The Growing Influence of State Governments on Population Health

March 15, 2022 3:49 PM

"Disparities in health across the 50 states are growing, a trend that began in the 1990s. For example, in 1990, life expectancy in New York was lower than in Oklahoma, but the trajectories separated sharply in the 1990s and, by 2016, New York ranked third in life expectancy, whereas Oklahoma ranked 45th... The widening gap cannot be explained by changes in the racial and ethnic composition of states, because the same trend occurred within racial and ethnic groups... States assumed increasing powers decades ago, when the Reagan administration in the 1980s and the US Congress in the 1990s promoted devolution... States with different political priorities and economic circumstances made diverse policy choices, widening the gap..."
posted by clawsoon (25 comments total)

Well, that's a little depressing for me, as someone who lives in a state with a deeply shitty government. We're definitely all going to get arsenic poisoned because Freedom. Sigh.
posted by ArbitraryAndCapricious at 3:53 PM on March 15, 2022 [5 favorites]

On the other hand, it means the things that intelligent observers have been suggesting would help do, in fact, help and the things that experts say would be bad ideas do turn out to be bad ideas with negative impacts.
posted by aramaic at 4:00 PM on March 15, 2022 [17 favorites]

New York ranked third in life expectancy, whereas Oklahoma ranked 45th

Is rankings really the best way to compare two states though? There are 48 other states that can impact that metric.
posted by pwnguin at 4:05 PM on March 15, 2022 [5 favorites]

In an ideal world, states would observe the results of this "marketplace of ideas" and choose policies adopted by other states that have the desired outcomes. However, in the current polarized environment, "health" is some sort of strange political football.
posted by meowzilla at 4:11 PM on March 15, 2022 [7 favorites]

COVID has obviously accelerated this.

Since the vaccine became widely available, the 14 states with the highest death rates were all run by Republican governors. Florida residents were nearly three times as likely to die as residents of California.
posted by CheeseDigestsAll at 4:23 PM on March 15, 2022 [24 favorites]

Washington Post: How does Ron DeSantis sleep at night?

via Lemieux at LGM, who notes "The Republican anti-vaxx campaign has been incredibly successful [at getting Republican voters killed]"

(I'm sure DeSantis sleeps quite well, actually.)
posted by tonycpsu at 4:24 PM on March 15, 2022 [8 favorites]

On the one hand, Missouri (which is 100% solid red at this point, at least as to how the state is run) looks to have had the Covid death rate at 0.6/100,000 per week AT THE HIGHEST. Looking at the graph in that article, that places Missouri's Covid death rate far, far, FAR lower than ANY of the six comparison states shown in that articles graphic (which is designed to contrast 3 Red with 3 Blue states' outcomes).

Say yay us, I guess?

We are very close to 50th out of 50 states in amount of health spending per citizen and the amount spent on health agencies. So I guess that bears out the wisdom of our plan to defund everything health-related as far as possible and let the chips fall where they may?

Every state in the union should be rushing to imitate Missouri! Everyone get going on this - guaranteed to be a huge success!

On the flip side, take a gander at this list of all 50 states listed by life expectancy. What I'm seeing there is all Blue states up at the top. The highest red states are Utah, Idaho, and then Nebraska (11, 13, and 17 respectively). Those three all have particular reasons they're closer to the top of the list.

But far more apparent than even the red/blue divide there is the divide between the South and everything else. If you look at, say, states that were in the Confederacy (or flirting with it) or slave states vs non-slave, the disparity is huge. Southern states are all way down at the bottom of the list. They own the bottom 10-15 spots.

The southern states that aren't quite at the bottom, like Florida & Texas, are those whose economy and population have sort of super-expanded to the point where their local culture isn't quite delineated by the old slavery-era power structures any more.

Anyway, I would say that is the big effect we're seeing here. And "states rights" do play into this to a significant degree. But it's also the terrible legacy of our slave economy, Civil War, reconstruction, continuing desperate attempts to continue the practice and social structures of slavery as best we can in all but name, racism and all that goes along with that, come home to roost in the most predictable possible way.

