Rising Geographic Disparities in US Mortality

Social and Demographic Determinants of Health: A Descriptive Study on the Impact of Place of Residence and Community Belonging

BACKGROUND

Social conditions in which individuals live, work, and interact have a significant impact on health. Extensive evidence suggests that place of residence influences health disparities and overall well-being. Understanding the characteristics of a population can help shape healthcare policies that contribute to improved public well-being.

OBJECTIVE

The aim of this research was to describe the main characteristics of the population under study, considering place of residence and other sociodemographic factors.

METHODS

This is a descriptive study. A tailored 79-item questionnaire was developed based on validated instruments, including variables related to sociodemographic, physical activity, rest and sleep patterns, emotional well-being, and sense of community belonging. The sample was obtained through an open invitation to the general population, ensuring representativeness in terms of sex, age, and nationality. Data were analysed using standard statistical methods for this type of study.

RESULTS

A total of 487 different response profiles were collected, representing 3.7% of the total population. Not all participants answered every question. Overall, 33.6% of respondents reported having a chronic disease, with the highest prevalence among individuals over 65 years old. Notably, those who live alone are not necessarily the ones who report feeling the loneliest. The findings highlight the need for new social and healthcare policies at the institutional level.

CONCLUSIONS

No statistically significant differences were found based on place of residence, except for those related to physical activity and sense of community belonging.

Progress in reducing mortality from 10 major causes by county poverty level, from 1990-1994 to 2016-2020, in the US

BACKGROUND

Overall death rates in the US have been declining in the past few decades. However, progress against mortality across counties with different socioeconomic profiles has not been well described. The objective of this study was to examine changes in death rates from leading causes of death by county poverty level in the contiguous US.

METHODS

Using county-level death (all causes, 10 leading causes in 2020, excluding COVID-19) and population data derived from the National Center for Health Statistics, we calculated absolute and relative changes in age-standardized death rates by county poverty level from 1990-1994 to 2016-2020.

FINDINGS

From 1990-1994 to 2016-2020, death rates from all causes, diseases of the heart, cancer, cerebrovascular disease, and pneumonia/influenza declined nationally, but rates increased for unintentional injury, chronic obstructive pulmonary disease, Alzheimer's disease, diabetes, suicide/self-inflicted injury, and kidney disease mortality. Counties with higher poverty levels (≥20%) had smaller declines or larger increases in death rates for each evaluated cause of death, exacerbating the disparities in mortality by county poverty level, except for unintentional injury and suicide/self-inflicted injury. Consequently, in 2016-2020, the death rates for leading causes of death were 12% (for Alzheimer's disease; suicide/self-inflicted injury) to 81% (for diabetes) higher in people residing in counties with the highest poverty level than in those residing in counties with the lowest poverty level.

CONCLUSIONS

Disparities in mortality from most leading causes of death by county poverty level widened during the past three decades.

FUNDING

There was no external funding for this study.

Mapping Mental Health Across US States: the Role of Economic and Social Support Policies

Policy Points This perspective argues that state economic and social support policies are key determinants of population mental health. Key policy successes of the past decade include state expansion of Medicaid eligibility, increase in minimum wage, and implementation of paid sick leave. Key policy priorities include the prioritization of evidence-based policies that improve economic security and the expansion of social support policies that are not tied to employment.

Role of signaling pathways in endometrial cancer

Endometrial cancer (EC) is a prevalent gynecological malignancy with a complex molecular landscape, contributing to significant global morbidity and mortality. Dysregulated signaling pathways such as PI3K/AKT/mTOR and RAS/RAF/MEK drive EC progression by promoting uncontrolled cell proliferation, survival, angiogenesis, and metastasis. Mutations in genes like PTEN and PIK3CA further underpin tumor aggressiveness. Molecular alterations in these pathways not only serve as biomarkers for prognosis but also guide the formulation of targeted therapies, such as mTOR inhibitors and anti-angiogenic agents. While such therapies show promise, optimizing their efficacy and minimizing adverse effects requires further research. A comprehensive approach integrating early detection (e.g., addressing postmenopausal bleeding), preventive strategies (e.g., managing obesity), increasing diagnostic sensitivity (e.g., transvaginal ultrasound) and advanced molecularly tailored treatments (e.g., AI & ML) is critical to reducing the burden of this disease. By targeting key signaling pathways, leveraging AI-driven methodologies, and addressing treatment resistance, we can enhance patient outcomes, also mitigate the rising global impact of EC.

