Place plays a part in helping the poor live longer

There is a new Raj Chetty paper out in JAMA ( with seven co-authors, including David Cutler), and it is garnering a lot of media attention.  Here is to my mind the main result, although it is not being presented as such (NYT here):

The JAMA paper found that several measures of access to medical care had no clear relationship with longevity among the poor. But there were correlations with smoking, exercise and obesity.

I enjoyed the NYC angle from Margot Sanger-Katz:

New York is a city with some of the worst income inequality in the country. But when it comes to inequality of life spans, it’s one of the best.

Impoverished New Yorkers tend to live far longer than their counterparts in other American cities, according to detailed new research of Social Security and earnings records published Monday in The Journal of the American Medical Association. They still die sooner than their richer neighbors, but the city’s life-expectancy gap was smaller in 2014 than nearly everywhere else, and it has shrunk since 2001 even as gaps grew nationwide.

That trend may appear surprising. New York is one of the country’s most unequal and expensive cities, where the poor struggle to find affordable housing and the money and time to take care of themselves.

But the research found that New York was, in many ways, a model city for factors that seem to predict where poor people live longer. It is a wealthy, highly educated city with a high tax base. The local government spends a lot on social services for low-income residents. It has low rates of smoking and has many immigrants, who tend to be healthier than native-born Americans.

Here is the accompanying NYT graphic about “your county.”  Here is Emily Badger and Christopher Ingraham, good graphics too:

The poor live shorter lives in Las Vegas, Louisville and industrial Midwest towns, such as Gary, Ind. Geography also matters much more for the poor than the rich. The health behaviors of the wealthy are similar wherever they live. For the poor, their likelihood of risky behaviors such as smoking depends a great deal on geography, on whether they live in a place where smoking is common or where, as in San Francisco, cigarettes have been shunted out of view.

It’s almost as if health care policy should be local in orientation.  The link to the paper includes three comments, including one by Angus Deaton.


Almost everything should be individual in orientation. Local is a better approximation than global, in many cases.
There are compelling reasons to have some scope of control/authority within your own family, and then
nearby, and so on, weakening in spirals outwards. But people who imagine that centralized planning is the best
solution are usually imagining themselves as Stalin and forgetting pretty much everything about Stalin.

Right, because places with good social services always end up murdering millions of political dissidents.

Anyways, I'm not sure what this article has to do with central planning, considering that it's discussing social services delivered within a specific municipality, practically the opposite of central planning.

It's almost as if you missed the last sentence in the post, Nathan

What does Stalin have to do with municipal funding for social services in a context of decentralized government?

Stalin limited sodas to 16 oz, and it was all downhill from there.

Pretty draconian. Thankfully, you're allowed to order two sodas. And for those who desperately need 20oz of soda in the same cup, there is no Berlin Wall to stop them from moving to NJ.

Funny how the right is all about decentralization except for when lower levels of government makes rules they disagree with and except for when they want to impose their will on all lower levels of government. Well, I think the same basically applies to some circles on the left, who often support decentralization to the extent that it enables them to achieve their agenda at local levels when it is stymied at higher levels.

There is planning and planning, but pretty much whenever you are going to do a thing, you should plan it. Perhaps there is broad, not just national, focus on the wrong things. That would make wasted planning all around.

If somone in Mississippi receives poor assistance, I don't think they'll be satisfied on their death bed that at least they avoided the coercive power of the national government.

What if they receive total consciousness instead?

I don't play golf but I plan excellent game of ping-pong.

What if 'assistance' isn't very helpful? Also, I can definitely imagine looking back satisfied I avoided the coercive power of the national government. Everyone dies, and looking back at a happier life adds value.

One of the kids did a stint as EMT, ferrying poor and poor-prospect patients to dialysis.

I think you might live in a bubble.

If by "avoided the coercive power of the national government" you mean "stayed out of ADX Florence," then I agree with you.

Coercive power means different things based on your wealth and ethnicity. To an upper middle class white guy it's mostly about taxes and gun ownership. To a poor black guy it's about being harassed by the police. Also rich black guys -- see James Blake.

I've posted a second in-depth analysis of Chetty's new paper at the Unz Review:

I think you'll find it clears up a lot of the confusion.

According to Chetty's paper, the poor live longest where there is massive economic inequality, lots and lots of cops, and little room for the poor to live: e.g., New York City. Health care access doesn't matter to the poor. Social conservatism doesn't matter either. In other words, the poor appear to do best in some kind of plutocratic Giuliani-ville.

(I don't actually believe this is true in terms of taking policy advice: I think Chetty's result is an artifact of churn of healthy young poor immigrants moving to plutocratic cities like NYC until they are used up, at which point they leave for some place cheaper.)

In contrast, the top quarter of income Americans live longest in economically more equal and socially conservative places, with broad health care access and few immigrants.

