State COVID-19 Policies and Drug Overdose Mortality Among Working-Age Adults in the United States, 2020.

Objectives. To identify relationships between US states' COVID-19 in-person activity limitation and economic support policies and drug overdose deaths among working-age adults in 2020. Methods. We used county-level data on 140 435 drug overdoses among adults aged 25 to 64 years during January 2019 to December 2020 from the National Vital Statistics System and data on states' COVID-19 policies from the Oxford COVID-19 Government Response Tracker to assess US trends in overdose deaths by sex in 3138 counties. Results. Policies limiting in-person activities significantly increased, whereas economic support policies significantly decreased, overdose rates. A 1-unit increase in policies restricting activities predicted a 15% average monthly increase in overdose rates for men (incident rate ratio [IRR] = 1.15; 95% confidence interval [CI] = 1.09, 1.20) and a 14% increase for women (IRR = 1.14; 95% CI = 1.09, 1.20). A 1-unit increase in economic support policies predicted a 3% average monthly decrease for men (IRR = 0.97; 95% CI = 0.95, 1.00) and a 4% decrease for women (IRR = 0.96; 95% CI = 0.93, 0.99). All states' policy combinations are predicted to have increased drug-poisoning mortality. Conclusions. The economic supports that states enacted were insufficient to fully mitigate the adverse relationship between activity limitations and drug overdoses. (Am J Public Health. 2024;114(7):714-722. https://doi.org/10.2105/AJPH.2024.307621).

Affordable Care Act Medicaid expansions and maternal morbidity.

In this paper, we test whether the Affordable Care Act Medicaid expansions are associated with maternal morbidity. The ACA expansions may have affected maternal morbidity by increasing pre-conception access to health care, and by improving the quality of delivery care, through enhancing hospitals' financial positions. We use difference-in-difference models in conjunction with event studies. Data come from individual-level birth certificates and state-level hospital discharge data. The results show little evidence that the expansions are associated with overall maternal morbidity or indicators of specific adverse events including eclampsia, ruptured uterus, and unplanned hysterectomy. The results are consistent with prior research showing that the ACA Medicaid expansions are not statistically associated with pre-pregnancy health or maternal health during pregnancy. Our results add to this story and find little evidence of improvements in maternal health upon delivery.

Electoral Democracy and Working-Age Mortality.

Policy Points The erosion of electoral democracy in the United States in recent decades may have contributed to the high and rising working-age mortality rates, which predate the COVID-19 pandemic. Eroding electoral democracy in a US state was associated with higher working-age mortality from homicide, suicide, and especially from drug poisoning and infectious disease. State and federal efforts to strengthen electoral democracy, such as banning partisan gerrymandering, improving voter enfranchisement, and reforming campaign finance laws, could potentially avert thousands of deaths each year among working-age adults. CONTEXT: Working-age mortality rates are high and rising in the United States, an alarming fact that predates the COVID-19 pandemic. Although several reasons for the high and rising rates have been hypothesized, the potential role of democratic erosion has been overlooked. This study examined the association between electoral democracy and working-age mortality and assessed how economic, behavioral, and social factors may have contributed to it. METHODS: We used the State Democracy Index (SDI), an annual summary of each state's electoral democracy from 2000 to 2018. We merged the SDI with annual age-adjusted mortality rates for adults 25-64 years in each state. Models estimated the association between the SDI and working-age mortality (from all causes and six specific causes) within states, adjusting for political party control, safety net generosity, union coverage, immigrant population, and stable characteristics of states. We assessed whether economic (income, unemployment), behavioral (alcohol consumption, sleep), and social (marriage, violent crime, incarceration) factors accounted for the association. FINDINGS: Increasing electoral democracy in a state from a moderate level (defined as the third quintile of the SDI distribution) to a high level (defined as the fifth quintile) was associated with an estimated 3.2% and 2.7% lower mortality rate among working-age men and women, respectively, over the next year. Increasing electoral democracy in all states from the third to the fifth quintile of the SDI distribution may have resulted in 20,408 fewer working-age deaths in 2019. The democracy-mortality association mainly reflected social factors and, to a lesser extent, health behaviors. Increasing electoral democracy in a state was mostly strongly associated with lower mortality from drug poisoning and infectious diseases, followed by reductions in homicide and suicide. CONCLUSIONS: Erosion of electoral democracy is a threat to population health. This study adds to growing evidence that electoral democracy and population health are inextricably linked.

