I shared these maps with cardiologist Donald Lloyd-Jones, a past president of the American Heart Association who chairs the preventive medicine department at Northwestern University in Chicago, who said they didn’t surprise him at all. “There’s a reason why the Southeastern portion of this country is called the Stroke Belt: It’s because the rates of stroke per capita are substantially higher there and mirrored by rates of cardiovascular disease, diabetes, obesity and other risk factors.”

“The places on your map where you see orange and red have structural and systemic issues that limit people’s ability to have socioeconomic opportunity, access health care, or achieve maximum levels of education,” Lloyd-Jones added. “All of these policies affect your health and these disparities in longevity absolutely reflect social and structural and historical policies in those regions.”

At Nationhood Lab we wondered if all of this is might just be a reflection of wealth. Some American regions have always had higher standards of living than others because their cultures prioritize the common good over individual liberty, social equality over economic freedom and quality services more than low taxes. The Deep South was founded by English slave lords from Barbados who didn’t care about shared prosperity; The Puritan founders of Yankeedom — who thought God had chosen them to create a more perfect society — very much did, and it made the average person materially a lot better off, both then and now. Maybe the differences between the regions would go away if you compared just rich counties to one another or just the poor ones?

Nope.

We used the prevalence of child poverty as our metric and compared the life expectancy of the least impoverished quartile of U.S. counties — the “richest” ones, in other words — across the regions. As you see in the graphic below, the gaps persisted: 4.6 years between the rich counties in the Left Coast and Deep South, for instance. And they got wider from there when we compared the counties with the highest percentage of children living in poverty: a staggering 6.7 years between those same two regions. Further, the life expectancy gaps between rich and poor counties within each of these regions varied: It was more than twice as wide in Greater Appalachia (3.4 years) and the Deep South (4.3 years) as in Yankeedom (1.7 years.) We saw similar patterns when we repeated the exercise using education levels. When it comes to life and death, some regions are less equal than others.

The same went for relative access to quality clinical care. CHRR assigns every U.S. county a ranking for this based on a combination of 10 factors, including the number of doctors, dentists, mental health professionals, mammography screens, flu vaccinations and uninsured people per capita, as well as how often Medicare enrollees wind up admitted to hospitals with conditions that should be able to be treated on an outpatient basis, an indication the latter services weren’t available. We compared those counties in the top quartiles of this ranking system to one another across the regions and found the gap between them not only persisted, it actually widened, with the Deep South falling about two and half years behind Yankeedom, El Norte and the Far West, 4.4 years behind New Netherland and 5.1 behind Left Coast.

We repeated the experiment using counties that fell in the worst quartile for clinical care and saw the gap grow even wider, with Greater Appalachian (74.6) and Deep Southern (74.7) life expectancy in those communities lagging Yankeedom by about 3 years and New Netherland by about five and a half. That there are fewer counties where most people can afford and access top-notch clinical care in these southern regions than the northern and Pacific coast ones isn’t really a surprise: laissez-faire political leaders tend to create systems that have looser health insurance regulations, leaner Medicaid programs and fewer public and non-profit hospitals. That those that do manage to have decent services nonetheless underperform suggests reversing these gaps won’t be easy.

Turns out even the “haves” are not doing better in the “laissez-faire” regions. One of the most arresting facts that emerged from our analysis was that the most impoverished quartile of U.S. counties in Yankeedom (ones where around 30 to 60 percent of children live in poverty) have a higher life expectancy than the least impoverished quartile of U.S. counties (where child poverty ranges from 3 to 15 percent) in the Deep South by 0.3 years. Those are both big regions (circa 50 million people each) with a wide mix of counties: rural, urban, rich, poor, blue-collar and white-collar, agricultural and industrial. If you compare the poorest category of counties in (completely urbanized) New Netherland to the richest ones in Deep South, the former has a 0.4-year advantage in life expectancy. And people in the Left Coast’s poorest quartile of counties live 2.4 years longer than those in the richest quartile counties in the Deep South.

I asked CHRR’s co-director, Marjory Givens, for her reaction to the gaps. “This is logical considering the overall values and variation in health and opportunity of Yankeedom are more favorable than the Deep South or Greater Appalachia,” she said. “There are regions of the country with structural barriers to health, where types of long-standing discrimination and disinvestment have occurred through policies and practices applied and reinforced by people with more power. … Counties in these regions have fewer social and economic opportunities today.”

One example: States that have expanded Medicaid eligibility have seen significant reductions in premature deaths while those that have not have seen increases. At this writing, 11 states still haven’t expanded the state-implemented program even though almost the entire burden of doing so comes from the federal government. All but two of those states are controlled by the Deep South and Greater Appalachia. Just one — Wisconsin — is in Yankeedom, and its Democratic governor has been trying to expand it through a (vigorously gerrymandered) Republican legislature. Expansion was a no-brainer for Republican administrations in Michigan, Ohio, New Jersey, New Hampshire and Vermont, but a bridge too far for their colleagues further south.