Geography matters for the poor

by MooshiMooshi

The NYTimes has been doing a series on health and longevity among different groups, All of the articles have been interesting, but this one popped out at me: If you are poor, where you live has a big impact on your lifespan.

And it turns out you are much better off in large cities on the coasts.

According to the article, if you are wealthy, you can pretty much live anywhere without an impact on your lifespan. That isn’t surprising, since the wealthy live pretty much the same way, and have access to similar services, no matter where they live.

But if you look at the chart towards the end of this article, you can see that the places where poor people live longer are pretty much clumped on the coasts: For poor men, the longest lifespans are in NYC, San Jose, Santa Barbara, Santa Rosa, Los Angeles, San Francisco, San Diego, Newark, Boston. Poor women live longest in Miami, NYC, Santa Barbara, San Jose, San Diego, Port San Lucie, Newark, Los Angeles, Portland ME, Providence.

Now look at the places where poor people have the shortest lifespans: Gary, Indianapolis, Tulsa, Las Vegas, Cincinnati, Knoxville, Little Rock and so on. Not a coastal city on the list, save possibly Honolulu which shows up for women but not men (what is with that?). Clearly something bad is going on in the middle of the country. The article mentions the drug abuse belt. But why is drug abuse so much worse in the middle of the country?

The positive takeaways from this article: first, average lifespans among the poor are still pretty good, but clearly should be better, especially among men living in the lower middle of the country. And second, poverty is not destiny: cities on the coasts are doing something right in terms of keeping poor people healthier. We need to figure out what that is.

The Rich Live Longer Everywhere.
For the Poor, Geography Matters.

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62 thoughts on “Geography matters for the poor

  1. I think all of the healthy rich people choose to live elsewhere in the “unhealthy” cities as they age. They then age in health in the suburbs.

  2. Health and longevity is such a complicated thing but I’m guessing the cities that do well have preventative care/education and cultural/social offerings that keep people engaged and thinking. I just read this book “Kale and Coffee” and the author tries all of these crazy things to try to attain peak health and he has a whole chapter about his donut eating long lived grandfather who retired but did not stop tinkering in his workshop, watching his investments and having friends. Most of the people that I know that have lived long lives (into their 90s) seem to keep an active social life and keep working on things that are important to them. My husband’s grandfather died in his 90s after smoking/drinking/eating bad food his whole life but until he died, he was still going out with his posse every night at 9:00 to drink coffee and shoot the breeze.

  3. Tulsa a few years back had won the title “meth capital of the US”. A guy I knew in college is in jail for causing an apartment explosion while cooking meth which killed his neighbors. So being low income puts you in housing with unskilled meth cookers?

    My opinion is that cooking styles plays a part. Although you can find plenty of good, healthy restaurants in mid-America, my rural and low-income extended family are all about the deep-frying. My husband said growing up there was just always a skillet full of oil on the stove. Whatever they were having got deep fried and put on the table. The safety net is much weaker in a lot of those states, so low income people get very little preventive care. Many may not be on statins or blood sugar medicine when they should be as a result of getting care only in the ER.

  4. I agree with Atlanta — I suspect a big driver is how easy it is to remain engaged (and in some ways to be forced out and about), vs. just sort of sinking into your mental recliner. Last time we were in Manhattan, on the Lower East Side, we were sitting at a restaurant watching this little old couple make their way up the street, arm in arm, her helping him, him pushing the rolling basket that was functioning as a walker. Must have been at least high ’80s. We then got in our car and caught up with them a half mile north, and then we got stuck in traffic and we basically played tag with them for at least another half-mile. And I turned to DH and said “that’s who I want to be when I grow up.”

    And all of my grandparents and great-grandparents who lived on the farm lived to their ’90s, except for one uncle who had a heart attack in I think his ’70s. Eggs and meat every day, lots of grits and homemade biscuits and noodles — basically, everything that is supposed to be so horrible for you no matter what version of dietary advice you believe. And they smoked. But they worked the farm all day every day, then sat around the big table and played cards and dice every night (many of the aunts/uncles/cousins lived right by the farm, so it was easy to gather in someone’s house all the time).