US State Policy Contexts and Population Health.

Policy Points This Perspective connects the dots between the polarization in US states' policy contexts and the divergence in population health across states. Key interlocking forces that fueled this polarization are the political investments of wealthy individuals and organizations and the nationalization of US political parties. Key policy priorities for the next decade include ensuring all Americans have opportunities for economic security, deterring behaviors that kill or injure hundreds of thousands of Americans each year, and protecting voting rights and democratic functioning.

Income Inequality and Population Health: Examining the Role of Social Policy.

Studies of the relationship between income inequality and life expectancy often speculate about the role of policy, but direct empirical research is limited. Drawing on the neo-materialist perspective, we examine whether the longitudinal association between income inequality and life expectancy is mediated and moderated by policy liberalism in U.S. states (2000-2014). More liberal policy contexts are characterized by greater efforts to regulate the economy, redistribute income, and protect vulnerable groups and lesser efforts to penalize deviant social behavior. We find that state-level income inequality is inversely associated with policy liberalism and life expectancy. The association between income inequality and life expectancy was not mediated by policy liberalism but was moderated by it. The association is attenuated in states with more liberal policy contexts, supporting the neo-materialist perspective. This finding illustrates how states like New York and California (with liberal policy contexts) can exhibit high income inequality and high life expectancy.

U.S. State Policy Contexts and Physical Health among Midlife Adults.

This study examines how state policy contexts may have contributed to unfavorable adult health in recent decades. It merges individual-level data from the 1993-2016 Behavioral Risk Factor Surveillance System (n=2,166,835) with 15 state-level policy domains measured annually on a conservative to liberal continuum. We examined associations between policy domains and health among adults ages 45-64 years and assess how much of the associations is accounted by adults' socioeconomic, behavioral/lifestyle, and family factors. A more liberal version of the civil rights domain was associated with better health. It was disproportionately important for less-educated adults and women, and its association with adult health was partly accounted by educational attainment, employment, and income. Environment, gun safety, and marijuana policy domains were, to a lesser degree, predictors of health in some model specifications. In sum, health improvements require a greater focus on macro-level factors that shape the conditions in which people live.

U.S. State Preemption Laws and Working-Age Mortality.

INTRODUCTION: The goal of this study was to estimate how state preemption laws that prohibit local authority to raise the minimum wage or mandate paid sick leave have contributed to working-age mortality from suicide, homicide, drug overdose, alcohol poisoning, and transport accidents. METHODS: County-by-quarter death counts by cause and sex for 1999-2019 were regressed on minimum wage levels and hours of paid sick-leave requirements, controlling for time-varying covariates and place- and time-specific fixed effects. The model coefficients were then used to predict expected reductions in mortality if the preemption laws were repealed. Analyses were conducted during January 2022-April 2022. RESULTS: Paid sick-leave requirements were associated with lower mortality. These associations were statistically significant for suicide and homicide deaths among men and for homicide and alcohol-related deaths among women. Mortality may decline by more than 5% in large central metropolitan counties currently constrained by preemption laws if they were able to mandate a 40-hour annual paid sick-leave requirement. CONCLUSIONS: State legislatures' preemption of local authority to enact health-promoting legislation may be contributing to the worrisome trends in external causes of death.

U.S. state policy contexts and mortality of working-age adults.

The rise in working-age mortality rates in the United States in recent decades largely reflects stalled declines in cardiovascular disease (CVD) mortality alongside rising mortality from alcohol-induced causes, suicide, and drug poisoning; and it has been especially severe in some U.S. states. Building on recent work, this study examined whether U.S. state policy contexts may be a central explanation. We modeled the associations between working-age mortality rates and state policies during 1999 to 2019. We used annual data from the 1999-2019 National Vital Statistics System to calculate state-level age-adjusted mortality rates for deaths from all causes and from CVD, alcohol-induced causes, suicide, and drug poisoning among adults ages 25-64 years. We merged that data with annual state-level data on eight policy domains, such as labor and taxes, where each domain was scored on a 0-1 conservative-to-liberal continuum. Results show that the policy domains were associated with working-age mortality. More conservative marijuana policies and more liberal policies on the environment, gun safety, labor, economic taxes, and tobacco taxes in a state were associated with lower mortality in that state. Especially strong associations were observed between certain domains and specific causes of death: between the gun safety domain and suicide mortality among men, between the labor domain and alcohol-induced mortality, and between both the economic tax and tobacco tax domains and CVD mortality. Simulations indicate that changing all policy domains in all states to a fully liberal orientation might have saved 171,030 lives in 2019, while changing them to a fully conservative orientation might have cost 217,635 lives.