This you see the Red/Blue breakdown fall out of this, too, but I would argue that the slave/racist society and economy is more the basis of it, and things like the Red/Blue divide are the result of that. Of course it plays both ways and the "conservative" idea that we don't want to spend a nickel on things like welfare, education, public health, and so on very much goes back to the racist mindset.

But if the Republican Party didn't cater to this mindset I guarantee you they would invent a new party that would do so, and then all flock to it.
posted by flug at 4:46 PM on March 15, 2022 [20 favorites]

The graph in the article is excess deaths, not covid death rate. It avoids issues with undercounting of COVID-caused deaths. If you want to make a comparison, make sure you’re using the same data.
posted by nat at 5:09 PM on March 15, 2022 [5 favorites]

Someone on another site recently referred to the US as “Fifty countries in one trench coat trying to sneak into the movies.”
posted by The Underpants Monster at 6:51 PM on March 15, 2022 [15 favorites]

Every state in the union should be rushing to imitate Missouri!

Because Missouri loves company!

(I’ll show myself out.)
posted by The Underpants Monster at 6:55 PM on March 15, 2022 [48 favorites]

I skimmed the article and didn't see an answer to this:

Why was California's excess mortality so high in the beginning of 2021?
posted by mikeand1 at 8:36 PM on March 15, 2022

I mean...I'll save you the drama. The trend line for life expectancy is the same for education outcomes: it's a graph of median income.
posted by Reasonably Everything Happens at 8:38 PM on March 15, 2022 [11 favorites]

Why was California's excess mortality so high in the beginning of 2021?

One possible answer to my own question -- CA has a high proportion of Latinos, and we know Latinos suffered higher mortality as a result of covid.
posted by mikeand1 at 8:45 PM on March 15, 2022

This is an excellent article. Many state governments actively undermined public health during the pandemic, resulting in thousands and thousands of deaths. It is shocking.
posted by emd3737 at 9:51 PM on March 15, 2022 [2 favorites]

mikeand1, [I]n every corner of California, the Latino population has faced a greater risk of exposure to COVID-19, undergone testing at a lower rate, and suffered more deaths than any other race or ethnicity [Stanford] (Re: that greater risk -- Latinos in California are far more likely to live in a household with an essential worker)
posted by Iris Gambol at 12:27 AM on March 16, 2022 [7 favorites]

> The graph in the article is excess deaths, not covid death rate. It avoids issues with undercounting of COVID-caused deaths. If you want to make a comparison, make sure you’re using the same data.

Oh, now, just LOOK what your gosh-darned scientific nitpicking went and made me do.

I went over to the CDC and downloaded the proper excess death data for all the states and analyzed it properly, comparing Missouri to the six states shown in the JAMA graphic, and WHAT A SURPRISE the results are.

You can see the chart with the results here.

I will describe them for you: Missouri started out 2021 with fewer excess deaths than ANY of the six comparison states.

But Missouri ended 2021 with notably MORE excess deaths than any of the six states. In fact, it looks like we ended the year at more than double the average of those other six states.

We didn't zoom up quite as high and hard as FL GA & TX in late 2021 but we have stayed consistently higher for a longer time through the last half of the year.

In short, I'm afraid you and your rascally scientific thinking have disproved the wisdom of our complete disinvestment in public health.

Who woulda thought?
posted by flug at 2:01 AM on March 16, 2022 [8 favorites]

Oof. That’s even less pleasant than I guessed. As someone in AZ, also not generally great with the whole public spending thing, is there an easy way for me to add AZ to your graphic? I expect it’s not great, either…
posted by nat at 2:07 AM on March 16, 2022

> is there an easy way for me to add AZ to your graphic

You just have to download the data here. But then to make a good comparison with the JAMA graph you do have to know your state's population and do a bit of massaging to turn it into excess deaths per 100,000. Then just graph it with Excel.

(Someone might know an easy way to graph all states in a way that would make it easy to compare them. My attempt: This link at the CDC may allow you to easily create graphs state-by-state once it is approved, which might be a while - just click on "filters" and change the state to the one you want to view.)