A simple model of the link between income and life expectancy is that of increased discounting between humans. Its both a cause and effect - people who have high discount rates would rather live for now rather than later so engage in more risky behavior and tend to spend more of the income rather than save it. So this creates an expectation that future happiness is expected to be low, and so encourages even higher discount rates. To put it another way - if you engage in risky behavior, like smoking, why bother saving for the future when you are not likely to be around to enjoy it. OTOH - if you are a naturally low discount rate person, then you can easily see the benefit of looking after your health, since you can expect to be around to enjoy it, so re-enforcing your tendency to save.

I think it is entirely reasonable for humans to differ in their approach to discounting, although this seems hard for some people to accept, I don't think it is right for low discount folks to force their preferences on high discount people.

Yeah, so long as the high discount rate people meet their expectations and the low discount rate people don't get stuck picking up the shortfall.

It’s almost as if health care policy should be local in orientation. This is mainly public health policy. And perhaps it means we should adopt things demonstrated to work, like what they've done in New York, at a national level. The political environment in many states and localities is not conducive to to taking steps to reduce disparities of any kind, especially helping the the poor live longer.

Here is to my mind the main result, although it is not being presented as such (NYT here):
The JAMA paper found that several measures of access to medical care had no clear relationship with longevity among the poor. But there were correlations with smoking, exercise and obesity.
Their measures of "access to medical care" include a bunch of things, like spending per Medicare enrollee and quality of care in Medicare, which 1) only reflect a person's later life and 2) are not exactly indicative of access to to care. In any case, health care has many goals beyond extending average lifespan. If it didn't matter nobody would want insurance or ever go to the doctor.

This has already been answered more fully.

"The political environment in many states and localities is not conducive to to taking steps to reduce disparities of any kind, especially helping the the poor live longer."

That's just laughably wrong. Every state in the US has a myriad of social services that are targeted directly at the poor and an even larger subset that are generalized and accessible to the poor. Let's try to be reality based with our comments, please.

Here are some interesting paragraphs from Raj Chetty's new paper:

"Correlational analysis of the differences in life expectancy across geographic areas did not provide strong support for 4 leading explanations for socioeconomic differences in longevity: differences in access to medical care (as measured by health insurance coverage and proxies for the quality and quantity of primary care), environmental differences (as measured by residential segregation), adverse effects of inequality (as measured by Gini indices), and labor market conditions (as measured by unemployment rates). Rather, most of the variation in life expectancy across areas was related to differences in health behaviors, including smoking, obesity, and exercise. Individuals in the lowest income quartile have more healthful behaviors and live longer in areas with more immigrants, higher home prices, and more college graduates. …

"Theories positing that differences in mortality are driven by the physical environment (eg, exposure to air pollution or a lack of access to healthy food) suggest that the gap in life expectancy between rich and poor individuals should be larger in more residentially segregated cities. Empirically, in areas where rich and poor individuals are more residentially segregated, differences in life expectancy between individuals in the top and bottom income quartile were smaller (r = −0.23, P = .09). Individuals in the bottom income quartile who lived in more segregated commuting zones had higher levels of life expectancy (r = 0.26, P = .04). …"

So, life expectancy is basically a Selection Effect, not a Treatment Effect. Healthy poor people move to expensive places New York and Santa Barbara where they can hustle for money, while sickish poor people move to cheaper places like Tulsa were they can stretch their fixed incomes further.

r= - 0.23 or r = 0.26 are fairly weak.

But they were hoping to have the headline "Segregation Kills."

"Healthy poor people move to expensive places New York and Santa Barbara where they can hustle for money, while sickish poor people move to cheaper places like Tulsa were they can stretch their fixed incomes further."

That does not account for the longer lifespans of poor people in rural areas of New England, the upper Midwest, and the Mountain West.

No, but why would you assume I'm asserting that?

There are so strong selection effects at play here that this kind of research is useless.


Like what? The healthy poor migrate to New York?

More like the sick move away.

The sick poor move away from New York? First I've heard of that one. What's the reasoning? Health care is relatively cheap in NY if you're poor. They cover more in Medicaid than Florida does.

Most people who are chronically sick are unable to work full-time or even at all. Usually they have to move in with friends or family. Few people in New York just have an extra bedroom lying around. Sure it's nice to have more extensive medicaid coverage, but it doesn't outweigh being homeless.

If New York tends to attract immigrant groups with better health and better life habits, then the answer is Yes. Different immigrant groups have different behavioral patterns. As do different Americans. Just contrast the buying habits and preferences for education of groups of equally poor people from different parts of Africa, Asia, and Latin America.

For someone born well into the last century, this was the most shocking line:

"It has low rates of smoking and has many immigrants, who tend to be healthier than native-born Americans."

What have we done to ourselves?

The American diet is terrible for you. The "peasant diet" of India, China, Ethiopia, Jamaica, etc. isn't actually all that bad.

Poor people in America eat processed crap. Poor immigrants haven't developed a taste for that stuff yet and are still eating what their grandparents ate. That alone probably adds three or four years to their life expectancy.

I'm guessing a good deal of the <$28k income earners in Manhattan and San Francisco are Trust Fund babies pursuing their dreams of acting, music, art, etc.

