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Perspective Population Health State Health Policy
Jennifer Karas Montez
Back to The Milbank Quarterly
The troubling trend in US life expectancy and the widening disparities in life expectancy across the United States have deep roots. This article posits that both trends are grounded in the dynamic changes in the policy and political landscapes since the 1980s. It first briefly describes the trends and the importance of excavating their structural roots. It then builds the case that changes in state policies and politics, as well as the forces behind those changes, are key explanations for both trends.
Americans live shorter and sicker lives than do people in most other high-income countries.1 The disadvantage in the United States exists across most age groups, from birth until around age 75.2 On average, US adults live 78.5 years, putting the country at 45th place in the world in 2017.3 This unenviable position was decades in the making. Since the 1980s, the United States has made smaller gains in life expectancy than have many other high-income countries; started to plateau around 2010; and experienced declines after 2014.2,4 If these trends continue, the United States is expected to realize smaller gains than other countries and to fall more than any other high-income country, to 64th place by 2040.5
Recent trends in US life expectancy have become widely known among researchers, policymakers, and the public, yet there is little agreement on their causes and no earnest bipartisan effort to reverse them. The closest effort was the proposed National Strategy to Increase Life Expectancy Act of 2018, which was never enacted. This bill would have required the US Department of Health and Human Services to develop a strategy to raise life expectancy to at least average among the OECD (Organisation of Economic Co-operation and Development) countries by identifying the major causes of and inequalities in premature death in the United States and by evaluating the federal government’s effectiveness in meeting that target.
A scientific panel developed five noncompeting hypotheses for the growing US disadvantage in health: policies and social values, physical and social environments, public health and medical care systems, social and economic factors, and individual behaviors.1 The hypotheses are grounded in a socioecological framework recognizing that health is shaped by multiple layers of causes, with the “macro” layers largely influencing the others.6 Macro (i.e., structural) layers include overarching institutions, policies, and systems such as political and economic systems.7 Micro layers refer to individuals and their immediate environment. Meso layers, such as workplaces, fall in between.7
Studies of the troubling US health trends have disproportionately examined the micro or meso hypotheses among these five hypotheses, particularly individual behaviors but also medical care and socioeconomic conditions. These studies, however, do not adequately explain the growing disadvantage,8 which applies to insured, nonsmoking, nondrinking adults, and across most education and income groups, although it is most pronounced for less-educated and low-income Americans.9-13
Similarly, the public narrative has focused predominantly on micro layers, especially individuals’ behaviors.14,15 Media reports imply that the explanation is rather obvious, pointing to individuals’ “bad habits.”16-18 This narrative aligns with a common belief among Americans that individuals are solely responsible for their health (e.g., most believe that only smokers, not cigarette manufacturers, are culpable for their health problems19), a message reinforced by corporations that profit from those behaviors.20 Some have suggested that the narrative may even have facilitated the US health trends.14,15 Sandro Galea writes that the US view of lifestyle as a personal and moral choice has led to bad policy decisions and to “spending [the nation’s] money on ineffectual, finger-wagging efforts to modify behaviors, then later on medicine to help us after we get sick” instead of fortifying the structural foundations of health.14(pXVII)
Improving US population health requires reorienting the public narrative and the focus of scientific research to explain these alarming trends. The aim of this article is to make progress on both fronts. It connects the dots between socioecological frameworks of population health, legal and political science insights into political polarization and policymaking power, and demographic data on life expectancy. It begins by briefly reviewing the prime role of the structural causes of health, a topic familiar to population health scientists but less so to policymakers, the media, and the public. It then builds the case that one cause of the worrisome trends in health is the changing policy contexts of the US states and the forces behind those changes.