I graphed AZ here and it does look bad - worse than Missouri even, I'm sorry to say.

It starts 2021 looking much like the other six states. By March-April 2021, everyone is pretty much at parity and low.

But after that, AZ just increases steadily and it ends the year noticeably higher than all 7 other states in the comparison, even including Missouri.
posted by flug at 3:30 AM on March 16, 2022 [2 favorites]

I'm guessing the slightly wonky results with Missouri are because the urban areas lean more Democratic. There have certainly been clashes between the state and local governments over it.

(And also in St. Louis County, between the Democratic county executive (a former medical doctor) and Republican-skewed county council (dipshits who used COVID as a political wedge). On any given day it was difficult to know whether or not there was a legally effective mask mandate in place, but at least it got prudent people to mask up and get vaccinated.)
posted by Foosnark at 4:30 AM on March 16, 2022 [1 favorite]

Regarding Missouri, Illinois state government actually just released some data the other day about how many Missourians are preferentially accessing Illinois's health care infrastructure instead of Missouri's, especially in the St. Louis area, and the answer turns out to be, "Everybody who can afford it." (Neighboring-state health system access became a bigger deal during Covid as states like Missouri, Iowa, Wisconsin, and Indiana rapidly ran out of ICU beds and were having to send patients to Illinois. Our ICU-bed utilization metrics were really fucked up as a result; there was a period of two weeks where basically every car accident in western Kentucky was being life-flighted to Illinois. Illinois had relatively low Covid rates but ultra-high ICU utilization because we were the overflow healthcare for the bad-decision-making states.)

I expect some of the general North/South divide you're seeing is about right-wing northern states, like Indiana, being able to piggyback on neighboring states' better decisions. Whereas Alabama is kinda SOL in terms of neighbors. It's not that Indiana did a better job than Alabama; it's that Illinois did a better job than Georgia, so Indiana got to free-ride on that.
posted by Eyebrows McGee at 8:16 AM on March 16, 2022 [17 favorites]

I wonder if there are any stats about the co-mingling of state populations. I'd expect Hawaii and Puerto Rico to be the most isolated and hubs like New York to be the most integrated with their neighbors, but I couldn't guess how you would measure this.
posted by meowzilla at 12:04 PM on March 16, 2022

OK, I made a kind of a cool plot using CDC data for "percent of expected deaths" for the covid pandemic period.

Initially it looks similar to the JAMA figure, with just those 6 states. However, you can click any state in the legend to add it to the graph and compare it to the others.

One interesting thing - the main features in the JAMA plot are the tail end of the winter 2020 wave and then the Delta wave in Fall 2021.

However, this plot also shows the Omicron wave - the deaths don't show up until January 2022, which is not shown on the JAMA plot.

The deaths in the Omicron wave are generally lower than all the earlier waves. However, there is definitely an equalizing effect going on - you don't see the nice sorting of red v. blue states as you do in the Delta wave. The high states from the Delta wave are lower than they were before, but the low states are higher than they were. Generally, all the states are more in the middle.
posted by flug at 2:27 PM on March 16, 2022 [6 favorites]

Flug, that's fascinating! Thanks for creating and sharing. Something I found interesting in looking at the data is Alaska's very jagged line: way up then way down. I wonder if this is due to the state's reporting methods or something else? (looks like Wyoming is similar, too)
posted by hydra77 at 10:36 AM on March 17, 2022

Alaska and Wyoming both have fairly small populations (700k for AK, 100k for WY). California is 40 million, so its curve looks smoother. (You see the same thing in curves for small countries as compared to large ones).

AK and WY are also both large states with a small number of sizeable cities, so that might matter too. When Anchorage gets a wave, that’s 400k of the 700k people in the state who are nearby. (Again as opposed to CA which has many cities which, while larger, are a smaller percentage of its total population).
posted by nat at 1:54 PM on March 17, 2022

Alaska has ongoing processing and reporting problems. There was a Department of Health cyberattack and then a huge backlog of death certificates after that and most stuff is still being done by hand and comes up in weird inexplicable batches and lumps.
posted by charmedimsure at 2:04 PM on March 17, 2022