Welcome to the May, 2023 episode of the Healthy Intersections podcast!
This month, we sit down again with Carol Schmitt, Chief Scientist at RTI International, to talk about another of the RTI Rarity interactive state maps. This time, we are looking at Oklahoma. You can watch the episode, download the audio file, and read the transcript below. And don’t forget, you can subscribe to the audio version anywhere you get your podcasts. Thanks for listening/watching, and please be sure to share with your colleagues who may be interested!
Download the audio file here.
Transcript (lightly edited)
Lisa Lines
Hello listeners (and viewers!). My name is Lisa Lines. And I’m happy to welcome you to the May edition of the Healthy Intersections Podcast, sponsored by the Medical Care Section of the American Public Health Association and the Medical Care journal. And we’re hosted on the Medical Care Blog.
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So, my special guest today is again, Carol Schmitt, chief scientist at RTI International. Welcome, Carol.
Carol Schmitt
Hi, Lisa.
Lisa Lines
Thanks for joining us today. And let me just say, we’re going to be turning our attention to another interactive map today, and that is of Oklahoma. The name actually comes from Chocktaw, “okla” meaning people and “homa” meaning red. Between 1830 and 1850, the Eastern “Civilized Tribes” of the Southeast, Florida, Georgia, those tribes like the Cherokee, Choctaw, Seminole, they were evicted from their lands and forced to march to what was then called Indian Territory. And, Carol, what else can you tell us about what you know about Oklahoma?
Carol Schmitt
Okay, back around 2015, we worked with the Robert Wood Johnson Foundation to characterize 30 sentinel communities in the country around their progress towards creating a culture of health. And Oklahoma was one of those 30 communities. Within Oklahoma, we were originally slated to look at the Chickasaw Nation. We did some initial studies and talks with them. But those of you who know about working with Native American tribes, now, it’s really difficult to get permissions and things. And we never really did get permissions. So, what I know from that has to do with the initial contact we had with them.
The state’s really interesting, they’re highly, highly reliant for state funding on the extraction industry. And so, they have really unstable state funding, because when prices of oil are high, they do well, when prices are low, they don’t do so well.
Unlike a lot of tribes, in Oklahoma, there aren’t necessarily reservations, it’s more like the tribal nations have a relationship with the state, but they serve their members. And a lot of what goes on in Oklahoma, for the Chickasaw Nation and the Cherokee Nation, it’s all that southern part of the state that’s rural.
When Lisa and I were first talking, what I expected to see was areas of those counties that have a lot of members of the Chickasaw Nation would have higher employment rates, because the nation does a really nice job of building businesses and employing tribal members. And I also expected to see significantly lower uninsurance rates, because they also provide strong health care services to their members.
It’s a bit difficult to look at it now. Because in spring of 2021, Oklahoma finally took the Medicaid expansion under Obamacare, and their uninsured rate, which was about 14 or 15%, went down to less than 10%. So that’s kind of a little mix in there. But as Lisa and I were looking at the social inequity indices, we found something else. So, Lisa, with that, go ahead and start on the map.
Lisa Lines
Great, let me go ahead and share my screen. So, this is another one of our RTI Rarity interactive state maps. And I will put the link in the notes. And this is publicly available, you can go and look at this map at home.
Just a couple of notes as we’re zoomed out to the whole state right now. As you can see, we have some heavy black lines around certain areas. Those are the second and fourth congressional districts, because we had an opportunity to speak to some folks in those offices. So, we wanted to highlight those congressional districts to show partly that there’s a lot of variation within districts and these scores are helpful in identifying places where a district might want to put extra resources.
The LSI score, local social inequity score, is a zero to one percentile rank score. Here we’re looking at within-state scores, and they’re actually based around life expectancy, which is a core public health outcome that we use to compare areas in terms of how well people are doing, overall. A summary health measure, core public health measure.
The local social inequity score, this base model that we’re showing you the scores for here, is Local Social Inequity in Life Expectancy based on the social and behavioral determinants of health. So, as you click on various areas on the map, you can actually zoom in. We’ll do that now.
Let’s zoom into Tulsa, I’ve got some family living in Tulsa, been there once or twice. It’s an interesting picture, because you can see quite starkly across the city, places that are doing pretty well, and places that are really not doing too well. Right, right next to each other.
