Health inequities have a tremendous impact on our society. The American Medical Association finds that racial health inequities resulted in a 24% higher mortality rate for Black populations than white populations nationally between 2016 and 2018.

It is estimated that health inequities result in $320 billion in health care spending each year, and that this could grow to $1 trillion by 2040 if not addressed. Moreover, health disparities are estimated to cause $42 billion in lost productivity each year nationwide. Eliminating these disparities by 2050 could result in a $230 billion annual economic gain for the country.

Since 2016, the region has evolved in some ways, but still faces many health disparities.

This report is an update to the 2016 State of the Region’s Health report dedicated to exploring this evolution, seven years later. The update presents many of the same indicators, but in the context of the changes that have taken place in the region, nation, and world since 2016.

Of course, one of the most significant impacts to public health and health equity was the onset of the COVID-19 pandemic. COVID-19 triggered a global physical health crisis that has led to 1.12 million deaths nationwide and tens of millions more hospitalizations. In addition to direct health impacts, the pandemic has also led to more indirect (and often less well-documented) adverse health outcomes. The lay-offs, sudden lifestyle changes, and financial strain that resulted from stay-at-home orders and a disrupted economy have impacted the mental and physical health of millions of families.

In April 2023, the Biden administration officially ended the national emergency declaration. While this ends some federal guidelines and programs, the long-term impacts of COVID-19 are still playing out, and they will likely present themselves in new, unprecedented ways in the years to come. This is because although the pandemic had universally devastating consequences, it did not impact all communities equally. Social determinants of health that caused health inequities even before the pandemic also contributed to poor COVID-19 outcomes.

Geographic, racial, and socio-economic factors contextualize the trends and disparities in health equity that continue to persist in the region. Some of these disparities have improved, but many others remain the same or have changed for the worse. While there may be a federal ​“moving on” from the COVID-19 pandemic, this report offers insights and identifies opportunities to address the many lingering health disparities we are still facing regionally and locally.

The state of the region’s health can be measured in many ways, but life expectancy and mortality are two of the most common metrics for determining how a population is faring. Both are often complicated by prominent geographic, racial, and economic disparities. Trends in life expectancy and mortality in the region—as well as some of the social disparities associated with them—are explored below to offer a snapshot of the region’s health in 2023.

Life Expectancy

Disparities in life expectancy, perhaps the most basic metric of health, cut across gender, race, and income levels—with social disparities playing a critical role not only in how long people live, but their quality of life during those years. The New York City metropolitan region is fortunate to have a longer average life span compared to many other parts of the country. Life expectancy in the NYC metropolitan region (80.6 years) is surpassed only by Los Angeles (81.4 years), Miami (81.5 years), and San Francisco (83.3 years) in a ranking of the 10 largest metro regions in the US.

The way our region has developed, with its reliance on public transportation, high quality schools and well-paying jobs among other things have generally enabled better health outcomes when compared to other parts of the country. However, disparities that can be observed nationally are still very prevalent in the region when life expectancy is broken down by geography, race, and income.

Geographic Disparities

Out of the 31 counties in the region, residents of New York County currently have the longest lifespan (83.7 years) and residents of Bronx County in New York and Essex County in New Jersey have the shortest life span (78 years). So, within New York City, even neighboring counties show significant disparities, with Manhattanites living more than five years longer than Bronxites on average. Land-use patterns, highway investments, the building of polluting facilities, and other impacts to local communities—coupled with socioeconomic differences—converge to create such distinct health narratives among neighbors.

On average, the region has seen a life expectancy increase of approximately seven years between 1985 and 2023. In New York County, life expectancy has increased 12 years. However, other counties (such as Ocean County and Sussex County in New Jersey and Litchfield County in Connecticut) have each only seen an increase in life expectancy of three years.

Many of the health disparities that emerge in the rural areas of the region are directly tied to issues around social disparities, including geographic barriers in access to healthcare and opportunities. Nationwide, the death rate in 2019 was 20% higher in rural areas than urban areas, and rural residents were more likely to die from heart disease, cancer, and chronic lower respiratory disease.

However, average weighted life expectancy in the most rural counties in the region (Sullivan and Ulster counties in New York, Hunterdon County in New Jersey, and Litchfield County in Connecticut) and the least rural counties (New York City and Essex, Union, and Hudson counties in New Jersey) is the same: about 80 years. This trend perhaps speaks to the interconnectedness of the region and suggests that lived experiences in the most rural and most urban counties are not terribly isolated from one another.