  5. How about this…even if the availability of healthcare is (were) equal for all, the wealthy are more likely to take advantage of it because:
    – the job they have, if they are working, allows them time to go to the doc when there’s an issue
    – they are ~100% likely to have insurance coverage
    – and even if they haven’t met their deductible on their high-deductible plan, they have set aside the money in an HSA so it’s not really out of pocket today, and even if it were, hey, they’re wealthy, so it’s just another cost of doing business.
    – and, not saying there are no expert specialists in flyover country, my gut tells me there are more of them per 1000 people on the coasts than in the middle of the country, so addressing something out of the ordinary is easier to do.

  6. The comments so far seem mainly to be talking about the wealthy and why they have more longevity. But the article isn’t about that. It is about differences in longevity between POOR people, based on geography. In fact, I think it says that geography doesn’t have much impact on the longevity of wealthy people. It is the differences among poor people that I found interesting.

  7. “My husband’s grandfather died in his 90s after smoking/drinking/eating bad food his whole life but until he died, he was still going out with his posse every night at 9:00 to drink coffee and shoot the breeze.”

    I want this when I grow up.

  8. “If I were poor, I’d want to live on the coasts. More social services and support.”

    But could you afford to do so? The map projects life expectancy based on being 40 years old and making less than $28k for the household. That money (thinking you have more than one person in the household) makes it very difficult to live on the coast.

  9. Clearly poor people afford to live on the coasts, because there are a lot of poor people in NYC, Boston, Newark, Los Angeles, and so on. Maybe the trick of figuring out how to live as a poor person in a very expensive city is what makes people live longer? More hustle?

  10. I wonder if treatment compliance among the poor is better on the coasts? Maybe they not only have better access to better healthcare they are more likely to do what their doctors advise?

  11. I don’t draw quite the same conclusions about the data that the NY Times researchers do. Bellingham and Port Angeles counties in northwest Washington (state) have no large cities but have high life expectancies on the chart. Much of the northern, western part of the country has no data, and I suspect that they have life expectancies comparable to Iowa and Minnesota, except in areas with large native American populations.

    I suspect that people with incomes of $28k who live in high cost-of-living areas have some unique characteristic. I would consider 1) What proportion of the population has an income of $28k at 40 years of age in high COLA compared to low COLA areas? Is it exceptional to be low income in a high COLA and common in a low COLA? 2) Is that low income sustained over a lifetime or is it associated with a gap in employment? 3) Educational level/IQ- low income people here tend to be grad students 4) Family support, such as housing that allows them to live in a high COLA, so that effective income is higher than earned income.

    When I look at the Iowa map, I see that the conservative Reformed areas of northwest Iowa are all “above average” in life expectancy (81.1 years), compared with a “very high” life expectancy in Port Angeles of 81.9 years. I want to see statistics that demonstrate that a 0.8 year difference is significant.

    I’d like to see this data overlaid with alcohol consumption rates and broken out roughly by ethnicity.

  12. I had a meeting this week with someone that left a large investment bank and is now working for a housing agency that supports the city of NY. This agency handles all of the applications and income from low income, and very low income housing in the city. Also, they issue bonds, refinance debt etc. I am familiar with many asset classes, but I never worked with this type of asset class. What struck me is that even though these families were really poor, there is housing for them in one of the most expensive cities in the country. There are waiting lists, but there are still a lot of housing options.

    They don’t have the same choices that I have for medical care, but sometimes we end up in the same place for the same test. For example, when I am waiting for a test at Mt Sinai, there are often medicaid patients waiting too. they are going into the same radiology department as me. There are many doctors that won’t take Medicaid, but there are plenty that will take it.

    I know because I qualified for other services as a child, that there are plenty of other free to almost free support systems. This includes reduced or free transportation to see these doctors. The systems in NY are far from perfect, and there are very long wait times…but they exist in large quantities for all different levels of income.

    The only city in the top ten that surprises me is Newark because most of the other cities contain populations that are much wealthier and can support via taxes the better health care for all. Many of the cities on the list also have high taxes to pay for these programs.

  13. Maybe it’s the social safety net (specifically medicare coverage) on the coasts that gets more poor people to see doctors affordably, and then post-appointment, what Rhett says.

