The Findings


by Dante Chinni and Ari Pinkus September 19, 2018 Print

The health of Americans varies greatly depending on the kind of community they call home, and different types of communities have knowledge they can share to improve citizens’ well-being. Those findings are at the heart of months of research and reporting from the American Communities Project (ACP) at The George Washington University.

The ACP, working with data from the 2018 County Health Rankings and with the support of the Robert Wood Johnson Foundation, examined thousands of data points through the prism of the ACP’s 15 community types — distinguishable by demographic variables such as income, occupation, race and religion — to find common worries and shareable solutions.

Three dominant themes emerged in the analysis.

  1. Communities with large populations of people of color fare poorly on a variety of important health and community measures. The data suggest the scores are less about specific populations in these communities than they are about the economic and cultural divides running through them.
  2. Mental health concerns cross all community types. The ACP’s community types hold very different geographies, people and economies, but the median county in every type has between 10% and 16% of its population reporting 14-or-more poor mental health days per month.
  3. Some commonly held understandings of many communities and the challenges they face are incorrect. For instance, raising children in a single-parent home is not just an urban worry. And the nation’s most racially and ethnically diverse communities, the big cities, are also its most segregated.

The data make clear that all kinds of communities — from well-educated urban enclaves to rural blue-collar boroughs — face health challenges. Furthermore, the data show what those specific concerns are.

The ACP also visited five communities, each representing one of its 15 types, to find best practices to address citizen health. Interviews with community leaders and officials in Dallas County, Texas; Douglas County, Colorado; Hood River County, Oregon; Jones County, Georgia; and Lake County, Ohio, led to insights into how those communities deal with their respective challenges and revealed programs and ideas that others can put into practice.

Combined, the ACP’s research and community investigations encompass a deep examination of the socioeconomic, cultural and health-related ties that bind together the United States’ complicated patchwork of communities in 2018 and an exploration of what these communities can learn from one another.

The Tapestry of American Communities

Your community is more than your home; it defines your life, from job opportunities and consumer choices, to the quality of education, to air quality and exercise options. And just a few miles can make a dramatic difference. Consider three Michigan counties that abut one another — Oakland, Macomb and Wayne.

In the 2018 County Health Rankings & Roadmaps— a partnership of the Robert Wood Johnson Foundation (RWJF) and the University of Wisconsin Population Health Institute — those three neighboring counties are, in essence, different worlds. In wealthy Oakland, 12% of the population report being in only fair or poor health. In Macomb, the number is 15%. In Wayne, it is 19%. Macomb has a significantly higher median household income than Wayne, but it also has a higher rate of drug overdose deaths. And Wayne is the most racially and ethnically diverse, but the economic development and history of the area has also left it more segregated.

The amount of variation in such a small geographic area is noteworthy, but not exceptional. Those communities are not just different places; based on the ACP community types, they are different kinds of places. Oakland, an educated, well-to-do county to the northwest of Detroit, is a quintessential Urban Suburb. Macomb, just east of Oakland, is a blue-collar Middle Suburb. Wayne, just south of both, includes Detroit and, thus, holds the density and diversity of a Big City.

When you look at the nation as a whole, the complexity of community types grows. The ACP’s map of the United States defines 15 community types among the nation’s 3,100 counties. These 15 types were created using dozens of demographic variables and are designed to explore likenesses and differences that exist among communities at the county level. The ACP’s 15 county types are mapped below.

Defining the ACP Types (Click type names to see more  on each.)

