Republican counties have higher death rates — except in Utah. Why?
The health divide between Republican and Democratic counties — and Utah’s anomalistic data — illustrates the need to depoliticize public health
A recent study published by the BMJ — formerly the British Medical Journal — shows that mortality rates are higher among Republican counties than in Democratic counties. The study measured the mortality gap between the two parties through five presidential elections from 2001 to 2019 and showed that in the early 2000s, the risk of death between both groups was similar. However, even as the country’s overall mortality rate decreased in the years since, the improvement was twice as good for Democratic counties as for Republican counties.
Some might assume the study’s findings should be attributed to the COVID-19 pandemic. After all, Republicans have been more than twice as likely to die of COVID-19 than Democrats due to lower vaccination rates and eschewing some public health measures. However, Republicans have fared worse in other health measurements and for much longer than the duration of the pandemic.
Per the authors of the study, since 2001 Republican counties also experienced worse health outcomes in terms of suicide rates, firearm-related deaths, cancer mortality rates, deaths from heart disease, drug overdose deaths, infant mortality rates and the number of fatal auto accidents. This provocative study, however, does not tell the whole story of the health divide between Republican and Democratic counties. And one state’s anomalistic data — Utah’s — illustrates the need to depoliticize public health.
While a Scientific American article about the BMJ study pointed to the higher death rates among Republicans as being the result of their “policy choices,” experts say such conclusions don’t tell the full truth. “I think the Scientific American article concluded that politics were to blame, which is certainly part of the problem, but other factors like rurality are also at play here,” said Dr. Karen Joynt Maddox, one of the study’s authors and the director of the Center for Health Services and Policy Research at Washington University School of Medicine.
According to the U.S. Census Bureau, about 60 million Americans — or 19% of the country — live in rural cities. And many more also live in predominantly rural states that have open swaths of land and few urban centers. Though not a hard and fast rule, rural states tend to lean red, while more densely populated states with more urban centers such as California and New York, tend to lean blue. In fact, among the 10 most rural states in the country, seven of them — Mississippi, Montana, Arkansas, South Dakota, Kentucky, Alabama and North Dakota — are comprised of more Republicans than Democrats, according to Pew Research Center. And even the three rural states that lean blue — Maine, Vermont and West Virginia — have elected Republican or independent senators who represent them in congress today.
“Where and how people live may contribute even more to mortality rates and health outcomes than politics.”
The rurality of a state matters because much of the research that investigates health care differences between Republicans and Democrats points to policy choices as being a dominant factor (and they may well be in some cases). But where and how people live may contribute more than politics to mortality rates and health outcomes.
For instance, research shows that opioid addiction and misuse are greater among rural populations than urban populations, regardless of one’s political affiliations. Many rural areas also lack quick and easy access to doctors and hospitals, which likely affects mortality rates. What’s more, U.S. Department of Agriculture data also shows that rural areas have higher rates of poverty than urban ones and, “poverty is likely the greatest overall public health problem in this country — the public health issue that affects all other outcomes,” explained Dr. Lois Lee, an associate professor of pediatrics and emergency medicine at Harvard Medical School.
Lee has conducted research that shows areas with higher levels of poverty are associated with increased rates of child abuse and death rates from suicide and firearm incidents. Lee explained, “the real Republican to Democrat state divide appears to be based on poverty,” and noted that in the 2012 presidential election, 8 out of 10 of the states with the lowest percentages of people living in poverty voted for Barack Obama, while 8 out of 10 of states with the highest percentages of people living in poverty voted for Mitt Romney. “So, our red state vs. blue state divide was likely more a poor state vs. rich state divide,” she concluded.
There are anomalies, however. Despite having far more rural and frontier counties than urban ones and being ranked the second-most Republican state in the country, Utah’s mortality rates often mirror those of more urban states: Utah has the 11th best health care ranking in the country, has America’s sixth lowest fatal car accident rate, ranks in the bottom half of the U.S. in terms of firearm death rates, has one of the highest state life expectancy rates in America, has one of the country’s lowest homicide rates, is in the CDC’s lowest drug overdose rated category, has the lowest heart disease rate of any state and has the third lowest COVID state death rate in the country, per 100,000 residents.
“It is hard to pinpoint exactly why Utah might be different from other Republican states, but it does seem to be an outlier,” said Dr. Haider Warraich, a physician and researcher at the VA Boston Healthcare System and Brigham and Women’s Hospital in Boston. But there may be a few reasons why Utah has better health outcomes than other red states. “Approximately 55% of the Utah population identify as members of The Church of Jesus Christ of Latter-day Saints, which has a unique doctrinal tenant against tobacco use resulting in better cardiovascular and respiratory health,” explained Sam LeFevre, the director of the Office of Communicable Diseases at Utah’s Department of Health and Human Services. Indeed, the state has the country’s third lowest rate of drug use and the country’s absolute lowest rate of alcohol consumption and tobacco use. What’s more, despite the state’s rural nature, it still has the 15th highest income average per capita in the country, meaning the poverty factors that affect other rural states aren’t as common in Utah.
