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We’re self-sufficient...instead of just saying we can’t do that. It’s a nevergive-up kind of culture.

—Lisa Gahagan, Director of Curriculum, Madison 

 County Schools

Madison County, North Carolina, sits just 20 minutes away from the eclectic arts community and thriving 

tourist destination of Asheville, North Carolina. Like its well-known neighbor, Madison County is nestled 

in the Blue Ridge Mountains, offers stunning scenery, miles of hiking trails, and a rooted music 

community. It is a popular destination for those seeking a more environmentally conscious lifestyle, for 

hobby farmers, and for retirees attracted to the hometown feel and mountain culture. But even with all of 

the opportunity the land promises, longtime Madison County residents have struggled with limited 

resources and numerous challenges impacting their health and well-being.

Like many other Bright Spot communities, Madison County is a rural community defined by rugged 

terrain, deep woods, and narrow country roads. Its population of approximately 21,000 is spread across 

vast distances, in small towns hemmed in by mountains. The unemployment rate hovers around 6 percent, 

but half the workforce is employed outside of the county, with many commuting to Asheville for jobs (as 

well as for community services). The poverty rate of 19.9 percent is higher than the national average of 

15.6 percent.

Despite these factors, the people of Madison County have a strong sense of place and intense community 

pride. Residents value independence and self-sufficiency and hold on to aspects of their Appalachian 

cultural heritage. Madison County is among the ten percent of Appalachian counties—and one of three 

Rural Madison County, North Carolina, is located in the Blue Ridge Mountains.

Steve Tweed
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counties in Appalachian North Carolina—identified as a Bright Spot. It performed better than expected on 

13 out of 19 health outcome measures. Most notably, the county performed better than expected on the 

following measures:

 Years of potential life lost: 25 percent better than expected

 Percentage of adults with obesity (>30 BMI): 18 percent better than expected

 Percentage of adults with diabetes: 12 percent better than expected

 Heart disease hospitalizations: 12 percent better than expected

 Cancer mortality: 12 percent better than expected

These better-than-expected results are likely influenced by local conditions and initiatives that improve 

overall health and well-being. The field work for this study showed that Madison County residents are 

committed to ensuring access to primary care services, including taking services to where residents live. 

Strong social networks connect communities in different parts of the county, reinforcing the importance 

of health.

Madison County’s classification as a Bright Spot means that, on average, the county performed better 

than expected on a number of health outcome measures, given its characteristics and resources—that is, 

the socioeconomics, demographics, behaviors, health care facilities, and other factors that influence health 

outcomes. It does not mean that all Madison County residents enjoy excellent health. In fact, Madison 

County lags behind the rest of the nation on many health outcome measures. Like other counties with 

limited resources, Bright Spot counties face many challenges to attaining good health outcomes. But 

Madison County’s performance does indicate that certain county conditions or programs may be helping 

generate better-than-expected outcomes—and that other resource-challenged Appalachian counties may 

benefit from adopting similar initiatives.1

 1 See Table 26 in the data appendix at the end of this case study for a full list of actual health outcomes for Madison 

County compared with predicted outcomes. For details on the outcome measures, see the data files accompanying 

the report Identifying Bright Spots in Appalachian Health: Statistical Analysis. 
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COUNTY OVERVIEW

Figure 10: Map - Bright Spot Community Madison County, North Carolina

Madison County represents a metropolitan county in South Central Appalachia. 

It is one of three Bright Spot counties in Appalachian North Carolina.

Madison County is located in South Central Appalachia, adjacent to the eastern border of Tennessee. 

Portions of the Pisgah National Forest cover much of the northwestern part of the county, accounting for 

16 percent of the county’s land area. Its residents live in three towns—Hot Springs, Mars Hill, and 

Marshall—and in more sparsely populated rural townships.