African American South: Places with large African American populations. Lower incomes and higher unemployment. Exurbs: Wealthy communities usually on the edge of metro areas, Largely white with lower crime rates. Military Posts: Located around military installations. Younger, middle-income, diverse communities.
Aging Farmlands: Sparsely populated and overwhelmingly white. Low unemployment, agricultural economy. Graying America: Places with large senior communities. Generally rural and less diverse, middle-income. Native American Lands: Places with large Native American populations. Young communities with lower incomes.
Big Cities: Counties holding the nation’s largest cities. Dense and diverse. Hispanic Centers: Large Hispanic populations in mostly rural communities. Younger with lower incomes. Rural Middle America: Largely rural and white communities. Middle income and average educational attainment.
College Towns: Urban and rural communities that are home to campuses and college students. LDS Enclaves: Places dominated by Latter-day Saints adherents. Younger and middle-income. Urban Suburbs: Educated and densely populated communities around major metros. Racially and economically diverse.
Evangelical Hubs: Places with above-average numbers for evangelical adherents. Largely Southern with fewer college grads. Middle Suburbs: Middle-income, blue-collar communities mostly around metro areas. Working Class Country: Rural, blue-collar communities. Low incomes and college graduation rates.

The ACP’s focus on types of community pairs neatly with RWJF’s County Health Rankings. Undergirding the Rankings is the idea that health is about a lot more than what happens in the doctor’s office. Ultimately people’s health is influenced by a complex mix of factors including family life, environmental inputs and economic circumstances — elements deeply tied to our communities. By merging the ACP and the Rankings we can look at how those small differences at the community level fit into broader, hidden national trends.

What the Numbers Say

On behalf of the ACP, the University of Wisconsin Population Health Institute used data compiled by the County Health Rankings & Roadmaps programs to determine variation within and across ACP county types. It also calculated a composite measure of length and quality of life for counties, which was then used to sort counties within each typology. The top-performing counties within each typology were further classified by their within-state rank on health outcomes and health factors.

Do the combined Rankings and ACP data suggest one type of community is the country’s healthiest? Not really. There were limitations. The ACP’s types are not evenly spread across the country. Utah, for instance, is dominated by LDS Enclave communities, meaning those places are spread across all four quartiles in that state. And many states have no Big Cities.

That said, there are some broad trends in the numbers. The semi-urban counties known as Exurbs are the most likely to score in the top quartile of their states’ healthiest places. Nearly 73% of those 222 counties placed in their state’s top quartile. The Urban Suburbs were next, with 57% of those 100 counties scoring in their state’s top quartile. The Big City counties and the College Towns, counties defined by academic institutions in them, followed with about 46% scoring in the top quartile.

Certain county types score lower in the rankings. The counties of the African American South and the places known as Hispanic Centers are much less likely to be in their state’s top quartile — about 6% and 13% respectively. The counties of the Native American Lands scored lowest in the rankings; none were in their state’s top quartile.

And a large number of community types reside in the middle of the Rankings. Military Posts, Rural Middle America, Middle Suburbs and LDS Enclaves, all have roughly 25% to 40% of their counties in the top quartile of their state’s health rankings.

But that surface look at the data misses the real story in the numbers and the people and place behind them. For important reasons, this report is not about finding the best type of place to live.

First, much can depend on the place you actually live and the measure you care most about. There is a lot of variation in the numbers even within types.

The chart below is interactive. You can choose the indicator you want to explore, from uninsured rates to premature death, by scrolling through the  options in the box in the top left. The black line within each type represents its median value. You can also search for any county in the country by entering its name in the “Find a County” box.  The chart shows not only the differences in the community type medians but also how communities are clustered in some types and spread across the line in others.

And, beyond those numbers, consider this: With all the different types of communities in the United States — from sparse rural areas to dense cities — the overwhelming majority of Americans are quite content with their community. In 2017, Gallup asked Americans to rank the statement “The city or area you live is perfect for you” on a scale of 1 (lowest) to 5 (highest). More than 60% of Americans gave the statement a 4 or 5. And that finding was remarkably consistent across the ACP types.

This report does not identify “winners.” Rather, it aims to find what we can learn from each community type about improving health and well-being, so people can make their communities healthier no matter where they live.

What can the Exurbs teach us about growing healthy communities and what can they teach each other? What are the shared drivers behind the challenges faced by the counties in the African American South? Are there lessons in the counties of Graying America for the rapidly aging Middle Suburbs?

Three Trends in the Data

Digging into the numbers, there are marked differences across many measures, including the three key findings in the analysis.

