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August 26, 2020
View from Here
Milbank State Leadership Network State Health Policy Leadership Population Health Social Determinants of Health
Christopher F. Koller
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The first sign that Millinocket, Maine, used to be something grand is the hulking shell of a paper mill a few miles east of town. It is the last one standing of several that once dominated the town.
Labeled “The Magic City” for how quickly it arose at the turn of the last century, Millinocket was the ultimate company town. The Great Northern Paper company turned an abundance of wood and water—from the East and West branches of the Penobscot River—into some of the largest paper mills in the world. Fueled by Italian immigrants who built the mills, the town prospered, with nice homes, company baseball teams, visits from touring theater troops, and its own hospital.
But Great Northern overextended itself and the market for paper shrunk. The company got bought out, its parent went out of business, and then private equity feasted on the remains. The last mill shut down in 2008. The town’s population now is two-thirds of what it was 30 years ago. Tourists on their way up to Maine’s scenic lakes might stop at the grocery store on the outskirts of town before zipping past the boarded-up buildings on Penobscot Ave., the town’s main drag, and Trump/Pence yard signs.
As the region’s main industry has gone south, so has its health. Penobscot County’s population health measures are not great. The County Health Rankings and Roadmaps ranks it 12th of Maine’s 16 counties for health outcomes, with particular challenges relative to the rest of the state for obesity rates and years of potential life lost before age 75. This last measure has trended up for both the county and the state over the last 20 years, in contrast to the national trend.
Similarly, an analysis by Steven Woolf and Heidi Schoomaker of 60 years of mortality data found that Maine had some of the largest increases in midlife (ages 20–65) mortality in the country between 2010 and 2017, caused not only by the well-publicized “deaths of despair” (suicide, alcohol, and depression) but a variety of organ system diseases.
In the face of the tectonic global forces that can bring down a once proud company like Northern Paper and consign an entire region to economic and health declines, what is a state policymaker to do? Perhaps a lot, if they can take a long and broad view, according to a new Milbank Quarterly article by Jennifer Karas Montez and her colleagues.
Taking as their starting point the increasingly varied life expectancy by state, as well as the sharp differences in trends among states, the authors studied whether state positions on certain types of social policies were related to these outcomes.
The short answer was: yes, when it comes to life expectancy, state positions on certain issues make a difference. “We found that policies on tobacco, labor, immigration, civil rights, and the environment were strongly associated with longevity among women and men,” the authors conclude, “With more liberal versions of each policy within a state predicting a nearly 1‐year increase in that state’s life expectancy.”
“Other policies also mattered,” the authors say. “For instance, more liberal policies on abortion and gun control predicted longer life expectancy among women, while more conservative marijuana policies predicted longer lives for both women and men.”
This research has some important implications for state policymakers.
First, public policy about a single issue for a small group of people can have significant and systemic consequences for many. This chain of connection from a policy that at first glance affects only narrow circumstances for a certain group of people—for instance, the LGBTQ community, hourly workers, immigrants, or gun owners—to one that affects overall lifespan is not fully understood but it apparently exists. When they act, policymakers are not just adjudicating between competing interest groups on a particular issue but affecting the common good in fundamental ways.
Second, ideologies have implications. The terms “liberal” and “conservative” have become so charged in the current political environment as to lose their neutral origins and cancel more thoughtful discussions. A key finding of this research, however, is to clarify the health impact of these positions. For some issues, the study finds, positions that “are consistent with expanding state power for economic regulation and redistribution or for protecting marginalized groups, or restricting state power for punishing deviant social behavior” appear to be connected with longer life expectancies for a state population. Positions on these issues consistent with smaller government and more limited economic redistribution, with the exception of marijuana, are not.
But what if longer life expectancies for all is not a shared policy value? The protection of liberty and personal and civic responsibility are determinative values which demand protection and promotion among large segments of the population. Expanded state authority over certain issues, which this research shows is connected with longer collective lifespans, can impinge on these values.
Conflicts between collective good and personal independence are not new in America. Historically we have resolved them, and other ideological conflicts, through politics, in all of its noble and messy variations. The authors refer to research to show that at the state level these conflicts are diminishing as states’ policy positions become more polarized. Through pre-emption authority, states are also taking away the ability to local jurisdictions to adopt a contrary position. The increasing variation in life expectancy rates among states may be an inexorable result of the policy choices being made in increasingly ideologically homogeneous environments.
What does that mean for the citizens of Millinocket, at least the ones who have stayed and who care about their pretty community at the edge of Baxter State Park? State policymakers may have been powerless to address the global economic forces that weakened a town built on one vulnerable industry. But by paying persistent attention to the broader impacts of policy proposals and implementing ones have been shown to have long-term systemic benefit—like establishing a minimum wage more in line with inflation—it appears they can soften the blow for individuals and communities, leaving them stronger to face their challenges.
That is a lesson for all of us at this economic and epidemiologic moment in our country.
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