54. Connecting Health Outcomes to Congressional Districts with Ben Spoer, PhD
Michelle Rathman: Hello one and all and welcome back to The Rural Impact. I'm Michelle Rathman and you know, we are the podcast that works hard to connect the dots between policy and rural everything. And I have to tell you in today's show we're gonna provide you with one of the best examples of why this is so. Now, if you've been around for a few minutes you know, it's likely that you've heard what I'm about to say.
And that is where we live should not determine how long or how well we live. And yet we also know that in rural places across the United States, on average life expectancy is lower. We know that we have higher rates of chronic diseases, poor health outcomes in the areas of maternal and infant health, just as one example.
And also, increasingly we have an alarming growth of food and housing insecurity. And to top it all off, if that weren't bad enough, we know that access to healthcare services are shrinking. And this is because hospitals and health clinics are forced to close their doors or reduce their services because they are not being equitably reimbursed for the care they provide.
Those are just the facts. So. You've heard me talk about that a lot on this podcast. And you know, while each one of us, I believe this, maybe you do as well, hopefully you share at least some of this belief. Each one of us should have the same opportunity to live the healthiest life possible. Policy designed to create persistent and systemic barriers to health and opportunity are making it very, very difficult to move the dial on those improved health outcomes.
And from there we know that many other dominoes fall to the detriment of countless, but not faceless millions among us. You know, I just, I wanna do a personal note. I just came back from a week on the road traveling to 10 different rural communities in the Northeast, and there's some common themes I wanna share with you.
Number one is just the commitment by community members working in nonprofit organizations to close those gaps, to remove those barriers to equitable health outcomes. And at the same time, I also saw some, some things that I just thought to myself, my goodness, we are in the year of 2025. Why are we here?
And so, I can't, I have some answers, but I can't answer them all. And so, knowing this, I really want to tackle these issues from a different angle and one that would make really seriously the direct connection between those who represent us in the United States and the health outcomes for their constituents.
So, I reached out to the brilliant folks at the Congressional District Health Dashboard to enlighten us on the first of its kind resource offering trusted data on health and its drivers for all 435 US congressional districts and Washington DC.
Now before introducing my guest, let me share that the Congressional District Health Dashboard. Now it was developed by a team at the Department of Population Health at NYU Grossman School of Medicine, in partnership with Robert Wood Johnson Foundation. And this map, this dashboard, it builds on their work creating the city health dashboard, which provides similar metrics at the city and census track level.
And the team behind this the project consists of epidemiologists, geospatial analysts, and public policy and population health experts, all of whom are a part of a non-partisan, very important academic institution that provides objective data on health and its drivers as well as health equity. Yes.
I'm gonna say the word because it exists and I've told people, you're gonna have to pry that out of my dead cold body for me to stop talking about the importance of focusing on health equity. Alright, so from this team, we are so fortunate to have the Program Director for City Health Dashboard and the Congressional District Health Dashboard join us.
So now it is that time when I'm going to invite you to tune out the background noise. We know there's plenty of it. And listen to my conversation with Ben Spoer, PhD and he again is the program director for Congressional District Health Dashboard. You know, I'm ready. I sure hope you are. So, let's go.
Michelle Rathman: Hey, Ben Spoer it is great to have you with us on The Rural Impact. Thank you so much and welcome to our studio.
Ben Spoer: Thanks so much, Michelle. Great to be here.
Michelle Rathman: Thank you again. So, you know, I'm gonna just kind of kick this out as our conversation starter. What really intrigued me people who know me know that I am fascinated with data, and I'm fascinated about laying out data over maps and with this congressional map. So that was what intrigued me. And it's really good timing because there's a lot going on right now that potentially may even change the work that we're gonna be talking about today.
But one of the things that I read on the website and I just wanna share with our listeners, and I wanna assure you that we will put links up on our website that you can access this information very easily for yourselves. But this is what I read. Most data on health, the drivers of health and health equity are organized at the county, state, or more recently, city level.
And contrast data about the health of people living in congressional districts is difficult to find. That's where the Congressional District Health Dashboard, the dashboard comes in. So again, our listeners know that on this podcast you hear me say all the time, all roads to quality of life are paved by a policy in my almost 60 years on this planet.