Across the county, the median household income is $38,445, compared with the national median of 

$56,135. Madison is racially homogeneous—roughly 96 percent of the population is white. Just over 50 

percent of adults have at least some college education, compared with the national median of 63.3 

percent. Classified by the Appalachian Regional Commission as at-risk in fiscal year 2017, 

unemployment in Madison County matched the national rate of 6.2 percent. The most commonly held 

jobs are in health care and social assistance, retail trade, and manufacturing. The major in-county 

employers are Madison County Schools, Mars Hill University, Madison County government, and 

Printpack, Inc., a packaging company.

2

 2 Table 24 in the Madison County data appendix at the end of this case study provides a quantitative profile of 

county characteristics.
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A DEEPER LOOK AT MADISON COUNTY: COMMUNITY STRENGTHS

Like people in other Bright Spot counties described in this report, Madison County stakeholders have a 

long tradition of relying on each other and local resources to address challenges. They do this by 

partnering with other organizations, often across sectors, and sharing resources creatively. 

Field work helped identify local practices in Madison County that appear to be contributing to overall 

health, document effective practices that could be replicated in other counties, and identify promising 

strategies that should be explored further.3 Specifically, the research identified these characteristics and 

strategies in Madison County:

 A strong focus on primary care: The county is actively committed to ensuring residents have 

access to primary care services. The Hot Springs Health Program (HSHP), which operates four 

clinics in the county, plays a significant role in keeping primary care front and center.

 Cross-sector collaboration: Regional partnerships and resource sharing occur across multiple 

sectors and with players both inside and outside of the county. 

 Commitment to outreach: Many programs take their services to where rural residents live, 

especially in unincorporated areas of the county. 

 Promoting health as a shared value: Madison County cultivates strong social networks to 

connect communities in different parts of the county and reinforce the importance of health. 

Many of Madison County’s initiatives fall into four overarching categories echoed in other Bright Spot 

counties: local providers committed to public health, cross-sector collaboration, resource sharing, and an 

active faith community. Leadership was also present, but less so in terms of specific leaders than in 

organizations taking the lead to improve health county-wide. What follows is a more in-depth description 

of the programs and activities that fall under these overarching categories.

Local Providers Committed to Public Health

Providing primary care, social services, and structured ways for people to connect are all part of the 

county’s overall approach to health. The Hot Springs Health Program (HSHP) is at the center of much 

of this work, providing a full range of primary and preventive medical services as well as treatment for 

acute and chronic conditions. There are three significant reasons why HSHP plays such a major role: it 

offers a broad range of services, it is easily accessible from all parts of the county, and it is “homegrown.” 

People here view HSHP as an institution that not only serves but also belongs to Madison County and its 

residents.

In 1971, community leaders came up with the vision for HSHP—a stable, accessible health care delivery 

system. Recruiting doctors to serve its poor, rural population had been a constant battle. With no hospital 

and only a few doctors, residents had to travel long distances over bad roads to get health care. The 

community’s access to medical care was tenuous—always on the brink of disruption if even a single 

doctor retired or moved on. Rather than rely on doctors to move in and establish a private practice, the 

community created its own nonprofit health care network, built its own clinics, and hired its own 

providers.

 3 For a full explanation of the methodology, see Appendix B: Research Approach. For a list of key informants 

interviewed for this county, see Table 25 in the data appendix at the end of this case study.
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Over the years, HSHP has expanded its operations to include four medical centers with 19 care providers 

and 140 employees, many of whom are long-term staff and integrated into the life of the community. In 

addition to a range of primary and acute care services, the centers offer home care, hospice care, and 

physical therapy. No resident has to travel more than 30 minutes to get care. 

HSHP’s range of services is unusual in a rural 

county of Madison’s size and economic status. 

When it is necessary to refer patients for 

specialized care, HSHP physicians coordinate 

with nearby Asheville hospitals. HSHP also 

extends operating hours into evenings and 

weekends. It essentially offers one-stop access 

to health care. 

Several stakeholders noted that HSHP’s 

integrated primary care model likely 

contributes to Madison County’s identification 

as a Bright Spot. Years of potential life lost—a 

measure of premature death—is 25 percent 

better than predicted, which is indicative of 

earlier detection, preventive medicine, chronic 

disease management, and follow-through on 

specialist treatment. Cancer mortality rates are also better than expected, signaling earlier detection and 

more diligent follow-up treatment. 

