Poor people who reside in expensive, well-educated cities such as San Francisco tend to live longer than low-income people in less affluent places, according to a study of more than a billion Social Security and tax records.

The study, published in The Journal of the American Medical Association, bolsters what was already well known — the poor tend to have shorter lifespans than those with more money. But it also says that among low-income people, big disparities exist in life expectancy from place to place, said Raj Chetty, professor of economics at Stanford University.

“There are some places where the poor are doing quite well, gaining just as much in terms of life span as the rich, but there are other places where they’re actually going in the other direction, where the poor are living shorter lives today than in they did in the past,” Chetty said, in an interview with NPR.

For example, low-income people in Birmingham, Ala., live about as long as the rich, but in Tampa, Fla., the poor have actually lost ground.

Chetty and his co-authors collected more than 1.4 billion records from the Social Security Administration and the Internal Revenue Service to try to measure the relationship between income and life expectancy.

“There are vast gaps in life expectancy between the richest and poorest Americans,” Chetty said. “Men in the top 1 percent distribution level live about 15 years longer than men in the bottom 1 percent on the income distribution in the United States.

“To give you a sense of the magnitude, men in the bottom one percent have life expectancy comparable to the average life expectancy in Pakistan or Sudan.”

And where lifespans are concerned the rich are getting richer.

Since 2001, life-expectancy has increased by 2.3 years for the wealthiest 5 percent of American men and by nearly 3 percent for similarly situated women. Meanwhile, life expectancy has increased barely at all for the poorest 5 percent.

Among the study’s findings was that poor people in affluent cities such as San Francisco and New York tend to live longer than people of similar income levels in rust belt cities such as Detroit, he said.

What accounts for the disparity isn’t clear, Chetty says.

It may be that some cities such as San Francisco may be better at promoting healthier lifestyles, with smoking bans, for example, or perhaps people tend to adopt healthier habits if they live in a place where everyone else is doing it, he says.

The study suggests that the relationship between life expectancy and income is not iron-clad, and changes at the local level can make a big difference.

“What our study shows is that thinking about these issues of inequality and health and life expectancy at a local level is very fruitful, and thinking about policies that change health behaviors at a local level is likely to be important,” he says.

Chetty notes that the study has clear implications for Social Security and Medicare. The fact that poor people don’t live as long means they are paying into the system without getting the same benefits, a fact that needs to be considered in any discussion about raising the retirement age, he says.

The study was co-authored by Michael Stepner and Sarah Abraham of the Massachusetts Institute of Technology; Benjamin Scuderi, David Culter and Augustin Bergeron of Harvard University; Shelby Lin of McKinsey and Co.; and Nicholas Turner of the U.S. Treasury Department’s Office of Tax Analysis.

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In an emergency, hospitals, by law, must treat any patient in the U.S. until he or she is stabilized, regardless of the patient’s immigration status or ability to pay.

Yet, when it comes time for the hospitals to discharge these patients, the same standard doesn’t apply.

Though hospitals are legally obligated to find suitable places to discharge patients (for example, to their homes, rehabilitation facilities or nursing homes), their insurance status makes all the difference.

Several years ago I began caring for a man who’d been in our hospital for more than three months. He was in his 50s and had suffered a stroke. Half his body was paralyzed and he couldn’t swallow food. After weeks of intensive physical, occupational and speech therapy, he regained his abilities to eat, drink and walk with only minimal help. But he still wasn’t well enough to live on his own, prepare food or even get to the toilet by himself.

Ideally, we would have discharged him from the hospital to a rehabilitation facility so he could continue therapy and make more progress toward his prestroke state.

But our plan faced insurmountable barriers. First off, the patient was an immigrant who had entered the country illegally. Second, he didn’t have insurance.

Because he lacked health coverage, no other facility would accept him. His immigration status meant that we couldn’t find an outside charity that would cover the costs of his care or pay for insurance.

Our comparatively expensive acute care hospital was therefore compelled to hold him — with the meter running. After another month, it began to seem that he’d become a permanent resident of our hospital ward.

“Could he go back to Mexico?” our case manager asked.

We were startled. No one on my team had ever experienced a situation like this, so we began researching the possibility. As it turned out, it’s a murky legal and ethical area that drew some public attention after an expose in The New York Times in 2008.

Nevertheless, our hospital faced a real financial burden, and the case manager pressed on. After reaching the patient’s family in Mexico, and discussing issues with the Mexican consulate, the case manager began making travel arrangements to a rehabilitation hospital in Mexico.