  14. It seems to me there is a lot more going on than a simple black and white equation about health care access, etc. If you’re poor in rural America, I think you have many fewer options all the way around. Fewer employment options, fewer entertainment options, more isolation. TV and Internet give people an outlet but also mean they are more likely to sit at home, eat and engage in less-than-healthy practices like drinking and drugs. You aren’t walking anywhere, and you don’t have the farm anymore to take care of. You either don’t have or can’t afford a gym. I don’t quite know what I’m getting at, but I think the increased isolation and complete lack of need to do any kind of physical work is really killing us, and the poorest among us the most.

    At least on the coasts in busier places, people are less spread out and have more options for shopping, food, work, school. People have more to keep them motivated and occupied.

  15. The Washington Post has a really depressing series on rising rates of death in white women in rural areas.

    “For younger age groups, drug overdose and suicide account for virtually all of the increases in death rate. For older groups, additional causes of death are also increasing, particularly heart and lung diseases for rural women, and cirrhosis for people over 45.”

    This is a general article about the trend: ttps://www.washingtonpost.com/graphics/national/white-death/

    This is a really sad article about a specific family: http://www.washingtonpost.com/sf/national/2016/04/08/we-dont-know-why-it-came-to-this/

  16. Lauren

    Newark doesn’t surprise me. It has one of the state’s largest medical schools (if not the largest) and two U-level hospitals within ~15 miles of each other, and public transportation between the two (University in Newark and Hackensack (HUMC, I think…)). Plus the taxes from all the industry may go to support the programs used primarily by the poorer populations. It’s also a train-ride from NYC. Lots of support in a small area.

    I think volvo may be on to something – it’s not healthcare, it’s a reason to leave the house. Whether cultural, employment, or entertainment, moving is always better for you than not moving.

  17. Looking at the map and mentally filling in data for the grey areas (why would the NY Times need to bother with a full data set for those areas in order to draw conclusions?), I would describe the rust belt and the south as being below average in life expectancy which I would associate with low economic opportunity.

    Another way to look at the data is, “What is your individual income percentile if you have a job that pays $30k annually in this county?”

    I think the presence of a strong social safety net and access to medical care are certainly factors in improved longevity. I’m curious about how much social services spending vs. earned household income is associated with a life expectancy increase of 0.5 years.

    I also wonder if telemedicine will sufficiently improve access to medical care that people in geographically sparse areas will no longer be disadvantaged. If I had joined the HMO my employer offers, I would have had to drive to Portland for every single prenatal appointment, for example, because the HMO doesn’t partner with perinatologists anywhere else in the state- you have to see their perinatologists, which are only in Portland.

  18. Wow, that WaPo article reads like every third episode of Intervention.

  19. “rising rates of death in white women in rural areas.”

    I’m guessing they really mean, lowering life expectancies.

    Death rates have historically been constant everywhere.

  20. As to why Honolulu might have made the poor women die young list, a sizable chunk of our poorest residents are Marshallese and other Micronesian immigrants who came in via the Compact of Free Association (federal government agreement with RMI and FSM that everyone can freely enter the US as an ‘oops, our bad’ for Bikini, but without providing much of the funding for the states getting most of the influx), and they tend to come with significant health problems, so that could be part of it.

  21. I didn’t read the article and only briefly looked at the map. I find it interesting that the area of Rochester, MN is only 80.7. This is where Mayo Clinic is and every single doctor in that area is tied to Mayo Clinic. My initial thought would be that they have an even higher score. Access to quality health care is not an issue for this rural area (and it is rural). I would assume that accidental deaths play a factor in people dying young – farm accidents, car accidents, motorcycle accidents and drug overdose. I’d prefer to see a map of Life Expectancy when you factor out accidental death.

  22. Poor people aren’t randomly selected to live in Gary versus NYC or San Francisco. Isn’t it possible that the people who stay behind in places like Detroit and Gary and rural Kentucky are fundamentally different from those who take the initiative to move to bigger coastal metro areas? Even if that latter group stays relatively poor, the same personal or health characteristics that led them (or their low-income parents) to flee their depressed hometowns also helps them take advantage of the social services and other resources that might help extend their lifespans.

  23. Many of the COFA immigrants come here because they have health problems. I believe the rate of diabetes among them is quite high.

  24. Lemon said “would assume that accidental deaths play a factor in people dying young – farm accidents, car accidents, motorcycle accidents and drug overdose. I’d prefer to see a map of Life Expectancy when you factor out accidental death.”