Racial Disparities

The CDC finds that the provisional national life expectancy at birth in 2021 for Black people was 70.8 and 83.5 years for Asian people, an astonishing 12.7 year range. And from 2019 to 2020, the American Indian/Alaskan Native (AIAN) population saw the largest decline in life expectancy, dropping 4.7 years, from 71.8 to 67.1 years. Mirroring these national trends, there are significant racial disparities in the region when it comes to life expectancy. Asian people generally hold the highest average life expectancy rates across all parts of the region. Black people consistently hold the lowest average life expectancy in the region.

Income Disparities

Income is directly connected to one’s ability to access opportunities, live in a healthy environment, and receive the medical care they need to lead longer lives. Nationally, estimates have shown that the wealthiest 1% of the population live 14.6 years longer and 10.1 years longer for women and men, respectively, compared to the poorest 1%.

County Health Rankings measures income inequality by calculating the ratio between household income at the 80th percentile to income at the 20th percentile, using data from 2017-2021. The New York metropolitan region has a moderate-low rate of income inequality compared to other parts of the country, with an average ratio of about five. However, within the region there are significant disparities. New York stands out as the county with the highest income inequality, with a ratio of 9.3, followed by Brooklyn and the Bronx, which both rank 6.9. Essex County has the highest rate of income inequality in New Jersey at 6.8, and Fairfield County has the highest rate in Connecticut at 5.9.

As the chart below illustrates, a high proportion of people of color in the region are poor. Black and other people of color experience poverty at rates twice as high as white people across the three states, with the exception of Asians. But in New York specifically, a large portion of Asians are also poor. The connection between race and income may further help to explain why there are such stark racial disparities when it comes to life expectancy in the region as well as in the nation.

Mortality and Morbidity

Mortality is the measure of the frequency of death in a population, while morbidity is defined as any illness or condition that can be considered a threat to a state of psychological or physiological well-being. Morbidities include diseases, such as cancer and HIV or addictions to drugs or alcohol. Morbidities are influenced by the social determinants of health and the way they are addressed can impact mortality rates in a population.

In 2020, COVID-19 was the leading cause of death in the region after heart disease, killing over 30,000 people in the New York metropolitan region. This is a higher rate compared to national statistics, where COVID-19 was the third leading cause of death after heart disease and cancer. It has also led to higher rates of comorbidities and exacerbated the death toll caused by other underlying conditions, such as heart and lung disease.

In addition to COVID-19, several morbidities show distinct trends among the states in the region and New York City. Since 2015, there has been a substantial rise in drug-induced deaths across the region—at rates four times higher than in 2000, and doubling in just the last five years to 27 deaths per 100,000 people. Within our region, both Connecticut and New Jersey are seeing drug-induced mortality rates higher than the national average, with Connecticut showing rates of 41 deaths per 100,000 people, nearly twice as high as New York City.

Connecticut also appears to be struggling with more alcohol-induced deaths in the past ten years, rising to 13 per 100,000 people in 2020. While many efforts to reduce harm come in the form of criminalization and seek to deal with the supply-side of the problem, more needs to be done with social determinants to address issues upstream. Segregation, income inequality, homelessness and other social determinants create racial health disparities in drug-related deaths, and must be better acknowledged and addressed.

Suicides have increased by 19% from 5.7 to 6.8 deaths per 100,000 people between 2000 and 2020, although this rate is lower than the national average. People with alcohol or drug dependence have a 10 to 14 times greater risk of death by suicide, and the downward spiral to suicide starts with social determinants that lead to unhealthy coping mechanisms. While drug and alcohol use went up during the pandemic, it was a relief to see suicide rates continue to decline. However, they are still at record highs and efforts to improve mental health are necessary to continue reducing suicide rates.

Several other common morbidities that help paint a picture of the region’s overall health are in decline, mirroring national trends. These include heart disease, cancer, stroke, chronic lower respiratory diseases, influenza and pneumonia, and HIV.

Unfortunately, other morbidities have only worsened in the past twenty years. Rates of mortality from brain degenerative diseases, such as Alzheimer’s and Parkinson’s, have also continued to rise and are expected to double over the next two decades due largely to an aging population. In fact, when compared with the rest of the Americas, the United States has the highest age-standardized death rates and third highest level of age-standardized years lived with disability due to neurological disorders. There is also evidence that exposure to pollution increases the burden of these disorders.