HSHP clinics provide access to health care close to home for traditionally underserved populations. 

Instead of presenting care as something out of reach or warranted only when things get dire, HSHP 

appears to be fostering in residents pride, trust, and a willingness to seek services regularly. 

Cross-Sector Collaboration

Madison County works to increase health and wellness by creating an extensive array of collaborative 

efforts to help residents get what they need. This includes health services, funding and assistance 

programs, and social and human services. 

One of the oldest collaborations is the Madison Community Health Consortium (MCHC), which grew 

out of an effort funded by the W.K. Kellogg Foundation to unite citizens, health care providers, local 

agencies, volunteers, and local leaders to identify health problems and barriers to health care. More than 

20 years after its formation, the MCHC remains an ongoing democratic forum where approximately 60 

people come together to assess and determine how to meet community health priorities. The health 

department works closely with the consortium during the federally mandated community health needs 

assessment every three years. 

The MCHC has expanded its reach by growing subcommittees or project groups into spin-off 

organizations to tackle specific health problems. MCHC provides a model for other local organizations 

that likewise want to take a collaborative approach to problem solving. 

In 2014, the Madison Substance Awareness Coalition (MSAC) launched with grant funding from the 

Wake Forest University School of Medicine and the North Carolina Coalition Initiative. The project 

brought together people from law enforcement, schools, public health, local medical centers, social 

The Hot Springs Health Program gives Madison County residents

one‐stop access to health care services.

Becky Johnson 
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service organizations, pharmacies, and churches to identify ways to reduce substance abuse and misuse of 

prescription medications. The MSAC continues to coordinate efforts to combat the abuse of 

methamphetamines, alcohol, and opioid analgesics. 

Madison County’s School Health Advisory Council (SHAC) is one of many supported by the North 

Carolina Department of Public Instruction and the State Board of Education. Madison’s SHAC consists of 

health and education professionals who help guide health programming efforts in the schools. Many of 

these programming efforts are aimed explicitly at improving the health status of students and, by 

extension, their families. For example, the SHAC group launched a food truck program that provides free 

fruits and vegetables to county residents. 

Local government is a critical piece of the collaboration puzzle. At county department head meetings, 

health literature is regularly distributed to staff to carry back to their respective county workforces. At a 

department head meeting in April 2017, the floor was turned over to a local representative from the 

American Cancer Society to talk about cancer prevention and treatment resources. It fell outside the 

normal business of a county department head meeting, but it was indicative of a culture of health where 

any avenue to advance community well-being is used.

Literature about wellness initiatives, upcoming screenings, and health resources is regularly distributed to 

Meals on Wheels clients and through eight senior meal sites. Local churches and nonprofits disseminate 

literature about their own social aid programs, offering services from supplying food care boxes to 

providing housing assistance.

Another regional collaborative program, WNC Health Impact, brings together leaders from county 

health departments, hospitals, and other agencies in western North Carolina to share information and 

ideas, identify problems and priorities, formulate plans, and coordinate action. WNC Health Impact has 

helped Madison County public health leaders identify priority health targets (for 2015 to 2018): obesity 

prevention, mental health screening and treatment access, and substance abuse prevention. 

Resource Sharing

Access to care, food, and transportation are issues that Madison County organizations, agencies, churches, 

and volunteers work to ameliorate by pooling resources across the county and regionally. Madison 

County residents bring a “pull yourself up by your bootstraps” mentality toward meeting community 

needs, an ingrained sense of responsibility toward the less fortunate, and strong collaboration among 

agencies.

For instance, Madison County has no hospital of its own but is within a 20-minute drive of Mission 

Hospital, western North Carolina’s major medical center located in adjacent Buncombe County. 