Medical air transport to another country is an expensive proposition — roughly $50,000, depending on the equipment needed and the distance to the receiving facility in the patient’s home nation.

From the hospital’s point of view, it was easy to see that this large one-time expense would be worthwhile. The transfer to Mexico would put a stop to the indefinite, uncompensated costs of continued hospitalization. Further, the transfer would open up the patient’s bed to a new (and presumably insured) patient.

After several meetings between our medical team, case management services, and a hospital administrator, I reluctantly agreed to sign off on the transfer.

Though the discharge plan left me feeling uncertain, I became more comfortable with the idea because our patient had the capacity to make his own decisions. He consented to return home to Mexico because it was clear that he was no longer physically able to work, and his family was also on board with the plan to help him.

A few weeks later the transfer was completed. The last I heard about the man, he had successfully arrived at the rehabilitation hospital near his hometown in Mexico.

I hadn’t thought of this case for years until the combination of a recent Shots piece about dialysis and the heated rhetoric of the election season about immigration caused the memory to bubble back up into my consciousness.

Reflecting on the man’s case, I began to wonder all over again: Who were we to send him back to Mexico? On the other hand, what alternative did we have for a safe and reasonable discharge?

I also hoped to understand if our experience was part of a broader trend or a sporadic occurrence. I could only find estimates of the number of so-called medical deportations because there isn’t any required reporting or specific oversight. It’s a murky area that falls in the gap between federal health and immigration regulations.

The best estimates suggest dozens or maybe a few hundred cases occur each year. I called several air ambulance companies to gauge the demand for such services, but none was willing to provide numbers or even go on record to discuss the practice in general.

One group that has studied the phenomenon offered a conservative estimate of 800 cases of medical deportation over a period of six years. “We field calls from across the country, so it is a national problem and not confined to border states,” Lori Nessel, director of the Center for Social Justice at Seton Hall University School of Law, told me in an email.

Even in the absence of hard numbers, the medical community has responded to the investigative reporting and advocacy around the practice. In 2012, the American Medical Association added an opinion to its Code of Medical Ethics that states, in part, a “discharge plan should be developed without regard to socioeconomic status, immigration status, or other clinically irrelevant considerations.”

A 2014 piece in The New England Journal of Medicine concluded with the opinion that doctors “…are uniquely equipped to display the moral courage necessary to advocate effectively for patients by calling attention to the profound ethical issues raised by repatriation,” using a slightly fancier word for deportation.

Health care for immigrants is a hot button issue. Though the Affordable Care Act excludes immigrants who entered the country illegally from the mandate to purchase health insurance, many U.S counties have taken steps to provide preventive and chronic care for them. The obvious rationale is that this care saves money and prevents suffering in emergency situations.

I’m confident that the transfer home of the Mexican man who’d had a stroke was both consensual and sensible. But given reports of patients being transported without their consent, this practice needs legal clarity to match the ethical aspirations of my profession.

One thing is clear: Without a policy change, hospitalized people who entered the country illegally and who don’t have insurance will remain vulnerable to the seemingly irreconcilable conflict in our society between commerce and medicine.

John Henning Schumann is a writer and doctor in Tulsa, Okla. He serves as president of the University of Oklahoma, Tulsa. He also hosts Public Radio Tulsa’s Medical Matters. He’s on Twitter: @GlassHospital.

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Every year, U.S. hospitals treat hundreds of thousands of violent injuries. Often, the injured are patched up and sent home, right back to the troubles that landed them in the hospital in the first place.

Now, as these institutions of healing are facing pressure under the Affordable Care Act to keep readmissions down, a growing number of hospitals are looking at ways to prevent violence. In Baltimore, health department workers have pitched hospitals an idea they want to take citywide.

The idea builds on the city’s Safe Streets program, which hires ex-offenders to intervene in conflicts before someone gets hurt. They’re called “violence interrupters,” and they use their street credibility and deep social ties to settle fights.

Now the health department is asking Baltimore hospitals to give the staff of Safe Streets access to patients who have been shot, stabbed or beaten up. The idea comes from Chicago, where the group CeaseFire is already working in four hospitals.

Seven years ago, Baltimore piloted such a program at Johns Hopkins Hospital. Dante Barksdale, now the outreach coordinator for Safe Streets, was one of a handful of violence interrupters trained to respond to these hospital calls.

“We had Johns Hopkins IDs,” Barksdale says. “I would walk through the hospital like I was an employee.”