Right, the top of the list for life expectancy for the poor are NYC, Santa Barbara, and San Jose: all super-expensive cities that shed poor people who suffer a health setback.

I critiqued Chetty's new paper here:

"There are so strong selection effects at play here that this kind of research is useless."

Raj Chetty's research isn't useless, except for the social engineering purposes he positions it as being relevant to.

I've found Chetty's research fascinating in understanding selection effects and long term historical trends:

It's just not very useful at advising Hillary Clinton or Jeb Bush, which is what Chetty has been trying to use it for.

What happens if you remove deaths from fatal injuries from the life expectancy tables? - See more at:

There's a remarkable difference between NY and Arizona.

So, a) Is smoking and being fat are low status in large urban areas? or b) at state level, the % of dangerous is smaller and/or violence is lower?

However, location matters. It less risky to be a poor janitor compared to a poor miner (or any other risky job).

"However, location matters. It less risky to be a poor janitor compared to a poor miner (or any other risky job). "

There aren't enough poor miners in the US to statistically matter. There are only 270K in the US and few of them would be classified as poor.

Where you have one miner, you almost certainly have 5 to 10 people who are breathing air with toxic particulates and drinking water with pollution like heavy metals or hydrocarbons.

NYC once had very polluted water and air which shortened life, but public policy addressed the health problems with massive jobs programs that drove the overall economy by making NYC more productive, thus quickly paying for those jobs programs: the water system which delivers pure unprocessed water, removes sewage, moves people underground with non-fossil fuel and non-horseshit transit, etc.

What I find interesting is the view that paying workers is harmful, a view that pervades the areas where health of the poor is worse than in places like NYC that were willing to pay lots of workers as public policy, making it the landmark city of the US.

Of course, you create poor people by refusing to pay them to work as a matter of public policy.

Arizona has a lot of Hispanics (higher life expectancy than non-Hispanic whites, even without adjusting for income), and very few blacks (lower life expectancy than non-Hispanic whites, even adjusting for income), so it has some demographic advantages over New York City, which is about 25% black.

Mexicans live a long time relative to their income, both in America and Mexico.

Black men have shorter life expectancies than whites, but the gap is rapidly closing due to lower homicide and AIDS death rates in this century compared to the 1990s. The NYT article flails about trying to figure out why life expectancy has climbed quickly in Birmingham, AL, but it's part of a general trend toward longer black life expectancies since NWA broke up.

The NYT cites Tulsa has having decreasing life expectancies among the poor, but Tulsa has a lot of poorish whites, heavily Scots-Irish, and American Indians, both of whom have been having a poor 21st century due to pain pills and heroin, obesity and smoking.

NYC is increasingly immigrant black. American blacks have been net leaving for decades.

The referenced NYT article is inconsistent, it simultaneously tells us that "Poor people in the Hawaii area live shorter lifespans than all of their neighbors." (and who are Hawaii's neighbors?) while also teloing us that the Poor in Hawaii have 0% difference in life expectancy: " why are life expectancies for the poor in the Hawaii area in line with those elsewhere in the U.S.? "

On the other hand, the total welfare benefits package in NY would put any low income household above the low income threshold for the article for NY anyway: (and DC, HI, MA, RI, NJ CT)

NY broken down even further, what is wrong with the Bronx and Staten Island?

A couple of suggestions re: Staten Island. Staten Island is functionally a very large suburb. Other than a few small sections of the North Shore, most areas aren't really walkable, and many if not most residents commute long distances to jobs in the other boroughs or New Jersey. Many Staten Islanders will also tell you that they are neglected by the city in terms of services and access to services.

Can't speak to the Bronx though.

I see that the article seems to mess up when failing to list Hawaii's neighbors like it does for the rest of the USA. It is also worth noting that by Hawaii, the article is only referencing Hawaii County (the big island). It then lists Maui, Honolulu, & Kauai separately.

Geography? Are they poor because they live in county B or they live in County B because they're poor?

Life in New York requires a lot more walking than life in most areas, which may contribute to longevity.


The 2 Jumbo Elephants in the room that people regularly fail to take into account when comparing the US and Europe are the fact that a significant number of Europeans walk a lot more and the eat a lot healthier.

Considering the fact that most Americans barely walk and what they eat, the American healthcare system is actually performing miracles.

I could not agree more. Simply walking around town daily does everything from burn more calories to reducing the chance of diabetes to reducing stress by getting away from blog comment sections.

We built the Sun Belt around the assumption that nobody would ever want to walk anywhere.

The planners were absolutely correct. Nobody actually does want to walk anywhere in Georgia in July.

The problem is that the human body still requires regular exercise in order to function properly.

I have heard this raised as New York's advantage in the past. Everybody walks.

My wife and I recently took the kids to NYC for a short vacation. Even with frequent cab rides, we still did a lot of walking. Somebody who couldn't afford cabs would end up walking all the time. Even if you take the bus, it's unlikely to drop you off in front of your house, you'll still have to walk a couple blocks.

