How long you can expect to live depends on what U.S. region you live in and the reasons for it go back centuries.
This spring I ran across an opinion column in the Los Angeles Times illustrated with a county-level map of life expectancy in the U.S., one with such stark and obvious affinity to the regional boundaries identified in my American Nations model I knew this was an issue we had to dig into here at Nationhood Lab.
Public health researchers have long known that health and longevity at the population level are closely related to socioeconomic status and access to quality food, exercise opportunities, clinical care, and social supports. Given America’s regional cultures have always had strongly divergent views on the desirability of social spending, equality, government regulation, and investment in public goods, it stands to reason that they would have similarly divergent health outcomes, including the bottom line statistic of how much time the average person will live.
So is it true?
With our partners at Motivf we crunched the numbers and found big differences between the U.S. regions – 3, 4, and nearly 5-year differences between the American Nations for the period 2018-2020 – which are like the gaps between the U.S. and Bulgaria, Libya, and the Philippines. In some comparisons – such as Left Coast (the Pacific coastal plain north of Monterey, California) and First Nation (the parts of Alaska where indigenous culture, though damaged, remains dominant on the ground) – the differences were more than a decade, comparable to the gulf between Japan and Peru.
The Deep South and Greater Appalachia had an overall life expectancy of 77 years during this period, similar to Albania’s in 2020, while in the Left Coast the figure is 81.6, which about the same as Canada’s. The differences between some of the smaller “enclaves” – small extensions of regional cultures that primarily exist outside the present borders of the U.S. – were even greater, with the gap between Hawaii (part of Greater Polynesia) and First nation standing at a staggering 10.8 years.
As with deadly gun violence, political behavior, or Covid-19 vaccination acceptance, it’s as if we’re living in different counties.
We thought this might just be a reflection of wealth. Some American regions have always had higher standards of living than others because of their cultural values the relative importance of individual liberty and the common good, economic freedom and social equality, or low taxes and quality services. From their arrival in the late 17th century, the Deep Southern oligarchy didn’t value shared prosperity, public education, or ordinary people’s participation in public affairs; for theological and political reasons, Yankeedom’s Puritan founders valued all three. Urbanized New Netherlanders — inhabitants of the Dutch-founded area around New York City — couldn’t avoid realizing their dependency on shared infrastructure, while the Scots and Scots-Irish founders of Greater Appalachia had historic reasons for equating government with tyranny. As a result, a much greater share of people are poor in the Deep South and Greater Appalachia than in Yankeedom, New Netherland, or their philosophical allies on the Left Coast. So maybe the differences between the regions would go away if you just compared life expectancy of rich counties or poor ones?
We did just that.
Researchers at the University of Wisconsin’s County Health Ranking and Roadmaps project – from which we got our life expectancy estimates – also calculated the percent of children living in poverty in each U.S. county and sorted them into quartiles. We compared the results between regions using just the least impoverished quartile of U.S. counties – the “richest” ones. As you can see in the map on the left below, the gaps persisted: 4.6 years between the rich counties in the Left Coast and Deep South, for instance. And they got even wider when we looked at just the counties in the bottom quartile, those with the most childhood poverty: a staggering 6.7 years between those same two regions, which is like the difference between the U.S. and Uzbekistan. Further, the gaps between these rich and poor counties within the American Nations was more than twice as wide in Greater Appalachia (3.4 years) and the Deep South (4.3 years) as in Yankeedom (1.7 years.)
And consider this: the poorest quartile of U.S. counties that happen to be in Yankeedom have a higher life expectancy than the richest quartile of U.S. counties that happen to be in the Deep South, by 0.3 years. And those are both big regions (circa 50 million people) with a wide mix of counties, rural, urban, rich, poor, blue and white collar, agricultural and industrial. If you compare the poorest category of counties in (completely urbanized) New Netherland to the richest ones in Deep South, the former have an 0.4 year advantage in life expectancy. And people in the Left Coast’s poorest quartile of counties live 2.4 years longer than those in the richest quartile counties in the Deep South.