“Though per capita, COVID mortality is lower in Utah, the per-capita incidence of COVID infection is higher”
Utah’s exceptionally low COVID-19 death rate is most easily explained by the state having the country’s lowest median age, and its population having one of the lowest obesity rates. Advanced age and obesity are two of the most common comorbidities known to exacerbate COVID-19 symptoms in patients. “Utah adults are also generally more active than U.S. adults,” explained LeFevre. Dr. Neil Sehgal, an assistant professor of health policy and management at the University of Maryland School of Public Health, noted also that, “Utah has lower incidence of chronic conditions associated with poorer COVID-19 outcomes.”
Despite the state’s lower COVID-19 death rates, Sehgal said it would be unwise to suggest that Utahns were necessarily better than residents of other red states at adhering to recommended preventive public health measures; he explained that the state’s better pandemic-related health outcomes were likely because its residents are affected by fewer of the aforementioned comorbidities. “Though per capita, COVID mortality is lower in Utah, the per-capita incidence of COVID infection is higher in Utah when compared to the national average,” Sehgal explained. “Which is to say, it is less that COVID didn’t spread in Utah, and more that the structure of the population in Utah was less likely on average to experience the most serious consequences of COVID-19 infection.”
It’s also worth noting that even with such advantages more than 5,000 Utahns have still died from COVID-19 — and many of those deaths likely could have been prevented. LeFevre explained also that the state’s hospitals still filled to near or beyond capacity during some waves of the virus. “During the pandemic, we’ve had to implement strategies to strengthen healthcare access,” he said. Such strategies included allowing Utah’s nursing students to provide supportive health care in hospitals while still in school and the state contracting with long-term care facilities to operate as overflow facilities for COVID patients.
Without such steps and the commitment to preventive measures demonstrated by some Utahns, even a state as young and healthy as Utah could have fared much worse at the height of the pandemic. It’s a lesson the experts hope Utah and other similar states will remember and hold on to.
Experts say that in many cases, red states have made policy choices that have impacted their health outcomes, including legislators that have voted against firearms restrictions despite guns being by far the most common means of suicide and the No. 1 cause of death for children and teens in America. “It’s long been known that states with robust regulatory approaches to firearm ownership and use have lower rates of firearm-related death than other states do,” explained Dr. Garen Wintemute, an emergency physician and director of the Violence Prevention Research Program at the University of California, Davis. Lee’s research into the 2012 presidential election led her to draw similar conclusions: “All 10 states with the lowest firearm mortality rates voted for Obama,” she said.
And while many have made a case against its long-term benefits, states blocking Medicaid expansion efforts is believed to be yet another contributing factor in the mortality gap between Republicans and Democrats. “Many red states have failed to expand Medicaid, which leaves huge numbers of people without any viable options for health insurance,” Maddox said. She explained that cancer care and research and other public health access have also similarly affected people in many republican states for some of the same reasons. “Investment in public health and access to care via insurance coverage have been systematically worse in red counties and states, and these choices are associated with worse outcomes for heart disease and cancer patients as well,” she said.
“Unless there is some serious engagement and soul searching about the factors leading to this trend, I worry that outcomes and health and wellness will continue to diverge.”
Perhaps one of the most surprising contributing factors to the growing mortality gap between Republicans and Democrats has been their social media habits. Conservative social media posts usually get more engagement than liberal ones, even when some of the medical information shared is false or misleading. “While social media and the internet have many advantages, it has also allowed many merchants of misinformation to thrive on people’s fears,” explained Warraich.
The sometimes-deadly impact of spreading or believing such misinformation has never been more apparent than during the pandemic. A Kaiser Family Foundation study published at the end of last year found that 78% of Americans believed or were unsure about at least one blatantly false statement circulating on social media, and nearly two-thirds (64%) of Republicans believed at least half of the false statements that were being shared on such platforms. In part because of how likely Republicans were to believe such misinformation, the group was more than three times as likely to be unvaccinated — a factor that at one point meant they were also more than twice as likely to die of COVID-19 than Democrats were.
This underscores the need for public health to remain authoritative and politically neutral. “We need to de-politicize health care,” Maddox said, and she stressed that concerned citizens ought to also “advocate for better evidence-based health policy among politicians of all stripes.” Without which, she worries, “things will get worse before they get better.”
Warraich said he hopes that people won’t view the results of the BMJ study through a political lens but will instead consider what the data means and how the mortality rate between Republicans and Democrats can close. “Unless there is some serious engagement and soul searching about the factors leading to this trend, I worry that outcomes and health and wellness will continue to diverge,” he said. “I hope that this growing gap in mortality rates, instead of pushing us further apart, will bring us together to think about how we can learn from each other and think about ways that will produce the best health for our communities.”