Plus, I would imagine many poorer people live in walk-up apartments. Walking a few blocks several times a day, along with climbing 3-4 flights, will keep you in good shape even if you otherwise take no exercise and have a poor diet.

I don't think it's enough to "keep you in good shape", but surely better than driving from your garage to parking in front of your office job.

I have also heard that the stress plus sitting of a commute is especially harmful. Leaves you tired, hungry, but without much muscle activity.

Illinois stuck out to me in a similar manner. It definitely seems to me like most of these kind of regional graphics that get put together show Chicago looking worse than most of Illinois, but this one shows Chicago looking better. Of course, it may also help Chicago that this graphic put all of Chicagoland together & therefore Cook County does not stand out.

Chetty uses "commuting zones" that are like metro areas except they divvy up all the rural counties as well. So "Chicago" in the study includes high end suburban counties like Lake and Dupage.

Grrrr -- where's the preview or edit button:

The emphasis on comparing cities seems a little silly. Judging by the <a href=""chart in the paper, people in the lowest quartile live longest in northern and western rural areas. Perhaps we should be encouraging people to get out of the unhealthy cities and move the the healthier nearby countryside? That would be much more feasible than moving to unaffordable places like New York City or San Francisco. But, in truth, the differences probably have very little to do with local political policy and a great deal more to do with the racial/ethnic/cultural characteristics of the poor populations in a given place (the poor in Detroit whose life expectancy is low have little in common with the poor in the countryside outside Traverse City whose life expectancy is much higher).

Daniel Patrick Moynihan's Law of the Canadian Border says that most good social metrics correlate negatively with distance from the Canadian border: e.g., Minnesota has higher school test scores and lower violence than Louisiana.

A lot of Moynihan's Law is race, but some of it is more subtle differences among white people.

Detroit of course is the anomaly: it could not be closer to Canada unless it was in Canada.

It has low rates of smoking and has many immigrants, who tend to be healthier than native-born Americans.

In other words, geography actually has nothing to do with it.
Here I was thinking this article would suggest that poor people in hilly areas lived longer because they spent more time biking and walking up and down hills and thus got more exercise. And then I read the article and find out that it's because poor people in certain areas aren't really from that area, they are from other countries.
Ok, so we really have no idea why immigrants are healthier, except maybe they are less likely to be obese couch potatos than native born Americans.

But describing this by saying that geography has something to do with it is widely missing the mark. Geography is just a loosely correlating factor, it does not cause health or ill health, the actual underlying causes are things like smoking and whatever other lifestyle factors are different between immigrants and Americans. The fact that in New York poor people live longer is just an accident.

So you're postulating that areas with more immigrants will have better health outcomes from the poor? If that turns out to be true, its an interesting finding. It's why studies like these are important. They prompt us to search for the reasons behind different phenomenon.

Never understood the conservative disdain for studying why certain parts of the country perform differently than others (not saying you're one of these people necessarily).

> Never understood the conservative disdain for studying why certain parts of the country perform differently than others (not saying you’re one of these people necessarily).

Maybe that's because 9 out of 10 of the discussions about those types of studies goes like this:

Liberal: Oh my god, look at these state-level statistics. Southern Red states like Mississippi and Alabama look horrible. Meanwhile Blue states like Vermont, Minnesota and Oregon have excellent metrics. Clearly this metric would improve if America adopted Nordic-policies. Republicans just hate science and evidence.

Conservative: The distribution of that map looks an awful lot like the black belt. Mississippi has the highest proportion of blacks in the Union and Vermont has the lowest. Sure blacks do very bad on Metric X in Mississippi, but in general blacks seem to do very bad on Metric X nearly everywhere. It's just less visible when they're a smaller percent of the population. This isn't evidence that Mississippi is an awful run state, just that the Vermont state government is playing on Easy Mode.

Liberal: Shut your goddamn racist mouth.

Even if you look at whites-only data Mississippi is at the bottom.

Chetty doesn't have whites only data.

He tries to adjust his data by the percentage of races in each geographic zone, but he's vague on how they differ by income level within each zone, so the adjustments are woozy.

But, yeah, even just among whites, Moynihan's Law of the Canadian Border says that northern whites will tend to outperform southern whites on most social measures. But the differences are smaller than the racial gaps.

I was talking about obesity and smoking rates.

Replace "place" with "culture" (food, exercise, smoking, drinking, etc) and maybe you are on to something.

As an actual geographer, allow me to point out that many geographers would say "place" is arguably conceptually closer to "culture" than it is to "physical location," which we would generally call "space"... although it's a bit of both.

Framing 1 : "Place plays a part in helping the poor live longer"
Framing 2 : "Culture plays a part in causing the poor to live shorter lives"

It's surprising this blog picked the NY Times framing.

Cherry picking. If you are poor there are differences between regions (hint: do not go to states which have not expanded Medicaid--see map in article and comment in results about government healthcare expenditures being significant to results) but the differences in regions does not remove the differences between rich and other words, being poor matters, and the difference in geography of where you are poor doesn't overcome the effect of being poor.

