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2 The Health of Marginalized Populations Richard Ingram, Julia F. Costich, and Debra Joy Pérez The United States: Pockets of Health Inequity The health status of the United States as a whole can be described as reasonably poor relative to other industrial nations. Evidence suggests that, while the United States ranks first among all countries in health care spending, it ranks thirty-sixth in life expectancy, thirty-ninth in infant mortality, forty-second in adult male mortality, and forty-third in adult female mortality.1 This may be due, at least in part, to an underperforming health care system; the U.S. health care system performs poorly when compared with other nations, ranking last or next to last in quality, access, efficiency, equity, and healthy lives while ranking first, again, in terms of cost.2 These statistics, though compelling, do not tell the entire story. The comparatively poor health of the United States is just one symptom of a deeper problem: health inequity. The United States is rife with pockets of both good health, where citizens have access to excellent health care and a large share of the nation’s plenty, and poor health, where citizens are marginalized economically and educationally and do not have access to their fair share of the nation’s wealth or to good health care. Sharp differences in health status exist among individual states. America’s Health Rankings, released by the United Health Foundation, measures states’ status in areas such as health behaviors, community and environmental factors , public and health policies, clinical care, and health outcomes.3 The 2010 edition of the rankings found that citizens of Vermont enjoyed the highest health status, with an average health score 1.131 standard deviations above the mean U.S. score. In contrast, citizens of Mississippi suffered the worst health, with an average health score –0.786 standard deviations below the mean.3 When viewed at any level, geography may explain some of the health 48   Ingram, Costich, and Pérez differences between and among populations, but it does not explain all of them. There appear to be sharp inequities between Mississippi and Vermont with regard to the socioecological determinants of health and health status. Vermont has less poverty: 12 percent of the children in Vermont live at or below the poverty threshold, compared with 31.9 percent of Mississippi’s children.3 Vermont does a better job educating its children, with approximately 88.6 percent of incoming ninth graders graduating from high school in four years; in Mississippi, this number drops to 63.6 percent.3 It should therefore be no surprise that per capita personal income is $38,503 in Vermont and only $30,103 in Mississippi.3 Income is also distributed more equitably in Vermont: the Gini coefficient (a measure of income inequality, where a value of 0 indicates complete equality and a value of 1 complete inequality) is 0.434 for Vermont and 0.478 for Mississippi.3 Inequities do not exist just between states; they exist within them as well. Each year, the University of Wisconsin Population Health Institute, with support from the Robert Wood Johnson Foundation, calculates the County Health Rankings, a measure of the health status (including mortality, morbidity, health behaviors, clinical care, social and economic factors, and physical environment) of all counties in the United States relative to their peers in each state.4 The rankings show that the citizens of some counties enjoy far greater access to the socioecological determinants of health and greater health status than do citizens in other counties in the same state. For example, the 2011 edition of the rankings found that even within Vermont (the healthiest state, according to America’s Health Rankings), the smoking rate in Essex County (30 percent) was more than double that in ChittendenCounty (14percent).4 Accesstohealthcarealsovariedwidelybetweenthetwo counties. While Essex County’s ratio of population to primary care physicians was 1,292:1, Chittenden County had a much more favorable ratio of 306:1.4 There were also sharp differences in the socioecological determinants of health between Chittenden and Essex Counties. Nine percent of the children in Chittenden County lived at or below the poverty level, versus 24 percent of the children in Essex County.4 Chittenden County’s unemployment rate was 5.9 percent, compared with 9.2 percent in Essex County.4 These stark economic differences were manifested at school, where 55.1 percent of students in Essex County received subsidized school lunches in 2010, but only...

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