Diabetes mortality rates were in decline up until 2015 and then increased between 2015 and 2020 by 22% to 20 deaths per 100,000 people, following national trends. It has been projected that the prevalence of type 1 and type 2 diabetes among youth under 20 years old will significantly increase in the coming decades, with widening racial and ethnic disparities — impacting Black youth the most. As the most expensive chronic condition in the nation — $1 out of every $4 in US healthcare costs — it’s critical to address the upstream social determinants that lead to the onset of diabetes, including issues around physical activity, access to healthy foods, and other preventative measures.

Within the three states, there are notable racial disparities when it comes to causes of death. Black residents have higher age-adjusted death rates for heart disease, cancer, diabetes, stroke, influenza, HIV, homicide, motor vehicle accidents, and drug-induced deaths. Latinx residents suffered the highest death rates from COVID-19 (followed closely by Black residents), and alcohol-induced deaths. White residents, meanwhile, have the highest death rates from Alzheimer’s Disease, chronic respiratory disease, Parkinson’s Disease, and suicide, as well as cancer and drug- and alcohol-induced deaths. Compared to the the white population of the NYC metropolitan region, the American Indian/Alaskan Native (AIAN) community in New York City ranks with lowest rate of overall mortality in comparison to other urban areas with AIAN populations, with a death rate of death 24.5 per 100,000.

The national infant mortality rate is 5.8 deaths per 1,000 live births. The region is thankfully doing better than that overall, with Connecticut at 4.2 deaths per 1,000 live births, New Jersey at 4.0, and New York at 3.9. However, these numbers hide significant racial disparities. Infants born to Black mothers have death rates nearly twice as high as those born to Latinx mothers, and nearly three times the rate as those born to white mothers. Addressing social determinants upstream through better education, access to prenatal care and other factors as discussed in this report can help reduce these disparities.

Quality of Life

Interventions in public health need to be made not just to extend life, but to improve quality of life. One measure of quality of life is the proportion of time people feel unhealthy. In the New York City metropolitan region, the average number of physically unhealthy days each month according to data from County Health Rankings was only 2.7 in 2020. The average number of mentally unhealthy days each month is higher at 4.4. There are certain individual behaviors that help determine the likelihood that someone will have good physical and mental health days and a good overall quality of life. Such behaviors include drug and alcohol consumption, diet, and exercise. While behaviors are individual choices, they can be indicative of larger societal trends, the social determinants of health, that impact certain people and geographic regions more than others.

Smoking and Tobacco

Smoking, for example, is one behavior with significant consequences for both life expectancy and quality of life. It is estimated that non-smokers are 37% more likely to live to 85 compared to smokers. Complications of smoking can also lead to conditions that are not necessarily lethal in and of themselves, but cause day-to-day life to be more difficult, such as asthma, Buerger’s disease, and periodontitis. Education and income factor into the impact of tobacco-related diseases on communities. Tobacco companies are known to target advertising to groups that might be more easily influenced, such as those facing poverty, discrimination, or violence in their neighborhoods. This can feed into the way certain groups understand the consequences of using tobacco and other drugs.

Within our region, New York State has the highest rate of smoking, with 19% of all adults on average consuming tobacco on a regular basis. According to data from County Health Rankings, Sullivan County (18%) and Bronx County (17%) have the highest proportion of smoking adults in the region. The counties with the lowest rates of smoking (10%) are Hunterdon, Morris, and Somerset counties in New Jersey.

Exercise

Daily exercise is another important behavior that can influence quality of life and life expectancy. Nationwide, one out of 12 adults do not get enough exercise and it is estimated that low physical activity accounts for $117 billion in healthcare costs each year. 110,000 deaths each year could be prevented if adults did ten more minutes of moderate-vigorous exercise everyday. A number of political and land use factors influence who has the opportunity to stay active, including land-use regulations, enabling walkable communities, proximity to open space and recreational facilities, education, income and others.

Thankfully, the vast majority of people in the region, 97%, have access to exercise opportunities in terms of proximity. However, that does not mean everyone is able to take advantage of those opportunities. Nearly 24% of the region’s residents are physically inactive, but that figure ranges from as low as 15% in Morris and Hunterdon counties in New Jersey, to as high as 37% in the Bronx, New York.