Here is the summary of results in the abstract:

"Results The sample consisted of 1 408 287 218 person-year observations for individuals aged 40 to 76 years (mean age, 53.0 years; median household earnings among working individuals, $61 175 per year). There were 4 114 380 deaths among men (mortality rate, 596.3 per 100 000) and 2 694 808 deaths among women (mortality rate, 375.1 per 100 000). The analysis yielded 4 results. First, higher income was associated with greater longevity throughout the income distribution. The gap in life expectancy between the richest 1% and poorest 1% of individuals was 14.6 years (95% CI, 14.4 to 14.8 years) for men and 10.1 years (95% CI, 9.9 to 10.3 years) for women. Second, inequality in life expectancy increased over time. Between 2001 and 2014, life expectancy increased by 2.34 years for men and 2.91 years for women in the top 5% of the income distribution, but by only 0.32 years for men and 0.04 years for women in the bottom 5% (P < .001 for the differences for both sexes). Third, life expectancy for low-income individuals varied substantially across local areas. In the bottom income quartile, life expectancy differed by approximately 4.5 years between areas with the highest and lowest longevity. Changes in life expectancy between 2001 and 2014 ranged from gains of more than 4 years to losses of more than 2 years across areas. Fourth, geographic differences in life expectancy for individuals in the lowest income quartile were significantly correlated with health behaviors such as smoking (r = −0.69, P < .001), but were not significantly correlated with access to medical care, physical environmental factors, income inequality, or labor market conditions. Life expectancy for low-income individuals was positively correlated with the local area fraction of immigrants (r = 0.72, P < .001), fraction of college graduates (r = 0.42, P < .001), and government expenditures (r = 0.57, P < .001).

Conclusions and Relevance In the United States between 2001 and 2014, higher income was associated with greater longevity, and differences in life expectancy across income groups increased over time. However, the association between life expectancy and income varied substantially across areas; differences in longevity across income groups decreased in some areas and increased in others. The differences in life expectancy were correlated with health behaviors and local area characteristics."


Here is the link with the map referred to above. Also, it pays to be in locations where rich and poor share the same healthcare facilities across an area, than in being in an area that has mostly poor residents.

Now that's an interesting insight. If you live near the ultra-rich, chances that there will be good doctors nearby go up.

And it appears that it trickles down to the poor in that area. So, to improve health outcomes of the poor in the US, we ought to promote health care access for the poor to similar hospitals used by the ultra-rich. Now we're getting somewhere!

No, the big factors in the life expectancy of the poor are smoking (negative), obesity (negative), and exercise (positive). In general, the upper middle class culture of the top quarter trickles down somewhat to the lower quarter. For example, Los Angeles is #5 on life expectancy for the lower quarter, in part because there's a general pattern of not being obese, not smoking, and exercise. Also, poor people in L.A. tend to move away if they suffer a health setback, since L.A. is an expensive place to be poor and sick.

In contrast, Los Angeles has rather bad life expectancy for people in the top quarter of income. Who knows why?

Perhaps because James Dean is a local culture hero? Live Fast, Die Young, Stay Pretty.

Steve, Sorry, but the study lists many factors beyond the three you mentioned, including increases in government expenditures.

Here's my new analysis of the factors affecting life expectancy among the bottom quarter and the top quarter in reported income:

The poor live longest in ultra-expensive cities with lots of income inequality and cops. But much of that is likely an artifact of churn: Rich cities attract energetic sojourners but then shed them if their health breaks down.

In contrast, people in the upper quarter of income live longest in the less fashionable sort of Stuff White People Like cities: Salt Lake City, the other Portland, and so forth, stable places with the Murray-Putnam community virtues.

See my comments to yours below at the end of this post.

Would you rather be a rich obese person than a poor one.

From the article: "But the characteristics that mattered less may be surprising, too. Research showed that the uninsured rate and the unemployment rate, for example, did not correlate to life expectancy."

If you are uninsured you still receive healthcare at the hospital but receive it as uncompensated care. Uninsured persons receive healthcare from government expenditures, which the report shows are significant to outcomes and longevity.

The Oregon medicaid experiment showed no effect on health outcomes.

"Approximately two years after the lottery, researchers found that Medicaid had no statistically significant impact on physical health measures, though "it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain."

Watts, You are purposely ignoring the findings of this study, which are:

"Life expectancies for low income individuals was positively correlated with ... government expenditures ( r=.57, P<.001)." Maybe you didn't read, or perhaps you didn't know that Medicaid is not all government expenditures for the low income. I suspect you know that Medicaid is not all government expenditure for the low income. And, I suspect that you also know that one study was on health care measures ,and the other was on longevity. I know it might be hard for you to understand, but there is a difference beyond the inclusion of only Medicaid, in your mind, as the government expenditure category, or the difference between health measures and longevity.

Bill you are ridiculous. You started with this:

"If you are poor there are differences between regions (hint: do not go to states which have not expanded Medicaid–see map in article and comment in results about government healthcare expenditures being significant to results) "

So, you are indicating that Medicaid is causal.

