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US State Polarization, Policymaking Power, and Population Health | Milbank Quarterly

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US State Polarization, Policymaking Power, and Population Health | Milbank Quarterly 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. View this on Milbank Memorial Fund >

 

Background

Americans live shorter and sicker lives than do people in most other high-income countries.¹The 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.