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“That’s a significant issue, especially when you are looking at things like health — because what we know is that poverty and some of the situations that poverty creates for a family and an individual and a community create long-term effects, such as chronic disease,” Shelp said. She said one of the biggest challenges for the health department is educating the public about income inequality in the county. “We don’t tend to hang our hats on ‘We’re number one or number two out of a hundred counties,’” Shelp said. “We hang our hats on we have got a heck of a lot of work still left to do.” The health department is continuing to work to combat poverty’s effects on health through early childhood education programs, Shelp said. “It’s about a holistic approach, giving children the opportunity to start equal to their peers and will ultimately impact lifelong chronic disease,” she said. Alice Ammerman, a nutrition professor at the Gillings School of Public Health, said Medicaid expansion would reduce health disparities and help to provide preventive care for people with lower income. “Most of the funding would come from the federal government, so it’d be quite a benefit. But there’s been a lot of pushback from the legislature, which is very conservative,” Ammerman said. “They don’t want to take that federal funding. Ultimately it’s a big loss to the state, especially for lower income classes.” It is important to understand the rankings don’t indicate everyone is doing well, Ammerman said. Schenck said the recent county and state rankings reflect a broader problem not only in North Carolina, but also in the United States. “The United States ranks (lower) than other countries, we spend a whole lot on expensive hospital emergency care, rather than spending our money in prevention,” Schenck said.