La Pine residents can expect to live an average of 12 years less than their Deschutes County neighbors to the north in Bend.

New data based on census tracts shows residents of southwest Bend are living to an average age of 84.5 years. Just 30 miles to the south, residents living near La Pine have a life expectancy of just 72.7 years.

How can a single county have a 12-year longevity gap? It’s an emerging tenet of population health: Long and healthy lives aren’t just the product of good medical care or genetics, but depend heavily on the environment in which people live.

“One of the biggest predictors of longevity in the country is ZIP code,” said Dr. Jim Guyn, senior vice president for population health for the St. Charles Health System.

People who live in more affluent areas not only have more money to take care of themselves but benefit from greater investments in their community that make healthy lifestyles easier. Studies have repeatedly found life expectancy is linked to the availability of education, housing and healthy food, and above all, to income.

“Those who have money and resources can have great health,” Guyn said. “But we’re not very good at taking care of our poor populations. We haven’t been and we still aren’t, and I think these kinds of differences just continue to point it out.”

Income inequality

Residents in the La Pine census tract had a median income of $34,836, compared to $66,833 in the southwest Bend tract. One in three residents of southwest Bend had a household income over $100,000, while in La Pine only one in 10 did. More than 19 percent of La Pine residents were living below the federal poverty level, compared to 11.2 percent in southwest Bend.

“The socioeconomics are much lower here in the La Pine area,” said Charla ­DeHate, CEO of the La Pine Health Center, a federally qualified health clinic. That impacts every part of the community. The clinic often sees patients who can’t afford the basics of life, living in tents or other types of insecure or unsafe housing.

“We have patients without electricity, without running water,” said Dr. Michael Allen, medical director of the clinic. “We have patients with diabetes who have to store their insulin at a friend’s house because it has to be refrigerated.”

Studies show rural areas often lag behind urban areas in socioeconomic status. Rural residents are likely to face issues — like inadequate transportation or a lack of grocery stores — that are linked to physical inactivity and poor diet. Those in turn lead to higher levels of obesity and diabetes that lead to premature death.

“They’ll buy fast food because it’s cheaper than going to the grocery store and buying fresh food,” DeHate said.

She says the health center’s patients often don’t understand the importance of healthy lifestyles and preventive health services. While the center continues to increase the percentage of patients who get cancer screenings, vaccinations and well-child visits, they have far to go. Many in the region lacked health insurance until Oregon expanded its Medicaid program under the Affordable Care Act in 2014, and often won’t come to the clinic until they’re facing a serious health problem.

“I have several patients who show up once a year with a list of 15 things,” Allen said. “I know that unless they break a leg, they’re not going to come back in to see me for their other health maintenance issues, like their cholesterol or their blood pressure. I’ve got to do what I can during that one visit.”

Education

La Pine residents also lag behind their Bend counterparts in terms of education. Despite being in the same school district, graduation rates in La Pine are significant lower.

Summit High in southwest Bend had a 2017-18 graduation rate of 92 percent. Even after raising its rate 8 percentage points from the previous year, La Pine High had a graduation rate of 77 percent.

That continues after high school. While nearly 45 percent of southwest Bend residents had a bachelor’s degree, less than 11 percent of those in La Pine had completed a degree.

“A lot of it is the multigenerational piece,” DeHate said. “Their family members have never gone to college. It takes a strong young person to really have a drive to break through that. It just holds some of the people back from where they could move forward.”

Studies have shown that adults with a college degree are more likely to adopt healthy behaviors and live, on average, five years longer than those without.

The lack of a college degree also affects their ability to get high-paying jobs with good health insurance. Within La Pine, the largest employers are the school district, the electric company, health care clinics and the garbage company. After that, it’s mainly small, mom-and-pop businesses. Teens work for family businesses or at fast food restaurants that offer little hope for a life-sustaining wage in the future.

Transportation

DeHate said that limited job market is slowly turning La Pine into a bedroom community. Workers are unable to find jobs locally, but can’t afford Bend’s expensive housing market. That puts them on the highway for at least an hour a day, limiting their time to exercise or prepare healthy meals, and increasing their risk of traffic accidents. Residents of La Pine averaged a 25-minute commute, while those in southwest Bend, only 16 minutes.

While Bend residents enjoy bike lanes and walking trails, those are sorely lacking in more rural areas. As a result, fewer than 1 percent of La Pine residents commute to work by walking or cycling, compared to 6 percent of southwest Bend residents.

Transportation issues also mar access to health care. A few specialists travel from Bend for a day or two a month to see patients in La Pine, but most specialty care requires a long drive and a half day off work. Hospital and emergency services are at least 30 miles away.

“We have patients that come in with chest pains, and we recommend they go to the emergency department,” Allen said. “They will flat out refuse, even if we call an ambulance to go pick them up, because they don’t they have transportation to get back.”

Allen has patients who are due for mammograms and colonoscopies, and willing to get them.

“But we don’t have those services in La Pine,” he said. “That’s just one more barrier.”

