The United States is one of the richest countries in the world, but it would look dramatically different if its 50 states were organized according to income instead of geography.
If that were the case, residents of the poorest state in the union would have a median household income that's just above the federal poverty line for a family of four. They would also expect to live shorter lives than people in more than half of the world's countries.
It's not a pretty picture, according to the researchers who carried out this thought experiment.
"In essence, there are several developing countries hidden within the borders of the United States — regions defined, in this case, by poverty," they wrote in a study published Thursday in the American Journal of Public Health. "The 'state' of poverty in this country is dramatic and deeply disturbing."
The research team, from East Tennessee State University, wrote that they could get a better sense of the "actual impact of poverty on health in the United States" if they focused on "the poorest counties in the nation, regardless of where they are geographically located."
So they took the country's 3,141 counties and sorted them according to their median household income, the amount at which half of households in a county had higher earnings and half had lower earnings. The income data came from the U.S. Census Bureau's American Community Survey. To make sure the rankings weren't skewed by a single fluky year, the researchers used income data from 2009 to 2013 and took the average over those five years.
The 2% of counties with the lowest median household income composed the poorest "state" in their alternative USA. The next 2% of counties formed the second-poorest "state." The researchers continued this process until they had 50 new "states," each with 62 or 63 counties.
The poorest "state" was made up of actual counties from Alabama, Arkansas, Georgia, Illinois, Kentucky, Louisiana, Mississippi, Oklahoma, South Carolina, South Dakota, Tennessee, Texas and West Virginia. The richest "state" included real counties from Alaska, California, Colorado, Connecticut, Georgia, Illinois, Indiana, Kentucky, Maryland, Massachusetts, Minnesota, Ohio, New Jersey, New Mexico, New York, Pennsylvania, Utah, Tennessee, Texas and Virginia.
(It's worth mentioning that five real states contributed counties to both the poorest and richest "states." This shows that "some of the challenges associated with poverty in the United States are related to factors associated with unequal distribution of resources within states, as opposed to simple lack of resources," the researchers wrote.)
The differences between the poorest "state" and the richest "state" were stark:
• The median household income in the poorest "state" was $24,960. In the richest "state," it was $89,723.
• The average number of people per county was about 14,000 in the poorest "state," compared with about 362,000 in the richest "state."
• Although the poorest "state" had a much smaller population, the ratio of people to primary care doctors there was twice that of the richest "state."
• Smoking prevalence was twice as high in the poorest "state" as in the richest "state," and the prevalence of obesity was 50% higher.
• Life expectancy for women in the poorest "state" was 75.9 years, compared with 83 years in the richest "state." For men, life expectancy in the poorest "state" was 69.8 years and 79.3 in the richest "state."
• The proportion of the population that was African American was 4.5 times higher in the poorest "state" than in the richest one.
• In the richest "state," 21% of residents lived in rural areas. In the poorest "state," 75% of people do.
The researchers took a deeper dive into the life expectancy data and determined that the people in the poorest "state" were living under conditions seen in the real United States around 1975 or 1980. Meanwhile, the people in the richest "state" were already living under conditions that won't apply to the real United States until 2020 or beyond.
In other words, they wrote, "the poorest 'state' is between 40 and 50 years behind the life expectancy achieved by the wealthiest 'state.'"
The study authors also compared the richest and poorest "states" to 222 actual countries with reliable data on life expectancy. They found that if the richest "state" were an independent country, it would rank eighth in the world in life expectancy for men and 25th for women. The poorest "state," on the other hand, would rank 123rd for men and 116th for women.
"More than half of the countries in the world have a longer life expectancy than the poorest counties in the United States," they wrote.
The study doesn't show that being poor leads to worse health — indeed, having health problems can contribute to poverty. But no matter how this chicken-and-egg problem is resolved, the analysis makes it easy to see health disparities that are masked by state-level data.
"The results should be deeply disturbing to all persons in the country," the researchers concluded.
Rather than focusing health interventions on the worst-off states, they wrote, policymakers would be better off targeting the poorest counties — wherever they happen to be.
MORE IN SCIENCE