PROJECT SUMMARY/ABSTRACT This project aims to identify factors responsible for levels and trends in geographic inequalities in mortality across the urban-rural continuum and regions of the United States. Urbanicity of one’s place of residence is itself an important stratifying dimension of socioeconomic status (SES) and access to health care services, and it has been largely overlooked in existing studies of SES gradients in life expectancy. Large central metropolitan areas and their suburbs, which experienced remarkable improvements in life expectancy between 1990 and 2015, were the only areas to have experienced life expectancy gains between 2010 and 2015. By contrast, smaller metros and non-metros experienced much slower improvements between 1990 and 2010, and actually experienced life expectancy declines between 2010 and 2015. Specific mechanisms hypothesized to contribute to urban-rural mortality inequalities include: (1) health behaviors and behavioral risk factors, (2) health care access and quality, and (3) domestic and international migration. To identify the contribution of each of these three mechanisms to the magnitudes of and widening in these inequalities between 1990 and 2015, we use three unique, restricted-use datasets (the National Health Interview Survey, the National Longitudinal Mortality Study, and the Mortality Disparities in American Communities database) in conjunction with vital statistics and several area-level datasets covering a wide array of contextual factors. These restricted-use datasets contain detailed information on cause of death, geography, and migration, and they have not been used in prior studies to identify mortality differences or mechanisms driving these differences across the urban-rural continuum. We will employ multiple methodological approaches including standard demographic methods, cause-deleted life tables, indirect estimation methods for quantifying smoking- attributable mortality, and discrete-time hazard models applied to both aggregate and individual-level data. Our rigorous and thorough assessment of the contribution of behavioral risk factors to mortality inequalities across the urban-rural continuum and regions improves on prior studies by focusing on multiple behaviors and causes of death (versus a single behavior or underlying cause), employing multiple methods, and accounting for the life course effects of behaviors like smoking on mortality. Migration’s impacts on mortality inequalities have received little attention to date. However, given the increased volume of migration to the United States, selective migration into different regions and metro/non-metro areas within the county, and the health advantages of migrants, migration is likely to play an important role in widening geographic inequalities in life expectancy. This project is the first study to quantify the impact of both international and domestic migration on mortality differentials within the United States. We will also examine how SES (education and income) inequalities in life expectancy vary across the urban-rural continuum and establish how growing inequality within the United States contributes to our life expectancy shortfall relative to other high-income countries.

PROJECT NARRATIVE Over the past quarter century, life expectancy improved much more slowly in rural areas than in large metropolitan areas in the United States, leading to widening geographic inequalities in mortality. This project aims to identify the mechanisms driving this divergence, focusing on the roles of health behaviors and behavioral risk factors (including drug overdose, obesity, smoking, and violence), health care access and quality, and domestic and international migration. Understanding these mechanisms will inform the development of effective policies to reduce life expectancy inequalities across the urban-rural continuum within the United States and help establish how geographic inequalities contribute to the United States’ poor performance in international rankings of life expectancy. !