Since the early 1980s, the United States has undergone major structural changes. Many areas of the country experienced a retrenchment of labor protections, tighter restrictions on abortion, loosened gun laws, shrinking investment in K-12 schooling, gutting of local economies as manufacturing plants closed, and so on.21-23 Such changes have likely had profound effects on population health.24,25 In fact, some researchers have called for a (re)focus on such structural factors,8,24-27 pointing out that efforts in the past to reduce mortality targeted structural factors such as improved sanitation, with great success, yet modern efforts often target curative, individual-level interventions (e.g., behavior change), with mixed success. Recently, researchers have urged a stronger focus on policies and political decisions in shaping the alarming trends in US health,8,24-26,28 noting that these structural factors are the “causes of the causes of the causes.”26
Correcting the culpable structural factors must be a priority,24-27,29-32 for several reasons. First, relying exclusively on the commonly used intervention of encouraging people to change their behaviors33 is costly, inefficient, and, on its own, ineffective in the long term.29,34 In contrast, interventions grounded in a socioecological framework, which recognizes that health is shaped by many causes, have higher odds of success.6,35 One of the most successful interventions used such a framework to reduce cigarette smoking after the 1964 US Surgeon General’s Report. It was successful because it targeted policies (e.g., cigarette sales tax), physical environments (e.g., indoor smoking bans), social values (e.g., antismoking campaigns), individuals’ behaviors (e.g., knowledge, cessation programs), and the like.35
Second, focusing mainly on changing individuals’ behaviors can, conversely, widen health disparities.36-38 Current disparities in cigarette smoking are illustrative of this unintended consequence. Before the 1964 report, the prevalence of smoking was high across all education levels. In 1954, 45.5% of college-educated adults smoked, as did 43.2% of adults without a high school credential.36 But after the report, higher-educated adults were more likely to stop smoking.36 By 2018, 36% of adults with a GED smoked, compared with 4% of adults with a graduate degree.39
Third, individual behaviors tend to be symptoms of an issue, not the issue itself. For example, in 2018, 32% of US adults who reported psychological distress were smokers, versus 13% of those without distress.39 Efforts to eliminate symptoms while leaving the underlying issues intact are unlikely to be effective; as one symptom is tackled, another takes its place.36 The growing popularity of e-cigarettes is illustrative. Between 2011 and 2017, the prevalence of conventional cigarette smoking among adults aged 18 to 24 fell from 18.9% to 10.4%.40 During roughly the same time (2014-2018), however, e-cigarette use among former smokers in that age range more than tripled, from 10.4% to 36.5%.41
Fourth, population health problems are disproportionately caused by the actions of wealthy individuals, large corporations, and the policy and legal structures they cultivate—not by the poor, the less educated, or other marginalized groups.30,42 In addition, the power of corporations on health has become increasingly apparent.43-46 Many corporations produce products that harm health, such as tobacco, alcohol, opioids, and sugar,29 and they hire product defense firms to mislead the public about those harms.47 They influence elections, regulations, laws, and policies through avenues like campaign donations, political advocacy advertising (recall the 2010 Citizens United case), and lobbying for tax breaks and deregulation. In sum, these corporations shape nearly all aspects of life, including air and water quality, the food supply, labor protections, access to medical care, and income inequality.22,48
Once recognizing the central role of the structural causes of population health, researchers must decide which of the myriad possible causes to investigate. The next section in this article proposes a fruitful place to begin. Following recent calls to focus on the potential role of the US policy and political environments,8,24,26 it builds the case that US state policy contexts, the dramatic changes in those contexts in recent decades, and the forces behind those changes play key roles.