Obesity

Obesity as a health outcome can be linked to genetic factors, but can also be influenced by behaviors such as poor diet or lack of exercise. Roughly a quarter of adults in each state in the region are obese, and obesity rates in New York City are especially high among Black and Hispanic people. About a third of people of both racial categories are obese and an additional third are overweight. Across the three states, childhood obesity in particular ranges from about 11% to 15%. New York City has a particularly high rate of childhood obesity: Nearly a quarter of children between the ages of 10 and 17 are obese.

Access to Healthcare

Whether preventative care is immediately available and people are able to afford it can directly impact health outcomes. The New York City metropolitan region ranks fifth when it comes to the rate of registered primary care physicians per 100,000 people. San Francisco, Boston, Philadelphia, and Washington all have relatively more physicians. Even where primary care physicians are available, the cost of care can be a barrier to access for residents of the NYC metropolitan region.

Household income plays an important role in determining who has access to healthcare. Households in the region earning between $25,000 and $50,000 a year are nearly three times as likely to be uninsured as people earning more than $100,000. Without access to primary care physicians and the insurance to help pay for them, it is more difficult for people to take the necessary measures to prevent serious illness, resulting in higher mortality rates and lower life expectancy compared to some other regions around the country.

As detailed in the sections above, health disparities are directly influenced by geographic, racial, and income disparities—some of the most important social determinants of health. But many of these factors have also been institutionalized in ways that cut across many of the most basic functions of our daily lives, from the jobs that we work to the homes we live in to the transportation we take. All of these, too, have health outcomes that can be explained by the social determinants of health. The following sections mirror many of the same trends outlined in the first half of this report, but more so reflect the way the social determinants of health have meshed with the basic infrastructure of our region, threatening the equitable distribution of our city’s most essential amenities.

Workforce & Economic Opportunity

Economic opportunity is influenced by cycles of growth and decline. The NYC metropolitan region has undergone five periods of economic growth and decline in the past twenty years that help contextualize the state of workforce and economic development in the region and the certain health outcomes associated with it.

In 2000, the dot com bubble peaked and eventually popped, resulting in a rapid decline in stocks and employment for many internet and telecom companies that triggered a recession in both the nation and the region. While the nation recovered quickly, the 9/11 attacks on the Twin Towers in 2001 further subjected the region’s economy to hardship and delayed recovery. Between 2003 and 2008, there was strong job and income growth for the region as a whole, but this ended with the financial crisis and steep economic recession from 2008-2010.

However, there was substantial growth following the Great Recession between 2010 and 2019, particularly in New York City. However, the COVID-19 pandemic halted this progress in March 2020, with the resulting recession causing a steep loss of jobs. While some parts of the region have recovered, as of February 2023, New York City and other parts of the region are still below pre-pandemic levels, and even gains have been uneven with certain sectors of the economy still struggling with job shortfalls.

Household income plays an important role in determining who has access to healthcare. Households in the region earning between $25,000 and $50,000 a year are nearly three times as likely to be uninsured as people earning more than $100,000. Without access to primary care physicians and the insurance to help pay for them, it is more difficult for people to take the necessary measures to prevent serious illness, resulting in higher mortality rates and lower life expectancy compared to some other regions around the country.

As illustrated in the chart below, region has seen an overall increase in median household income from 2000 to 2022, particularly for higher income households. Those earning in the top 20% have a median income of over $200,000, and this number is climbing. While the median increased 19% for the wealthiest income bracket, the median for the poorest income bracket has decreased by 12% to just $16,500 over the twenty year period, especially since the pandemic. So, while the rich have been getting richer at a faster rate, the status of the poorest households is hardly improving, widening income inequality.

For all but the top 20%, any income gains mostly occurred during the five-year period from 2015-2019 when the economy was particularly strong. Nationally, impacts to household income due to COVID-19 were also harder on lower-income households. Lower income households were 17% more likely to see big income declines during COVID-19 than during the Great Recession. Higher-income households were 11% less likely to see similar declines during the pandemic. These trends show that the impacts of COVID-19 are likely to continue widening income inequality.

