A new study published in the Journal of the American Medical Association (JAMA) brings more nuance to our understanding of life expectancy among rich and poor Americans.

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The study, released today, correlates the relationship between household income and mortality rates between 1999-2014. Some of the findings were unsurprising: the rich live longer than the poor, a trend that’s long been a feature of modern healthcare, but in the last few years the life expectancy gap has increased. Among men, there’s nearly a 15-year difference in life expectancy between the wealthiest one percent and the poorest one percent; for women, that gap is 10 years. The New York Times reports that “rich Americans have gained three years of longevity just in this century.” That gain for the wealthy is nationwide, with little regard to geographical location. For the poor, however, life expectancy seems deeply tied to geography.

JAMA’s study found that along with lifestyle, zip code was the greatest determining factor for longevity among the poor. More surprisingly, perhaps, is that the study found that access to health care had little impact on life expectancy among the poor. Rather, places where the poor had longer life spans, have high government expenditures and more college graduates. Via JAMA’s study:

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[...] Geographic differences in life expectancy for individuals in the lowest income quartile were significantly correlated with health behaviors such as smoking, but were not significantly correlated with access to medical care, physical environmental factors, income inequality, or labor market conditions. Life expectancy for low-income individuals was positively correlated with the local area fraction of immigrants, fraction of college graduates, and government expenditures.

The Times notes that JAMA’s study shows that addressing public health gaps between the rich and poor isn’t necessarily about “fixing the broader, multidecade problem of income inequality.” Rather, hyperlocal policies designed at addressing specific health issues have a far more profound effect on lengthening the lifespan of the poor. Cities like New York, where the income-longevity gap is one of the nation’s smallest, have invested in public spending aimed at eliminating trans fats and regulating smoking. JAMA’s study found that poor Americans tended to be more impacted by obesity and smoking than their wealthier counterparts.

Poorer Americans also fare better in urban areas. The mortality gap was largest in the middle of America, in large part because of a large number of early death fueled by opioid addiction. A recent two-part feature from the Washington Post found that death rates among white women in the middle of America have soared over the last decade:

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White women between 25 and 55 have been dying at accelerating rates over the past decade, a spike in mortality not seen since the AIDS epidemic in the early 1980s. According to recent studies of death certificates, the trend is worse for women in the center of the United States, worse still in rural areas, and worst of all for those in the lower middle class. Drug and alcohol overdose rates for working-age white women have quadrupled. Suicides are up by as much as 50 percent.

That alarming trend, identified last year by Princeton economists Anne Case and Angus Deaton, corresponds to JAMA’s findings: lifespan is tied to income and geography.

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Economists and public health officials see JAMA’s study as a silver lining of sorts, a point of comparison to scrutinize local health and economic initiatives that could lead to small-scale solutions with large impacts.

Image via Getty.