I haven't been proven wrong yet. I would be glad to be proven wrong on this, but you all have receipts and it's giving users access to information that shows them exactly how. In so many areas their districts are doing on health outcomes, social and economic factors, and so much more. So, Ben, let's start there.
The dashboard has been around for a while, but it's been updated to reflect this 119th Congress and it includes new metrics. So, tell us about the map, the data, about the dashboard and what is new right now.
Ben Spoer: Yeah. Thanks so much, Michelle. I don't think anyone's been proven wrong on, on that good policies lead to good outcomes, right? So, I agree with you there. The Congressional District Health Dashboard, we launched about two years ago, and what we noticed is that there's a lot of policy responsibility in this administrative geography, the congressional district, but data for health and health drivers are typically organized at the county level, sometimes the city level, especially for bigger cities.
And congressional district data was like hard to find. And so, we used a geospatial aggregation technique, which I could explain in a, like a totally impenetrable way, but it kind of boils down to something similar to Legos, right? You have your, your Lego rocket ship and you know you're an excitable 7-year-old boy like I once was.
And you wanna build a Lego dinosaur. You break the thing down into smaller pieces and you build it back up into a new shape. And so, the smallest geography of available from US census, which is the main sort of US maintainer of geographies, as it seems like you probably know already, is the census block.
And we population weighted, census tracked, and county level estimates at the census block level, and then built those back up into congressional districts. And we actually published a paper validating the method, trying to demonstrate that, you know, the numbers are pretty rigorous and, and I believe they're pretty rigorous.
And so, we launched the website in the hopes that folks who make policies can see it and use it to inform the policies they make. Period.
Michelle Rathman: That is the hope. And we know that hope is not a strategy, and that's where data comes in. And so, one of the things I wanted to mention to our listeners is that what I'm looking at here is some of the new data that you're collecting focuses on, number one was youth not working? Independent living difficulty, food insecurity, and of course the designated primary care shortage area.
And we know any listener of this podcast, if you don't know, before you know now, these are all things that are hugely impactful in rural counties and rural, you know, congressional districts that we're talking about across this country. And so can you just talk a little bit about why the add-on of youth networking, for example.
People might not understand what that could lead to down the road.
Ben Spoer: Of course. So, the metric we call it youth not in worker school. If you Google that, you're not gonna find very much. Most other sources will call it disconnected youth. We just kind of felt that we were overstepping our knowledge by calling it disconnected youth because there are surely.
You know, teenagers who are not working and not in school, who are still like totally connected to a vibrant community. But for many teens, if you're not working or in school, you're kind of at loose ends. And the research around it suggests that this period of time, right, these late teenage years especially, are an important transition into adulthood.
And if folks aren't connected to society in a productive way, then they find other paths for themselves, some of which can lead to poor health outcomes for them. And so, we wanted to help folks think through, you know, where are their kids who could use help getting sort of connected back into society.
Michelle Rathman: Job training, apprenticeship programs, parent supports and things of that nature. And then the other one, again, we know, very consequential and so many rural areas is independent living difficulty. I know there's a lot of talk going on right now about isolation and things of that nature, and so that is kind of a no-brainer.
But I wanna just focus for a moment on food insecurity, Ben, because we know that access to adequate, not just food, but nutritious food, let's talk a little bit about some of the things that you're looking at in that area, where rural is concerned. If you don't mind.
Ben Spoer: Yeah, so the food insecurity metric is based on a, like a single question from the Behavioral Risk Factor Surveillance System conducted by CDC. And it says, at any point in the last year did you run out of food and didn't have enough money to afford more, right? So, it doesn't say much about the nutritional quality of that food, and, and that's something that's missing from the metric.
One thing to also point out is that this specific module for the, for the behavioral risk factor, surveillance system is optional, and not every state took that option. And so, there are some states that have substantial rural areas that did not choose to implement this question, New York, Pennsylvania, Louisiana, Arkansas, Colorado. You know, there are 11 states, total, Oregon, South Dakota.
And so, we don't have perfect data on food insecurity in rural areas. Amongst the data we do have as we as categorized by our district density index, we do see that that food insecurity is lower in rural areas than we expected.