Wealth is another important measure of economic opportunity. Unlike income, wealth includes retirement accounts and equity in a home, as well as stocks, businesses, vehicles, etc. Wealth is often passed down from one generation to the next, and its accumulation opens up opportunities to live better and healthier lives. The racial wealth gap is striking. In the United States, the average Black family has one tenth the wealth of the average white family. In the state of New Jersey, the gap is nearly double, with an estimated racial wealth gap of a staggering $300,000.

Poverty rates in the region also reflect these racial inequities. Patterns in racial inequality have fluctuated over the years, but the same general trends remain consistent. White residents in the region consistently maintain the lowest rates of poverty between 2009 and 2019. Asian, Black, and other people of color all consistently have higher poverty rates compared to their white counterparts during the same time frame.

Lower-income households were also more likely to face immediate hardship at the start of the pandemic due to overrepresentation in jobs that did not lend themselves to stay-at-home requirements. A national survey conducted by the Commonwealth Fund in 2020 found that ​“more than half of Latinx respondents and nearly half of Black respondents reported facing economic hardship due to the pandemic, compared to 21% of white respondents,” and that ​“40% of Latinx respondents, 39% of Black respondents, and 44% of people with below average incomes experienced mental health concerns related to the pandemic, much more than whites or those with above average incomes.”

Some of these economic disparities can be attributed to the fact that people of color are overrepresented as essential workers across the country and were on the front lines during the pandemic. These groups occupy 40% of all frontline industry jobs, 56% of all cleaning jobs, 38% of all healthcare jobs, and 46% of all child care and social service jobs. They disproportionately witnessed firsthand the negative physical, mental, and economic effects of the pandemic.

Education

Geographic segregation is a driver of many racial disparities in wealth and income because where a person lives is a determinant of where they go to school. K-12 schools are highly segregated in much of the region and education outcomes vary dramatically by school district. Of New York City public high schools, for example—which are predominantly Black and Hispanic—those that performed at or above target had the highest proportions of white students, very likely due to the fact that less resourced schools are disproportionately concentrated in areas with Black and Latinx students.

Levels of educational attainment directly influence eligibility for certain jobs and career sectors. In most job sectors, people earn more money based on their education level and other certifications. According to data from the Bureau of Labor Statistics, people with a doctorate degree earn more than twice as much as individuals with only a high school diploma, and the unemployment rate for the highest educated is much lower.

Within the region, poverty rates are highest amongst those who did not complete high school and second highest amongst those who completed high school but did not go to college. On average, poverty rates for those without a high school diploma are nearly five times higher than poverty rates for those with a college degree. This mirrors national trends, highlighting the importance of education in shrinking income inequality. There are also racial disparities within this trend. According to data from the National Center for Education Statistics, Blacks and Hispanics of all education levels consistently earn less than their white counterparts.

The method for funding school systems has reinforced patterns of inequality and segregation. During the pandemic, these issues were further exacerbated by unequal access to technology needed to facilitate virtual learning. In New York City, for example, only 85% of students attended online classes compared to 92% attending in-person prior to the pandemic. The New York City metropolitan region has room to improve when it comes to expanding broadband access to those in need. Although some progress has been made since 2014 when 22% of households were without high speed, reliable internet, currently nearly 12% of households still do not have broadband subscriptions. The broadband gap is especially acute for low income households. In New York City, for example, two-thirds of households at the lowest decile of income lack broadband at home.

Even for students graduating high school, pandemic-related disruptions and resulting stress and anxiety, accompanied by financial pressures, have been influential in their decision to delay their education. It has been estimated that the class of 2020 had a nearly 7% decline in college enrollment with high-poverty schools having four times the decline as low-poverty schools.

A report by Strada finds that health concerns and caregiving responsibilities were more likely to cause enrollment disruption for Black students. Almost one-third of Black students were influenced in their enrollment decision by the need to care for a family member, compared with 28% of Latinx students and 23% of white students. Latinx students were most likely to be influenced by financial pressure.

The achievement gap impacting students due to the pandemic is not closing fast enough, and many students could face long-term barriers to success. McKinsey found that racial inequalities in education got much worse due to COVID-19. Students in majority Black schools were nine months behind their peers in majority white schools in math before the pandemic, and that lag grew to twelve months during the pandemic. It is estimated that in poorer districts, nearly all federal recovery aid would need to be spent on helping students make up for achievement losses.