We repeated the exercise for education, comparing CHRR’s top and bottom quartile counties for the percent of the adult population with at least some college. The patterns were very similar to the childhood poverty ones, as shown on the following table:
So maybe this is a rural vs urban phenomenon? In the U.S., metropolitan places tend to be richer and more educated and have been demonstrated to have higher life expectancy, so it stands to reason the regional gaps might close if you compared just urban counties or just rural ones. So we calculated that too, using the National Center for Health Statistics’ six-tiered categorization system. The gaps persist. Here’s just urban counties across the American Nations:
And here are just the rural ones. Life expectancy is lower in almost every nation, but rural people live 4.7 years longer in the Left Coast or Yankeedom than in the Deep South (and 9.9 years longer in Hawaii than in First Nation.) And the gap between rural and urban health almost vanishes in Yankeedom (where municipalities have wide powers) and the Far West (for reasons less clear), but remains about 3 or 4 years wide in most of the other big regions.
We also compared counties based on the quality and accessibility of clinical care as rated and ranked by CHR&R. Whether looking only at counties that ranked in the top or bottom quartile in the U.S. for this metric, the gaps between the regions grew rather than shrank: to more than five years between the best and worst large “nations.”
So maybe it’s a matter of racial disparities. Black Americans live about three and a half years shorter than white ones, so it’s logical that the regional differences could simply be an artifact of the proportion of African-Americans living in each. (The Deep South, for instance, is just shy of 25% Black, while Yankeedom is only 9%). But when we looked at white-only life expectancy across the regions the pattern and gaps remained:
Here are the results for Black Americans. Gaps persist, but there’s a little shift in the ranking of the regional cultures. Relatively speaking, Blacks live longer in Greater Appalachia than in Yankeedom or the Far West (which isn’t true of whites or the overall population). And – in a pattern we also saw with gun deaths – the Midlands move from the middle of the pack to the worst large region, with Black life expectancy about five months shorter than in the Deep South and 3.9 years less than in New Netherland. Yankeedom isn’t much better, with a Black life expectancy of 73.6, the same as in the Deep South. Tidewater, which like the Deep South is about a quarter Black, has one of the best Black life expectancies (75.6), while the Left Coast – where Blacks are just 4% of the population – it’s 76.3. In Hawaii (part of Greater Polynesia) the data has Black life expectancy higher than that for whites, though that could be a statistical anomaly as there are only about 10,000 Black people living there.
We weren’t able to confidently do a cross-regional comparison of Asian-American life expectancy as this group constitutes less than five percent of the population in most of the American Nations. But given that the average Asian-American lives more than seven years longer than other Americans, the fact they constitute 16.5 percent of the population of Left Coast – and 36.5 percent of Hawaii’s – is likely part of the reason those two regions outperform most of the rest of the country.
Hispanic Americans also have much better life expectancy than whites and we found that was true in every region (save Hawaii, for which see above; and their numbers are too small in First Nation to even try to calculate longevity with any confidence.) Researchers call this the “Hispanic Paradox,” because it confounds the usual associations between socioeconomic status and life expectancy, and they’ve spent considerable time trying to understand why without solid consensus. It has been established – by demographers Alberto Palloni and Elizabeth Arias – that Cuban and Puerto Rican Americans don’t have better life expectancy than whites, but Mexican-Americans do.
I share this background because, curiously, we found that Hispanic life expectancy is relatively poor in El Norte (80.7 years) and the Far West (81.1), the two regions where people of Mexican descent presumably form a supermajority of the “Hispanic” population. New Netherland – home to the largest concentration of Puerto Ricans on Earth, including San Juan – isn’t that great either, at 82.7. Surprisingly, southern regions do really well, with Tidewater and New France hitting the upper 80s to top the list (though you may want to take the latter finding with a grain of salt as the number of Hispanics there is pretty small.)
Keith Gennuso of the University of Wisconsin’s Population Health Institute – which hosts CHR&R – has studied border life expectancy issues. He said the reason Hispanic life expectancy is worse in El Norte is likely linked to centuries of discrimination against them. “Unjust housing policies and forced land dispossessions, immigration enforcement, racial profiling, taxation laws, and historical trauma, among numerous other issues, all act as barriers to equal health opportunities for these populations at the border, with known impacts across generations,” he noted. Other researchers have found the mortality advantage is greatest among Mexican migrants who’d moved to places with few existing Mexicans and suspect these newer immigrant communities are more insulated from less healthy U.S. dietary and lifestyle choices than those that have been in the U.S. for decades or centuries.