    The article isn’t about access to healthcare – it is about differences in longevity among the poor. Perhaps farm accidents are part of the puzzle. If you factor out accidental deaths, you might miss something like that

  25. Also, the Mayo clinic may be in that area – but can poor people access it? Even if they take Medicaid, they can make it difficult for the poor to use them in other ways.

  26. Many of the poor people in NYC and Newark are descendents of the Great Migration, the massive movement of black people to northern cities. One could argue that they had more gumption than those left behind – but the black population of Detroit and other cities with worse longevity are also the descendents of the Great Migration

  27. sn’t it possible that the people who stay behind in places like Detroit and Gary and rural Kentucky are fundamentally different from those who take the initiative to move to bigger coastal metro areas?

    Yeah, I was wondering along those lines as well.

  28. Isn’t it possible that the people who stay behind in places like Detroit and Gary and rural Kentucky are fundamentally different from those who take the initiative to move to bigger coastal metro areas?

    It’s also true that 37% of people in NYC were born in another country. You could be poor because you’re fresh off the boat from China, but you’re kids won’t be poor. And, getting here means you are likely healthier, more ambitious, etc. than average.

  29. has any one already mentioned the time it takes to get to a hospital? in rural areas, in case of emergency, you may be DOA

  30. also higher # fatalities in car accidents than in places with more public transport (subway)

  31. “You could be poor because you’re fresh off the boat from China, but you’re kids won’t be poor. ”

    That is kind of a generalization about immigrants. Many immigrants here are from places like Haiti. Somalia, and Mexico, who often do not ascend the prosperity ladder so fast. It is even a generalization about Asian immigrants – for example, Laotian families tend to stay poor longer.

  32. I agree with everything that Lauren wrote about health care access in Nyc. And none of it is true for St. Louis. I don’t think people understand the discrepancies in Medicaid across state lines well; but the benefit is vastly different.

    I’m not sure why we are accusing the Mayo of making it hard for Medicaid patients to see them. A lot of tribal patients with unsolved issues get referred there from out of state and I have not witnessed that problem, and BIA is not a good payor.

    But I also don’t think it’s about access to care. We all have grandmas that smoked a pack per day, ate bacon for breakfast and refused to see doctors. Mine lived to 92, in the Midwest. But the Midwest population is not mainly farmers and manual laborers anymore. The poor aren’t bowling together Saturday night and going to Lutheran potluck on Sunday. The poor are living in areas where every third house is abandoned, the schools are terrible and it’s dangerous to walk around the block.

  33. The poor in Northwest Iowa are still going to Lutheran (or possibly Reformed) potlucks on Sundays. Wedding rehearsal dinners still include pea, Velveeta and mayonnaise salad. If you have a job that pays less than $28k and are living independently, there’s a good chance you’re working as a farmhand and someone is letting you live in an old farmhouse for the cost of utilities. This is analogous to the low income housing in New York City, perhaps, but the support system is less formal and less thorough.

    I suspect that being poor is correlated, but not causally linked, with other behaviors that cause poor outcomes.

    Regarding life expectancy in Rochester, MN, I suspect the number of people who are getting treated at Mayo Clinic who die while being treated is a significant enough fraction of the people who die in that county each year to affect the life expectancy by a fraction of a year. When my cousin lived in Rochester, people were better off there than in surrounding counties, due to job opportunities with Mayo Clinic.

    I’d like to see the error bars on the life expectancies in this graph. Did it say how many years of data they were based off of?

  34. My college roommate is a doctor, and she is from Detroit. Her husband, grandfather, and many family members are doctors. Her entire generation has left Michigan and relocated to other parts of the country because they didn’t see the opportunities to practice medicine in/near Detroit. It is a large city, but it is still a metro area in decline. I am just guessing, and I didn’t look it up – but many of the cities on the list maintain population levels from all levels of income.

    The example I gave about my experience at a large hospital in NY isn’t just limited to care at a hospital. My neighbor is an orthopedist and he has a large practice in the burbs and the city. My friends take their soccer and lacrosse kids to him for knee surgery, and they always talk about his waiting room being filled with Medicaid patients too. I think that the access to quality doctors and hospitals whether you live in Chappaqua or the Bronx levels the playing field a bit. Also, this guy has three offices. It isn’t hard to get to him via a car, or public transportation. He isn’t the only one because my daughter’s ophthalmologist is the same. Office in the burbs and Manhattan.

