A 20-year gap in life expectancy exists between the healthiest and least healthy counties in the United States. While life expectancy at birth for the nation increased to 79.1 years, the gap between healthiest and least healthy counties expanded between 1990 and 2014.

This geographic disparity increased in the 34 years analyzed in a 2017 study reported in JAMA Internal Medicine (doi:10.1001/jamainternalmed.2017.0918). (Last week we looked at troubling broad trends in the nation's overall health.)

some text Dr. Clif Cleaveland

Apart from counties in the Dakotas, which contain large Indian reservations, the least healthy counties occupy a band extending from southern West Virginia into eastern Kentucky. Another band extends along the lower Mississippi River Valley. Counties in Northeastern, Upper Midwestern and West Coast states had higher life expectancies.

For most of the country, death rates fell across for all age groups. Eleven percent of counties, however, exhibited higher death rates for adults aged 25 to 45 years.

The study identified three major, interlocking causes underlying poor health:

Socioeconomic and race/ethnicity factors included measures of educational attainment, unemployment, median household income and racial and ethnic composition of each county's population. Health outcomes were worse for African-American and Hispanic residents.

Health-care factors included percent of population with health insurance and physicians per 1,000 population.

Metabolic and behavioral factors included incidences of obesity, cigarette smoking, high blood pressure, diabetes and leisure-time physical activity. These were the most potent forces for undermining a population's health.

Additional studies of state and county health, sponsored by the Robert Wood Johnson Foundation, are detailed at An overview of each state is offered along with a health assessment for each county within that state. A series of maps provide useful overviews of each state's health issues and outcomes.

Data for each county include many of the same health determinants as the first study. Sexually transmitted diseases and teen birth rates are added to health behaviors.

Clinical care is measured in terms of medical personnel — primary-care providers, dentists and mental health professionals — and availability for screening for diabetes mellitus and breast cancer.

Physical environment is assessed in terms of air pollution, water quality, housing and leisure-time activity.

From 2015 forward, the leading causes of premature mortality were drug overdoses, motor vehicular accidents and firearms.

Tennessee presents a typical picture for states in the central South. Prosperous, healthier counties are surrounded by counties marked by poorer health. In Tennessee, Williamson County is healthiest. Hamilton County ranks 13th, Bradley 23rd, Sequatchie 53rd, Marion 61st and Grundy 95th. Striking differences exist among counties.

Surrounding states show similar health profiles and wide variations among individual counties.

There are no simple fixes for poor health outcomes in counties within Tennessee and surrounding states. Solutions require statewide planning and funding since poor counties lack money and infrastructure to pull themselves from the gullies of poor health.

Expansion of Medicaid would be beneficial since up to 15 percent of residents in less-healthy counties have no health insurance. This would permit more health screenings and coverage for mental-health services, which are essential in addressing the opioid epidemic.

Addressing unhealthy behaviors — smoking, excessive use of alcohol and overeating — is a major challenge. The three behaviors generate a range of illnesses from diabetes to heart disease to cancer. Sustained media campaigns and enhanced health education in schools would be helpful over time. Promoting gun safety fits within these programs.

Particular attention must be paid to opioid and other chemical addictions. Access to acute detoxification and long-term care must be readily accessible in every community.

Another priority is the development of innovative strategies to address shortages of health-care professionals and facilities. Telemedicine could link a poor county with no physicians to a regional clinic. Clinics could be established within public schools to serve students, their families and the wider public.

Gubernatorial and legislative candidates should check out the grim statistics and then propose specific solutions to problems that have dragged down the health of too many people for too many years. Slogans will not suffice.

Should not access to the means for a healthy life be considered a constitutional right?

Clif Cleaveland, M.D., is a retired internist and former president of the American College of Physicians. Email him at