The reasons are many, but, increasingly, it is state — and not just federal — policies that have begun to shape the economic, family, environmental and behavioral circumstances that affect people’s well-being. Some states have expanded their social safety nets, raising minimum wages and offering earned income tax credits while using excise taxes to discourage behaviors — such as smoking — that have deleterious health consequences. Other states have moved in the opposite direction.
Researchers say the result of this growing polarization is clear: The nation’s overall health profile is going from bad to worse. Americans can expect to live as long as they did in 1996 — 76.1 years, with life spans truncated by higher rates of chronic illnesses, deaths in childbirth and covid.
“I’m not doing this research to be partisan, simplistically supporting one party or another,” said Nancy Krieger, a social epidemiologist at the Harvard T.H. Chan School of Public Health and a co-author on one of the two studies. “This is about looking at the behavior of different actors, some of whom have a lot more power than others to set standards, make demands and allocate resources.”
Krieger said it is fair for people to ask their elected officials, “Are you doing what you should to protect our health?”
Harvard researchers analyzed data on covid-19 mortality rates and the stress on hospital intensive care units across all 435 congressional districts from April 2021 to March 2022. They also examined congressional members’ overall voting records, how they voted on four coronavirus relief bills, and whether the governor’s office and legislature of a state were controlled by one party.
The study, published this month in the Lancet Regional Health-Americas, found that the more conservative the voting records of members of Congress and state legislators, the higher the age-adjusted covid mortality rates — even after taking into account the racial, education and income characteristics of each congressional district along with vaccination rates.
Covid death rates were 11 percent higher in states with Republican-controlled governments and 26 percent higher in areas where voters lean conservative. Similar results emerged about hospital ICU capacity when the concentration of political power in a state was conservative.
The findings cannot be explained away as features of the economic and social conditions of the people who live in various congressional districts, Krieger said. This is “somehow above and beyond the demographics of the district [that members] represent. It’s suggesting that there is something going on through political processes associated with the political voting patterns of elected officials,” she said.
Public policies — along with public opinions about masks and vaccines and a constellation of other factors — helped change the nation’s pattern of covid mortality.
A Washington Post analysis of covid data from the Centers for Disease Control and Prevention from April 2020 through this summer found the age-adjusted death rates for covid shifted. Early in the pandemic, communities of color — especially Black people — disproportionately bore the burden. But by mid-October 2021, that pattern had shifted, with the death rate for White Americans, who form the core of the Republican base, sometimes eclipsing that of other groups.
And still, the unequal burden of death and disease transcends covid: A chasm of inequality puts communities of color at higher risk of chronic conditions that leave immune systems vulnerable — a reflection of systemic racism, public health experts say.
“Too often, public health and medical behavior is understood to be individual-level behavior. Politicians behave. Institutions behave,” Krieger said. “If your congressional representative is encouraging you to wear masks or not wear masks, those are very different messages.”
The division in American politics has grown increasingly caustic and polarized, but it wasn’t always this way.
From the 1930s to the 1970s, there were major investments to improve the lives of vulnerable people nationwide. The Social Security Act of 1935. Medicare and Medicaid in 1965. Before these federal programs, the nation was a hodgepodge of state programs that varied widely, said University of Washington political scientist Jake Grumbach, a co-author of a study on the effects of state policy on the mortality of working-age adults published in October in the journal PLOS One.
Everyone saw benefits, but the federal legislation from earlier decades “pulled the poorer states up faster,” Grumbach said, adding that “you saw a convergence between states” in terms of health outcomes.
Then came the breakdown of the New Deal coalition. The nationalization of media. Increased money in politics. And the social upheaval of the 1960s and ’70s — the civil rights movement, the women’s movement, the sexual revolution, environmentalism.
“All of those things contributed to polarization,” Grumbach said, adding that the rupture began “kicking up in the ’90s” and has really taken hold since 2010, an era that “saw the real radicalization of the Republican Party … that culminated with Trump.”
The gridlock and lack of productivity that polarization causes mean that “if you want to do anything, you have to do it at the state level,” he said.
State elections were battlegrounds during the 2022 midterm elections, which didn’t produce the red wave that was forecast.
Of the 36 gubernatorial elections, Democrats flipped three seats that were up for grabs and Republicans flipped one, so that now, the nation’s governors are almost evenly split along party lines. And voters in six states passed ballot initiatives to protect abortion rights and to expand access to health care, including in three states where Republicans control the legislature and had opposed taking action on those measures on their own.
