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When It Comes to Health, Place Matters

October 02, 2013

(Dr. Brian D. Smedley is vice president and director of the Health Policy Institute of the Joint Center for Political and Economic Studies in Washington, D.C.)

Headshot_brian_smedley.jpg_3The implementation of the Affordable Care Act is an achievement Americans can be proud of. Making sure that all our brothers and sisters, children and grandchildren, have proper health insurance makes us a stronger, more prosperous nation.

Amid this important change, however, we cannot ignore the work that remains to be done, especially in communities of color. Insurance cards are not enough.

To become a society with better health -- not just better health coverage -- we must also look at the role "place" plays in the lives of minority communities.

Where we live, work, and play is surprisingly predictive of lifespan. Within the City of Boston, for instance, people in some census tracts live thirty-three years less than those in nearby tracts. In Bernalillo County, New Mexico, the difference is twenty-two years.

Researchers are releasing Community Health Equity Reports at the Place Matters 2013 National Health Equity Conference today in Washington, D.C. Data from Baltimore, Birmingham, Chicago, New Orleans, and other cities demonstrates that where you live is a powerful determinant for how long you'll live.

"Health equity" may sound like jargon, but it's really a simple and just concept: all people should have equal opportunities for good health. Unfortunately, in conversations, people often reduce health issues to questions of access to health care or to behavior; in other words, if people only ate right, exercised, or saw a doctor regularly, health inequities could be eliminated.

Now, to be sure, access to high-quality health care is important, particularly for those who face health risks. And individuals should strive for active lifestyles and healthy diets. But a large and growing body of research demonstrates that the spaces and places where people live, work, study, and play powerfully shape the opportunities they have to achieve good health.

People of color -- who are still subject to persistent social, if not legal, segregation -- are disproportionately located in unhealthy spaces. This is a major factor that helps explain the poorer health of many minority groups.

Consider the numbers: One in four African Americans, one in six Hispanics, and one in eight American Indians in metropolitan America lives in a census tract in which 30 percent or more of the population is in poverty. But only an estimated one in twenty-five non-Hispanic whites live in one of these tracts.

Neighborhood conditions can overwhelm even the most persistent and determined efforts of individuals to take steps to improve their health. Neighborhoods with high rates of poverty are subject to significant health risks, from the presence of polluting industries to the absence of a grocery offering fresh fruits and vegetables.

These same communities typically have poorer quality housing and transportation options, and were hit hardest by the home-mortgage lending crisis, which crushed wealth opportunities and disproportionately affected communities of color.

Many of these neighborhoods also experience high rates of crime and violence, which affect even those who are not directly victimized in the form of stress and an inability to exercise or play outside. Even healthcare providers, hospitals, and clinics are harder to find in these neighborhoods.

It's no wonder life-spans vary so greatly among neighborhoods, even those close to each other.

Some policy makers are working to address these place-based disparities. Federal programs that stimulate investment in the nation's hardest-hit communities are working to attract businesses, create jobs, and reduce the concentration of health risks. The Healthy Food Financing Initiative creates financial incentives for grocery stores or farmers' markets to open in "food deserts." And the Obama administration's "Promise Zones" initiative will streamline a host of federal "place-based" projects and offer technical assistance to jurisdictions that seek to stimulate economic activity and build ladders of opportunity.

Indeed, investments in vulnerable communities may be among the most cost-effective strategies to close the health gap and improve the overall health of the nation. A study commissioned by the Joint Center for Political and Economic Studies found that the direct medical costs associated with health inequities -- in other words, additional costs of health care incurred because of the higher burden of disease and illness experienced by minorities -- was nearly $230 billion between 2003 and 2006. Add the indirect costs, such as lost wages and productivity and lost tax revenue, and the total cost of health inequities for the nation was $1.24 trillion.

Our nation's poorest need health insurance. But we cannot afford to stop there. Only by recognizing and then erasing the deep divides that create communities with fewer health opportunities can we create a nation of individuals with the chance to reach their full potential.

-- Brian D. Smedley

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