The level-two trauma center offers a wide range of standard and specialized services, including a weight 

management center and a diabetes and health education center. The Madison County Health Department 

works with Mission Hospital to provide diabetes education and conduct its community health needs 

assessment, and the department also contracts with the hospital for ambulance and emergency services. 

North Carolina’s Office of Rural Health (ORH) funds HSHP to subsidize care for indigent patients. 

ORH’s mission includes expanding health care access for at-risk rural populations. Many of Madison 

County’s residents do not have high-speed Internet, so they cannot pay bills online from home, research 

medical symptoms, look up doctors, learn about social assistance programs, or find a phone number for a 

specialist. To resolve this need, Madison County Schools and U.S. Cellular are looking at a project to 

retrofit school buses to operate as mobile Wi-Fi hotspots to give community members Internet access. 
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Madison County’s Smart Start program works with community volunteers and social work students at 

Mars Hill University to make literacy education available at childcare centers throughout the county. The 

childcare centers also screen for learning disabilities and help parents and school personnel respond 

appropriately. Smart Start is described as going out to places in the county where its services are needed

most.

To help the many residents of unincorporated areas that are difficult to reach, Madison County has several 

efforts that take health-related resources to these rural locations. The Community Health Advisor 

Program (CHA), started in 2011, is one example. Operated by the American Cancer Society, this 

program trains volunteers to educate their neighbors about the importance of preventive screening, 

especially for colon, breast, and cervical cancers. The Madison County program is one of only a few pilot 

programs of this kind. Madison County was chosen as a pilot site precisely because of historically low 

levels of preventive screening, higher levels of poverty and cancer mortality, and few local clinical 

resources. 

Food

Several communities in Madison County may well be considered a food desert, with many residents 

having to travel long distances to get to the nearest grocery store. Meals on Wheels serves a number of 

residents across this challenging landscape. 

In 2011, the Mars Hill Baptist Church launched the Lord’s Harvest, a nonprofit targeting the nearly 30 

percent of children living in Madison County who are food insecure. With grants from other 

congregations in North Carolina and Florida, and donations from members of the church and the 

community, the nonprofit puts 100 percent of funding toward feeding the hungry in Madison County and 

neighboring counties. The Lord’s Harvest provides 1,790 families each month with a total of 4,100 

pounds of potatoes, 1,000 pounds of cornmeal, and 1,000 pounds of pinto beans. 

Mars Hill Baptist Church Pastor Tommy Justus pieced together supplies from the regional food bank, 

human capital from the faith-based community, and a packing site in his church basement, but he lacked a 

way to get the food to the schools that serve as the three distribution sites across Madison County. So the 

sheriff volunteered his deputies to courier the food to the schools.

The Food Connections program is an innovative collaboration between the Madison County 

Cooperative Extension, the Beacon of Hope Food Bank, and the University of North Carolina (UNC) at 

Asheville. The program takes leftover food prepared for the cafeteria lines at UNC Asheville, repackages 

it, refrigerates it, and distributes it—through the food bank or through the community center in Spring 

Creek—to low-income families in Madison County. 

Similarly, a food truck program operated jointly by the Madison County Health Department and the 

YMCA delivers free fruits and vegetables to low-income residents around the county. A food hub 

program operated by the county extension office helps small-scale local farmers bring their products to 

market, and also provides a place where low-income families can obtain high-quality organic produce at 

low prices. The same program delivers fruits and vegetables to senior centers around the county. 

Madison County’s Healthy Eating and Active Living (HEAL) team operates out of the county health 

department and works with other groups to promote positive health behaviors. The HEAL team has 

collaborated with social work students at Mars Hill University to conduct a study of Madison County

residents to learn about barriers to physical activity and good nutrition. HEAL also helped initiate a 
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project with the YMCA—the Healthy Living Mobile Market—to bring fruits and vegetables, along with 

nutrition education, to more remote parts of Madison County. 

Programs to impart healthier lifestyle choices among youth have shown promise in changing eating 

habits. At the Hot Springs Community Learning Center, children’s packed lunches may not include 

sugary drinks or desserts or other low-nutrition foods. The childcare center also partners with local 

farmers who provide free produce for daily snacks and as a supplement to lunches brought from home. 