And I don't think that's because this is not a problem in rural areas. I think that we, we run the risk of, of misunderstanding the data when we don't appreciate that the data are not perfect, right? We don't have a perfect immediate understanding of everybody who's going hungry, right now. And so that's why I start this conversation with, here are the states that are missing data, and anybody who's listening to your podcast regularly probably recognizes those states as having big rural populations.
If we don't have data from those rural populations, I don't, I wouldn't necessarily bet too heavily on the, the totalizing trends for that metric. What I would say is, if you're interested in this, go to the congressional district, you live in on our website, and though our data for this metric are missing for 11 states, we have it for all the other ones.
And also crucially, we have data at the census track level. And the census tracks are, are the third smallest geography census produces. They're intended for statistical comparisons, but their boundaries are also drawn to approximate neighborhoods. And so you get this important within congressional district variation, almost quasi neighborhood level variation.
And so, if you have food insecurity data, right, you can look very, at a very granular level, at where do we need to carefully target our outreach? You know, where do we get the best bang for our buck, so to speak, in terms of outreach and food distribution?
Michelle Rathman: You know, Ben, I wonder, and I'll just before we move on, I'll just say as we are recording this at the end of March of 2025, we do know that there have been significant cuts to the supplemental nutrition assistance programs, and so I do wonder what the data will look like. A year from now, or maybe less.
So, I really want us to be paying attention to that. And one of the follow up questions I have for you is it, you may or may not have the answer to this is. I mean, obviously you all, you're all of you working on this amazing dashboard. You go out and you, you seek data, you seek information, but sometimes, as you said, it's not available for certain metrics.
And so, I want us to be mindful about, you know, maybe why that is, if you could surmise a little bit. If not, but I do find it curious. I think it does in every state want their data? Doesn't every congressional district want their data? What might be the motivation behind not providing that data?
Ben Spoer: Yeah, so, I wanna make an important distinction, which is between not collecting versus not providing. In the case of the food insecurity metric, many of these states choose to just not ask the question, and that could be for many reasons. The first thing we think about when we're administering a big survey in the public health world is, how much of a burden does this put on someone who is responding to the survey?
And the behavioral risk factor, surveillance survey is like an essential Hallmark. It's like this pillar of our understanding of health in the US. It's also a long survey, right? There's a lot of questions on it, and so some states may have said to themselves, we are not gonna get people to sign up if it even has one or two more questions on it, or God forbid, eight or 10 more questions.
No one's gonna take this thing. It's gonna be too long. Right, especially important to consider given there's increasing skepticism about science and data collection. There were a lot of fear about the reliability of the 2020 decennial census. And so, I think a lot of states take, they have the base survey and then there are many optional modules and they may think, you know, food insecurity is important, but it's not as important as these other two things that we really need to add.
I don't think it's the case. I do not think it's the case for this metric that states collect the data and then they sort of hold onto it. They don't share it. I think if they have that information, they're gonna share it. There, that may change with some of the direction the current administration is, is going with in terms of federal data sources.
But for the data years that are current rep currently represented on the website, I don't think that's a concern.
Michelle Rathman: Right. Thank you for that. So, let's talk a little bit, let's shift, a bit to discuss congressional districts based on household density. I thought that was interesting. From pure rural to pure urban and the numerous categories in between. Can you go into that for us?
Ben Spoer: Yeah, so, when we launched the website, we found something called the District Density Index, which is put together by a reporter at City Lab who then moved on and we picked up the project. And it uses some fancy math to categorize congressional districts into these categories. Predominantly rural, rural- suburban, sparse- suburban dense- suburban, urban and suburban, and then pure urban.
So, we've got these, what, six categories? One, two, three, four, five, yeah. six, seven categories. And we took a look at the distribution of the average metric value across the different categories. We're in the process of updating it for the hundred 19th Congress, which Michelle you had mentioned earlier.
That's just as a sign aside. Being able to quickly update our metrics for new congressional district boundaries is one of the things I'm most proud of. It used to take like a year to get those data realigned, and though it's only relevant for some states, those realignments are implemented because the courts think that the old boundaries don't effectively represent the people living there.
So, it's like a, 'what are data meant to do?' Question. They're meant to represent the people who live in these places effectively, so we can make good decisions based on that. Right? So, we are rerunning our analysis for the hundred 19th Congress and there's not a lot of congressional districts that switched from one category to another, and I don't believe any of 'em, for instance, went from pure rural to pure urban. That would be a, it's hard to build that many housing units.
