Q&A: Where do people have the highest and lowest levels of well-being in the US?

IHME Director Dr. Chris Murray discusses our latest research using the Human Development Index (HDI) to measure well-being in the United States. 

The following transcript has been lightly edited for clarity

So, this week in The Lancet, we published the first of a series of papers on health in the US, trying to explore inequalities in the US. What are the drivers and where are the prospects for improved health in the future? The first paper is trying to answer a simple question: Who are the worst-off in the country and where do they live?

And rather than trying to invent our own metrics for well-being, to understand who is the worst-off, we have used the well-established Human Development Index, from the United Nations Development Programme, that was originally formulated by Amartya Sen and others to try to be a pragmatic measurement of three domains of well-being – health as measured by life expectancy, educational attainment, and income per capita.

And so we’ve been able to bring that construct down to the individual level in the United States by using the American Community Survey, which tells us about household or individual income, and average years of schooling for educational attainment. And then we’ve used our US Health Disparities program of research, funded by the National Institutes of Health in the US, to use life expectancy at the county, race, ethnicity, age, and sex level. 

Pulling all those together, we were able to construct the HDI and then ask the question, who’s in the bottom decile? And, in fact, we reported in the paper who’s in the top as well, and all the deciles in between. And then which communities are those living in the bottom decile? So what are the key findings from this exploration of the worst-off?

First, if you look across all the data across the US, what you see is that in the worst-off categories, certain race, ethnicity, sex groups are hugely overrepresented. You know, you’d think if everybody was roughly the same or had the same odds of success in terms of well-being, you’d have equal representation, proportionate to population size, of each of the race and ethnicity groups across generations and by sex.

But that’s not what we see. You see an overrepresentation, particularly of American Indian and Alaska Natives in the worst-off, for men and women. We see a very substantial overrepresentation of black men particularly. And we see an overrepresentation of white men. And then we see an underrepresentation in the worst-off of pretty much all the groups that are women, and very much an underrepresentation both for Asian men and Asian women.

At the top end of the spectrum we see, sort of, the inverse. There’s 70% of the top decile who are female. We see an overrepresentation, you know, higher than 10% of that group, proportionally to population size, from Asian populations, from white females. So a real spectrum. The second big observation is that this concentration in certain groups varies by generation.

So if you look at the oldest generation, 80-plus, compared to those under age 45, you see quite different compositions. You see an increasing shift toward men in the bottom deciles as you look at younger generations, and the inverse at the top, those who are best-off. And so it’s a dynamic situation of terms of the makeup of the best- and the worst-off in the United States.

The third observation is if we look at where the worst-off live, there are people in the bottom decile in every state. But you see concentrations in areas like eastern Kentucky, West Virginia, the Mississippi Basin, some of the Deep South states, where there’s a lot of black populations, for example, and then on some of the Native American reservations. And that becomes very obvious when you look at a map of the worst-off and the map of the best-off, the top decile in the country – you see a lot of them concentrated in some of the major urban areas.

Colorado really stands out as having a number of counties where there’s a large fraction of the population living in the top decile. So why is this important? Why do we care about trying to measure this Human Development Index? It’s our fundamental belief that we can use this information to help target social policies and programs that are meant to help the worst-off, as well as targeting health programs to address the worst-off.

And it’s only by an understanding of who and where the worst-off are that we’re going to be able to, hopefully, have greater effect at reducing inequalities in our society. And it sets us up in the next series of studies that will be coming out to understand how those basic inequalities in well-being translate into, unfortunately, growing inequalities in health outcomes, and where might be the more proximate levers that we can also intervene on, even as we think about reducing inequalities in education, in income and, ultimately, inequalities in health.