Access to care

That lack of access to specialty care also impacts life expectancy. Studies show that for every 10 additional cardiologists per 100,000 residents in a community, five fewer people die. For every 20 additional oncologists, three fewer people die.

While 17 percent of Americans lived in rural areas in 2010, only 12 percent of hospitalizations, 11 percent of days of care and 6 percent of inpatient procedures were provided in rural hospitals, according to a recent study. That could reflect the frequent need for rural residents to go to big cities for more advanced care, while city dwellers rarely go to rural hospitals for services.

Studies show breast cancer patients, for example, are more likely to have mastectomies for cancer if they live far away from a facility that offers radiation treatment. When new radiation treatment facilities are built in rural areas, mastectomy rates drop by 16 percent.

For many in La Pine, transportation challenges hinder their ability to access care.

“They can’t get to Bend,” DeHate said. “We talk about it being 35 miles, it’s more like a hundred.”

Lifestyle

Researchers from the University of Washington’s Institute for Health Metrics and Evaluation found that 74 percent of the variation in life expectancy hinges on four risk factors that people can control: high blood pressure, obesity, smoking and physical inactivity. A recent study that found people who didn’t drink or smoke and weren’t obese lived more than a decade longer than people with all three of those unhealthy risk factors.

Research also suggests rural areas have been hit harder by the opioid epidemic than urban areas. From 2005 to 2009, the single biggest factor impacting life expectancy was unintentional injuries, a category that includes drug overdoses.

Meanwhile, rural areas haven’t benefited from a reduction in smoking rates the way cities have. In 1976, 38 percent of people in cities, and 25 percent of people on rural farms smoked. By 2010, those numbers flipped. Only 17 percent of people in large metropolitan areas smoked, compared to 27 percent of those in non-metropolitan areas.

That’s led to a corresponding reversal in lung cancer rates. In 1950, the lung cancer mortality rate for persons in rural areas was 33 percent lower than in urban areas. By 2007, the rural rate was 20 percent higher.

Similarly, obesity rates have risen faster in rural areas. In 1976, both urban and rural areas had obesity rates of just over 9 percent. By 2010, the urban obesity rate climbed to 26 percent, while the rural rate jumped to 33 percent.

“We are sort of quick to blame individuals — that you shouldn’t be smoking, you should have a healthier diet, and that’s true,” said Oktawia Wojcik, senior program officer at the Robert Wood Johnson Foundation that helped calculate the census tract life expectancy data. “Are healthier food options available to this individual? Not everybody lives in a place where there is a supermarket, with fruits and vegetables.”

Others may not have access to transportation and have difficulty getting to their doctor’s office. Some can’t afford to pay for prescriptions.

“It really is a combination of things,” Wojcik said. “Some that are outside of your control and certainly some that are in your control.”

Trend lines

Now as income inequality increases, the longevity gap between urban and rural areas is widening. High-income areas like Bend are advancing, while low-income areas like La Pine remained mired in poor health. According to data from the American Medical Association, those living in the poorest 5 percent of U.S. households had almost no increase in life expectancy from 2001 to 2014, whereas women in the top half of the income distribution and men in the top quarter added 2.5 years of life.

Some researchers describe it as a poverty trap. A lack of resources leads to poor health, which in turns limits economic productivity, bankrupts households and impoverishes families. Generations of families can’t break out of the cycle.

In fact, many of those same factors impact the health of lower income residents of Bend. That leads to great variations in life expectancy within the city limits.

“It isn’t about being in a more metropolitan versus a rural area,” said Emily ­Salmon, program manager at St. Charles. “Downtown Bend and West Bend have a 10-year swing and they share a census tract line.”

Salmon also pointed to research about stress levels and health. People who struggle to meet the basic needs of life deal with as much stress as people facing crime or violence. Over time, that stress wears away their health.

“You look at an affluent population, they do not experience life that way,” Salmon said. “Physiologically these populations are different. Their bodies are physiologically different.”

That’s spurred area health care groups to work with nonprofits and other community partners to work on housing, education and transportation challenges. As health systems like St. Charles enter into contracts that pay them a fixed amount to care for their population of patients, they’ll have more incentive to address those social factors outside of medical care that impact the cost of health care.

The La Pine Health Center, for example, has a grocery voucher program that helps low income people pay for fruits and vegetables. The clinic’s diabetes educator often reviews family budgets to teach them how they can afford to eat healthier. The clinic has received a grant from the Knight Cancer Institute in Portland to work with businesses on smoking cessation programs for their employees. And the city of La Pine is working on adding sidewalks and bike paths that will allow residents to walk or cycle instead of driving.

Such efforts are aimed at leveling the playing field so that everyone in the county has a chance to live a long and healthy life regardless of where they live.

“Not everyone has the same opportunity to be healthy,” said Megan Haase, CEO at Mosaic Medical in Bend. “Choices we make depend on choices available to us.”

— Reporter: 541-633-2162, mhawryluk@bendbulletin.com

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