    NY can be a tough city, but there are local neighborhood resources to get help in Chinatown if you don’t speak English. There are examples of this across the city depending on the community where you live, and this could be for Haitians, Dominicans, and a zillion other ethnic groups.

    If you walk into most of the ERs, and you speak another language – they will try to find someone that can help you. Many of the other big cities on the list such as LA, Boston, San Fran, Miami will be similar. The cities are huge, but there are micro communities in these cities that will help lower income families, and immigrant families with the “system” to obtain medical care and other benefits.

  35. http://www.nytimes.com/interactive/2016/04/11/upshot/where-the-poor-live-longer-how-your-area-compares.html

    I just realized the data on the map is adjusted for race and is based on 14 years of death statistics, which answers some of the questions I had above.

    I find Lauren’s comment fascinating regarding access to medical care. Maybe another data point would be “percentage of physicians accepting Medicaid patients”. Where there are fewer physicians per capita (rural areas), physicians can choose not to accept new Medicaid patients and still have an adequate patient population. Where there are more physicians per capita, accepting new Medicaid patients is the norm.

  36. WCE, I don’t want to give you the wrong impression because there are plenty of doctors that will NOT take Medicaid patients because they don’t want to deal. I just think it is interesting that for those that do decide to take Medicaid, it isn’t as if they have a separate level of service for Medicaid patients except when it comes to the number of Medicaid patients that they might allow their practice to accept. Also, as Rhode points about Newark – there are so many other doctors in these cities because the population is so dense.

    Also, the wait time to get an appt for a new patient can be long for anyone. This is where I do think it helps to be wealthy, or have private insurance because that private patient is probably going to get in earlier if they have a connection that someone on Medicaid won’t have access to unless they really know how to navigate the system.

  37. I’ve never lived anywhere with the diversity of languages that NYC has. Your comment makes me think of an analysis I heard from an LDS dentist who stayed late ~2 nights/week, with slots for 8 indigent patients (probably qualifying for Medicaid, but he treated them whether they’d done the paperwork or not) at each session. His analysis of why he didn’t take these patients in his regular schedule (because of his overhead costs for no-shows), but why he would see them personally (because of his religious obligations) was interesting.
    Of the 8 patients, on average 4 would show up.
    Of those 4, 2 would not need dental work and would just be seeking narcotics. He would discuss addiction and local treatment options for them, but would not prescribe narcotics.
    Two of the 8 would need dental work. Once in a while, someone would need a lot of dental work, and he would have this person return for a “dedicated” session, where he didn’t make an appointment for anyone else.

  38. “Where there are fewer physicians per capita (rural areas), physicians can choose not to accept new Medicaid patients and still have an adequate patient population. Where there are more physicians per capita, accepting new Medicaid patients is the norm.”

    My understanding is that medicaid reimbursement amounts are less than the cost of care. Many physicians see a limited number of medicaid patients as a community service, but it can be difficult for a medicaid patients to find a physician willing to see him/her.

    But this is consistent with it being easier for medicaid patients to find physicians in areas with more physicians per capita, as well as in areas of higher population density.

  39. Finn, the marginal cost of seeing a patient is different than the average cost of seeing a patient. That was why the dentist saw patients without his usual staff in his paid-for-by-paying-patients office.

  40. But this is consistent with it being easier for medicaid patients to find physicians in areas with more physicians per capita, as well as in areas of higher population density.

    In Wyoming 99% of doctors take Medicaid and they are 40th in doctors per capita. In New Jersey, which is 10th in doctors per capita, only 40% take Medicaid. Why that is? I have no idea.

  41. Per Ada’s point medicaid payment rates vary widely by state. In MA +85% of specialists take MassHealth which pays 1.23x the national average. Wyoming pays 1.5x the national average and 99% of doctors participate New Jersey pays 0.76x the national avearge and only 40% participate.

    http://kff.org/medicaid/state-indicator/medicaid-fee-index/.

    Note North Dakota 2.15 South Dakota 1.14.

  42. Those medicaid rates are relative to the average national medicaid reimbursement. On average, medicaid reimburses 61% what medicare reimburses. Medicare reimburses roughly 60% what commercial insurance reimburses. Private insurance typically reimburses less than the bill, but the percentage varies wildly.