Michelle Rathman: I would agree with you.
Ben Spoer: Right, but. You know what's interesting is that there are, there are lots of metrics that behave like you might, that some people might expect, right?
Where it's a sort of, things are better in urban areas and then there's a decline through to rural areas across the categories. Then there are some metrics where there are high in pure rural and pure urban, and they're kind of lower in between. And there are some metrics where things are actually kind of better in rural areas and they get worse across the, the categories.
And so, I was sort of excited to see when we ran these. Well, it's not really analysis when we graft these data points that there's a lot of resources and attention and advocacy that need to be directed to rural areas. And also, there's a like a lot of resilience and a lot of people working hard to support each other in rural areas.
And sometimes you can see hints of that in the data.
Michelle Rathman: I think that's the frustrating part, little commentary for so many people, because there has been so many, there was strides, a lot of strides in, in addressing some of the disparities that the data shows us. I mean, this is not make believe this is, you know, this is raw data put into a context where you can really see where there are disparities.
And you know, with that, looking at the congressional districts, what I found was so interesting. So, I took some time to just tool around on there and, taking a look at the places that I work. I will be leaving in a few days to tour the entire state of Massachusetts and going to 12 different rural communities.
And so, I wanna do, I did my own look. You know what the, the districts are, the zip codes and so forth. And one of the things that I found so interesting was that in the same state you can see different categories such as child and children in poverty, dental care access, food insecurity from one district to the next.
I mean, they're in the same darn state right next to each other. Can you talk a little bit about just the nuances here about, you know, how we could, you know, especially when you take a look at congressional maps that are changing, it's almost sometimes like flipping a switch. You could just cross a border, and things are different for their population.
Ben Spoer: Yeah, it's tricky stuff, Michelle. In, the mapping data world. We call this the modifiable aerial unit problem, the MAUP, which if you get a degree in geospatial analysis, you have it like tattooed on the back of your eyelids, but if you didn't do that, then you're like, what is this awkward mouthful of vowels?
But what it comes down to, if you draw your boundaries differently, you get vastly different numbers. And the most obvious example, and this is the one I use even when I'm not talking about congressional districts, is gerrymandering, right? If we draw our lines like this, we get a, a demographic population that is this way. We draw our lines like this, we get this other demographic population and they vote very differently, right?
Same is true of health outcomes. So, you can draw boundaries that have only wealthy people in them and your child poverty numbers are gonna be really low, poof. And it's like, oh, wow, we fixed the problem. It's like, no, you,
Michelle Rathman: just shifted it.
Ben Spoer: you manipulated the boundaries, right? Or changed. Maybe it be manipulated and implies too much bad intent. But you know, I took a look at the numbers for children in poverty average in the, in the pure rural and pure urban congressional districts, according to our district density index, and the, the highest percentage children in poverty was in pure urban districts. The second highest was pure rural.
And so the bar charts have this sort of like U shape, right? And I think that a lot of folks will say, oh yeah, well we bel, we sort of call socially, societally believe that there's high impoverishment in, in rural areas. And then when you see that it's, it's similar-ish, you know, it's not quite the same, but it's similar in urban areas.
It makes you really think about what do the boundaries mean? You know, who's enclosed in the boundaries and how do we, how do we, create our shared impressions of what it means to be in a rural place versus an urban place. I think they, that we should be helping both groups. We, we should. There just should not be children living in poverty, period.
Michelle Rathman: No, not in the wealthiest country. I agree with you on that. We've done a lot of episodes on food security and children in poverty. And you know, and as a part of that, as you said earlier, is advocacy. And advocacy is a good thing. And now I will just say we need it more than ever. And I think one of the key benefits for this dashboard.
That I'm excited about, and that, that says a lot for me is that the dashboard, the data can be used to drive change and we have to drive change and. It's being, it can be used for our policy makers, you know, so many of us out here who depending on your industry, whether you're in transportation or broadband or healthcare or education, because you guys cover the full gamut of, you know, spectrum of so many things.
