Political Leanings Found to Affect Mortality Rates Now More Than Ever
White Americans in Republican counties saw a larger increase in death over two decades than did those in Democratic counties.
Living in areas of the United States where the majority of the population consistently vote Republican may have an adverse effect on mortality risk, including cardiovascular death, new data hint. Things were not always this way, though, raising the question of what has happened and if it can be reversed.
In the cross-sectional study of US counties from 2001 to 2019—a period that spanned five presidential elections—rates of most leading causes of death, including cardiovascular, were initially similar between Democratic-leaning and Republican-leaning counties. Over time, however, mortality rates decreased by 22% in Democratic counties but only 11% in Republican counties.
Lead author Haider J. Warraich, MD (Brigham and Women’s Hospital, Boston, MA), said the study grew out of prior work showing that between 1999 and 2017, age-adjusted CVD mortality rates were greater in rural versus urban areas across all patient subgroups, and that the absolute difference between rural areas and large metropolitan areas nearly doubled over the study period. That led Warraich and colleagues to ponder the vast political divide in the United States and delve into whether political affiliation might be associated with the mortality gap.
“One thing we already know is that more-rural areas vote Republican and more-urban areas vote Democrat. So, the question was whether those different political leanings were also factors that were affecting people's health outcomes,” Warraich told TCTMD. “What we found surprised us. This gap wasn’t just between Democratic and Republican rural areas. It was also noted for cities, for suburbs, for males and females.”
Howard Forman, MD (Yale School of Medicine, New Haven, CT), who was not involved in the study, said that while provocative, the research asks as many questions as it answers.
“It doesn't account for factors like education and economic status as independent variables. We know that education is a direct factor in predicting health status. The same is true for income,” he told TCTMD. “What they are showing is a correlation. There's no causation here.”
Worse Trends for White Americans
For the study, published June 7, 2022, in the BMJ, Warraich and colleagues examined mortality trends and voting patterns in more than 3,000 US counties. From 2001 to 2019, the age-adjusted mortality rate gap between Democratic and Republican counties widened from 16.7 per 100,000 residents to 107.1 per 100,000 residents.
While white American men and women followed the trend of having worse mortality rates if they lived in Republic-leaning counties, the same could not be said for Black Americans. Although the gap did widen for Black adults in Democratic versus Republican counties (from 18.5 to 45.6 per 100,000), those living in Republican counties actually had an improvement in age-adjusted mortality twice that of all other residents in Republican counties. In contrast, the gap between white residents in Democratic versus Republican counties increased fourfold over the study period, from 24.7 to 101.3 per 100,000.
“It is possible that Black Americans have benefitted most from advances in medicine, public health, and healthcare delivery that are independent of county political environment,” Warraich and colleagues write. Still, there were a few isolated periods (2004-2005, 2009-2010, and 2016-2017) where age-adjusted mortality among Black residents of Republican counties did show an upward trend.
No matter where you are or what side you are on, you have to believe that people care deeply about the health and wellness of their communities. Haider Warraich
A look at the 10 most common causes of death found that in 2001 heart disease, cancer, influenza, and pneumonia occurred less often in Republican than Democratic counties. But by 2019, all causes of death were higher in Republican counties, with CVD accounting for 27.6 extra deaths per 100,000 and cancer accounting for 17.3 extra deaths per 100,000. Chronic lower respiratory tract diseases, unintentional injuries, and suicide rates also were higher. A sensitivity analysis assessing the relationship between county-level gubernatorial political and age-adjusted mortality rate was consistent with the main analysis.
Warraich said the evidence of little difference in age-adjusted mortality rates between Democratic and Republican counties in 2001 could be viewed as a piece of good news, hinting that it’s not too late to close up the gap and stop it from becoming permanent.
“That certainly it is something that I hope that the American people and their constituents can aspire to, because there really is no reason why the political affiliation of an area should have any effect on someone's health outcome,” he added.
Taking on a Taboo Topic
Other studies have looked at the impact of the bitter political environment in the United States during the 2020 elections. One recent study, for instance, found that rates of hospitalization for acute MI, heart failure, or stroke were significantly higher in the 5 days after the November 2020 election compared with the 5 days before it.
Steven Woolf, MD (Virginia Commonwealth University School of Medicine, Richmond), writing in an editorial accompanying Warraich et al’s paper, notes that the new study “advances the evidence” by adding to accumulating data that connect the dots between some conservative policies and harmful health effects. Those policies include opposing Medicaid expansion, minimum wage legislation, and tobacco and gun controls.
Woolf points to several studies, including one that looked at life expectancy and found it to be negatively associated with President Donald Trump's vote share. Counties with less Trump support had greater survival gains. Another study looking at an earlier time period found that states adopting more-conservative policies between 1970 and 2014 had smaller improvements in life expectancy.
“To understand the implications for population health, researchers must break with custom; although scientific literature has traditionally avoided discussing politics, the growing influence of partisan affiliation on policies affecting health makes this covariate an increasingly important subject of study,” Woolf writes.
What they are showing is a correlation. There's no causation here. Howard Forman
Warraich said while more study is needed, existing data support the contention that Democratic-leaning governors are more likely to invest in public health, and that voters who identify as Democrats may be more likely than those identifying as Republicans to engage in heart-healthy behaviors.
However, both Warraich and Woolf acknowledge that this study and others do not prove causation.
“The association could represent the harmful effects of Republican policies, but it could also reflect a preference for Republican candidates among disadvantaged voters or characteristics outside the control of politicians—such as changes in the economy, migration, or demographics—that happen to predominate in places that elect Republicans,” Woolf writes.
Warraich agreed that there likely are multiple factors involved. “But, I think the reality is that regardless of how you see it, for the folks who live in areas that vote Republican, their chances of having benefited from the advances in medicine that we've seen in the last 20 years are much lower than areas that vote Democratic,” he added. “You would think that this would enrage or energize people living in Republican areas to at least have more questions, to maybe even challenge the data, or to think about using the data to advocate for better health. No matter where you are or what side you are on, you have to believe that people care deeply about the health and wellness of their communities.”
For Forman, however, the knowledge that political party leanings highly correlate with other variables that directly impact health make him less likely to think the findings stem purely from politics.
“This is the type of paper that would benefit from an interdisciplinary approach between economists, political scientists, and perhaps public health professionals,” he added. “A lot more work needs to be done to answer the questions that are purportedly being answered in the paper.”
Warraich HJ, Kumar P, Nasir K, et al. Political environment and mortality rates in the United States, 2001-19: population based cross sectional analysis. BMJ. 2022;377:e069308.
Woolf S. Politics and mortality in the United States. BMJ. 2022;377:o1308
- Warraich reports being an advisor for Embrace Prevention Care.
- Woolf and Forman report no relevant conflicts of interest.