Housing

Whether a family is housing cost burdened can be determined by how much of their income is spent on rent or a mortgage. The Department of Housing and Urban Development considers families spending 30% to 50% of their monthly income on housing to be moderately housing cost burdened; families spending more than 50% of their monthly income on housing are considered to be severely housing cost burdened.

Housing instability has a significant impact on health because the more a family is spending on housing, the less money it has available to spend on other expenses that are necessary for healthy living, such as nutritious food or recreational activities. Cost burdened families are also more likely to live in housing with lead, mold, pests, and other health hazards. Furthermore, families who are housing cost burdened are at higher risk for homelessness.

Of the major metropolitan areas of the United States, the New York City metropolitan region ranks third in terms of highest rates of housing cost burden, with 49% of its population spending more than 30% of their monthly income on housing. This is higher than a decade ago when rates were at 45%. The region’s housing affordability crisis is surpassed only by Miami and Los Angeles who currently see rates of housing cost burden as high as 56% and 52%, respectively, metro-wide.

The following chart shows rates of housing cost burden across different areas of the region. New York City hosts the highest proportion of households who are cost burdened at 48%, of which more than half are severely burdened. And across other parts of the region, over one third of households are cost burdened.

Housing cost burden in New York City and across the region declined from 2010 to 2019, but has risen since the pandemic. In New York City, the percentage of housing cost burdened households in 2021 almost returned to the 2010 levels. The pandemic caused a jump in unemployment, from which New York City has been slower to recover from than the suburbs. Rent has also increased significantly across the region, particularly in New York City. These are two factors that may explain the recent rise in housing cost burden.

Those who struggle to pay rent because it costs 50% or more of their monthly income tend to be those who are in the lowest income quintile while a negligible proportion of those in the highest income have trouble affording their rent. This pattern has not shifted much over the past 20 years. Moreover, there are significant wealth and income gaps between renter households and homeowners. In 2019, nationwide median net worth for homeowners was $255,000—forty times that of renters whose median net worth was estimated to be $6,300.

In terms of race, disparities in housing cost burden are disproportionately higher for people of color than for whites. In the New York City metropolitan region, 59% of people who identify as American Indian/Alaskan Native experience moderate to severe housing cost burden, followed closely by 55% of Black renters. These findings affirm that the region’s housing market is widely unaffordable and that older people of color with lower income cannot find housing that they can afford. This raises the important equity issue of healthy, affordable housing as a basic necessity to which everyone should have a right, regardless of their income, race, or age.

In the most dire circumstances, families and individuals are forced out of their homes altogether and into the streets. In 2016, there were more than 88,000 homeless individuals documented across the region, with a large portion of the region’s homeless children (87% or about 25,000) living in NYC. The homelessness crisis for single men and women has since been exacerbated by COVID-19. The changing policy landscape for migrants has also resulted in housing challenges that are disrupting already strained emergency shelter spaces and resources. Such policies include the expiration of the Trump administration’s Title 42 policy, which limited migration into the United States during the pandemic, not to mention the expulsion of migrants from southern states into the region in recent years. The humanitarian crisis, coupled with long-standing housing insecurity for vulnerable populations could exacerbate the homeless situation if our region is unable to work together and obtain the resources and units it needs to house people safely and with dignity.

Segregation

The racial dissimilarity index was a tool developed to measure racial inequality and geographic segregation in the United States. Originally developed by Jahn, Schmid & Schrag in 1947, the index ​“examines the evenness with which two racial groups are distributed across a geographic area, such as neighborhoods within a city. It can be interpreted as the percentage of either group that would have to move so that each neighborhood would have the same proportion of both groups as the city’s overall population. The dissimilarity index ranges from 0, which represents perfect integration, to 100, which indicates total segregation.

According to guidance from HUD published in 2015, dissimilarity scores of 0 to 39 represent ​‘low’ segregation; 40 to 54 represents ​‘moderate’ segregation; and 55 to 100 represents ​‘high’ segregation. Along with other major metropolitan regions in 2020, the NYC metropolitan region remains moderately segregated between whites and people of color. Dissimilarity scores can also be calculated for different geographies within the region, and for different race categories. For example, in 2020 the region had a Black-white dissimilarity score of 77, a Latinx-white dissimilarity score of 62, and an Asian-white dissimilarity score of 50.