Let's talk a little bit about how you see the data being used to do just that in the hands of advocates, in the hands of journalists and of researchers. I mean, this is not just you know, just for the fainted heart, this. This can, this can get a lot of traction if we get more people to pay attention to it.
Ben Spoer: Yeah, so, we imagine ourselves as a nonpartisan tool, right? We provide the information. I have, I have not talked to a single person that uses our tool, who thinks, man, I want to use data to make people's lives worse. I just haven't heard that take, you know, I'm interested to hear it in a, in a slightly morbid way if it's out there.
But in a, in a sort of nonpartisan way, I want people to use our tool to get in the fight. It's like, take a look at your district, take a look at the congressional, at the census tracks in your district, see what the neighborhood-to-neighborhood variation.
You can compare districts, right? So, there's a portion of our website where you can say, what's going on in the district next door? What's going on in the district in the next state? What's going on in the district that has the state capital? You know, it gives you an idea of what's possible, both good and bad.
You can compare your entire state's districts. If you see something that makes you curious, if you see something that makes you mad, if you see something that inspires you, that's the way this tool works, right?
We know that people in Washington DC are using it. We hear about it all the time. We know the journalists are using it. What I want to hear is about folks listening to this podcast, right? People out in the world saying, I saw this number on the Congressional District Health dashboard, and I called my representative 'cause I was fired up about it.
That's how I want this to drive change, and I don't necessarily think it needs to drive the changes that I wanna see. I just want it to drive change, period. I want people to see it and get in the fight.
Michelle Rathman: I love that you said that, Ben, because as I think about it right now and all these town hall meetings going on in my own community, we've got an election coming up in just a few days from now, and I see people going to town hall meetings and they're kind of talking about their own needs.
And I love the idea that as a community you can be well informed. You don't have to be a scientist or a researcher yourself to go to the dashboard, plug in your district and you can see many, many, many different things. And one of those, and before I let you go, I really wanted to talk about the, within that framework you do have data for clinical care and subcategories for clinical care.
And one of those looks at those who fall under the uninsured category, as well as whether a resident in a district 18 years or older, as you guys have it, have routine checkups. Something that we talk about a lot as well. So, let's talk about these numbers and if you could maybe have a little crystal ball here, what might change?
Should, for example, all the things we're talking about right now are drastic draconian cuts to Medicaid. That would definitely impact those two populations that you just mentioned. Pure urban, pure rural. So, what does it look like now? And what, what might we be needing to brace ourselves for, if I may?
Ben Spoer: Yeah, so the most direct answer to your question is we probably won't see changes in the data immediately because the data, because they're national data, they take a long time to collect and then a long time to rigorously analyze and then put it on the website, right? So, the data are right now are like two years old. The other thing is we, we do a pretty careful validation process, right? And, and so we take a look at variation across geographies, variation across time, and with these big metrics, right, big national level metrics, we don't expect to see huge changes over time because when you have, as such a large population is the entire US population or the, even the entire population of a, of a congressional district, things change slowly over time.
The exception to that is when there are large policy shocks, we call 'em policy shocks sometimes. And a big cut to Medicaid would be such a policy shock, right? It would create a huge change immediately. So, we, our tool, our websites have not existed in a period in which there was a big cut to Medicaid, right.
Our, the city health dashboard, the sister site that focuses on cities launch in 2018. So, it's like kind of modern era. I would expect to see a lot more people reporting that they don't have insurance, especially 'cause the, the question in the census that our uninsurance metric is based on, it says, do you have insurance through any of these sources?
Private insurance, labor unit, and Medicaid is right there, right? So, it'd be inconceivable that if people are kicked off the rules, that the number wouldn't change.
In terms of routine checkup, the other thing I think about is our, which you mentioned at the top, Michelle, the healthcare provider shortage area, because a lot of rural areas and, and in looking across the district density index, the primary care shortage areas are highest in rural
Michelle Rathman: inescapable.
Ben Spoer: inescapable.
And then it's one of those that like behaves exactly as you might assume it would behave. It's high in rural and then it declines across the other categories. If you don't have insurance and there aren't primary care doctors around, how are you gonna go get a checkup? I'm not a healthcare services researcher, so I'm not an expert in this, but my guess is that those primary care access metrics are gonna go down
Michelle Rathman: Yes.
Ben Spoer: and then what happens to disease rates?