Now you are moving the goal post with this argument: "but there is a difference beyond the inclusion of only Medicaid, in your mind, as the government expenditure category, or the difference between health measures and longevity."

Go look at the map re Medicaid expansion and longevity.

And, go look at the study, which finds that government expenditures is positively correlated with longevity.

Re: government expenditures and longevity:

From the NYT article:

"Dr. Mark E. Wilson, chief executive of the health department in Jefferson County, Ala., which includes Birmingham, ticked off a number of things that might have helped.

The county expanded availability of preventive health care like vaccinations and mammograms by opening clinics in poorer neighborhoods in the 1990s and early 2000s (though recently it has closed some of the clinics). Although a relatively high percentage of the population lacks health insurance, a portion of local taxes goes to hospital care for those who cannot pay. The county has been ahead of the rest of Alabama in banning smoking in restaurants and workplaces, with a law enacted in 2012. And philanthropic foundations backed by old industrial money have funded campaigns to make people healthier in the Birmingham area.

“These aren’t all huge-scale projects, but there is still an alignment of getting resources moving in the same direction around health,” Dr. Wilson said. “We’re trying to establish a culture of health and get it more and more on the radar screen of our community.”

Re: The Oregon medicaid experiment showed no effect on health outcomes.

I invite anyone who thinks that passes the laugh test to put their life where their opinion is: next time you are seriously ill or have a major injury, forego healthcare. Do you really think the results will be the same as for someone who does not forego healthcare in similar situations?

"Poor residents in the New York area gained about 2.5 years of life expectancy since 2001."

How correlated is this with smoking and obesity?

Simple addition of the two rates (smoking + obesity): NY 18 + 27 = 45 versus Nevada 23 + 28 = 51 versus Arkansas 26 + 36 = 62

I assume this is in JAMA instead of an econ journal because they don't have any identification to get at a causal effect?

"Health care," in study after study after study, pretty much boils down to "Don't smoke, eat right, exercise, avoid toxic substances."

Which leads me to conclude that if we are going to socialize medicine, then it should be for things like serious illness and injury. Otherwise we're just subsidizing poor lifestyle choices.

I'd have little problem with single-payer that covered vaccination, antibiotics, the setting of broken bones, and palliative care.

We'd get 95% of the benefit of healthcare and 1% of the cost. If you want to insure for your own cardiac care, diabetes care, and oncology, go ahead.

I had some hope when Obamacare was first discussed that the Bronze plan would be something similar to what you described. Sort of a Federal Basic Medical care, that truly covered the basics. Instead, the Bronze/Silver/Gold ended up being primarily based upon the financial structuring.

To me, this is what showed they weren't really serious about addressing health. They just wanted some big Federal potlatch to show constituents how much they care, and there were pockets that needed lining.

Maybe that's slightly part of the dynamic.But there are a lot of people who deeply believe that access to medical services should not be contingent on what you have managed to earn in the market.

Did you even read what I wrote? Obviously what you wrote isn't true, because that's not even close to what they implemented. At a societal level it's not even possible for it to be true.

"But there are a lot of people who deeply believe that access to medical services should not be contingent on what you have managed to earn in the market. "

Maybe, but it's clear that the administration didn't much care about those opinions once they won the election. If that was a high priority, they would have instituted single payer. Instead, they went with the conclusion that kept the campaign contributions from the health insurers and health industry intact.

"Maybe, but it’s clear that the administration didn’t much care about those opinions once they won the election. If that was a high priority, they would have instituted single payer. Instead, they went with the conclusion that kept the campaign contributions from the health insurers and health industry intact"

I'm sure that's what they wanted, but they knew that single payer was politically impossible, so instead they went for the best they could achieve. Obama thought this was just a first step.

My single payer, with 95% of the benefit and 1% of the cost, would have flown through Congress.

L A - They tried to achieve the possible, instead of digging in for what was not politically feasible. If Republicans signaled support for universal healthcare, Obama would be on board tomorrow.


Healthcare for democrats is like abortion for republicans. God forbid they solve the problem, 'cause then they're losing money and votes for years to come. So they chose to line some pockets and show they cared for a few politically important groups and leave the problem unaddressed.

The disparate treatment of different ages also shows they aren't serious about addressing health.

Spending a lot of Federal money on the treatment of 70 year-olds is insane.

Those services can be easily commoditized to the point that most people could afford them. What people really fear, and rightly so, is catastrophic injury or illness that wipes them out financially.

Also being locked into a job because of the insurance. Not just for you but for children & spouses with chronic illnesses.

Your healthcare statement only holds true until around age 65, after that it is basically false. Older people come down with many adverse health conditions and outcomes, and that goes far beyond just the ones with bad lifestyle choices

Yes, "getting old and dying," I'm familiar with the phenomenon. The debate is over what we are going to socialize. So far, a fiscally responsible, economically sustainable way to socialize getting old and dying eludes us.

Actually, there is a way: have lots of children and stay on good terms with them.

Older people can, almost uniformly, self insure. The Federal government should pay _nothing_ or almost nothing for the healthcare of people over 65.

