Every New Year brings with it well-known traditions. We lift a glass, set a resolution, and propose a toast to changes we aspire to see this time: improved habits, enhanced balance, better health. We exclaim “I’ll drink to that” as a shorthand for hope, a quick affirmation that the future remains negotiable and a longer life is achievable.
Then a map appears.
At first look, it appears political, with counties tinted red and blue, borders distinct enough to evoke tribal impulses. However, this map isn’t about votes or beliefs. It’s focused on life expectancy. And once you grasp that, it’s difficult to ignore. In certain areas of the nation, the average lifespan nears the mid-80s. In others, it barely surpasses the mid-60s. A 20-year difference, not between countries, but between neighbors divided by a state boundary or a quick drive.
That’s not a minor error. That’s a whole generation, or as I prefer to see it, an additional adulthood.
The map (a close reflection of the CDC small-area life expectancy statistics) dives deep not just into states, but into counties and even census tracts, providing one of the most detailed perspectives we’ve ever had on American longevity. What it reveals is troubling precisely because it’s so clear. The patterns are indubitable. The Southeast exhibits red. Appalachia is faltering. Sections of the Midwest are declining. Meanwhile, certain regions of the Northeast, the West Coast, and a few urban corridors shine blue, indicating longer lifespans.
Predictably, commentary followed suit. Social media performed its usual role: it debated.
Some interpreted social determinants of health as the sole factor. Others claimed the map was merely an indicator of wealth. A few questioned whether it represented life expectancy or just the average age at which people died. Still others introduced various explanations (race, rurality, education, heat exposure, Medicaid expansion, hospital closures, food insecurity, trauma, tornadoes, even politics).
I held my own opinion: aging baby boomers from the north were relocating to milder southern states and “altering the statistics.”
Regardless, here’s the disheartening reality: Most interpretations were correct. And also somewhat incorrect.
Geography as fate
In medicine, we often seek a single dominant factor (the one lever that clarifies everything) or, as portrayed in television (Law & Order: Criminal Intent) and film, “The Theory of Everything.” Yet this map resists that inclination. It cannot be simplified to a single cause. Instead, it compels us to engage with something more complex: geography as fate, influenced by history, policy, and culture across generations.
The Nationhood Lab analysis of regional life expectancy provides clarity on this matter. When researchers categorized counties based on established regional cultures (which they describe as “American Nations”), life expectancy discrepancies remained even after adjusting for income, education, urban versus rural status, quality of healthcare, and race. Impoverished counties in some regions outlived affluent counties in others. Rural individuals in specific parts of the country lived several more years than urban dwellers elsewhere. Even when examining exclusively white or Black populations, the same regional patterns re-emerged.
In essence, this isn’t only about personal choices or even access to healthcare. It’s about the environments we have collectively established.
Health follows policy
Health adheres more closely to policy than it does to New Year’s resolutions.
Regions that prioritize public goods (education, infrastructure, preventive care, social services) generally yield longer lifespans. Regions that consistently underinvest, accept medical deserts, and view health as solely an individual responsibility do not. Medicaid expansion counts. Hospital closures matter. Accessibility to housing and food is significant. Safe areas for walking are important. So is whether a community regards health as a collective endeavor or a personal issue.
What surprised me most about the online debate wasn’t the divergence of opinions, but the tone. There was an underlying sense of resignation in many comments, as if these outcomes were tragic but unavoidable: “That’s just how it is.” “Those counties are not the same.” “You can’t change culture.”
Yet we have changed culture in the past. Or at least transformed it.
Seatbelts. Smoking prohibitions. Clean drinking water. Vaccinations. These weren’t instances of individual enlightenment; they were collective choices, implemented through policy, that added millions of life-years to the population. No one wished their way into clean air. Someone enforced it.
Which brings us back to the New Year.
We love to discuss fresh starts. We tell patients (and ourselves) that this will be the year for improvement. Eat healthier. Exercise more. Reduce stress. These aspirations are significant. But life expectancy maps remind us that no degree of personal virtue can surpass a ZIP code stacked against you.
Steven Klasko, MD, MBA, my high school classmate and former president of Thomas Jefferson University, comprehended that more than anyone. His “health care