[New research shows widening gaps between red and blue states in
life expectancy. ]
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THE LIFE-AND-DEATH COST OF CONSERVATIVE POWER  
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Paul Starr
December 8, 2023
The American Prospect
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_ New research shows widening gaps between red and blue states in
life expectancy. _

Attendees recite the Pledge of Allegiance at the South Dakota
Republican Party Monumental Leaders rally, September 8, 2023, in Rapid
City, South Dakota., Toby Brusseau/AP Photo

 

Conservatives often argue against proposals for public remedy on
grounds of futility. Public remedy will be ineffectual, they say,
because the problems it is meant to fix arise from intractable social
conditions or human nature. When the new Speaker of the House Mike
Johnson recently responded to demands for gun regulation after a mass
shooting by saying that “at the end of the day” the true problem
is not guns but the “human heart,”
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he was making the futility argument.

The “futility thesis,” as Albert Hirschman calls it in his classic
_The Rhetoric of Reaction_, has a long history, but it has special
relevance to contemporary politics. It played a major role in the
neoconservative attack on liberal programs of the 1960s and subsequent
rollback of federal regulation and spending. One of Ronald Reagan’s
favorite lines, “We had a war on poverty, and poverty won,
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perfectly expressed the conservative charge that liberal reform was
futile. That view helped persuade Congress under Reagan and his
successors not only to cut programs for low-income communities but
also to devolve policy to the states through such measures as block
grants that let the states decide how money would be spent.

Although we hardly knew it at the time, the United States was
conducting a national experiment: What would be the effect on
Americans’ well-being if we turned over a wider array of policies to
states controlled by political parties with opposed agendas? Three
other developments have made state governments more central in
policymaking. One is preemption. Since the 1980s, states in Republican
hands have increasingly preempted local laws, preventing
Democratic-run cities from adopting such policies as tobacco taxes and
anti-smoking regulations, paid sick leave, and higher minimum wages.

The other two developments advancing the power of states are the work
of the Supreme Court. By striking down the constitutional right to
abortion, the Court has given states leeway to adopt diametrically
opposed policies on reproductive rights. And by refusing to impose any
limits on partisan gerrymandering, the Court has enabled incumbent
state parties to expand their legislative majorities and entrench
themselves in power.

These shifts have greatly increased both the importance of state-level
policy and divergences between red and blue states. For many purposes,
it no longer makes sense to think of the United States as one country.
Depending on their state of residence, Americans live under
drastically different policies concerning public health, taxes, the
stinginess or generosity of public benefits, unionization, gun safety,
and many other things that affect their well-being, indeed, their
survival.

SO WHAT HAVE BEEN THE RESULTS OF THE NATIONAL EXPERIMENT of putting
more policymaking in the hands of states? Survival, as registered in
mortality rates and life expectancy, is the ultimate measure of
well-being, and the data for the United States in recent decades do
not tell a happy story. While life expectancy continued rising in all
the high-income countries in the late 20th century, the United States
began lagging behind its peers. By 2006, it ranked last
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expectancy in this country began falling
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pattern, however, varies considerably across states.

As state-level policy has diverged since the 1970s (and especially
since 2000), so have differences in mortality rates and life
expectancy among the states. These differences are correlated with a
state’s dominant political ideology. Americans’ chances of living
longer are better if they live in a blue state and worse if they live
in a red state. The differences by state particularly matter for
low-income people, who are most likely to suffer the consequences of
red states’ higher death rates. To be sure, correlation does not
prove causation, and many different factors affect who lives and who
dies. But a series of recent studies make a convincing case that the
divergence of state-level policymaking on liberal-conservative lines
has contributed significantly to the widening gap across states in
life expectancy.

In a 2020 paper
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team of researchers led by Jennifer Karas Montez assembled annual data
from 1970 through 2014 on both life expectancy and state policies in
18 different policy domains, including health, labor, the environment,
and taxation. In previous work, one of the collaborating scholars,
Jacob M. Grumbach, had shown that state-level policies over that
period had polarized on a liberal-to-conservative spectrum
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According to the new Montez study, which controlled for differences in
state populations, the polarized shifts in state policy were
associated with changes in life expectancy. States that adopted
liberal policies were more likely to experience larger gains in life
expectancy (and in recent years to avoid an outright decline).
Connecticut and Oklahoma were the two states whose policies shifted
the most, Connecticut toward the liberal side and Oklahoma toward the
conservative side. In 1959, life expectancy in both states was 71.1
years; by 2017, it had increased to 80.7 years in Connecticut but only
to 75.8 years in Oklahoma.