If you're worried about what we do with all the people who value plasma TVs over saving dying on the streets at age 78, institute mandatory HSAs that aren't accessible until 65 and that are transferable to you heirs or charity on death.

"Older people can, almost uniformly, self insure."

"All unicorns are pink"

Pulled equivalently from out of your ass and mine, respectively


The only ones who can't are those that somehow had a disability that kept them from working _their entire life_ and yet somehow made it to 70+ years old. Those are your unicorns.

The old have had time. Of course they can self-insure. Children can't self-insure; they don't choose the circumstances they were born into. But old people have chosen their circumstances nearly uniformly.

Do you consider genes to be a matter of choice?

What about genes selected by diet over hundreds of generations which are incompatible with the foods provided by the subsidized corporate food industry? Ie, first nation people's in the Artic circle lived long eating meat high in fat and no fruits and veggies? Or on the prairie, a diet heavy in bison?

Not to mention genes that promote cancers and tumors, plus various auto immune and degenerative conditions?

What about being born in an area with industrial pollution and growing up breathing polluted air, drinking polluted water, thus suffering from heavy metal poisoning or particulates affecting your lungs, all before you become even a teen?

I'm familiar with Gary, Indiana from providing customer support to Inland Steel when it was investing billions on cutting pollution in the 70s, going in winter from West of Chicago into Gary and seeing snow go from white to gray to near black the closer we got.

A certain group believes in genes, but only to the extent that it means they are better, and can forget about everyone else.

If you weren't in a permanent marijuana-induced fog, you'd notice I didn't mention genetics.

But now that you mention it, if society is to cover the cost of genetic illness, then don't be surprised when society demands a say in people's genetics.


In fact the government could easily cover everyone for less than what they spend now. They could pretty much set the amount they want to spend and cover everyone. Even just covering evidence based medicine would cover everyone for what Government spends now.

The lifetime risk of cancer is 42%. Anyone choosing your no-cancer bronze "plan" is putting themselves at huge risk, and putting all the burdens on society that universal coverage was meant to cure.

The average cost of cancer for the US is about $400 per capita per year. So, adding it to a baseline bronze plan would increase the cost by $33 per month.

That assumes you were trying to recover 100% of the cost via insurance. A more logical approach would be to capture some out of pocket (through a deductible) and the rest via monthly premiums. And perhaps you base the premiums on a tobacco using versus non-tobacco using model, which would allow the users to better judge the costs of their individual behavior.

Are you aware that ACA policies often have huge deductibles, and this is becoming the norm in workplace policies too?

Major med care (which definitely includes oncology, cardiac medicine etc.) is exactly what people should have healthcare coverage for. Along with preventative services of course.

The Deaton comment makes sense. Another case of conflating "income" and:"wealth" which is pretty much de riguer in the US. The Chetty paper uses "Pretax household earnings" as a measure of wealth. There are no doubt lots of "poor" people living in Manhattan penthouses who choose not to earn any income and live off their accumulated wealth which is probably not earning much interest if it is in relatively safe investments. Not sure how you would measure household consumption among the elderly by county though.

Funny, my conclusion would have been "It’s almost as if health care policy should be (national) in

If NYC can discourage smoking via initiatives such as smoking, why not role out similar legislation nationwide? Is local control really so great if the result is higher rates of smoking-related illnesses?

I really don't understand the argument as to why local control would be better using this set of data - national control means NYC would be hurt because it would be forbidden from raising tobacco taxes?

Ms. Sanger-Katz (the author of The Upshot column referenced by Cowen) got her break in medical economics when Austin Frakt and Aaron Carroll made her a regular contributor to The Incidental Economist - Frakt and Carroll, the creators of TIE, are now also regular contributors to The Upshot. Dr. Carroll blogged at TIE earlier today about the JAMA study: "This is an amazing analysis, don’t get me wrong. But exactly how does one go about getting tax records for every individual in the US for every year from 1999 through 2014? How does one get the SSA to turn over the records of every individual with a valid SSN between 1999 and 2014? I wouldn’t even know where to start. . . . Sometimes studies like these are completely dependent on one’s ability and influence to get the data from the organizations that house it. We never talk about that. No one shares their secrets. Studies like this are, therefore, rare."

It doesn't help that the government manufactures poor people faster than we create productive citizens. Nor does it help that government housing policies either remove the middle class or make it prohibitively expensive to live in certain places. All that is left is the poor. Maybe we should socialize these propagandists on the left and give them a taste of their own medicine. No doubt they use government grants to do these self-serving studies. Of course, they can't be bothered about finding the causes of poverty. That might embarrass their political masters.

What's the cause of poverty?

Low demand for your skill-set.

Might there be social gains in helping people to expand their skill sets and enjoying greater access to networks which can match their skills in the market?

Could it all be explained by people in NYC tending to walk more.

BTW This si another reason let the builders build up in NYC so more people can move there.