In regard to life expectancy, some states have performed much better than others. The range in life expectancy across states has fluctuated between periods of shrinking and widening during the 1960s and 1970s, and then has notably widened since the early 1980s. Between 1980 and 2017, the range expanded from 5.4 to 7.0 years.49 The 10 states with the largest increases in life expectancy realized gains of 5.6 to 7.6 years, while the 10 states with the smallest increases improved just 2.0 to 3.4 years.49 In 2017, a resident of Hawaii could expect to live for 81.6 years, compared with just 74.6 years for residents of West Virginia. Moreover, in recent years, some states suffered greater declines in life expectancy than did the country as a whole, while others continued to make gains.49 This growing disparity in life expectancy, with the lowest life-expectancy states performing particularly poorly, appears to have partially contributed to the falling position of the United States in international rankings of life expectancy, according to a study of adults aged 50 and older from 1980 to 2000.50
States’ policies and politics may have contributed to the growing disparities in their life expectancy, as they have always played a decisive role in regulating everyday life.51 States “regulate birth and death, marriage and divorce, crime and punishment, and commercial law … manage education, prisons, highways, welfare, environmental protection, corporate law, and the professions.”51 States also play a major role in numerous other domains that affect population health, such as medical care (e.g., Medicaid, abortion), economic circumstances (e.g., minimum wage), and behaviors like smoking, alcohol consumption, and marijuana and seat belt use.51
Since the 1970s, the policy context in which people live has been increasingly determined by their state of residence,21 owing in large part to two movements. The “devolution movement” transferred certain federal oversights and fiscal responsibilities to the states. It is often associated with the Reagan administration but accelerated into a “devolution revolution” after the 1994 midterm elections.52-54 An explicit goal was to shrink government and reduce federal spending on social services by shifting the fiscal and regulatory control of those services to the states.52,53 To do so, the newly controlled Republican Congress replaced certain categorical and matching grants to the states to fund social services with block grants that were smaller and let the states decide how to spend them. Consequently, the states crafted vastly different social safety nets. All else being equal, those states with larger proportions of Black and Hispanic residents tended to implement the most restrictive safety nets, which pointed to discrimination as a factor in this divergence.55 In addition, by placing more fiscal responsibility on the states, devolution shifted the burden of paying for such services away from high-income to middle- and low-income persons, because the state tax systems are less progressive (and often more regressive) than the federal tax system.53 In effect, devolution was a 1-2-3 punch to all but the most advantaged Americans.
The second movement was the emergence of a new brand of state preemption laws, in which the preemption laws enacted by state governments prohibit or severely restrict local governments from legislating on certain issues. Historically, state preemption laws have been used mainly to harmonize state and local regulations or to provide a regulatory floor by, for example, setting a minimum wage for the state.56 In the 1980s and especially after 2010, a new brand of preemption emerged. In response to the rising tide of local antismoking legislation in the 1980s, the tobacco industry successfully lobbied many states to preempt their local tobacco control legislation. In the 1990s, the National Rifle Association successfully convinced many states to preempt local authority on gun control. This “new preemption” movement was turbocharged after the 2010 midterms when the Republican Party made significant legislative gains in state governments.56 Many conservative states began rapidly preempting local authority on various policy domains, particularly targeting labor rights, to stymie the progressive-leaning policy agendas of their cities and to appease businesses and industry lobbying groups.56 The proliferation of these laws is astonishing. For example, in 2000, just 2 states preempted local authority to raise the minimum wage, and no state preempted local authority on paid leave, but by 2019, 25 states had preempted the former, and 23 had preempted the latter.57
As states absorbed more policymaking authority through devolution and preemption, their policy contexts hyperpolarized along partisan lines.21,25 Before the two movements, the states often had a mix of liberal-leaning and conservative-leaning policies. For instance, in 1970, there was no relationship between the political orientation of the states’ immigration-related policies (e.g., driver licenses for undocumented persons) and their gun control policies. Indeed, the correlation across the 50 states was −0.01.25 But by 2014, it had increased to a statistically significant 0.56, meaning that those states with conservative, immigration-related, policies tended to have conservative gun policies (and states with liberal immigration-related policies tended to have liberal gun policies).25 As another example of hyperpolarization, the correlation between the political orientation of the states’ labor policies and their abortion policies rose from 0.27 to 0.70 between 1970 and 2014.25
One consequence of this hyperpolarization is that the state in which one resides has a potentially profound impact on one’s livelihood and health. Some states created an overarching policy context that promoted well-being, while many others did precisely the opposite. Illustrating this contrast, Table 1 highlights some state policies that are particularly relevant to population health. States like New York invest in the health and human capital development of its youngest residents through, for example, relatively generous Medicaid coverage and schooling expenditures; provide an economic floor for working adults; and discourage risky behaviors. In contrast, states like Mississippi invest little in its youngest residents; decline to provide an economic floor for working adults; do little to discourage risky behaviors; and go so far as to prohibit its localities from legislating on many domains that would improve their residents’ livelihoods and health.
Data on education are from 2015/201658; data on firearms59 and healthy life expectancy60 are from 2016; data on life expectancy are from 201749; and data on Medicaid,61 cigarette taxes,62 minimum wage,63 EITC,64 and preemption,65 are from 2020. aEmployers subject to the Fair Labor Standards Act are required to pay the federal minimum wage, which is currently $7.25 per hour. bThe wage is higher in and around New York City.