Segregation limits opportunities for people of color that continue to perpetuate health inequities. Access to quality education, home price appreciation, clean air and water - social determinants of health that are largely place-based limit the quality of life for people living in segregated neighborhoods. While dissimilarity indices in the NYC metropolitan region may be comparable to other major metros around the country, this does not excuse the social and health disparities that emerge from segregated regions. Disparities in socio-economic status, perinatal and neonatal care for mothers and infants, and stress and mental health challenges all follow the same lines of segregation in regions across the country, with people of color in racially segregated neighborhoods largely receiving fewer resources and healthy opportunities than people of color in more integrated communities.

Environment & Public Space

The region’s physical environment and public spaces provide both health advantages and disadvantages compared to other regions. Its density and extensive transit network result in fewer auto emissions, more walking, and greater access to healthy food. Data from County Health Rankings suggests the New York City metropolitan region has seen improvements in its access to healthy food in recent years. According to the Food Environment Index, an indicator that incorporates both access to food and socioeconomic factors, such as poverty, the region’s index has risen to 8.6/10 in 2020, up from 8.1/10 in 2013.

In addition, over 97% of residents in the region have access to exercise opportunities, which ranks 4th among the nation’s twelve largest metros. However, many communities still have limited access to nature, and segregated settlement patterns with high concentrations of poverty put many in the proximity of health hazards such as flooding and extreme heat.

Air quality is one of the most critical ways that the region’s environment affects the health of its residents. Living in areas of high pollution leads to a number of health equity challenges. This is especially true for children, who have a greater risk for serious disease in adulthood if they are exposed to polluted air during childhood. Pollution can also exacerbate poor health outcomes in communities with existing stressors, such as a high prevalence of violence, family stress, or socio-economic challenges. Researchers have found that children frequently exposed to PM2.5 fine particulate matter could be at risk for heart disease as adults and could have altered DNA that gets passed down to future generations.

Due to a history of policies that enforced racial and economic segregation, much of the region’s low-income housing and communities of color are located near highways, transportation facilities and other sources of air pollution. In the New York City metropolitan region, 26% of children live in areas at the top quintile for national PM 2.5 levels. Nearly 40% of the region’s people of color experience the top quintile of PM2.5 levels, compared with just 5% of the region’s white population. Higher exposure to air pollution can cause asthma and other respiratory illnesses. Air pollution is also linked to higher death rates from COVID-19 due to these underlying conditions. This is one of the possible explanations for why so many low-income communities have seen such high mortality rates of COVID-19.

Similarly, people of color in the region are more than four times more likely than white people to be in the top quintile for living in proximity to sites where hazardous waste is generated, treated, stored, or disposed of. As illustrated in the chart below, over 60% of low-income households are also in the top quintile.

The effects of climate change will exacerbate many existing public health issues in the coming decades. New York and New Jersey rank eighth and ninth, respectively, among states in the number of National Flood Insurance Claims submitted. By 2050, as many as two million people in the region will be vulnerable to flooding from ever more frequent and intense storms. By 2045, more than 450,000 people could find their homes permanently at risk due to rising sea levels.

In addition to the increased flood risk that comes with climate change in the region, pavement and buildings trap and retain heat during the day, leading to higher temperatures than surrounding areas. This is known as the urban heat island effect. Neighborhoods with little vegetation and few green spaces have particularly acute effects. Urban heat island effect exacerbates environmental health problems, such as air quality and heat stress, and places greater strain on the electric grid, which can lead to dangerous outages.

Extreme heat is one of the greatest climate-related risks to public health in the region. In New York City, there are already an average of 370 heat-related deaths every year, most of those due to heat exacerbating underlying illnesses. Black New Yorkers are twice as likely to die from heat stress as white New Yorkers, due largely to structural inequalities in healthcare and housing and lower likelihood of having air conditioning in the home. Older adults and socially isolated individuals are also more likely to be vulnerable to extreme heat. Over the next 30 years, the number of ​“extreme heat event” days is expected to multiply fivefold from 11 to 55 days in New York City: from eight to 55 in Newark and from six to 31 in Hartford. Heat-related deaths could double by mid-century.

Transportation

Transportation and mobility are important factors for health because they help determine accessibility to jobs, education, and open spaces. Moreover, for people without access to cars, transportation provides important connections to healthcare. Those with unmet transportation needs may grapple with worsening health outcomes.