Additionally, the center grows food in its own garden, provides free produce to parents gleaned from the 

regional food bank, and exposes children to produce through art projects and science experiments. Parents 

are reporting that their children are trying vegetables and limiting soft drinks.

Transportation

The isolation of Madison County’s distant communities separated by narrow, twisting roads is acute, 

making a lack of transportation a considerable barrier to resources enabling good health. Many elderly 

residents either can’t drive or don’t have a vehicle; others can’t afford the gas to get to medical 

appointments. The remote community of Spill Corn, located 45 minutes from the closest grocery store, is 

home to 23 individuals who either can’t drive or don’t have a car. 

Volunteers and others use a daisy-chain system to overcome this hurdle. Volunteer couriers carry food 

from a central location to a middleman site—often churches but also community centers, volunteer fire 

departments, and a subsidized housing development. Volunteers from individual communities then 

deliver the food to the doorsteps of those who are housebound or lack transportation. 

In addition, the county operates eight senior meal sites and sends county vans to pick up seniors who 

don’t have transportation. Stakeholders noted that if it weren’t for this transportation, many residents 

would not be able to get to the meal sites. They also noted that many residents come to the sites for 

interaction as well as the meal; in Madison County, food provides not only nourishment but also

community connectedness.

Active Faith Community

The faith-based community in the county plays an important role in promoting health and helping provide 

resources and opportunities for residents to pursue a healthy lifestyle. 

A network known as AMOM, Assisting Ministries of Madison, holds roundtable meetings every month 

to bring together representatives of faith-based groups, community outreach programs, and government 

social services agencies. They share information on their respective initiatives and assess pressing needs. 

Everything from food pantry assistance and Thanksgiving turkey drives to heating assistance and free 

firewood programs are coordinated through AMOM. Pastors actively share information on new programs 

and services that their congregations can support by volunteering time and resources. 

Troubled by the plight of impoverished elderly living in rundown homes, Mars Hill Baptist Church Pastor 

Tommy Justus called on volunteers in the faith community to install bathroom grab bars and building 

ramps, and fix roof leaks. That call has since turned into a full-fledged nonprofit, the Community 

Housing Coalition. Madison County is flush with these sorts of homegrown social assistance initiatives, 

and the faith community is actively serving a role in stewarding many of them.
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CREATING A CULTURE OF HEALTH IN MADISON COUNTY

Madison County clearly places a high value on health, and the commitment to doing so is evident on the 

part of numerous players: health officials, volunteers, educators, local employers, and the faith-based 

community. Likewise, the emphasis on outreach and getting services to people where they are affirms 

that health matters to this community. 

Madison County has a lower obesity rate, lower prevalence of diabetes, and fewer heart disease

hospitalizations than were predicted for the county, given its characteristics and resources. Those 

interviewed for this case study credit that success in part to minimal numbers of fast-food restaurants in 

the area and Appalachians’ long tradition of growing and raising their own food.

Organizations and institutions across Madison County are growing a new culture around health and wellbeing—transforming diets and enabling access to fresh produce, and connecting people to health services 

with transportation supports and strong employer-provided health insurance. 
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REFERENCES

Ellison, Ayla. 2016. Hospital CFO Report: 6 common characteristics of hospitals vulnerable to closure.

February 09. Accessed July 27, 2017. 

http://www.beckershospitalreview.com/finance/6-common-characteristics-of-hospitals-vulnerable-toclosure.html

Holmes, G. Mark, Nancy M. Lane, Thomas A. Arcury, Michael L. Schwalbe, Randy Randolph, John 

Frank, Sharita Thomas, et. al. 2018. Identifying Bright Spots in Appalachian Health: Statistical Analysis.

Washington, D.C.: Appalachian Regional Commission.

