Opinion | Understanding the Red State Death Trip

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By Paul Krugman

Opinion Columnist

Last Friday the Medicare trustees released their latest report on the system’s finances, and it contained some unexpected good news: Expenditures are running below projections, and the Hospital Insurance Trust Fund won’t be exhausted as soon as previously predicted.

But one important reason for this financial improvement was grisly: Covid killed a substantial number of Medicare beneficiaries. And the victims were disproportionately seniors already suffering from severe — and expensive — health problems. “As a result, the surviving population had spending that was lower than average.”

Now, Covid killed a lot of people around the world, so wasn’t this just an act of God? Not exactly. You see, America experienced a bigger decline in life expectancy when Covid struck than any other wealthy country. Furthermore, while life expectancy recovered in many countries in 2021, here it continued to fall.

And America’s dismal Covid performance was part of a larger story. I don’t know how many Americans are aware that over the past four decades, our life expectancy has been lagging ever further that of other advanced nations — even nations whose economic performance has been poor by conventional measures. Italy, for example, has experienced a generation of economic stagnation, with basically no growth in real G.D.P. per capita since 2000, compared with a 29 percent rise here. Yet Italians can expect to live about five years longer than Americans, a gap that has widened even as the Italian economy flounders.

What explains the American way of death? A large part of the answer seems to be political.

One important clue is that the problem of premature death isn’t evenly distributed across the country. Life expectancy is hugely unequal across U.S. regions, with major coastal cities not looking much worse than Europe but the South and the eastern heartland doing far worse.

But wasn’t it always thus? No. Geographic health disparities have surged in recent decades. According to the U.S. mortality database, as recently as 1990, Ohio had slightly higher life expectancy than New York. Since then, New York’s life expectancy has risen rapidly, nearly converging with that of other rich countries, while Ohio’s has hardly risen at all and is now four years less than New York’s.

There has been considerable research into the causes of these growing disparities. A 2021 paper published in The Journal of Economic Perspectives examined various possible causes, like the increasing concentration of highly educated Americans (who tend to be healthier than those with less education) in states that are already highly educated and the widening per capita income gaps among states. The authors found that these factors can’t explain more than a small fraction of the growing mortality gap.

Instead, they argued, the best explanation lay in policy: “The most promising explanation for our findings involve efforts by high-income states to adopt specific health-improving policies and behaviors since at least the early 1990s. Over time, these efforts reduced mortality in high-income states more rapidly than in low-income states, leading to widening spatial disparities in health.”

That sounds right. But did high-income states adopt health-improving policies because they were rich and could afford to? Or was it because in 21st-century America, high-income states tend to be politically progressive and politics, rather than money per se, account for the difference?

There is, in fact, a strong correlation between how much a state’s life expectancy rose from 1990 to 2019 and its political lean, as measured by Joe Biden’s margin over Donald Trump in the 2020 election — a correlation slightly stronger, by my estimates, than the correlation with income.

There are several reasons to believe that America’s death trip is largely political rather than economic. One is the comparison with European nations, which have had much better health trends even when, as in Italy, their economies have performed badly.

Another is the fact that some of the poorest states in America, with the lowest life expectancy, are still refusing to expand Medicaid, even though the federal government would cover the bulk of the cost (and the failure to expand Medicaid is killing many hospitals). This suggests that they’re failing to improve health because they don’t want to, not because they can’t afford to.

Finally, since Covid struck, residents of Republican-leaning counties have been far less likely to get vaccinated and far more likely to die of it than residents of Democratic-leaning counties — even though vaccines are free.

All of this seems relevant to our current era of culture war, with many Republican politicians praising rural and red-state values while denigrating those of coastal elites. Gov. Ron DeSantis of Florida, for example, claims that although he grew up around Tampa Bay, he’s culturally a product of western Pennsylvania and northeastern Ohio. It’s worth noting, then, that the culture these politicians want all of America to emulate seems to have a problem with one of society’s most important functions: keeping people from dying early.

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