Communities with large populations of people of color fare poorly on a variety of important health and economic measures. This seems to be less about the specific populations in these communities than it is about the socioeconomic and cultural divides running through them. Those pressures create special challenges for these communities. The challenges are visible in data on the African American South, Hispanic Centers and Native American Lands.

The median county in those three types stands apart on a range of important factors and outcomes. They sit above the other county types on the percentage of people reporting they are in poor or fair health and the percentage of uninsured adults, but also on broader socioeconomic measures, including the percentage of disconnected youth and the percentage of children eligible for free or reduced school lunch. That combination of scores suggests that limited economic and educational opportunities are at the root of the obstacles these communities face.

In a sense, these data speak to the long-term challenges these communities face and how interconnected those challenges are — for all age groups. Children in these places start off behind their peers in other community types and are more likely to need aid in school. Later, as adults, they are less likely to have health insurance and, ultimately, less likely to be healthy. Again, these splits aren’t just about the lower incomes in these communities, but about deeper community rifts. (We explore these rifts further in the community narratives of this report.)

Mental health concerns cross all community types. The ACP’s community types look very different in their geographies, people and economies, but the median county in every type has between 10% and 16% of its population reporting 14-or-more poor mental health days per month.

Those numbers are particularly arresting when you take into account the Centers for Disease Control 2018 report that death by suicide climbed by 25% between 1999 and 2016. And while the figures are higher in some places than others, they seem to defy simple explanation. The well-to-do, semi-urban Exurbs and Urban Suburbs, at 11%, look the same as middle-income Rural Middle America. The number for the youthful College Towns, 12%, is the same as the number for the aging Graying America counties.

Furthermore, we found mental health concerns to be a top priority in every county we visited — though the driving factors were not necessarily the same. The one true outlier in the data is the Native American Lands.

The data also reveal how we may misunderstand different kind of communities. Some findings in the County Health Rankings are somewhat counterintuitive.

For instance, while urban areas are often viewed as the core of the nation’s struggle with single-parent homes, the figures are actually spread across the country to many different kinds of communities. About 38% of the children in the median Big City county, as well as 36% in the Middle Suburbs, live in single-parent homes.

Looking at diversity, we also found noteworthy revelations. Big City communities are among the most diverse in the country — the median Big City is only about 47% white. But those same communities also score higher on segregation than other kinds of communities, even those with fairly multicultural populations such as the Urban Suburbs, African American South and Hispanic Centers. That is to say, even if you live in a place that looks like a melting pot from 30,000 feet, on the ground it may look much more monochromatic.

The numbers show that the much-publicized racial and ethnic diversification of the nation has a hard time breaking through the racial and ethnic boundaries that define many communities — even in places that look diverse in high-level data. Those boundaries often have deep historical roots that were created by generations of migration patterns — conscious and unconscious decisions by racial and ethnic groups that essentially remain in effect today, particularly in Big Cities.

And rural living doesn’t necessarily mean long, solitary drives. In fact, the county type known as the Aging Farmlands is among the least likely to have long commutes driving alone. In the median Aging Farmlands county, only 22% of the people who drive to work alone have a commute time of more than 30 minutes. The figure is 27% in the median Rural Middle America county, 39% in the dense, prosperous Urban Suburbs and 45% in the Exurbs. In other words, small town/rural communities seem to offer drivers an advantage over more densely populated areas.

Next Steps

There are other large patterns in the data, which can be explored in the index of this report. Short analyses of all the ACP community types as well as an excel sheet with data can be downloaded by individuals and communities. We believe these community trends and data sets are crucial to communities and community leaders. First, they allow community leaders to see how their home compares to similar places — and whether their community is an outlier in certain statistical areas. Second, the trend data should give communities other places to turn to for models and approaches to community health and engagement.

To see what these data look like on the ground, we visited five specific communities and talked to local leaders about how they are handling the concerns they face every day. How do they strive to make their communities better? What challenges do they face? What successes have they had? You can read descriptions and solution highlights below, and dive deeper into the communities by clicking the links.