Educational disparities in adult health across U.S. states: Larger disparities reflect economic factors.

Introduction: Education level is positively associated with adult health in the United States. However, new research shows that the association is stronger in some U.S. states than others, and that states with stronger associations also tend to have poorer overall levels of health. Understanding why educational disparities in health are larger in some states than others can advance knowledge of the major drivers of these disparities, between individuals and states. To that end, this study examined how key mechanisms (economic conditions, health behaviors, family, healthcare) help explain the education-health association in each state and whether they do so systematically. Methods: Using data on over 1.7 million adults ages 25-64 in the 2011-2018 Behavioral Risk Factor Surveillance System, we estimated the association between education level and self-rated health in each state, net of age, sex, race/ethnicity, and calendar year. We then estimated the contribution of economic, behavioral, family, and healthcare mechanisms to the association in each state. Results: The strength of the education-health association differed markedly across states and was strongest in the Midwest and South. Collectively, the mechanisms accounted for most of the association in all states, from 55% of it in North Dakota to 73% in Oklahoma. Economic (employment, income) and behavioral (smoking, obesity) mechanisms were key, but their contribution to the association differed systematically across states. In states with stronger education-health associations, economic conditions were the dominant mechanism linking education to health, but in states with weaker associations, the contribution of economic mechanisms waned and that of behavioral mechanisms rose. Discussion: Meaningful reductions in educational disparities in health, and overall improvements in health, may come from prioritizing access to employment and livable income among adults without a 4-year college degree, particularly in Southern and Midwestern states.

Trends in U.S. Population Health: The Central Role of Policies, Politics, and Profits.

Recent trends in U.S. health have been mixed, with improvements among some groups and geographic areas alongside declines among others. Medical sociologists have contributed to the understanding of those disparate trends, although important questions remain. In this article, we review trends since the 1980s in key indicators of U.S. health and weigh evidence from the last decade on their causes. To better understand contemporary trends in health, we propose that commonly used conceptual frameworks, such as social determinants of health, should be strengthened by prominently incorporating commercial, political-economic, and legal determinants. We illustrate how these structural determinants can provide new insights into health trends, using disparate health trajectories across U.S. states as an example. We conclude with suggestions for future research: focusing on structural causes of health trends and inequalities, expanding interdisciplinary perspectives, and integrating methods better equipped to handle the complexity of causal processes driving health trends and inequalities.

US State Disparities in Life Expectancy, Disability-Free Life Expectancy, and Disabled Life Expectancy Among Adults Aged 25 to 89 Years.

Objectives. To estimate total life expectancy (TLE), disability-free life expectancy (DFLE), and disabled life expectancy (DLE) by US state for women and men aged 25 to 89 years and examine the cross-state patterns.Methods. We used data from the 2013-2017 American Community Survey and the 2017 US Mortality Database to calculate state-specific TLE, DFLE, and DLE by gender for US adults and hypothetical worst- and best-case scenarios.Results. For men and women, DFLEs and DLEs varied widely by state. Among women, DFLE ranged from 45.8 years in West Virginia to 52.5 years in Hawaii, a 6.7-year gap. Men had a similar range. The gap in DLEs across states was 2.4 years for women and 1.6 years for men. The correlation among DFLE, DLE, and TLE was particularly strong in southern states. The South is doubly disadvantaged: residents have shorter lives and spend a greater proportion of those lives with disability.Conclusions. The stark variation in DFLE and DLE across states highlights the large health inequalities present today across the United States, which have significant implications for individuals' well-being and US states' financial costs and medical care burden.

Effects of US state preemption laws on infant mortality.