For example, right here, we have this tract in bright yellow, which indicates higher risk of shorter life expectancy, essentially, based on the social determinants of health. And we’ve listed out a few of the factors that may be driving some of this. For example, you can see here in this tract that I’ve highlighted, it’s got one of the higher LSI scores in the state, and then this other tract right next to it, bordering it, has one of the lowest LSI scores in the state.
And when we click on these two tracts, next to each other, we can see really big differences in terms of the percent of black and Hispanic populations. And in the tract, the life expectancy is quite high, 81 years, on average, it’s a very low poverty rate, and a very low unemployment rate, very low uninsured rate, and a low sedentary lifestyle. Right. So, this is a pretty healthy area in Tulsa.
And then right next door, if we look at the life expectancy, it’s quite a bit shorter, shorter than average, quite a bit more people of color, and very high poverty, very high smoking, pretty high unemployment rate — triple the state average — and then very high uninsured, and physically inactive, or sedentary, population. So, it’s, it’s really quite remarkable to see communities, with these tracts having an average of around 4000 people in them, really quite, quite small neighborhood level areas, and they’re just so so different tract to tract.
I mean, I live in a place where things can change block to block, in LA and Los Angeles County. So we see this in our communities, and it’s just a really good way to summarize the picture, when you can look, and drill down, and look at some of these are these differences.
And I do want to say, if you are in Oklahoma, and you need help, if you need help with getting insurance, or need help with shelter, we’ve got links down here at the bottom, where you can click and put in your ZIP code and get a list of every resource that’s available in your area.
Carol Schmitt
You know, it’s shocking in that, high social inequity score tract has a smoking rate of almost 30%. Lisa lives in California where the smoking rate is like 8%, and I live in Colorado, where I’m pretty sure it’s below 10%. So you’re seeing three times the rate. I know, it varies wildly from state to state. But I mean, that’s even higher than the state average, which I’m sure is in the high teens.
Lisa Lines
And when you think about the state as a whole, if you look at the summary health statistics of the state as a whole, across the state, there are high high rates of obesity and overweight, there are high rates of the associated things that kill you, like heart disease and stroke and cancer. There are high rates of diabetes as well, which we know comes along with a ton of horrible things that happen when you have untreated, undiagnosed diabetes.
So in these pockets where you’ve got really high, high rates of chronic illness and low rates of insurance coverage, how many of those people even know, necessarily, that they have high blood sugar? It’s a real potential avenue for the healthcare system to put some resources in those areas, send some mobile clinics to screen for blood sugar and HbA1c, and just try to put more resources where they are needed.
Carol Schmitt
And maybe when the Medicaid expansion has more time to take effect, we might see things improve in Oklahoma in some of these places, in the longer run. I don’t mean to make it sound like a horrible place. Because there’s some lovely, I mean, Tulsa is gorgeous!
Lisa Lines
True story! It’s not all doom and gloom, these communities do have a lot of like you were talking about and some of these nations have done a really good job of reaching out. I have a friend who is a Native American activist, and she told me that she tells people in her community, the most important thing they can do is avoid white sugar and white flour. And these are the things that, when you when you have a busy family and you maybe don’t have access to the best healthy food choices, those things really do accumulate across the life course. The stress of that situation of always being too busy, too stressed.
You mentioned the extraction industry. I think it’s interesting that Oklahoma City is the only state capitol that has a working oil well at the Capitol. So that points to, really, a couple of things. The importance, like you said, of the industry to the state, but also, I mean, think about the land that the oil wells are on. Like I mentioned, I live in LA County, and there are oil wells in public parks here. And the pollution associated with those oil wells is nothing to be sneezed at, because it really is a factor in how healthy your air, your water, and your soil is.
Carol Schmitt
I remember when we were looking outside of the Houston area, Lisa, one of the big predictors of cancer death was the air pollution in those areas right around Houston. People’s houses back up to refineries.
Lisa Lines
Yeah, and there’s a refinery across the street from a playground here, near where I live. It’s really kind of mind blowing.
Carol Schmitt
It is really interesting, the states, how they regulate where you can put oil wells. I don’t, off the top of my head, know what it is in Oklahoma, but it would be worth taking a quick look at.
Lisa Lines
Yes, so we were going to talk about some of the more rural areas. Love County. So here we have top 20% in terms of risk of a shorter life expectancy, and you know, quite a bit lower life expectancy than is average. Very high percent Hispanic. We don’t actually have, unfortunately, in this drill-down, the percent Native American, but we can look at other maps that tell us. And I think, the Hispanic population, a lot of folks are working in the extraction industries, and also in the meat-packing and farming industries. So, tell us a little about Love County.