When someone from the neighborhood turned up at Johns Hopkins with a violent injury, one of the hospital’s social workers would call Barksdale. He’d head over and try to talk to the patient, sometimes just as the patient was coming out of surgery, or just waking up.

The first aim, Barksdale says, is “to get him to buy into talking to me. Most of the time, people know who shot them. They know if they wronged somebody. I’m trying to get information so I can be calling out to my outreach workers.”

Barksdale’s co-workers in the neighborhood would then head out to find others who were involved, to try to prevent a retaliatory attack.

One big reason why Safe Streets is able to get people talking is because they do not work with the police. That’s earned them a certain code of honor on the street, Barksdale says.

He says that after being shot, people almost always talk.

“That right there has them vulnerable, ready to talk,” he says. “And then they see a familiar face. ‘Oh, that’s one of them Safe Street dudes. I can relate to him,’ as opposed to the chaplain, the doctor, the people who don’t know nothing about their world.”

“We don’t live in the neighborhood,” says Carol Stansbury, director of social work at Johns Hopkins Hospital. She says the Safe Streets workers “brought the love of their neighborhood and the love of their community that we could not bring.”

The Safe Streets program as a whole has run into trouble a few times in Baltimore; most recently in the summer of 2015, when two staffers were arrested on gun and drug charges.

Stansbury says she never had reservations about giving hospital access to the violence interrupters, almost all of whom have criminal histories.

“It makes sense to me, as a social worker, to have people that have walked the walk,” she says, “who certainly understand what the issues are, and the troubles, barriers and obstacles people face. They only help me do my job better.”

For a variety of reasons, Hopkins’ collaboration with Safe Streets was short-lived. Some of the violence interrupters who were trained as hospital responders left their jobs. The work was never funded, and the responders working in the hospital were actually needed on the streets.

But the Baltimore health department found the hospital responders program valuable, and is working to revive the concept, in a bigger way. The idea is to get six or seven hospitals on board, with hopes that at some point the hospitals will pay for it — to the tune of roughly $100,000 annually per institution. That would pay for two violence interrupters per hospital, plus someone to oversee the whole program.

The health department would also like each hospital to dedicate a social worker to the program, to help patients with follow up treatment and social services.

Several dozen hospitals around the country have violence prevention programs, but most are not staffed around-the-clock. Funding remains a challenge, with the vast majority paid for with grants or in-kind contributions.

This year, the National Network of Hospital-based Violence Intervention Programs successfully pushed to have violence prevention workers recognized as health care providers, which is a key first step to getting reimbursed by Medicaid and other insurers for services rendered.

There is a growing body of evidence that this type of public health intervention can stop the cycle of neighborhood violence that sends people repeatedly to the ER. The studies to date are small, proponents of these programs admit, but all the findings point in the same direction.

There is plenty of evidence for the need to intervene. A study out of Detroit’s Henry Ford Hospital in the 1980s is today seen as a landmark paper. Researchers tracked victims of violent crimes for five years, and found that, within that period, 44 percent suffered at least one more violent injury, and 20 percent died. A majority of these victims of violence abused alcohol or drugs, and most were unemployed.

The study concluded, “Such data suggest that efforts to reduce urban violence might fruitfully be focused on the victims of violence.”

Dr. William Jaquis, chief of emergency medicine at Baltimore’s Sinai Hospital, notes that hospitals are already spending a great deal of money on the treatment of violent injuries.

“We can look at the people who are victims of violence, and we can treat them four to six times, and obviously it’s got a tremendous cost to us,” he says. “The first time may be a blunt injury, a strike to the head. The next time may be a knife, and the next time may be a gunshot wound. I think what we find is we spend the resources anyway. And so it’s starting to look at how we spend them.”

In fact, his hospital already has informal ties to the Safe Streets operation in the nearby neighborhood of Park Heights; hospital staffers call Safe Streets when someone from the neighborhood turns up in Sinai’s ER.

Albert Brown, violence prevention coordinator for Safe Streets Park Heights, takes many of those calls. Recently, he headed to the hospital to talk with a patient who had been stabbed. After meeting with the man, he sent his colleague out to get the perpetrator’s side of the story, which he wanted to relay back to the guy in the hospital. Intervening quickly is crucial.

“He should be released any day,” Brown explains. “So the best thing to do is to hurry up and try to get on top of it, before he gets home and any retaliation or anything like that happens.”

Brown’s goal is to get the two men to sit down in a room and talk. The sooner, he says, the better.

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Top officials with the Obama administration said Wednesday that they’ll redirect $589 million toward the Zika virus response. Most of that money was to be used to deal with Ebola virus.