These consequences have been spotlighted on the national stage through the fractured US response to COVID-19. The federal government largely abdicated its responsibility for a coordinated response and put the onus on the states to handle the crisis, which former Maryland Governor Martin O’Malley labeled a “Darwinian approach to federalism.”66 In general, Republican governors were slower than their Democratic counterparts to implement social-distancing policies, with major implications for rates of infection and mortality.67 And some governors, such as Ron DeSantis (Florida), Tate Reeves (Mississippi), and Brian Kemp (Georgia) pulled the preemption card to prohibit their localities from implementing measures to combat the spread the of virus that were stricter than those of the state.68
The current landscape of polarized state policy contexts did not result from random events. Instead, these contexts were molded by a well-resourced and coordinated strategy to alter the US policy environment, “one state capital at a time.”22 The long historical arc of this strategy has been well documented.22,69-71 Although space constraints here preclude a detailed recounting, highlights of key events and actors can paint a clear picture. It is essential to understand the structural forces that may underlie the poor health and premature death of many Americans.
One of the oldest and most powerful forces behind devolution, preemption, and polarization is the American Legislative Exchange Council (ALEC). Formed in 1973, ALEC is a coalition of (mainly conservative) politicians, businesses, big donors, and activists, which drafts model bills that are beneficial to its members and offers the legislation to state policymakers to enact.22 ALEC targets statehouses instead of the federal government partly because the former are more responsive to business demands, especially to businesses located in their state, and it is easier to change state legislation under the radar, as few people pay attention to state politics.21,22 ALEC’s legislation is probusiness (e.g., dismantling of labor protections), with its main financial support coming from roughly 200 of the largest US corporations.22 This increasingly dominant influence of large corporations on US policy and people’s lives has been documented by scientists such as Nicholas Freudenberg, who claimed, “Never before in human history has any single social institution been able to influence so many of the determinants of health for so many of the world’s people.”29 To be clear, ALEC is not the only organization of its kind. Along with the State Policy Network and the Koch-funded Americans for Prosperity, it is part of what Alexander Hertel-Fernandez termed the “troika.”22
In the 1980s, ALEC became a close partner of the Reagan administration. In fact, they were “soldiers in a common cause,” according to Reagan in his speech accepting ALEC’s Thomas Jefferson award.72 Over the next decade, ALEC and its corporate backers became successful in altering the state policy landscape, carving deeper divisions between conservative-leaning and liberal-leaning states.22 This gradual change became apparent after the 1994 midterms and the 2010 midterms. The latter has been called a watershed moment in the troika’s success, with its quick adoption of a similar set of probusiness and ideologically conservative policies (e.g., right to work laws, stand your ground laws, voter ID laws) across Republican-controlled states.22
State policies shape population health through numerous avenues, such as educational attainment (e.g., states allocate expenditures to primary and secondary schooling); economic circumstances (e.g., states can raise the minimum wage and mandate or prohibit paid leave); access to medical care (e.g., states alter Medicaid eligibility rules and access to abortion); and behaviors (e.g., states can levy excise taxes on cigarettes, legalize marijuana, and set firearm regulations). Indeed, a large body of evidence has shown that state policies influence population health.25,27 In addition, many state policies are disproportionately relevant to economically disadvantaged individuals, which may explain why disparities in the states’ health are the largest for less-educated adults.73,74
Evidence regarding the effects of state policies on population health derives mainly from studies isolating the effect of a single policy. Evidence regarding how the constellation of a state’s policies affects health is lacking, however. Filling that gap is necessary, given that state contexts have become increasingly cohesive sets of either liberal or conservative policies. More important, robust evidence is needed concerning how the dynamic changes and polarization in state policy contexts since the 1980s have influenced trends in US health, at both the state and national levels, since that time.