Carol Schmitt
Oh, Love County is down there in Chickasaw Nation area. And like I said, they don’t have really a defined reservation, per se, but they they are served by the Chickasaw Nation. And so you can see that the unemployment rate is pretty this is the state average, and it pretty much sticks around 3%. The percent uninsured like I said, before, Medicaid expansions, it was about 14 15%. But I’m struck by 22.5% of people out of poverty, again, it’s it’s I non white area, lower life expectancy, it’s not the prevalence rate that’s really high. State, a lot of physically inactive people. And this, it looks similar to Tulsa.
I mean, we we tend to talk about rural problems, which are different from city problems. But at the end of the day, what we’re seeing here is that we these areas that where people are dying before they should die, are characterized by high percentages of non-white people, and high poverty levels. And fundamentally, it’s unfair. It suggests that first that something is happening there, are they being exposed to something? Are there state policies that that omit them?
You know, we’d have to take a closer look at this, like we like to deal with really mixed methods, but it’s, I had expected to see maybe a little bit better profile in this part of the state only because of the high number of Native American tribes, and the extent to which I was really impressed that when we were looking at the Chickasaw Nation, how much how aware they were of the need to build businesses, and how they were aware of the need to build medical care, and provide medical care that incorporated tribal values and cultural traditions.
Lisa Lines
The other part of Love County that’s doing pretty well still has a pretty high smoking prevalence rate. And a third are sedentary. But very low unemployment, and half the poverty rate of the other area there. I think there’s always a lot going on, even within a single county.
And that’s why these Census tract level scores are so helpful in helping us dig down a little bit deeper and below the surface. You can say, oh, Oklahoma has a high rate of this or that across the state. But as you can see, when you zoom in, there’s a real patchwork. Over here in this county, where Will Rogers was born, life expectancy is 79. And if there’s one thing that the healthcare system really ought to be prioritizing, it’s trying to ensure that no matter where you live, you have the same opportunities as everyone else to attain a long and healthy life.
Carol Schmitt
I like that you focus on life expectancy because for me, that’s always a story about…
I did hospice care for a while and people who die in their 50s, and 60s, early 70s, are people who may have worked really hard, they’ve been saving for retirement, just starting to get grandchildren, and they’re really feeling like all the work they put in across their lifespan is coming to fruition. And then they die, and they miss it all, after having worked a long life.
And it seems to me so fundamentally unfair, in such a rich country, that happens. Whereas other people, we have a colleague whose mother is turning 102 or 103. And she lives in an area of Florida that has high life expectancy. It’s, I’m gonna go on my bandwagon, but it’s fundamentally unfair.
Lisa Lines
Yes, agreed. And I think when we talk about health equity we have to, before we can make a lot more progress, we really all have to just get on the same page that health equity is a thing that we all think is important that we all want to try to to promote.
Carol Schmitt
Yeah, and I noticed that when you sent me what the predictors of life expectancy were in Oklahoma, among the top 10, drought was one of them. And most people know, in the Midwest, we are facing a huge extended drought. That, that does not bode well for the future. I don’t know why, what’s behind that factor being predictive, but it’s something that we should probably look at the why of.
Lisa Lines
If I had to guess, if drought is turning some farms fallow, those farmworkers are out of work. And that affects the whole family. Oklahoma has pretty high rates of maternal mortality and infant mortality as well. And that points to uninsurance, as you know, as a potential really important thing, because, I mean, the thing about it is even before Medicaid expansion, if you were a pregnant person, or you know, parent-to-be, you could sign up for Medicaid, and the birth would be covered by Medicaid, prenatal care, it will be covered by Medicaid.
But the barriers to signing up are something that we’ve talked about before. If you don’t have access to a working computer with broadband, and the know-how to actually go to find the site where you need to sign up and the documentation that you need to prove your status and all these other things. I mean, there’s big gaps in that so-called “safety net”.
Thank you so much, Carol, for talking with me today about Oklahoma. It was wonderful to get your thoughts about how these scores could be helpful in looking at situations in the state and communities in the state and figuring out how to target resources where they might be needed. But also just the stories behind the data is always really important. Thanks so much.
Carol Schmitt
Thank you, Lisa.
Lisa M. Lines