Couldn’t the explanation for such changes lie in changes in
education, income, and other characteristics of the states? Montez and
her co-authors estimated the association of life expectancy with state
policy liberalism, net of other factors such as the composition of the
state’s population. Taking those factors into account, their model
indicated that if all states’ policies were the same as
Connecticut’s in 2014, U.S. life expectancy would have been two
years longer for women and 1.3 years longer for men—and if all
states’ policies were like Oklahoma’s, Americans’ lives would
have been shorter.

IN A 2021 STUDY
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COUILLARD AND CO-AUTHORS APPROACHED the question a different way,
exploring alternative explanations for the increased geographic
divergence in life expectancy. Much recent research on individual
mortality rates has pointed to the increase in “deaths of despair”
(drug overdoses, suicides, and alcohol-related disease), concentrated
among Americans without a college degree. Might those deaths and the
share of the college-educated population account for the increased
divergence across states? The Couillard study found that it accounts
for only about one-sixth of the change.

And what about changes in per capita income among the states? Perhaps
life expectancy has fallen in states where incomes have fallen, while
it has risen in states where incomes have gone up. It turns out,
however, that _changes_ in state incomes don’t predict changes in
life expectancy. What does have an impact are differences in _levels_
of state income over the preceding three decades. The longevity of a
population today reflects the investments in health made in years
past. The Couillard study concluded that “the most promising
explanation” for rising geographic disparities lies in “efforts by
high-income states to adopt specific health-improving policies and
behaviors,” efforts which have “reduced mortality in high-income
states more rapidly than in low-income states, leading to widening
spatial disparities in health.” These efforts, they write,
“include anti-smoking policies, expansions of Medicaid, income
support, and norms around health behaviors.”

The full impact on life expectancy of a change in policy often takes
years to emerge. For example, higher tobacco taxes may reduce smoking
and deaths from lung cancer and other diseases, but mortality rates do
not immediately register the effect. Similarly, much of the benefit
from providing health care to children shows up only in adulthood.
Untreated disease in children affects their energy and performance in
school, onset of disabilities, adult health, and overall ability to
thrive later in life.

In one of the rare studies that tracks long-term effects of policy,
Andrew Goodman-Bacon used state-by-state variations in the original
introduction of Medicaid coverage for children
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and 1970 to estimate health and economic effects in adulthood. He
found that early childhood eligibility for Medicaid reduced death and
disability and increased employment up to 50 years later. In fact, it
saved the government more than its original cost because the
recipients later received less in public benefits and paid more in
taxes.

Another recent study also makes a powerful case against the futility
thesis. So many Americans already own guns that it may seem that no
policy limiting firearms can make any difference. But in a paper
published this year analyzing state-level changes in gun regulations
and gun mortality from 1991 to 2016
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Patrick Sharkey and Megan Kang found “strong, consistent evidence
supporting the hypothesis that restrictive state gun policies reduce
overall gun deaths,” including both homicides and suicides committed
with guns. They used data on nine categories of gun laws to create an
index for each state based on the balance between restrictive
policies, such as background check requirements, and permissive
policies, such as concealed-carry laws. For 2016 alone, they estimated
that restrictive policies passed since 1991 averted 4,297 deaths,
about 11 percent of the total gun deaths that year.

The shift of policymaking to the states is often justified on grounds
of federalism and the belief that decisions should be left to the
level of government closest to the people. But if conservatives
genuinely believed in that principle, would they be agitating now for
a national law to ban abortion? Would they be hoping that the Supreme
Court continues to strike down state and local gun restrictions? Would
they continue to support decisions by state legislatures to preempt
local laws? What unites the right is not a principled belief in
federalism or local control but a preference for making decisions at
whatever level of government they dominate.

What also unites conservatives is a complete absence of any
self-reflection about the impact of their policies on life and death
in America. The futility thesis must be a great consolation to those
who believe in it because otherwise they would have to confront the
toll that their policies have taken. The balance of power in the
states has been literally a life-and-death matter. Liberals and
progressives should know that the policies they have struggled to
enact have not been in vain.

Paul Starr is co-founder and co-editor of The American Prospect, and
professor of sociology and public affairs at Princeton University.

_The American Prospect_ is devoted to promoting informed discussion on
public policy from a progressive perspective. In print and online, the
_Prospect_ brings a narrative, journalistic approach to complex
issues, addressing the policy alternatives and the politics necessary
to create good legislation. We help to dispel myths, challenge
conventional wisdom, and expand the dialogue.

Founded by Robert Kuttner, Paul Starr, and Robert Reich, read the
original 1989 prospectus for the magazine.
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* life expectancy
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* Red States
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* Blue States
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