If you are interested in what insights can be gleaned from Raj Chetty's huge data project, last year I wrote a lengthy critical analysis of the strengths and weaknesses of his 2015 "income mobility" study that I called "Moneyball for Real Estate:"

The quality of his analyses have been improving since he first went public with this giant manna-from-heaven IRS database in 2013, but he still needs in-depth criticism. A general problem with Chetty is that he doesn't demonstrate that he has much insight into the different kinds of people who live in different places in America. So, he constantly is searching for Treatment Effects to explain differences among places when they are often Selection Effects.

Chetty's findings always have a heavy PC spin on them but he is reasonably straight forward with the results, he just cant bring himself to identify problems as being primarily with people and their cultures as opposed to lack of interventions. Government is a second order effect on differentials.

Well said.

If you read Chetty's papers carefully, they are quite revealing. But he crafts them to make them easy to spin in a PC manner by journalists who don't really have a clue.

Professor Chetty has talked his way into access to an unbelievable trove of your confidential data from your 1040s (anonymized [hopefully]). The database he uses should be thought of as national asset, so he should be exposed to frank criticism when his analytical methodologies have weaknesses or he tries to spin the results to distract from his politically incorrect findings.

The only ones who seem not to having a clue are those who haven't read the paper or seek to deny the conclusion: increased government expenditures are positively correlated with longevity. You don't have to spin if you just read the conclusions. A poor obese person next to a rich obese person has different longevity outcomes, and has better outcomes where there are greater government healthcare expenditures for poor persons.

Have you ever seen an obese wealthy person? Or one who smokes?

Guess not.

Re obesity:
"High-income countries have greater rates of obesity than middle- and low-income countries (1). Countries that develop wealth also develop obesity; for instance, with economic growth in China and India, obesity rates have increased by several-fold (1). The international trend is that greater obesity tracks with greater wealth (2,3).

The U.S. is one of the wealthiest countries in the world and accordingly has high obesity rates; one-third of the population has obesity plus another third is overweight. The situation is predicted to worsen; rising childhood obesity rates forewarn of worsening statistics (4). While it is agreed that both individual factors such as genetic susceptibility and behavior are important in life-long weight gain, evidence is ill-defined with respect to the nature of the environmental influences that impact obesity (5)."

Re: poverty and obesity:

"How is poverty linked to obesity? It has been suggested that individuals who live in impoverished regions have poor access to fresh food. Poverty-dense areas are oftentimes called “food deserts,” implying diminished access to fresh food (7). However, 43% of households with incomes below the poverty line ($21,756) are food insecure (uncertain of having, or unable to acquire, sufficient food) (7). Accordingly, 14% of U.S. counties have more than 1 in 5 individuals use the Supplemental Nutrition Assistance Program. The county-wide utility of the program, as expected, correlates with county-wide poverty rates (r = 0.81) (7). Thus, in many poverty-dense regions, people are in hunger and unable to access affordable healthy food, even when funds avail. The double-edged sword of hunger and poor availability of healthy food is, however, unlikely to be the only reason as to why obesity tracks with poverty.

There is evidence of the association between sedentariness, poor health, obesity, diabetes, other metabolic diseases, and premature death (8). Sedentary individuals move 2 h per day less than active individuals and expend less energy, and they are thereby prone to obesity, chronic metabolic disease, and cardiovascular death (9). More than half of county-to-county variance in obesity can be accounted for by variance in sedentariness (Fig. 1B). Overall, the poorest counties have the greatest sedentariness (Fig. 1C) and obesity.

Several reasons may explain why people living in poor counties are less active. One reason may be that violence tracks with poverty, thereby preventing people from being active out-of-doors. Similarly, parks and sports facilities are less available to people living in poor counties (5), and people who live in poverty-dense regions may be less able to afford gym membership, sports clothing, and/or exercise equipment. There are multiple individual and environmental reasons to explain why poverty-dense counties may be more sedentary and bear greater obesity burdens. What is unknown is whether reversing poverty would reverse sedentariness and obesity. It is an urgent matter to address—both rates of childhood obesity and poverty are concomitantly on the rise (1,2)."

When I was poor, I couldn't afford any of that processed crap that "poor" people eat. I cooked Indian-style and Central American-style food. Lots of lentils, chick peas and other beans, rice, frozen vegetables, potatoes, and as a luxury to make it taste good, lots of butter or some peanut or olive oil. Spice accordingly and use some variety of preparation methods, and you've got dozens of meal options at under 50 cents a serving. I mean, who the hell can afford white bread or no name potato chips when you're actually poor?

Nathan, Marie Antoinette instead of saying "Let them eat Cake"

Should have said,

Let them eat Lentils.

While morbid obesity is certainly bad, there no hard evidence that being overweight predicts bad health outcomes.

From here:
Contrary to conventional wisdom, … the poor have never had a statistically significant higher prevalence of overweight status at any time in the last 35 years. Despite this empirical evidence, the view that the poor are less healthy in terms of excess accumulation of fat persists.

A new paper manages to find a relation between poverty and fat – both the very fattest and the very thinnest people tend to be poor

How many people who blame people and culture oppose nudges because those same choices are freedom?

Comments for this post are closed