The Association between the Volatility of Income and Life Expectancy in the United States

We examine the relationship between income volatility and life expectancy in mid-sized U.S. commuting zones between 2006 and 2014. We use a commercial dataset, InfoUSA, to measure income volatility which we link to estimates of life expectancy by gender, county, race, and income. We find that higher income volatility in a county is associated with lower life expectancy, but only at the bottom of the income distribution and primarily for non-Hispanic Whites. Though we cannot extrapolate our findings to individual-level relationships, we do link them to existing literatures on place-based differences in mortality and the relationship between volatility and health.

Place effects on adult obesity and cardiometabolic health: Evidence from a natural experiment

Despite considerable evidence on clustering of obesity within geographic areas causal estimates of place effects on cardiometabolic health, and their causal pathways, remain rare. This study utilizes a natural experiment based on the quasi-random assignment of military families to different installations to show that adults exposed to places with higher obesity prevalence have a greater likelihood of obesity and other downstream cardiometabolic conditions. We find no evidence to support shared environments as a causal pathway for these place effects, suggesting that alternate pathways such as social influence may be at play. We also provide the first real-world evidence on the effect of exogenous exposure to obesogenic places on theoretically-grounded social influence constructs, such as social norms and social networks. We find evidence of place effects on individuals' perceptions of descriptive norms and obesogenic composition of social networks, but not on injunctive and subjective norms. The mediating role of social influence in explaining place effects on cardiometabolic health should be examined further in future work.

Identifying high-impact-opportunity hospitals for improving healthcare quality based on a national population analysis of inter-hospital variation in mortality, readmissions and prolonged length of stay

OBJECTIVES

To study between-hospital variation in mortality, readmissions and prolonged length of stay across Belgian hospitals.

DESIGN

A retrospective nationwide observational study.

SETTING

Secondary and tertiary acute-care hospitals in Belgium.

PARTICIPANTS

We studied 4 560 993 hospital stays in 99 (98%) Belgian acute-care hospitals between 2016 and 2018.

PRIMARY OUTCOME MEASURES

Using generalised linear mixed models, we calculated hospital-specific and Major Diagnostic Category (MDC)-specific risk-adjusted in-hospital mortality, readmissions within 30 days and length of stay above the MDC-specific 90th percentile and assessed between-hospital variation through estimated variance components.

RESULTS

There was strong evidence of between-hospital variation in mortality, readmissions and prolonged length of stay across the vast majority of patient service lines. Overall, should hospitals with upper-quartile risk-standardised rates succeed in improving to the median level, a yearly 4076 hospital deaths, 3671 readmissions and 15 787 long patient stays could potentially be avoided in those hospitals. Our analysis revealed a select set of 'high-impact-opportunity hospitals' characterised by poor performance across outcomes and across a large number of MDCs.

CONCLUSIONS

Analysis of between-hospital variation highlights important differences in patient outcomes that are not explained by known patient or hospital characteristics. Identifying 'high-impact-opportunity hospitals' can help government inspection bodies and hospital managers to establish targeted audits and inspections to generate effective quality improvement initiatives.

Ten Americas: a systematic analysis of life expectancy disparities in the USA

BACKGROUND

Nearly two decades ago, the Eight Americas study offered a novel lens for examining health inequities in the USA by partitioning the US population into eight groups based on geography, race, urbanicity, income per capita, and homicide rate. That study found gaps of 12·8 years for females and 15·4 years for males in life expectancy in 2001 across these eight groups. In this study, we aimed to update and expand the original Eight Americas study, examining trends in life expectancy from 2000 to 2021 for ten Americas (analogues to the original eight, plus two additional groups comprising the US Latino population), by year, sex, and age group.

