Tuesday, February 16, 2021

How state policies influence how long you live

Last summer, I temporarily moved from one of the most politically liberal places in America to one of the most conservative. In the 2020 Presidential election, Joe Biden carried DC's 3 electoral votes with more than 92% of ballots cast, while Donald Trump carried Utah's 6 electoral votes over Biden by a comfortable 58% to 38% margin. As the COVID-19 pandemic became increasingly politicized, the orientations of DC and Utah predicted their public health responses. Although nearly all public and private schools in both places initially switched to online learning, most Utah schools re-opened for in-person learning last fall, while DC public schools stayed closed and are only beginning to re-open this month. DC's mayor instituted a mask-wearing mandate on July 22, while Utah's governor did not do so until November 9, when its hospitals were nearly full and the per capita incidence of COVID-19 was among the top 5 states in the nation. DC has also kept in place more restrictive rules on operating restaurants (including closing indoor dining entirely from Dec. 18 to Jan. 22) and other "non-essential" businesses than most parts of Utah.

A research study in Science Advances examined the relationship between social mobility, community COVID-19 incidence, and partisan differences. Logically, people should be more likely to stay at home when viral spread is higher, and more likely to go out when viral spread is lower. Instead, the researchers found that there was only a weak association of mobility with COVID-19 activity over time; a far stronger predictor of people's willingness to leave home to socialize with others outside of their immediate family was party affiliation:

Using daily data on the reported activities of 1,135,638 U.S. adults collected starting on 4 April 2020, we show that partisanship is 27 times more important than the local incidence of COVID-19 in explaining mobility. Moreover, all else equal, Democrats are 13.1% less likely to be socially mobile over time compared to independents, while Republicans are 27.8% more likely to be mobile.

This study's findings correlate with my own experience. I can't remember seeing anyone indoors in DC who wasn't wearing a mask after mid-March, but outside of Salt Lake City (which leans liberal and has a Democratic mayor) it was common to see unapologetically maskless people shopping in stores where mask-wearing was required by law. In a recent article in The New Yorker, Dr. Atul Gawande reported on the debate surrounding mask mandates in Minot, North Dakota, which in mid-October 2020 held the unenviable distinction of being the county seat of "the worst-hit county in the worst-hit state in the worst-hit country" in the world in new COVID-19 cases and deaths per capita. From a public health perspective, a mask mandate ought to have been a no-brainer. Instead, as the city council debated a mask mandate motion for an hour, a YouTube chat of residents watching the proceedings online erupted with angry comments such as "unconstitutional," "tyrannical," and threats of "mass protests." (The council ultimately adopted a mask mandate with no penalties or other means of enforcement.) A few weeks later, Donald Trump easily carried Ward County over Joe Biden, 65% to 32%.

The influence of partisanship on states' public health approaches to the coronavirus is just the tip of the health policy iceberg, though. A study in Pediatrics showed that higher state and local expenditures on non-health care services such as social services, environment and housing were associated with lower infant mortality from 2000 to 2016. Another, more ambitious study graded state policies on a conservative to liberal continuum from 1970 to 2014 ("liberal was defined as expanding state power for economic regulation and redistribution or for protecting marginalized groups, or restricting state power for punishing deviant social behavior, conservative was defined as the opposite") and found that people consistently live longer in states with more liberal policies than in those with conservative ones. The authors estimated that overall U.S. life expectancy (which since the 1990s has been at or near the bottom of the world compared to other high-income countries) would be nearly 3 years longer among women and 2 years longer among men "if all states enjoyed the health advantages of states with more liberal policies," and would mostly erase the current U.S. life expectancy disadvantage. A few years may not seem like that much, but consider this: the 350,000 excess deaths that the U.S. experienced in 2020 due to COVID-19 reduced life expectancy at birth by just over a year, enough to lower U.S. life expectancy to its lowest level since 2003.

In a recent perspective in The Milbank Quarterly, Dr. Jennifer Karas Montez observed that as states became increasingly polarized to the right or the left in their politics, the range of state life expectancies widened from 5.4 to 7 years between 1980 and 2017. She hypothesized that two major factors have driven the widening disparities between liberal and conservative states: devolution (transferring federal oversight and fiscal responsibilities to the state level) and state preemption laws, which "prohibit or severely restrict local governments from legislating on certain issues," such as social distancing and mask regulations in Florida, Mississippi, and Georgia in 2020. Of course, millions of people immigrate from outside of the U.S. and move from one state to another every year, which complicates the picture: it's possible that healthier people move to certain states in order to enjoy the benefits of more livable environments or liberal policies, rather than those environments or policies creating better health. But all things considered, it's important to recognize that what my Georgetown family physician colleague Ranit Mishori calls "the political determinants of health" act powerfully at the state level, not only through national legislation and executive actions.