Almost two months ago, the Obama administration requested $1.9 billion from Congress to respond to the Zika threat.

“But Congress has yet to act,” Shaun Donovan, director of the Office of Management and Budget, said in a news conference. “In the absence of congressional action, we must scale up Zika preparedness and response activities right now.”

Over 600 people with Zika, including 64 pregnant women, have been reported in U.S. states and territories. In most cases, people contracted the virus while traveling.

But Sylvia Burwell, secretary of the U.S. Department of Health and Human Services, says she expects to see local Zika virus transmission in the continental U.S. in coming months.

The redirected funds will go to mosquito control and surveillance; education about how to prevent transmission; supporting states and territories in their own Zika virus responses; and developing vaccines and better diagnostic tests.

Burwell and Donovan reiterated that the administration’s earlier request for supplemental funding from Congress remains in place. And, they say, the administration will also ask for funds to replenish the amount currently being moved from the Ebola response to the Zika response.

Without the full supplemental funding, Burwell says, a number of crucial activities would be impacted.

“Mosquito control and surveillance might need to be delayed or stopped. Our ability to move to a subsequent phase of vaccine development could be jeopardized. And without more funding, the development of faster and more accurate diagnostics could be impaired,” says Burwell.

One reason for the haste is that public health officials want to get mosquito control and surveillance underway before the peak summer mosquito season in the U.S., and before the rainy season in Central America and the Caribbean.

Most of the redirected funding — $510 million — is coming from the Ebola response. That’s concerning, because while the public panic over Ebola has faded, the virus continues to flare up.

“We face two real global health challenges — Ebola and Zika — and we don’t have an option to set one aside in the name of the other,” says Burwell.

Last week, a woman in Liberia died of Ebola. And though Guinea was declared Ebola-free in December, last month World Health Organization officials put more than 1,000 people under medical watch because they may have come into contact with eight people who contracted Ebola.

It’s those kind of activities that could be shortchanged by diverting funds away from Ebola and toward Zika, administration officials say.

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Talking about money is never easy. But when doctors are reluctant to talk about medical costs, patients’ health can be undermined.

A study published Monday in the journal Health Affairs explores the opportunities that are often missed in the exam room.

Patients are increasingly responsible for more of their own health costs. In theory, financial incentives are supposed to make them sharper consumers and empower them to trim unnecessary health spending. But previous work has shown it often leads them to skimp on both valuable preventive care and superfluous testing.

Doctors could play a role in helping patients find appropriate and affordable care by talking with them about out-of-pocket costs.

But, a range of physician behaviors currently stand in the way, according to the study. “We need to prepare physicians to hold more productive conversations about health care expenses with their patients,” said Peter Ubel, a physician and behavioral scientist at Duke University.

The researchers analyzed transcripts of almost 2,000 physician-patient conversations regarding breast cancer, rheumatoid arthritis and depression treatment. They identified instances in which patients suggested the cost of care might be difficult for them to bear and assessed how doctors responded.

Overall, researchers noted two ways in which doctors dismissed patients’ financial concerns. They either didn’t acknowledge them or only addressed them halfway.

For instance, if a patient commented on how expensive a drug was, the doctor might ignore the comment entirely, or might suggest a temporary solution – like a free trial – without exploring long-term strategies to address the issue.

Without a long-term plan, patients may eventually stop taking the medication, or take it irregularly. Either way, a patient would get less benefit from treatment and could getter sicker, perhaps even winding up in the hospital.

The study doesn’t measure how often doctors dismissed patient concerns – because, the researchers wrote, they didn’t know how often those dismissals led to people actually forgoing needed treatments.

Still, Ubel said, it’s clear doctors aren’t talking to patients about these expenses. He pointed to a separate analysis of those same conversations, which found that doctors discussed medical costs with patients about 30 percent of the time. And only in a minority of those discussions did doctors and patients brainstorm about ways to make medication more affordable.

“A majority of [physicians] – they don’t talk about costs,” he said. “When they do talk about it, they don’t talk about it productively.”

Why do physicians hesitate? For one thing, they aren’t used to discussing cost barriers, and many think it’s inappropriate to bring up money at all, Ubel said. When he lectures on the subject, he always encounters people who worry that discussing finances will “contaminate the doctor-patient relationship.”

Plus, doctors haven’t been taught to listen for patients’ pocketbook concerns. If a patient comes in with heartburn and indigestion, a good internist will start probing for signs of coronary disease, Ubel said. By contrast, physicians aren’t primed to pick up on cues that patients may face financial strains.

