The Atlanta Journal-Constitution led Wednesday morning’s print edition with a story headlined “Georgians in rural areas more likely to die early.” The story was based on a new report from the U.S. Centers for Disease Control and Prevention (CDC). I’m glad to see my long-ago employer covering this issue, but it’s not exactly like this is new news.

I’ve been tracking county-level premature death rates in Georgia for nearly a decade and have reported that the premature death gap between urban and rural Georgia has been widening steadily since the Georgia Department of Public Health (DPH) began reporting this data back in 1994. In ’94, the difference in premature death rates between Georgia’s urban and rural counties (those with populations of more than 50,000 versus less than 50,000, by current definitions) was 14.6 percent, not great but not shocking. In 2022, that gap was up to 34.3 percent, and that was an improvement from the Covid-driven spikes in 2020 and ’21.

Premature death rates — known formally in public health circles as the rate for Years of Potential Life Lost before Age 75, or YPLL 75 — are generally recognized as the Dow Jones Industrial Average for population health. It’s the best single number you can look at and get a sense of the health of a community. One difference between the Dow and premature death rates is that you want the latter to be low and going down. The graph at right illustrates the premature death rates for the counties that now fall into the urban and rural categories — over 50,000 versus under 50,000.

I realize that these numbers shown in the graph above can seem a little abstract, but they’re easy enough to calculate and explain. DPH keeps track of all deaths by age and county and totals up all the years of life lost before the age of 75 on a county-by-county basis. Then it divides that number by what’s called the YPLL 75 population — the number of people in each county under the age of 75. Then it multiplies that result by 100,000. (More about the economic and political implications of this data below, with a couple of examples.)

These maps should help tell the story. One of the datapoints I’ve been tracking for nearly a decade is the rising number of Georgia counties — all rural — that are recording more deaths than births. I call this the ratio of baptisms to burials. The map at right illustrates whether counties are recording more births than deaths — what I call the ratio of Baptisms to burials. The counties in green produced more births than deaths, those in red the opposite. The darker the color, the bigger the margin one way or the other. In 2022, 108 of Georgia’s 159 counties suffered more deaths than births. Madison County, in northeast Georgia, broke even, with 393 births and 393 deaths. Only five counties produced two births for every death. This was actually an improvement over 2021, when the number of counties on the wrong side of the baptisms-to-burials ratio peaked at a Covid- and fentanyl-fueld 123 counties.

The map at left illustrates the range of premature death rates and paints a similar picture. The darker the green, the better the premature death rate; the darker the red, the worse it is. One thing that should be clear from all this is that size matters. Most of the counties shown in red lack a sufficient population to support any kind of community of healthcare providers, let alone a hospital.

Medicaid expansion, long resisted by Georgia’s GOP leaders, would no doubt help, but at this point it wouldn’t be a magic wand or a silver bullet. The AJC quoted various sources with familiar data points: at least 10 rural hospitals have closed or given up full-service licenses, nine counties don’t have a single physician, 78 don’t have an OB/GYN. Even if Medicaid expansion were approved today and the money started flowing tomorrow, it would take years, probably at least a generation, to rebuild a healthcare service delivery infrastructure in rural Georgia.

Back to the premature death rate graph and explanation above, with a couple of specific examples.

The county with the best premature death rate in the state in 2022 was Forsyth County, located on the northern edge of Metro Atlanta. It lost 10,852.5 years of life to the deaths of people under the age of 75, but its overall YPLL 75 population was 252,467; do the math on that and you get a premature death rate of 4,298.6, among the best in the nation. In Southwest Georgia, Baker County, with Georgia’s worst premature death rate, suffered only 509.5 years of life lost to the deaths of people under the age of 75, but bounce that number off its tiny YPLL 75 population of 2,502 people and you get a Third World premature death rate of 20,363.7.

It shouldn’t come as a surprise that these numbers have significant implications for both economic productivity and aggregate healthcare costs. Based on IRS data, Forsyth County residents had $1.88 billion-with-a-B in federal income tax liability in 2020, or about $7,481 per capita; tiny Baker County, meanwhile, had a 2020 federal tax liability of $5.74 million-with-an-M, or a little under $2,000 per capita.

The picture for Medicaid costs is the reverse. According to Georgia Department of Community Health (DCH) data, Baker County consumed $2.7 million in Medicaid services in 2020, or about $917 per capita; that’s versus $62.7 million in Forsyth County, or $250 per capita. Put another way, it took nearly half of Baker County’s 2020 federal tax liability to cover its Medicaid costs; for Forsyth County, it took only 3.3 percent.

Then of course there’s the political irony in all this. As I’ve noted before, rural Georgia is overwhelmingly Republican Georgia. The small rural counties that are burying more people than are being born are represented largely by GOP legislators, and those 118 rural counties gave Republican Governor Brian Kemp 74 percent of their vote in 2022.

Barring a movement to legalize ballot drop boxes at rural graveyards, you’d think Kemp & Co. would do more to keep these voters alive.

© Trouble in God’s Country 2024