Income and rural–urban status moderate the association between income inequality and life expectancy in US census tracts

BACKGROUND: A preponderance of evidence suggests that higher income inequality is associated with poorer population health, yet recent research suggests that this association may vary based on other social determinants, such as socioeconomic status (SES) and other geographic factors, such as rural–urban status. The objective of this empirical study was to assess the potential for SES and rural–urban status to moderate the association between income inequality and life expectancy (LE) at the census-tract level. METHODS: Census-tract LE values for 2010–2015 were abstracted from the US Small-area Life Expectancy Estimates Project and linked by census tract to Gini index, a summary measure of income inequality, median household income, and population density for all US census tracts with non-zero populations (n = 66,857). Partial correlation and multivariable linear regression modeling was used to examine the association between Gini index and LE using stratification by median household income and interaction terms to assess statistical significance. RESULTS: In the four lowest quintiles of income in the four most rural quintiles of census tracts, the associations between LE and Gini index were significant and negative (p between < 0.001 and 0.021). In contrast, the associations between LE and Gini index were significant and positive for the census tracts in the highest income quintiles, regardless of rural–urban status. CONCLUSION: The magnitude and direction of the association between income inequality and population health depend upon area-level income and, to a lesser extent, on rural–urban status. The rationale behind these unexpected findings remains unclear. Further research is needed to understand the mechanisms driving these patterns.