First Nation’s life expectancy rates are catastrophically bad however you look at them, a well-documented legacy of exploitation, ethnic cleansing, and – in many cases – attempted genocide. Native Americans and Alaska Natives in the U.S. are disadvantaged in nutrition status, access to safe drinking water, health care, educational opportunities, and jobs, and have higher exposure to disease, drugs, alcohol, tobacco, and violence. This can be seen in the “Lower 48” county map — where some of the worse life expectancy “hot spot” islands are Indian reservations — as well as in other parts of First Nation such as Greenland which, despite being part of the more vigorous social welfare norms of the Kingdom of Denmark, has a life expectancy of 71.6 years. Inuit born in Canada have a life expectancy of just over 72 years which, as in Denmark and the U.S., is a decade less than their fellow nationals. We do note, however, that the total population of the U.S. portion of First Nation is only 59,000 so there’s a greater margin of error in life expectancy estimates and some of the figures, especially the highly unlikely white life expectancy figure of 98 years.
Regional differences persist in other measures of health outcomes. With my colleagues, health scientists Ross Arena and Deepika Laddu of the University of Illinois–Chicago and Nicolaas Pronk of the University of Minnesota and HealthPartners Institute, we looked at county-level data for 2020-2022 to examine rates of obesity and diabetes and also the self-reported prevalence of exercise and the availability of exercise opportunities. (A lack of exercise is one of the key factors leading to obesity, diabetes, and ultimately heart disease.) Our findings, published in the academic journal Progress in Cardiovascular Diseases, revealed the familiar regional patterns.
Here’s the prevalence of Obesity:
Here’s diabetes:
Here is self-reported lack of physical activity, defined as the percentage of adults reporting no leisure time physical activity:
And this is the access to exercise opportunities map, defined via CHR&R’s multi-factor metric. Notice the large gap between Greater Appalachia and the Deep South and everyone else (save First Nation, where conditions are apparently highly adverse for exercise.)
“It’s no big surprise when you look at county-level data that the southern regions have higher prevalence of these things, but never has the relationship been so clean as with the American Nations settlement maps,” says the lead author of our paper, Arena, a physiologist at the University of Illinois-Chicago who studies the health effects of exercise. “With the American Nations it became clear that these issues are not bound by state and that a big piece of this may be culture.”
The model, he says, “puts distinct regional boundaries to what we have been observing for years. In particular, Greater Appalachia is a distinct region of concern for these health characteristics, but we have not specifically talked about that region in the context of a distinct, unique culture.”
Earlier this year at Nationhood Lab we analyzed deadly gun violence – now the largest killer of U.S. children – and found similar patterns, which also echo those we saw when we looked at Covid-19 vaccination rates, are a driver of post-2020 life expectancy declines in the U.S.
So why are there such profound differences between the regions. We asked a number of experts who all emphasized the same points: life expectancy follows from policy, not individual behavior, and the various U.S. regions have very different policy environments.
“We don’t have these differences in health outcomes because of individual behaviors, it’s related to the policy environments people are living in,” said Jeanne Ayers, who was Wisconsin’s top public health official during the Covid pandemic and is now executive director of the Healthy Democracy Healthy People, a nationwide coalition of 11 national public health agencies probing the relationship between political participation and health. “Your health is only ten percent influenced by the medical environment and maybe 20 or 30 percent in behavioral choices. The social and political determinants of health are overwhelmingly what you’re seeing in these maps.”
Cardiologist Donald Lloyd-Jones, a past president of the American Heart Association who chairs the preventive medicine at Northwestern University in Chicago, said much the same. “We have too much of a tendency to put these problems on individuals when it is very much the policy environment that shapes just how long and how well a person can live,” he told me. ““The places on your map where you see orange and red have structural and systemic issues that limit people’s ability to have socioeconomic opportunity, access health care, or achieve maximum levels of education. All of these policies effect your health and these disparities in longevity absolutely reflect social and structural and historical policies in those regions.”