Studies show that raising the minimum wage in a US state above the federal minimum wage can reduce infant mortality rates in those states. Some states have raised their minimum wage in recent decades, while many others did not, and have prohibited local authorities from doing so by enacting preemption laws. This study investigates how the recent emergence of state preemption laws that remove local authority to raise the minimum wage has affected infant mortality rates. Using county- and state- level data spanning 2001 through 2018, this study models infant mortality rates as a function of minimum wage levels, controlling for confounders. The estimated model, combined with information on the timing, location, and level of preempted minimum wages, is then used to estimate the number of infant deaths that occurred in 2018 that could be attributed to state preemption of local minimum wage increases. In the 9 largest (pop. > 250,000) metro counties most directly affected by state preemption, we estimate that in 2018, 25 infant deaths were attributable to preemption. This equates to a 5.4% reduction in these counties' infant mortality rate. When considering all large metro counties in preemption states, as many as 605 infant deaths could be attributed to preemption. State preemption laws that remove local authority to enact health-promoting legislation, such as minimum wage increases, are a significant threat to population health. The growing tide of these laws, particularly since 2010, may be contributing to recent troubling trends in US life expectancy.

US State Polarization, Policymaking Power, and Population Health.

Policy Points Explanations for the troubling trend in US life expectancy since the 1980s should be grounded in the dynamic changes in policies and political landscapes. Efforts to reverse this trend and put US life expectancy on par with other high-income countries must address those factors. Of prime importance are the shifts in the balance of policymaking power in the United States, the polarization of state policy contexts, and the forces behind those changes.

US State Policies, Politics, and Life Expectancy.

Policy Points Changes in US state policies since the 1970s, particularly after 2010, have played an important role in the stagnation and recent decline in US life expectancy. Some US state policies appear to be key levers for improving life expectancy, such as policies on tobacco, labor, immigration, civil rights, and the environment. US life expectancy is estimated to be 2.8 years longer among women and 2.1 years longer among men if all US states enjoyed the health advantages of states with more liberal policies, which would put US life expectancy on par with other high-income countries. CONTEXT: Life expectancy in the United States has increased little in previous decades, declined in recent years, and become more unequal across US states. Those trends were accompanied by substantial changes in the US policy environment, particularly at the state level. State policies affect nearly every aspect of people's lives, including economic well-being, social relationships, education, housing, lifestyles, and access to medical care. This study examines the extent to which the state policy environment may have contributed to the troubling trends in US life expectancy. METHODS: We merged annual data on life expectancy for US states from 1970 to 2014 with annual data on 18 state-level policy domains such as tobacco, environment, tax, and labor. Using the 45 years of data and controlling for differences in the characteristics of states and their populations, we modeled the association between state policies and life expectancy, and assessed how changes in those policies may have contributed to trends in US life expectancy from 1970 through 2014. FINDINGS: Results show that changes in life expectancy during 1970-2014 were associated with changes in state policies on a conservative-liberal continuum, where more liberal policies expand economic regulations and protect marginalized groups. States that implemented more conservative policies were more likely to experience a reduction in life expectancy. We estimated that the shallow upward trend in US life expectancy from 2010 to 2014 would have been 25% steeper for women and 13% steeper for men had state policies not changed as they did. We also estimated that US life expectancy would be 2.8 years longer among women and 2.1 years longer among men if all states enjoyed the health advantages of states with more liberal policies. CONCLUSIONS: Understanding and reversing the troubling trends and growing inequalities in US life expectancy requires attention to US state policy contexts, their dynamic changes in recent decades, and the forces behind those changes. Changes in US political and policy contexts since the 1970s may undergird the deterioration of Americans' health and longevity.

Equity First: Conceptualizing a Normative Framework to Assess the Role of Preemption in Public Health.