A few recent studies provide some evidence that there is indeed a relationship. Those states making the smallest gains in life expectancy in recent decades tend to be the same states that implemented the new type of state preemption laws and moved their overall policy context in a conservative direction. One analysis assigned to each state a score representing the number of policy domains (e.g., minimum wage, firearms) for which the state preempted localities from enacting liberal-leaning legislation. It found a negative correlation between the number of domains preempted in 2014 and both life expectancy in 2014 and gains in life expectancy between 1980 and 2014.75 Using more robust statistical methods, a recent study merged annual data on states’ life expectancy and 18 policy domains, such as labor and abortion, from 1970 to 2014, showing key differences in the characteristics of states and their populations.27 Its findings suggest that changes in state policy contexts suppressed gains in US life expectancy during the 1980s and again after 2010. It estimated that after 2010, the trend of US life expectancy gains would have been 25% steeper among women and 13% steeper among men if state policies had not changed in the way that they did.
Although the well-coordinated, well-resourced effort to alter state policy contexts may have contributed to the divergence in life expectancy across states, other factors may also matter, most notably interstate migration and geographic sorting of the population. Because people who move across state lines tend to be healthier than those who do not, migration flows may have (dis)advantaged some states. Nevertheless, migration does not appear to adequately explain state mortality trends,76 perhaps because interstate migration has steadily declined since the middle of the 20th century, with the rate cut further in half since 1980.77 The states also differ in population characteristics, like education and race, which pose health risks in certain contexts.73,78 These differences are inadequate explanations for the states’ health disparities. For one, state contexts predict health, net of such characteristics.79 More important, state contexts influence the prevalence of some characteristics (e.g., education, poverty) and the extent to which characteristics such as race, gender, education, and immigration status pose a health risk.73,74,80 Another possible explanation is that state policy contexts are polarized simply because people geographically sorted themselves into political and ideological clusters. Although sorting has occurred, it is unlikely to explain policy polarization, because policymakers have become quite unresponsive to nonwealthy constituents.81 As a sobering example, a study of policymaking between 1981 and 2006 found that the main influencers were wealthy individuals and coordinated groups representing business interests and that the average person had “a minuscule, near-zero, statistically nonsignificant impact upon public policy.”48
Research on US health trends must forge alliances across a broader range of disciplines than it has up until now. Even though perspectives from sociology, demography, and epidemiology will remain central, political science, history, and the law are equally relevant. In addition, population health research must give as much attention to the legal, political, and commercial determinants of health—particularly those outlined in this article—as it has to the social determinants.43,45,82 Specifically, to better understand how the development and deployment of laws and policies at federal and state levels since the 1980s have shaped population health, perspectives from legal epidemiology should be integrated into the socioecological framework.83 And to better understand how political polarization and the power of corporations and their lobbying groups have shaped health, perspectives from the political and commercial determinants of health should be considered as well.43,45,82,84 These perspectives would greatly strengthen a socioecological framework and would direct attention to some of the most powerful forces shaping population health in the world today.
Another element that would be helpful would be expanding funding to support scientific research at the intersection of politics and population health. Although a few private foundations already support such research, it would greatly benefit from additional support from other foundations and the nation’s largest funder of health research, the National Institutes of Health. Funding could direct attention toward questions like, has population health been shaped by the emergence of political organizations such as ALEC and the Koch-funded Americans for Prosperity? Does the fact that states like Oklahoma that have more actively implemented ALEC bills than states like Connecticut help explain the states’ growing health disparities?22 Has population health been shaped by the proliferation of the new type of state preemption laws? Is there a link between the 2010 Citizens United Supreme Court case and health?85 Has political redistricting affected health?
The public narrative of the main drivers of population health must be overhauled as well,86 as it may have life-and-death consequences.14,15 In their 2020 book, Tightrope, Kristof and WuDunn assert that the deteriorating health and well-being of working-class Americans has been mostly “driven by policy mistakes and by a distorted obsession with personal responsibility.”15 Building the evidence regarding the structural causes of US health trends is an important step. More generally, knowledge of the causes of population health must be communicated in clear, consistent, and compelling language that resonates with the values of the public and of elected representatives.87
In sum, the troubling trend in US life expectancy and the growing gap in life expectancy across the states since the 1980s have deep historical, political, and ideological roots. Efforts to reverse the trend and to improve the United States’ population health must recognize those roots and the forces behind them.
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