“People will hold their nose and vote for a candidate that represents their party, but they don’t have to hold their nose when they’re voting on a policy issue,” said Erin O’Brien, a political scientist at the University of Massachusetts at Boston.
That’s because conservative politics is as much about identity as it is about issues of concern — even as health care remains critically important, O’Brien said. “But how that broad concern can be manipulated, framed, used in politics is different,” she said.
So, while Grumbach’s recent study suggests “if you want people to live longer and more healthy you should implement policies that are associated with the Democratic Party but for marijuana,” O’Brien said she wonders “how would a libertarian or a real conservative read that?”
A sense of liberty informed by a fatalistic acceptance that hardships happen in life is bedrock in many conservative areas, she said. “If liberty means you’ve got guns and that gun is accessible when you’re having a depressive episode, they’re not there to coddle other citizens,” O’Brien said.
The October report found that if all states implemented liberal policies on the environment, gun safety, criminal justice, health and welfare, labor, marijuana, and economic and tobacco taxes, more than 170,000 lives would have been saved in 2019. On the flip side, if states went with conservative versions of those policies, there would have been about 217,000 more deaths that year — “the equivalent of a 600-passenger airplane crashing every day of the year,” the study said.
The largest projected number of lives saved — about 201,000 — came from a more mixed menu of ideologies, with conservative marijuana policies and liberal policies on everything else, according to the report. The study noted that the emergence of more-conservative state policies and shifts in population to states governed by these policies only partially explains why U.S. life expectancy is abysmal compared with other high-income nations.
Jennifer Karas Montez, the director of the Center for Aging and Policy Studies at Syracuse University and lead author of the October study, said the findings show “state policy knobs are a lever that we could use to really turn this country around and stop this alarming — just horrible when you think about it — increase in the risk of dying before age 65.”
Midterm ballot initiatives showed the direct role voters can play in determining state health policy. South Dakota voters passed a measure to expand Medicaid, joining voters in six other states who previously insisted a wider pool of people be eligible for health insurance than allowed under the Affordable Care Act.
Despite there being 11 holdout states that refuse to expand Medicaid and ongoing legal challenges, Jennifer Young, a Republican health policy expert, said the issue is becoming “a little bit less politicized” and awareness is increasing that people’s access to health insurance is being harmed and states are leaving money on the table.
“The fact that these states are continuing to have ballot initiatives that kind of forced the decision makes those states who have not yet done so” reflect on their actions, Young said during a Kaiser Family Foundation panel discussion. “I wouldn’t want to be naive or Pollyanna-ish, but I think it’s more of a reasonable topic to discuss today than it was five years ago.”
Another issue caused Republicans consternation during the midterm elections: abortion rights, which were on the ballot in five states after the Supreme Court struck down Roe v. Wade in June.
California, Michigan and Vermont enshrined abortion rights in their state constitutions, and voters in Kentucky and Montana rejected antiabortion measures.
“We saw states step back from the brink of the most aggressive interventions, and I do hope that’s a lesson that the party takes seriously,” Young said, adding she doubts House Republicans will abandon their “aggressive positioning on abortion.”
But, she said, “that’s not what voters are saying to us.”
With abortion services no longer legal nationwide, university researchers have estimated that maternal deaths could increase by up to 25 to 30 percent, worsening the nation’s maternal mortality and morbidity crisis. Americans live shorter lives than people in peer nations, in part because it is the worst place among high-income countries to give birth.
The nation is entering a period that some political scientists say is certain to be fractious and gridlocked on the federal level. Still, they predict some movement in the lame-duck congressional session on a handful of issues possessing bipartisan appeal.
One reason Democrats retained the Senate is that voters were motivated by “the fear of losing protections that people care about, whether it was electoral or whether it’s abortion, or frankly, health care in general,” said Chris Jennings, a Democratic health policy strategist. “Democrats feel somewhat reaffirmed by both their advocacy of policy and their positioning to protect those rights.”
Health care is a priority agenda item, “for good or for bad,” Jennings said, cautioning that “sometimes we have to lower our expectations of how big and broad” policy accomplishments will look. “There’s bipartisan interest in coverage for post-incarceration populations in the Medicaid program. There’s real interest in postpartum care.”
Political scientists also say there could be bipartisan movement on extending telehealth flexibilities, including those that made it easier for doctors to be reimbursed for the virtual appointments, and improving care for mental health and substance abuse.
“It’s not going to be easy,” Jennings said during the same Kaiser Family Foundation panel. “It’s not going to be comprehensive, but there will be developments of progress.”