Dallas County, Texas: The Big City

Scattered around the country, the Big Cities stand out for their diversity. These counties are a true mosaic socioeconomically, racially and ethnically (48% white, non-Hispanic, 16% African American, 11% Hispanic and 6% Asian). They are also the most segregated communities in the country.

  • Collaborations among nearly 100 community nonprofits, including the North Texas Food Bank, large shelters and faith-based institutions, share information about patients to better coordinate care and understand the social and economic factors that shape health.
  • An initiative started by Children’s Health in Dallas integrates mental health care within children’s primary care — with encouraging results.
  • Paul Quinn College, a historically black college in southern Dallas, has adopted the work-college model, reducing its graduates’ student-loan debt. The college has also turned its football field into a farm, helping alleviate food insecurity in a food desert.

Douglas County, Colorado: The Exurb

Exurbs, which tend to sit on the edge of major metropolitan areas, are generally wealthy (median household income of more than $65,000), well educated (34% with a bachelor’s degree) and not especially diverse (81% white, non-Hispanic). They are also known for long, solo commutes by car; 83% of workers drive alone to work. In short, they are communities where the old suburban ideal still reigns.

  • Through the Douglas County Mental Health Initiative, 40 community partners help connect people with mental health services they need. Since May 2017, the county has created two Community Response Teams, each composed of fire/EMS, law enforcement and a clinician — with promising results.
  • To cope with rapid growth, including an increasing senior population, the county is helping seniors, people with disabilities, low-income residents and others get from one point to another through a partnership with Lyft and faith-based organizations.
  • The Regional Transit District is extending light rail lines in the county.

Hood River County, Oregon: The Hispanic Center

Heavily rural and based primarily in the nation’s Southwest with pockets in the Northwest, Hispanic Centers face significant socioeconomic and health challenges. Only about 17% of these individuals hold a bachelor’s degree and the average median household income sits low at $45,800. These communities have limited access to care. About 19% are uninsured, nearly twice the national average.

  • Community health workers have long facilitated residents’ connections with healthcare and social service providers. The successful model is now helping Latinos launch businesses.
  • As state-issued IDs have become harder for immigrants and others to obtain, a community ID card, approved in June, is expected to allow county residents to connect with civic, public safety and other community services.
  • Built in 2011, Hood River Crossing contains 40 one-, two- and three-bedroom units, and more affordable housing is in the works to address access to safe and affordable housing.

Jones County, Georgia: The African American South 

 Based heavily in the Southeast states, the counties of the African American South struggled on the whole in the County Health Rankings, having the second-highest premature death rate among all types (more than 10,000 years lost per 100,000 population). Obesity rates (35%) and smoking rates (21%) also tend to be higher.

  • The initiative Live Healthy Jones aims for residents to better attend to their health, including choices about diet and exercise.
  • To provide for residents without health insurance, Community Health Care Systems opened in Jones County about five years ago.
  •  A group of white and African American pastors meets regularly and discusses touchy issues, including politics and racial profiling. African American and white churches worship together over holidays.

Lake County, Ohio: The Middle Suburb 

Primarily nestled in the aging, inner-ring suburban areas of the Industrial Midwest, Middle Suburbs contain a unique mix advantages and challenges. They hold the lowest percentage of uninsured people (7%), but they score highest for drug-overdose deaths (26 per 100,000 people).

  • Lake County General Health District generated an idea that uses Geographical Information Systems to tackle the opioid crisis.
  • The Better Flip is an initiative by the Lake County Ohio Port & Economic Development Authority to make post-World War II homes on the west end of the county more attractive to young potential homeowners.
  • Leadership Lake County started a program two years ago to help millennials see their place in the county. The organization encourages other groups in the county to diversify their boards, including appointing two millennials at a time because the buddy system works.

More to Come

In a country as big and diverse as the United States, we need a new way to understand geography. Sometimes a community has more in common with a place hundreds of miles away than it does with the city or county next door. This report begins to explore this idea. There will be more deep dives in subsequent work, including one into the complexities of rural America.