    So: A Procedure bills at $120.

    Private insurance pays $100
    Medicare pays $60
    Medicaid pays $36
    North Dakota Medicaid pays $75 (2.15 x $36)
    California Medicaid pays $27 (0.75 x $36)

    The uninsured gets a bill for $120 and needs to pay that, or it will be sent to collections.

  43. Just hours before Prince’s shocking death, he was seen at his local pharmacy in Minnesota for the fourth time in just a few days.

    I don’t really know how celebrities live, but in my imagination I would have thought he had “people” to go to the pharmacy for him.

  44. Most doctors take Medicaid because they feel it is their moral obligation or because they are required to due to hospital privileging.

    For example, Fancy Hospital sees 10% medicaid patients. Fancy ortho wants to take call, because she wants access to the skiing fractures that come in – those things need a lot of surgery and generate a lot of cash. She also wants access to the ORs at Fancy Hospital. So, every 4th night, she gets calls from the ER about orthopedic patients that need emergent treatment or some kind of follow up. She is bound (contractually with the hospital and legally under EMTALA) to see those patients in follow up. She ends up getting a stream of Medicaid patients. However, the stream of broken ankles makes up for it.

    On the other hand, Fancy ENT doesn’t need Fancy Hospital’s ORs. They have their own day surgery center and it turns a nice profit. He is able to get all of his lucrative traffic from the excellent relationship he maintains with primary care providers. The stream of ear tubes, tonsillectomies, and nasal septal deviation surgeries flows just fine without taking care of the difficult and risky ENT patients that come through the ER. He also never gets woken up in the middle of the night. The ER is very sad because when they have a life threatening peritonisillar abscess, they can’t find an ENT that will help. They have to put the patient in an ambulance and send them to County University Hospital, because they are the only ones in the major metro area that have ENT coverage.

  45. Ada,

    But isn’t Fancy Hospital buying up all the specialty practices and all the providers are going on salary?

  46. That’s informative, Ada. Thank you. So how does fancy doctor or any doctor limit the percentage of Medicaid patients he sees? Can he arbitrarily limit the percentage and then when he reaches that limit he simply refuses any more Medicaid patients? But still take new patients who have insurance?

  47. Rhett – yes. Partly because they need the call coverage, and partly because they want a slice of those lucrative ankle surgeries. But in many community hospitals, you will find that they do not have many specialties on staff – which is bad for the community and bad for admitted patients.

    COC – method of payment is not a protected class. So, for non emergency care you are able to discriminate based on that. “Oh, we’re not taking any more Medicaid patients. Try somewhere else.”

  48. I agree with Rhett that moving to a new country or even geographic area for better opportunities may be a marker for the same genetic and behavioral assets that contribute to longer lifespans. Correlation not causation.

  49. Wyoming has 27k people on Medicaid (not counting children, because those are reimbursed a bit differently). That works out to 5% of the population. The US has almost 30M (non-children) on Medicaid, about 10%. That may be why doctors in Wyoming are more willing to accept Medicaid patients – everyone does it, there aren’t that many – your practice is unlikely to get overwhelmed.

  50. “I don’t really know how celebrities live, but in my imagination I would have thought he had “people” to go to the pharmacy for him.”

    If it is true that Prince himself went to the pharmacy, it doesn’t surprise me at all. He was Jehovah’s Witness and there are stories that he would go door to door. Also, celebs around here have more freedom than on the coasts. TMZ broke the news, so I’m curious how they operate and get legit information so quickly.

    This story is very big news here and many radio stations are only playing Prince. He has a very large catalog.

  51. Ada, the Reed/Harvard-educated physician I mentioned yesterday takes emergency room calls in his general specialty, and his specialist specialty has no emergencies. It makes me more impressed with him, now that I understand the system. His comment was just, “I typically am not reimbursed for those cases, but it’s the right thing to do.”

  52. Off topic – Scarlett – I mentioned Sue Klebold’s book. It was a real eye opener. The sad think was that the kids were all so close to the end of the school year and graduation.
    There is a topic coming up so save comments for later.

  53. That was an interesting read, RMS, especially the taxes part and how everyone is pretty happy.

  54. I read that article too, RMS. I also found interesting how much they spend on groceries, which is consistent with my contention that $200/week for a family of four is more than sufficient.

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