Public transit is one of the most cost-effective, environmentally-friendly, and convenient ways to get around the New York City metropolitan region. The region has by far the highest percentage of workers relying on public transit for their daily commute. New lines (such as the proposed Interborough Express) and major capacity expansions (such as the recently completed East Side Access project and the planned Gateway Tunnel project) will greatly expand transit options.

Unfortunately, even in such a transit-oriented metropolis as New York City, trains and subways are not always accessible to all. In 2015, most trains across all major lines—including Metro-North, the NYC subway, Long Island Rail Road, and NJ Transit—were not ADA-accessible. The only exception was the PATH train. Improvements have been made in recent years, but the majority of stations still do not have elevators or other amenities that would make them ADA-compliant. The Subway and the accompanying Staten Island Railway are among the least accessible lines, although they collectively have the highest daily ridership of any public transit in the country. The MTA estimates that it will take decades to create a 95% fully accessible system by 2050. In the meantime, persons with disabilities, the elderly, families with small children, and other patrons cannot take full advantage of public transit.

Much like other transit systems across the nation, service providers such as NJ Transit and the MTA face ongoing challenges with their operating budget that could significantly impact the quality of public transit. Because a significant portion of revenue relies on ridership, the reductions in ridership due to the COVID-19 pandemic are putting our systems at risk of reaching their fiscal cliff sooner than anticipated. Although the MTA’s budget deficit has been addressed for now after New York State lawmakers agreed to allocate resources to help maintain operations, the agency needs new recurring revenue to ensure that future funding deficits don’t occur. If not addressed, our region could see reductions in train and bus service, which would pose a significant health equity concern to the region—especially for those who rely exclusively on public transit.

While the region has by far the most extensive public transit network in the United States, much of the population lives well beyond walking distance to a train or bus—particularly in more suburban and rural areas. Even when bus and train stations are within physical proximity, the cost of commuter rail and the infrequency of many bus routes make these unaffordable or infeasible options for many who live beyond the reach of NYC’s subway system. Even within the five boroughs, 38% live more than a 10-minute walk from a subway, including in large swaths of Queens, Brooklyn, and Staten Island.

Although 26.2% is a high percentage of people in the New York metropolitan region taking public transit to work, it still means that the majority of the population does not take public transit. In some cases, this can mean that people are walking or biking to and from work, which are some of the more physically active modes of transportation available. Too often, however, people who do not take public transit to work are relying on cars.

Vehicles are not only a major contributor to greenhouse gas emissions (which affect air quality and expedite global warming), they also present personal health risks to drivers as well as to pedestrians. Mortality and injury due to motor vehicle collisions are a pervasive problem in any metropolis that relies heavily on cars. Fortunately, because a substantial proportion of the New York metropolitan region depends on public transit over motor vehicles, mortality rates due to car crashes are relatively low. In 2020, New York suffered 5.6 motor vehicle-related deaths per 100,000 people compared to other regions, such as Miami, which has suffered more than twice that rate of lives lost.

Motor vehicle-related deaths have fallen by 11% to 28% across the three states of the region and New York City since 2000 as more communities have adopted complete street and vision zero policies to make streets safer for pedestrians and cyclists. In Hoboken, New Jersey, for example, there have been zero traffic deaths in four years, likely due in part to a commitment to create safer streets. Unfortunately, in other places, trends for avoidable deaths increased during the pandemic. In 2020 and 2021, traffic fatalities for motorists in New York City peaked for the first time since 2016. Thankfully, fatalities came down again as of 2022. Consistent long-term investments in policies and infrastructure to improve safety for all road users, especially pedestrians, resulted in the steady decline we see around the region.

But more needs to be done. Within the New York City metropolitan region, motor vehicle crash incidents tend to occur in areas that have less prominent public transit networks and people rely more on cars to get around. This is a testament to the importance of affordable, accessible, and convenient public transportation when it comes to reducing rates of premature deaths from vehicle collisions, as well as safer, pedestrian-oriented streets and crossings.

During the pandemic, and continuing today, many white-collar workers were able to take advantage of flexible remote and hybrid work schedules, lessening their reliance on transit. However, thousands of workers do not have that option, and public transportation is critical infrastructure to make sure essential and frontline workers are able to get around. Cuts to service and lack of adapting to new off-peak demand will further health inequities by adding stress and uncertainty to the lives of lower-income workers that have limited options. These health inequities and avoidable deaths can be dealt with by enacting complete streets and vision zero policies, and investing in frequent and reliable public transit.