Policy Points Preemption is a legal doctrine whereby a higher level of government may limit or even eliminate the power of a lower level of government to regulate a certain issue. Some state legislatures are using preemption with increasing regularity to thwart local policies that have the potential to reduce health inequities. Despite recent trends, preemption is not inherently adversarial to public health, equity, or good governance but rather reflects its wielder's goals and values. Existing frameworks for assessing preemption fail to reconcile its potential to both advance and hinder health equity. An equity-first preemption framework can facilitate case-by-case assessments of whether preemption is likely to worsen inequities or whether it is an appropriate response to address existing inequities. Robust empirical evidence is needed to develop and operationalize such a framework. CONTEXT: Due to the inequitable distribution of various social determinants of health, disparities in health and well-being are tied to where an individual lives. In the United States, a zip code often better predicts a person's health than their genetic code. As communities seek to redress these inequities, many find that, due to state preemption, their zip code also dictates their ability to pursue more equitable laws through local government action. Preemption is a legal doctrine whereby a higher level of government may limit or even eliminate the power of a lower level of government to regulate a certain issue. METHODS: We conducted a literature review to survey existing scholarship about the effects of preemption on public health and health equity using online databases such as PubMed, WestLaw, and Google Scholar. We also cohosted a series of cross-sector, interdisciplinary research convenings with preemption, public health, and equity experts. Based on our findings, this article reviews the role of law and policy in the genesis of health inequities and highlights how preemption has both created and alleviated such inequities. We demonstrate how a normative framework rooted in redressing health inequities can advance a more just approach to preemption and outline a research agenda to support future action. FINDINGS: Law and policy have been central to creating health inequities, and while those same tools can promote health equity, some state legislatures are using preemption with increasing regularity to thwart local policies that may improve health and equity. Nevertheless, preemption is not inherently adversarial to public health, equity, or good governance. Preemptive federal civil rights laws, for example, have countered government-sanctioned discrimination. However, existing frameworks for assessing preemption fail to reconcile its potential to both advance and hinder health equity. CONCLUSIONS: Shortcomings in existing preemption frameworks demonstrate the need for new approaches to elevate equity as a central consideration in assessing preemption. We propose the development of an equity-first preemption framework to establish evidence-based criteria for assessing when preemption will enhance or inhibit equity and a research agenda for developing the evidence necessary to inform and operationalize the framework. An equity-first reconceptualization of preemption can help ensure that local governments remain places of innovation while allowing states and the federal government to block local actions that are likely to create or perpetuate inequities.

POLICY POLARIZATION AND DEATH IN THE UNITED STATES.

The United States currently ranks last among high-income countries for life expectancy. Since 2014, U.S. life expectancy has declined. By now, these alarming trends are well known to researchers, the public, and policymakers. Nevertheless, there is no consensus among researchers on the causes of the trends, and there has been no serious and effective bipartisan effort to solve the problem. The dominant narrative has implicated Americans' behaviors, such as smoking, illicit drug use, and suicide; yet, this narrative is misguided and counterproductive. It also exonerates the key structural drivers of behaviors and health, namely the U.S. policy context and the outsized influence of corporations and big donors on those policies. The U.S. policy context has changed dramatically since the 1970s, particularly at the state level. State policies have hyperpolarized along partisan lines. These changes have likely had a profound impact on nearly every aspect of Americans' lives, cutting short many of them. Consequently, this Essay argues that state policies increasingly affect life and death in the United States. It raises concerns about how the polarization of state policies will further deteriorate the health of many Americans. It points to three significant forces behind the polarization and the growing importance of state policy contexts on Americans' lives-(1) New Federalism; (2) the new type of state preemption laws; and (3) the emergence of organizations, such as the American Legislative Exchange Council, through which corporations and big donors influence policies.

Educational Disparities in Adult Mortality Across U.S. States: How Do They Differ, and Have They Changed Since the Mid-1980s?

Adult mortality varies greatly by educational attainment. Explanations have focused on actions and choices made by individuals, neglecting contextual factors such as economic and policy environments. This study takes an important step toward explaining educational disparities in U.S. adult mortality and their growth since the mid-1980s by examining them across U.S. states. We analyzed data on adults aged 45-89 in the 1985-2011 National Health Interview Survey Linked Mortality File (721,448 adults; 225,592 deaths). We compared educational disparities in mortality in the early twenty-first century (1999-2011) with those of the late twentieth century (1985-1998) for 36 large-sample states, accounting for demographic covariates and birth state. We found that disparities vary considerably by state: in the early twenty-first century, the greater risk of death associated with lacking a high school credential, compared with having completed at least one year of college, ranged from 40 % in Arizona to 104 % in Maryland. The size of the disparities varies across states primarily because mortality associated with low education varies. Between the two periods, higher-educated adult mortality declined to similar levels across most states, but lower-educated adult mortality decreased, increased, or changed little, depending on the state. Consequently, educational disparities in mortality grew over time in many, but not all, states, with growth most common in the South and Midwest. The findings provide new insights into the troubling trends and disparities in U.S. adult mortality.