Politics and Public Health

Montana’s Senate Bill 235 sponsored by Sen. Daniel Emrich, R-Great Falls would establish requirements for science instruction in public schools. The bill would prohibit teaching anything not considered scientific fact. The bill defines “scientific fact” as an “indisputable and repeatable observation of a natural phenomenon.” The bill’s sponsor argued this doesn’t block teaching scientific theories, but he admits an amendment may be needed to allow specific courses, including some Advanced Placement classes, to be taught.

Consider the Republican-controlled Missouri House of Representatives rejected a proposal Wednesday  (2/9/2023) that would have banned children from being able to carry firearms on public land without adult supervision openly.

Anti-science and anti-education are rampant in Republican-controlled states. The anti-science messaging is popular with Republican leaders because it plays so well with their constituents. Far-right crowds celebrate states missed vaccine targets and joke about executing scientific leaders.

In an environment where partisanship is everything—including trying to save people’s lives—such messaging is both politically influential and morally abhorrent. Acknowledging how many Republicans didn’t have to die would mean giving credence to scientific and medical expertise. So long as America remains locked in a toxic partisan battle in which science is dismissed as associated with the left, the death toll will only rise.

During the first few years of the COVID-19 pandemic, the link between politics and health became obvious. Democrat-leaning states were likelier to enact mask requirements and vaccine and social distancing mandates. Conversely, Republican-leaning states were resistant to health measures.

The consequences of those differences emerged by the end of 2020 when rates of hospitalization and death from COVID rose in conservative counties and dropped in liberal ones. That divergence continued through 2021, when vaccines became widely available. And although the highly transmissible Omicron variant narrowed the gap in infection rates, hospitalization, and death rates, which are dramatically reduced by vaccines, they remain higher in Republican-leaning parts of the country.

But COVID is only the latest in the story of politics and health. COVID has magnified what had already been growing in American society for decades – where you live determines your risk of death.

A study published in June of 2022 (Warraich et al. 2022) showed that over the two decades before the pandemic, there was a growing gap in mortality rates for residents of Republican and Democratic counties across the US.

In 2001, the study’s starting point, the risk of death among red and blue counties (as defined by the results of presidential elections) was similar. The US mortality rate has decreased for nearly two decades. However, not as much as in most other high-income countries. The improvement for those living in Republican counties by 2019 was 11%, while for those living in Democratic counties was twice as much (22%).

Another study (Sehgal et al. 2022), covers the years 2001 through 2019 and examines age-adjusted mortality rates—the number of deaths per 100,000 people each year—from the top 10 leading causes of death (heart disease, cancer, lung disease, unintentional injuries, and suicide). The researchers analyzed county-level results for each of the five presidential elections during their study period, identifying counties as Republican or Democratic for the subsequent four years. They found the gap in mortality rates between Republican and Democratic counties increased for nine out of 10 causes of death. (The gap for cerebrovascular disease, which includes stroke and aneurysms, remained but narrowed.) The political environment, the authors suggest in the paper, is a “core determinant of health.”

What is it about conservative areas that might lead to this disadvantage in health outcomes? Multiple factors probably contribute to the gap. Previous research has found differences between Republican and Democratic regions in health-related behaviors such as exercising or smoking. Those findings were nuanced. For example, Democrats had higher odds of smoking, and Republicans were less likely to exercise. But people living in Republican states, whatever their political leanings, were more likely to smoke.

An  analysis of the new study’s data by subgroups supports the idea that individual choices play a role. Hispanic Americans everywhere saw significant improvements in their risk of death. Black Americans still have the highest mortality rates of any racial group, but they saw relatively similar improvements. “It didn’t really matter where they lived,” Warraich says. For white Americans, however, the difference was profound—a fourfold increase in the mortality gap between those living in Republican and Democratic areas.

Montez et al. (2020) looked at life expectancy in the US between 1970 and 2014. They also looked at benchmarks beyond those years, and showed that in 1959 a person in Oklahoma could expect to live. On average, they lived about the same number of years. But by 2017, Connecticut’s citizens had a five-year advantage in life expectancy over their peers in Oklahoma, a politically conservative state. Moreover, they were near the top of the chart, whereas Oklahomans were near the bottom.

In the intervening decades, liberal states enacted more policies to address health concerns while conservative states went in the opposite direction, with inflection points in the early 1980s, 1994, and 2010. Montez notes that those dates align with Ronald Reagan’s election as US president, Newt Gingrich’s control of Congress, and Tea Party politics.

Political affiliation drives social policies and spending. Conservatives see health as a matter of individual responsibility and prefer less government intervention. Liberals often promote the role of government in implementing regulations to protect health. The Democratic approach has included expanding Medicaid under the Affordable Care Act. Access to health care and having health insurance is essential for well-being. Democrats also spend more on what is known as the social determinants of health.

Several policies—tobacco, labor laws, the environment, and guns—repeatedly emerge as significant. Each party has bundled multiple policies together. In Mississippi, for example, there are no statewide clean indoor air policies restricting smoking in bars, restaurants, or workplaces, Montez says. In California, on the other hand, smoking is prohibited in all three environments. Cigarette taxes also differ dramatically. The places where you can’t smoke indoors are also where cigarettes cost a lot (Montez et al. 2020).

As with COVID, the divergence between states over gun safety laws is dramatic. Firearms contribute to deaths from suicide, unintentional injury, and many nonlethal injuries. Blue states are more likely to require background checks, whereas red states more often allow concealed carry of guns. Before California enacted a suite of laws regulating firearms and their ownership and use in the late 1980s and early 1990s, firearm violence mortality rates here were higher than in the rest of the country. After those laws were enacted, rates plummeted in California. Until recently, that kind of research has been severely curtailed by the Dickey Amendment, a 1996 addition to a federal spending bill that effectively prevented the Centers for Disease Control and Prevention from researching firearm violence. Congress clarified the law in 2018, paving the way for research funding.

Cultural differences between red and blue counties also likely contributed to COVID deaths. You’re affected by your neighbors. Sehgal and his colleagues (2022) found that through October 2021, majority-Republican counties experienced 72.9 additional deaths per 100,000 people relative to majority-Democratic counties. To the researchers’ surprise, vaccine uptake explained only 10 percent of the difference. The finding suggests that differences in COVID outcomes are driven by a combination of factors, including the likelihood of engaging in unmasked social events or in-person dining, Sehgal says. By February 2022, the COVID death rate in all counties Donald Trump won in the 2020 presidential election was substantially higher than in counties that Joe Biden won—326 deaths per 100,000 people versus 258.

The takeaway from these studies is that the partisan mortality gap doesn’t have to keep growing. However, changing behavior is critical, and given the current partisan divide, that seems unlikely,

Lit cited

Montez JK, Beckfield J, Cooney JK, Grumbach JM, Hayward MD, Koytak HZ, Woolf SH, Zajacova A. US state policies, politics, and life expectancy. The Milbank Quarterly. 2020 Sep;98(3):668-99.

Sehgal NJ, Yue D, Pope E, Wang RH, Roby DH. The Association Between COVID-19 Mortality And The County-Level Partisan Divide In The United States: Study examines the association between COVID-19 mortality and county-level political party affiliation. Health Affairs. 2022 Jun 1;41(6):853-63.

Warraich HJ, Kumar P, Nasir K, Maddox KE, Wadhera RK. Political environment and mortality rates in the United States, 2001-19: population based cross-sectional analysis. bmj. 2022 Jun 7;377.

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