What if we woke up tomorrow in a completely different small town? Would we feel at home in Summerville, GA, with 4 colleges just a county over? Or in Hartford, KY, among generations of coal miners? I imagine our neighbors in Greensburg, IN, heading off to the Honda plant every day, would be a little like those of us who work at Volvo. But our friends who work over at the Radford munitions plant might feel more at home in Texarkana, AR, home of the Red River Army Depot. Some Pulaskians wish our town was growing, the way that Shelbyville, TN is quickly changing. Others might like some place quieter, like sparsely populated Newcastle, WY. And I know of a few folks around us who want to see Pulaski become a tourist destination, maybe a little like Taos, NM. If we followed along with the people of these small towns, would we notice the same neighbor we have right here? Would we be able to tell that death is as at home in Cameron, TX as it is here in our Appalachian county?

After my last two pieces, I wanted to get a broader, national view of how “below average” counties from state to state compare. Those places I’ve listed would make for an eclectic travelogue. From the edge of Death Valley in California to the peaks of White Mountain National Forest in Maine, our nation is dotted with counties that are around 50% rural and between half and twice the population of our own. Those I already mentioned all shared in a similar rate of premature deaths in 2016, losing an average of 2700 potential years of life through the deaths of 130 citizens under the age of 75. They came from a larger sample I decided to use as points of comparison: 44 counties that countyhealthrankings.org ranked around 63% within their state based on their county health profile, as we did in 2016. I wanted to know if we had anything in common, or even more importantly, any factors that hit Pulaski harder. You can find all the data I complied here.

Looking at the group of 44 as a whole, Pulaski sits close to the average for several health factors, from obesity and diabetes rates to use of tobacco and alcohol, and even injury-related deaths. In some areas, we actually do significantly better than our “below average” counterparts in other states:

•             25% fewer automobile crash deaths
•             30% fewer cases of HIV
•             35% more primary care physicians (with 7 more serving our county than the average “63%”er)
•             35% more insured children

But we also fall behind those counterparts in significant ways with:

•             15% more premature deaths and years of potential life lost
•             15% more alcohol-impaired driving deaths
•             20% more drug overdose deaths
•             20% fewer dentists
•             33% fewer mental health providers
•             45% fewer NPs and PAs
•             40% more preventable hospital stays

Demographically, we are also significantly older than these other 43 counties, averaging 20% fewer children and 20% more citizens 65 and older. This general data makes it look like we were below the “below average” for our country, which got me curious. I began breaking that big chunk of statistics into smaller clusters.

Where Policy Meets Region and Race

My first thought was to split up the counties into the states that had and hadn’t adopted the Medicaid expansion included in the 2010 Affordable Care Act. You might remember back in 2012, the Supreme Court stated that it was beyond the power of Congress to expand Medicaid; that was a decision for the states. Since then, 32 states (including 6 I didn’t compare) have expanded their Medicaid program. Virginia has not. When just comparing the counties in my sample between ones, like Pulaski, which don’t have expanded Medicaid and ones that do, the differences are startling. Rates of health factors like uninsured adults and child mortality are 20% higher in counties without the expansion, while they also have 80% fewer primary care physicians and 90% more cases of HIV. A map of this split between Medicaid adopters shows an even more significant division.

Geographically, 10 of the 18 states that didn’t adopt the Medicaid expansion are located in the South (the US Census Bureau includes Texas and Oklahoma as Southern states, if you are checking my math). I used the Census Bureau regions to breakout the data further, splitting my same 44 counties into the Northeast, the Midwest, the South, and the West. Regionally, the Southern counties sink to the bottom of many health factors. Of 57 factors measured, these “below average” Southern counties only come out on top for least “excessive drinking” and least “residentially segregated”. For 40, Southern counties perform the worst, while Northeastern counties rank best on 17, and Midwestern and Western counties top 13 and 11 respectively. For premature deaths alone, Southern counties lost 40-45% more people than the other three regions.

This could be written off as an accident of size: 38% of Americans live in the South as defined by the Census Bureau. Texas, Florida, Georgia, and North Carolina rank in the top 10 for most populous and numerical growth. Maybe we simply have too many Southerners to take care of. But if that’s the case, it seems odd that Virginia and our neighboring states rejected an expansion to Medicaid.

But the regional stats that I compared showed another Southern anomaly: our counties are demographically the least white and have the highest African American populations, by nearly 20%. Even more starkly, the 18 counties without the Medicaid expansion average 3 times as many black residents as those with the expansion. This racial element of the data puzzled me. Fortunately, I’m not the only person who noticed this trend (and am definitely not the smartest!). A professor and a grad student at the University of Chicago’s School of Social Service Administration published findings this summer that racial makeup predicted strongly for whether or not a state adopted the Medicaid expansion. They began with a simple question: did the citizens reject the Medicaid expansion? After all, we live in a democracy, so public opinion must have held sway in the states’ decisions not to expand.

From 4 national public opinion polls, the study found an average support level of 51% across all states, with most settling between 45 and 55%. Not only that, 8 Southern states that didn’t adopt the expansion (AL, FL, GA, MS, NC, SC, TX, and VA) all showed a majority in favor of adopting broader Medicaid. The researchers found that these levels of support split along racial lines: white citizens showed an average support of 45%, where nonwhites averaged 73%. In states like Georgia, Alabama, and Mississippi, with black citizens making up between a quarter and a third of the population, their overwhelming support gives these states a favorable majority for an expanded Medicaid. In all of these cases, the study finds that the state legislatures and governors were more responsive to the lack of support of their white constituents than the favor of their black ones.

Why’s all this uncomfortable talk about race matter in my look at health and death in our small towns? The coverage gap Jill wrote about is made up of 56% black or Hispanic American adults who do not qualify for Medicaid nor subsidies through the marketplace, but could if Medicaid were expanded. And when states make their decision to expand Medicaid along the lines of racial support, it winds up leaving the 44% of uninsured whites who would be eligible under an expanded program behind as well. For counties like Pulaski, which is both 90% white, but also has one the highest proportions (5%) of black residents in the NRV, this policy decision is detrimental to the health of everyone.

A wrap up?

Where do we go from here? Like I said in Part 1 of this series, death visits our small town more often than big cities. Can we do anything about this? Would Virginia adopting an expansion of Medicaid make death feel less at home in Pulaski? If Supreme Court Justice Louis Brandeis is right, that our states are the laboratories of democracy, then yes, it’s a start. Small towns in the states with expanded Medicaid are seeing improvements in health and decreases in premature death. Of the 44 counties I compared, counties without the Medicaid expansion had 13% more premature deaths than those with it. Would an expansion of Medicaid be a perfect fix? No. With hospitals seeking to increase revenues faster than they improve patient health, towns like ours will lose out to bigger cities when it comes to service. With insurance companies writing national legislation that increases their bottom lines, people in small, poor communities are the ones getting gouged. With doctors owing extraordinary amounts of debt for medical school, practices like those in Pulaski will become rarer and rarer. Small towns like ours will need to place our hope in broader changes, beyond what DC legislation can provide. I don’t know what that would look like. But with our neighbors’ lives at stake, I’m willing to help us fight for more.