Lord’s Harvest for the Hungry. 2018. “February 2018 Newsletter.” Accessed May 15, 2018. 

http://www.lordsharvestforthehungry.org/

Marshall, Julie L., Logan Thomas, Nancy M. Lane, G. Mark Holmes, Thomas A. Arcury, Randy 

Randolph, Pam Silberman, et al. 2017. Health Disparities in Appalachia. Washington, D.C.: Appalachian 

Regional Commission.

Office of Disease Prevention and Health Promotion. US DHHS. 2017. Healthy People / 2020 Topics & 

Objectives/ Access to Health Services. Accessed July 27, 2017. 

https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services

Southeastern University Consortium on Hunger, Poverty, and Nutrition. Hunger Research, Understanding 

Food Insecurity in Your Community, Madison, North Carolina, 2013. 

http://hunger-research.sog.unc.edu/content/2013-madison-county-nc
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APPENDIX: MADISON COUNTY DATA

Table 24: Madison County Characteristics

Characteristic Madison County United States

Population, 2010–2014 20,951 314,107,084

Percent population change, 2010–2015 1.80% 4.10%

Median age, 2015 43.7 37.8

Percent of persons over age 65, 2015 20.40% 14.90%

Median household income, 2014 $38,445 $56,135

Per capita income in past 12 months (in 2015 

dollars), 2011–2015 $21,076 $28,930

Unemployment rate, 2014 6.2% 6.2%

Percent persons in poverty, 2014 19.9% 15.6%

Percent white alone, 2015 95.80% 77.10%

Percent black alone, 2015 1.80% 13.30%

Percent adults with at least some college, 2010–

2014 51.15% 63.27%

Distance to nearest large population center from 

county center Asheville, NC (21.5 mi) N/A

ARC designations, fiscal year 2017 At-Risk

South Central Appalachia N/A

Source: These data are compiled from the U.S. Bureau of Labor Statistics, Local Area Unemployment Statistics, 

2014, and the U.S. Census Bureau American Community Survey Selected Social Characteristics, General Economic 

Characteristics, Demographic and Housing Characteristics, and Educational Attainment Tables for years 2010–2014 

and 2011–2015.
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Table 25: Madison County Key Informants

Name Location Title Organization Interview 

Date

Marianna Daly Marshall Physician and Medical 

Director

Hot Springs Health Program 

and Madison County Health 

Department

4/4/2017

Lisa Gahagan Marshall Director of Curriculum Madison County Schools 4/4/2017

Ross Young Marshall Director North Carolina Cooperative 

Extension 4/4/2017

Deana Stephens Marshall Community Health 

Director, RN

Madison County Health 

Department 4/4/2017

Teresa Strom Marshall CEO Hot Springs Health Program 4/4/2017

Molly Campbell Mars Hill Executive Director, 

Program Coordinator

North Carolina Early 

Education Initiative 4/4/2017

Lynda Bowles Mars Hill Specialist for 

Community Health American Cancer Society 4/5/2017

Thomas Fields Marshall Coordinator Gear-Up Grant 4/5/2017

O’Neal Shelton Mars Hill President Madison County Chamber of 

Commerce 4/6/2017
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Table 26: Madison County Health Outcomes – Actual vs. Predicted

Outcome Measure Actual Predicted

Percentage 

Difference

(negative = 

better)