Jeremy Ney is a data scientist who works by day at the Federal Reserve in New York and at other times on his American Inequality substack site, the source the Los Angeles Times turned to for the column that first brought my attention on this subject. He says policies shape income inequality and racial disparities. “And inequality can be a matter of life and death,” he told me earlier this month. “It’s not just about the bills in your pocket, but the breaths you have on this planet.”
New Netherland is a case in point, he notes. Despite its density and diversity, it’s one of the healthiest places to live, with an overall life expectancy of 80.9 years. “You can have policies that can meaningfully change life expectancy: reduce drug overdoses, expand Medicaid, adopt gun control, protect abortion and maternal health,” Ney continued. “That New Netherland regions ticks the box on all five of those.” The region is also near the top of the list for Black longevity and life expectancy for residents of the poor counties.
Readers of American Character: A History of the Epic Struggle Between Individual Liberty and the Common Good, the sequel to American Nations, will quickly recognize that the regions that consistently deliver the worst health outcomes come from the individualistic side of the cultural spectrum, which fosters policy environments favoring low taxes, a soft regulatory environment and weak public services and social safety provisions. The best performing ones – Left Coast, New Netherland, and Greater Polynesia — are communitarian, with a greater emphasis on public goods and robust regulations, even if it results in higher taxation. Those tendencies aren’t a new phenomenon, but are tied back to the cultural milieu of rival 17th and 18th century colonizing groups, yielding very different civic cultures and political agendas in the 19th, 20th, and 21st centuries.
One example. Guess which states still haven’t expanded Medicaid, even though almost the entire burden of doing so comes from the federal government? At this writing there are eleven of them and all but two are controlled by the Deep South and Greater Appalachia. One is in the Far West (Wyoming) and another is split between the Far West and Midlands (Kansas). Just one – Wisconsin – is in Yankeedom, and its Democratic governor has been trying to expand it through a (vigorously gerrymandered) Republican legislature. States that have expanded Medicare have seen significant reductions in premature deaths while those that have not have seen increases.
There are some derivations from this pattern. The Midlands – the legacy of a settlement stream founded by William Penn’s utopian Quaker-led project on the shores of Delaware Bay – is communitarian, though suspicious of distant governmental power. But it performs pretty badly overall (a 78.1 year life expectancy), in urban counties (78.2) and is the worst region of all for African-Americans, save New France. As with political behavior and gun violence, this region shows much starker differences between urban and rural regions than the other American Nations; understanding why is a topic for further research.
Yankeedom, the quintessential communitarian region, performs better than the U.S. average, but has surprisingly little differences between urban and rural life expectancy. (In terms of life expectancy, it’s tied with Left Coast as the best large region in the country.) It’s also has the least difference between rich and poor counties, just 1.7 years or less than half that of the southern regions. It may not have the best life expectancy outcomes, but it has the fairest ones socioeconomically. Race, though, is another matter, with Black life expectancy no better than the Deep South and worse than Greater Appalachia.
As in politics and gun violence, New France’s enclave in southern Louisiana – Cajun country, the old “Bourbon” plantation parishes along the river, plus New Orleans (shared with Deep South) – has in recent decades come to resemble the Deep South on steroids rather than the communitarian culture of its Acadian counterparts. This – like Tidewater, in an opposite direction of travel – offers an example of a smaller regional culture undergoing fundamental cultural change under the influence of more powerful neighbors.
Cultural values drive politics. Politics drive policy. The policy environment drives health outcomes, which in turn drive life and death. There are some quick fixes to boost these stats, like taxing tobacco, but from there improving the quality and duration of people’s lives will likely take different forms in different regions with varied shortcomings. At Nationhood Lab we’ll continue delving into this in the months and years ahead.
— Colin Woodard, author of American Nations, is the director of Nationhood Lab at Salve Regina University’s Pell Center for International Relations and Public Policy. He thanks his colleagues at Motivf, Tova Perlman (for crunching life expectancy data) and John Liberty (for the maps in this piece.) Also thanks to Ross Arena of the University of Ilinois-Chicago for the data analysis of additional health metrics.
