Q&A: The Ten Americas reveal increasing health disparities in the US

Although the US spends more on health than any other country in the world, disparities in health outcomes between different demographics are increasing. Dr. Ali Mokdad explains the latest research using the "Ten Americas" framework to examine health disparities by race, ethnicity, and geography.

This transcript has been lightly edited for clarity

What are the key findings from your research into health disparities in America?

The purpose of this manuscript is to show the variation by geography, by race, ethnicity, and life expectancy in the United States. And there are huge variations. There are several points that come out in this analysis. One of them is that the disparity between races is increasing with time.

It used to be about 12.6 years in 2000. Right now, it’s about 20.4 years. So this gap between the races, race and ethnicity, is increasing. The second message here is COVID-19 has impacted minorities much more than the White population and Asian population. The third message here is Alaska Natives and Native Americans have decreased their life expectancy through our period of observation; they had the most decrease due to COVID-19, and they’re the only group that saw a decline in life expectancy throughout our observation. Hispanics and African Americans saw a higher drop in life expectancy due to the pandemic.

What this study reveals is that in the United States we have a lot of disparities, and they are increasing. And it’s a call for action, for all of us to address the drivers of this disparity and the decline in life expectancy for some of us who are left behind, as some people in the country make an improvement. 

Most of the drivers of these declines in life expectancy, and that disparity in life expectancy, are explained by socioeconomic factors such education and income. For many in the United States, job opportunities are not as prevalent as in many places, and educational attainment is not as high as other places.

For example, Asian women and Asian men are more likely to finish college education than the rest of the United States. The second one is access to medical care and quality of medical care, and many of us in the United States do not have health insurance. And some of us, even if they have health insurance, it doesn’t cover preventive medicine, such as regular checkups or screening procedures.

And the last one, which is the most important one, is risk factors. These are like obesity, which in our analysis is showing a rapid increase in the United States, and it’s impacting cardiovascular diseases and diabetes. Risk factors such as smoking, physical inactivity and diet, high blood pressure are leading a lot of these disparities.

What is your reaction to the findings of your research?

These findings, to put it mildly, are shocking for all of us. Remember, the United States is one of the richest countries in the world, and we also spend on health more than anybody else. Almost, our expenditure on health is half of what the whole world spends on health. Almost half of it. And to see the outcomes we see here makes all of us stop and ask the question, why?

The key issue here is not spending more money. We should spend more money since we have more money. The issue here is are we getting the return on our investment? And the answer is quite clearly “No.” Even any metric you look at, we looked at life expectancy, even if you look at any other metric here, we are falling behind the [other] rich countries.

We are falling behind many of the middle-income countries. And it’s time for all of us to sit down and ask ourselves, what should we do here? We should address the pillars that are driving these disparities: socioeconomic factors, health insurance, these risk factors, and access to medical care in the United States.

Can we meet this challenge, and if so, how do we do it?

These problems cannot be solved by one entity. So the government has to do its part. We, as people, have to do our part. Civil society has to do its part. But we have to put ahead, for all of us, a roadmap, how we can fix these problems. And, as we can see from this manuscript, the problems vary in different places, and we need to address them at the local level –  working with communities, working with leaders in these communities, in order to make a difference.

What are the Ten Americas?

We defined the ten Americas as America 1 – Asian; America 2 – Latino individuals in some counties, and America 3 is White majority counties. There are, of course, in America 3, some Asian and some American Indian and Alaska Natives. America 4 is White individuals in non-metropolitan and low- income Northlands.

America 5 is Latino individuals in the Southwest. America 6 is Black individuals in some counties; America 7, Black individuals in highly segregated metropolitan areas; America 8, White individuals in low-income Appalachia and Lower Mississippi Valley; America 9, Black individuals in the non-metropolitan and low-income South; and America 10, American Indian and Alaska Natives living in the West.

Our analysis showed a large gap in life expectancy between the Americas. So if you look at America 1, Asian, the life expectancy in the United States is about 84, whereas, for example, America 10, American Indian and Alaska Native individuals who are living in the West, the life expectancy is 63.6. Looking at this, it’s about 20.4 years of difference in life expectancy between these two Americas.

This finding, in itself, is not acceptable for a country with such resources, where we see that huge gap in life expectancy between Americas. And also keep in mind that that gap is increasing with time.