.S. are in the shadow of Barnes Hospital in St. Louis or Boston City Hospital,” he said. Over the course of his career, Myers said he “reached the conclusion that doctors don’t make much difference to health.”

Other factors do.

Some of the other health indicators considered in the rankings are things like smoking rates, access to good food and exercise facilities, percent of adults with some college education and the percentage of children living in poverty. (Rural counties ranked last in each of those measures, by the way.)

Tim Size, executive director of the Rural Wisconsin Health Cooperative, in Sauk, said the study’s emphasis on factors beyond the control of health-care providers doesn’t let the medical community off the hook.

“It just means we have a large hook with plenty of room for company,” Size wrote in a commentary about the rankings. “No single person or organization can tackle this problem alone.”

Other Findings

Noncore counties scored at the bottom in three of the five “health outcomes” categories and ranked next to last in another of those categories:

  • Noncore counties were last in the percent of adults reporting fair or poor health (18.3).
  • Noncore counties were at the bottom in the number of physically unhealthy days (an average of 4.0 in the last 30-day period).
  • Noncore counties ranked worst in premature death  —  8,733 years of potential life lost before age 75 per 100,000 in population. (That figure was age adjusted, meaning noncore counties didn’t score last just because they have older populations.)
  • Noncore counties were next to last in the number of mentally unhealthy days (an average of 3.6 in the last 30-day period).

Micropolitan counties (ones outside a metro area that have a city of 10,000 residents and up) ranked last in one health-outcomes category and next to last in three more:

  • Micropolitan counties were last in the number of mentally unhealthy days (an average of 3.6 over the last 30-day period).
  • Micropolitan counties were next to last (behind noncore) in premature death (8,097 years of potential life lost before age 75 per 100,000 in population).
  • Micropolitan counties were next to last (behind noncore) in the percent of adults reporting fair or poor health (18.0) and physically unhealthy days (an average of 3.9 in the last 30-day period).

Major suburbs tied with major cities for the largest number of best-ranked categories, but the suburbs had far fewer last-place rankings:

  • Big cities and big suburbs each had 14 of 34 first-place rankings.
  • Big suburbs had only two last-place ranking; major cities had five times that amount.
  • Half of counties in major suburbs ranked in the top quartile within their state (see the blue bar chart), meaning they ranked ahead of three-quarters of the other counties in their states.

Rural people had less access to health insurance and to exercise facilities:

  • Noncore and micropolitan counties had the highest percentage of residents younger than 65 who lacked health insurance: 19.1% in noncore, 18% in micropolitan. Large suburbs were ranked best in this category, with 15.1% of the under-65 population uninsured.
  • Only 44.0% of noncore residents had access to exercise facilities, while 92.8% of the residents of large suburban counties did.

More Information

The County Health Rankings and Roadmap website shows how individual counties scored within their respective states. The site also provides tools that it says can help residents improve community health.

Bar Chart Categories

Here are the definitions used for the categories in the blue bar chart:

1.            “Major Urban” (a county within an Metropolitan Statistical Area [MSA] > 1 million population).
2.            “Suburban Metro”  (a non-central county within an MSA > 1 million).
3.            “Medium Metro” (a county within an MSA between 250,000 and 1 million)
4.            “Small Metro” (a county within an MSA between 50,000 and 250,000).
5.            “Micropolitan” (a “rural” [non-MSA] county with a city of 10,000 or more population).
6.            “Non-core” (a “rural” [non-MSA] county without a city of 10,000 or more population).

 

Topics: Health
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