“If we had that on our list to be aware of, we’d pick up the cues. If we don’t, it’ll be right in front of our eyes, and we’ll miss it,” he added.

The idea of patients acting as consumers – weighing cost and shopping for the best health care deal – is still relatively new, the study notes. As it becomes more commonplace, patients may push doctors for more help in making cost-based decisions, Ubel said.

That said, navigating a patient’s financial circumstances and medical needs in the course of a 15-minute visit is tricky, said Jonathan Kolstad, an assistant professor of economic analysis and policy at the University of California, Berkeley. Kolstad wasn’t involved in the Health Affairs study but has researched how medical costs affect people’s decision-making.

“It’s not as though, ‘Oh, it’s just consumers can’t figure it out.’ Doctors don’t know,” he said. When it comes to figuring out what a drug will cost, doctors are in the same boat.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Shefali Luthra is on Twitter: @shefalil.

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The first sign seems innocuous enough if you don’t know what you’re looking at: Files in the computer appear as decrypt.html, or decrypt.txt instead of their usual names.

Then, you click. A box pops up that gives you an ultimatum: Want the file? You’ll have to pay up, and probably in bitcoin.

That is what happened at U.S. hospitals in the past month in California, Kentucky, Maryland and the District of Columbia. The malware attacks have left the 14 hospitals — 10 of which are part of the MedStar hospital group — unable to access patient data and, in some cases, having to turn patients away.

Hospitals are not alone in their vulnerability; last month, a cafe in Maryland was hit with a ransomware attack. In another instance, Mac computers were targeted. Last year, police in Massachusetts paid hackers to return access to their data. Companies and individuals in the U.S. lost more than $24 million to ransomware in 2015, according to the FBI.

And in February at the Hollywood Presbyterian Medical Center in Los Angeles, administrators paid the asking price of 40 bitcoin, about $16,664 at the time, to regain access to their data. At MedStar, the hospital is being asked to pay 45 bitcoin.

Several MedStar employees saw a message on their computer screens: “You just have 10 days to send us the Bitcoin. After 10 days we will remove your private key and it’s impossible to recover your files.”

“The big difference with health care is that the consequences are greater,” Kevin Fu, an associate professor at the University of Michigan who studies computer security issues in hospitals, told the MIT Technology Review. “You can lose your email and that’s annoying, but patient records are needed in order to treat patients.”

Though bitcoin is not in itself a driver of cybercrime, it allows the hackers to have instant access to the money without its having to go through a bank or credit card. Peter Van Valkenburgh, director of research at Coin Center, a nonprofit dedicated to digital currency advocacy, explains that often the ransomware will include easy-to-follow instructions on how to quickly access and trade bitcoin.

Hospitals hit by the attack felt the pressure of being without patient information. At a MedStar hospital, a patient was given an antibiotic that, a nurse told the Washington Post, “should have been stopped eight hours earlier.” At the Hollywood Presbyterian Medical Center last month, patients were diverted to other hospitals. In both situations, the hospitals returned to paper records.

On its website Thursday, MedStar posted: “MedStar Health’s priority continues to be providing high quality, safe patient care, as we work to fully restore all of our major IT systems. Our doors remain open, with a few exceptions. With the dedication and commitment of our clinicians and associates, we are thankful that we have been able to perform more than 1,000 surgeries since Monday morning’s malicious malware attack.”

Rick Pollack, president and CEO of the American Hospital Association, emphasizes that hospitals should take steps to protect patient data: “Hospital leaders are using the lessons learned in previous attacks and are applying best cybersecurity practices shared by the AHA in an effort to anticipate and respond to existing and emerging threats,” he says.

The FBI is investigating several of these recent attacks. An FBI official tells NPR:

“Companies can prevent and mitigate malware infection by utilizing appropriate backup and malware detection and prevention systems, and training employees to be skeptical of emails, attachments, and websites they don’t recognize. The FBI does not condone payment of ransom, as payment of extortion monies may encourage continued criminal activity, lead to other victimizations, or be used to facilitate serious crimes.”

Hospitals can take a variety of steps to safeguard against these kinds of attacks, like using HTTPS encryption, two-factor authentication and implementing file backups on a separate server. “For hospitals right now, backups of customer data on unconnected machines or machines in other networks is essential,” Van Valkenburgh says.

He adds that patients should have more control over who has access to their personal records, and when. But until then? “We really are at the mercy of these centralized institutions,” he says.

Naomi LaChance is a business news intern at NPR.

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