Years of potential life lost, 2011–2013 6,129 8,138 -24.7%

Percentage of obese adults (>30 BMI), 2012 24.8% 30.1% -17.7%

Percentage of adults with diabetes, 2012 10.40% 11.86% -12.3%

Heart disease hospitalizations per 1,000 Medicare 

beneficiaries, 2012 49.40 56.14 -12.0%

Cancer mortality per 100,000 people, 2008–2014 159.40 180.77 -11.8%

Infant mortality per 1,000 births, 2008–2014 6.77 7.51 -9.9%

Low-birth-weight births (<2,500) per 1,000 births, 

2007–2013 7.73 8.48 -8.9%

Injury mortality per 100,000 people, 2008–2014 51.92 56.14 -7.5%

Percentage of Medicare beneficiaries w/ depression, 

2012 15.8% 17.0% -6.8%

Heart disease mortality per 100,000 people, 2008–

2014 182.60 194.47 -6.1%

Average Medicare condition score, 2013 0.91 0.96 -5.9%

Physically unhealthy days per month per person, 2014 3.70 3.92 -5.5%

Mentally unhealthy days per month per person, 2014 3.80 3.87 -1.7%

Percentage of excessive drinkers, 2014 15.60% 15.51% 0.6%

Suicide mortality per 100,000 people, 2008–2014 16.15 15.71 2.8%

Opioid prescriptions as a percent of Part D claims, 

2013 5.91 5.57 6.2%

Poisoning mortality per 100,000 people, 2008–2014 19.35 18.04 7.3%

Stroke mortality per 100,000 people, 2008–2014 48.54 43.76 10.9%

COPD mortality per 100,000 people, 2008–2014 59.40 53.23 11.6%

Notes:

Percentage Difference = 100 * [ (Actual / Predicted) – 1]

Green = County value was better than predicted

For details on the outcome measures, see the data files accompanying the report Identifying Bright Spots in 

Appalachian Health: Statistical Analysis.
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Table 27: Madison County Health Drivers vs. National Median

Driver Measure Lower is 

Better?

National 

Median

Madison 

County

Air pollution (average daily particulate matter 2.5), 

2011 Yes 11.87 13.14 

Average travel time to work in minutes, 2010–2014 Yes 22.82 28.19 

Chlamydia incidence rate per 100,000, 2013 Yes 287.16 221.77 

Dentists per 100,000 population, 2014 No 37.45 23.64 

Economic index, fiscal year 2017 Yes 108.79 132.79 

Full-service restaurants per 1,000, 2012 No 0.68 0.43 

Grocery stores per 1,000 residents, 2012 No 0.20 0.10 

Median household income, 2014 No $45,226 $38,445 

Mental health providers per 100,000 population, 2015 No 80.00 156.25 

Percentage of adults currently smoking, 2014 Yes 17.8% 18.9%

Percentage of adults not physically active, 2012 Yes 27.7% 27.8%

Percentage of adults with at least some college, 

2010–2014 No 56.3% 51.2%

Income inequality ratio,

4 2010–2014 Yes 4.4% 4.8%

Percentage of diabetics with A1C testing, 2012 No 85.4% 92.4%

Percentage of doctors who e-prescribe, 2014 No 65.0% 71.0%

Percentage of eligibles enrolled in SNAP, 2014 No 78.0% 78.0%

Percentage of households with income below poverty, 

2014 Yes 15.8% 19.9%

Percentage of Medicare women with recent 

mammogram, 2013 No 61.0% 61.0%

Percentage of population with access to places for 

physical activity, 2011 and 2014 No 61.9% 39.9%

Percentage of total population in social assistant jobs, 

2013 N/A 0.01% --

Percentage receiving disability OASDI and/or SSI, 

2014 Yes 5.4% 8.5%

Percentage spending >30% of income on housing, 

2010–2014 Yes 29.0% 30.1%

Percentage w/ no car, low access, 2010–2014 Yes 19.7% 10.0%

Primary care physicians per 100,000 population, 2013 No 48.54 47.62 

 4 Income inequality is the ratio of household income at the 80th percentile to that at the 20th percentile. A higher 

ratio reflects greater division between the top and the bottom of the income spectrum.
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Driver Measure Lower is 

Better?

National 

Median

Madison 

County

Social associations per 10,000 population, 2013 No 12.68 10.94 

Specialist physicians per 100,000 population, 2013 No 25.93 --

Students per teacher, 2013–2014 Yes 14.13 13.54 

Teenage births per 1,000, 2007–2013 Yes 39.96 30.89 

Uninsured rate for people under 65, 2013 Yes 17.24 17.69 

Notes:

Green = County value was better than national median

For details on the driver measures, see the data files accompanying the report Identifying Bright Spots in 

Appalachian Health: Statistical Analysis.