What happens? Like, how can you manage your diabetes? Right? So there, it's just sort of a dominos falling moment.
Michelle Rathman: Yes. And in the worst possible way. And we've just closed out an entire series talking about this as well. And so, folks know, I mean, that is why it's so crucial to connect these dots. They don't, these things that we're talking about don't exist on a, in a silo or a bubble of their own at some point in time.
I loved your Lego analogy as a grandmother of five grandsons who build Lego stuff all the time. I think it's a great analogy, Ben. My goodness. Last thing I just gonna close out by saying, you know, just your professional head and all of the work that you've done and how, kind of looking through a long range, what would you say to our listeners who may not say all this interesting information, but how do we inspire people to use this information if you are a member of Congress, to use this information to really shape policy that improves outcomes for rural populations and urban for that matter, because we are connected, you know, it's just geography.
Ben Spoer: Yeah, it's a great question, Michelle. I love your point about it's all, you know, it's, the boundaries are drawn on maps by governments, but we're really all connected and we learned that in Covid, right? If there's one Covid case in the country, then it starts to spread and it's really not paying like the Covid virus wasn't like, oh, well household density is low here, so I'm gonna skip it.
You know, I'm not advocating for any specific policy. Not only is it not my personal philosophy to try and tell people what to do, but also like professionally, we don't do that here. Period. What I do want people to do is, if through this podcast people get curious about what's going on and go look at the numbers, the sort of underlying idea is that if you get a clear-eyed picture of what's going on in your congressional district, you will be motivated to make decisions that improve those numbers.
Something there will call to you. Maybe it's food insecurity, maybe it's cardiovascular disease, death rate. Maybe it's the, the primary care shortage areas, there's some metric on there that's gonna be important to you.
Michelle Rathman: Yes.
Ben Spoer: And once you find that metric, my hope and my belief is it's going to, it's gonna whisper in the back of your mind.
It's gonna be like a, a hook from a Taylor Swift song. It just lives in your head forever, in good time, soon and bad. And at some point you'll take some action on it. So that's what I mean when I say I want it to help people get in the fight.
Michelle Rathman: Yeah, and I'll tell you, you could spend an entire day on that dashboard. It is really fascinating, Ben. I am so, I mean it, so grateful for your time, appreciative for the work that you all are doing. We're gonna continue to pay attention and as I say, we'll make sure that these links are on our website so that you can easily go find this information and you are welcome back anytime you and your colleagues if you've got some new information for us to that it's important for us to cover for our listeners.
Thanks for joining us on The Rural Impact.
Ben Spoer: Thanks so much for having Michelle.
Michelle Rathman: Hey, my thanks to Ben Spoer for his time and expertise. Really did enjoy his very enlightening conversation. We know these are not light subjects. We said that all the time. But at the end of the day, we do hope that the content we're bringing you, enlightens you.
And just as a quick reminder, we're gonna make sure that we have links on theruralimpact.com website for you to explore the dashboard for yourself. It's fascinating, and I certainly do wanna encourage you to use the information you find on that website and connect with your own member of Congress, ask them how they intend through policy to remove those barriers Bill programs.
And invest in that which is essential for your district to have, not just a fighting chance, but a winning strategy to improve and sustain. Better health outcomes across the dashboard. All right. Silence is not an option in these times. We have to advocate for ourselves and our community, before we leave you.
A quick reminder that we sure do appreciate all of our subscribers. If you have not done so yet, just go to theruralimpact.com, click that subscribe button. It'll take you less than two seconds to do it. And you know, we also do appreciate it when you rate us. Leave us comments wherever you like to listen or watch if you're watching us on YouTube.
And finally, I wanna mention to you if your organization has an interest in increasing your rural reach. We invite you to connect with us to explore all the ways that we can help you do that, and we can also take the show on the road and podcast from one of your rural focus conferences. I wanna put that out there.
You'll be seeing me on the road this summer. Lastly, I'm gonna put this out there to the universe. These are some pretty challenging times that we find ourselves in, and that is all the more reason to make sure that you are taking good care of yourself. To the best of your ability, those around you. Real quick, thanks to Brea Corsaro and Sarah Staub for their hard work behind the scenes.
Until next time on a new episode of The Rural Impact, we will see you soon.