METHODS

In this systematic analysis, we defined ten mutually exclusive and collectively exhaustive Americas comprising the entire US population, starting with all combinations of county and race and ethnicity, and assigning each to one of the ten Americas based on race and ethnicity and a variable combination of geographical location, metropolitan status, income, and Black-White residential segregation. We adjusted deaths from the National Vital Statistics System to account for misreporting of race and ethnicity on death certificates. We then tabulated deaths from the National Vital Statistics System and population estimates from the US Census Bureau and the National Center for Health Statistics from Jan 1, 2000, to Dec 31, 2021, by America, year, sex, and age, and calculated age-specific mortality rates in each of these strata. Finally, we constructed abridged life tables for each America, year, and sex, and extracted life expectancy at birth, partial life expectancy within five age groups (0-4, 5-24, 25-44, 45-64, and 65-84 years), and remaining life expectancy at age 85 years.

FINDINGS

We defined the ten Americas as: America 1-Asian individuals; America 2-Latino individuals in other counties; America 3-White (majority), Asian, and American Indian or Alaska Native (AIAN) individuals in other counties; America 4-White individuals in non-metropolitan and low-income Northlands; America 5-Latino individuals in the Southwest; America 6-Black individuals in other counties; America 7-Black individuals in highly segregated metropolitan areas; America 8-White individuals in low-income Appalachia and Lower Mississippi Valley; America 9-Black individuals in the non-metropolitan and low-income South; and America 10-AIAN individuals in the West. Large disparities in life expectancy between the Americas were apparent throughout the study period but grew more substantial over time, particularly during the first 2 years of the COVID-19 pandemic. In 2000, life expectancy ranged 12·6 years (95% uncertainty interval 12·2-13·1), from 70·5 years (70·3-70·7) for America 9 to 83·1 years (82·7-83·5) for America 1. The gap between Americas with the lowest and highest life expectancies increased to 13·9 years (12·6-15·2) in 2010, 15·8 years (14·4-17·1) in 2019, 18·9 years (17·7-20·2) in 2020, and 20·4 years (19·0-21·8) in 2021. The trends over time in life expectancy varied by America, leading to changes in the ordering of the Americas over this time period. America 10 was the only America to experience substantial declines in life expectancy from 2000 to 2019, and experienced the largest declines from 2019 to 2021. The three Black Americas (Americas 6, 7, and 9) all experienced relatively large increases in life expectancy before 2020, and thus all three had higher life expectancy than America 10 by 2006, despite starting at a lower level in 2000. By 2010, the increase in America 6 was sufficient to also overtake America 8, which had a relatively flat trend from 2000 to 2019. America 5 had relatively similar life expectancy to Americas 3 and 4 in 2000, but a faster rate of increase in life expectancy from 2000 to 2019, and thus higher life expectancy in 2019; however, America 5 experienced a much larger decline in 2020, reversing this advantage. In some cases, these trends varied substantially by sex and age group. There were also large differences in income and educational attainment among the ten Americas, but the patterns in these variables differed from each other and from the patterns in life expectancy in some notable ways. For example, America 3 had the highest income in most years, and the highest proportion of high-school graduates in all years, but was ranked fourth or fifth in life expectancy before 2020.

INTERPRETATION

Our analysis confirms the continued existence of different Americas within the USA. One's life expectancy varies dramatically depending on where one lives, the economic conditions in that location, and one's racial and ethnic identity. This gulf was large at the beginning of the century, only grew larger over the first two decades, and was dramatically exacerbated by the COVID-19 pandemic. These results underscore the vital need to reduce the massive inequity in longevity in the USA, as well as the benefits of detailed analyses of the interacting drivers of health disparities to fully understand the nature of the problem. Such analyses make targeted action possible-local planning and national prioritisation and resource allocation-to address the root causes of poor health for those most disadvantaged so that all Americans can live long, healthy lives, regardless of where they live and their race, ethnicity, or income.

FUNDING

State of Washington, Bloomberg Philanthropies, Bill & Melinda Gates Foundation.

Cancer mortality and geographic inequalities: a detailed descriptive and spatial analysis of social determinants across US counties, 2018-2021

OBJECTIVE

In the United States, cancer mortality rates continue to decline, yet geographic and racial disparities persist and are particularly evident in the Delta region, characterized by high economic distress and disease burden. We examined cancer mortality patterns by demographic groups across geographic region (Delta vs non-Delta) and investigated the influence of macro-level social determinants of health (SDoH) in cancer death.

STUDY DESIGN AND METHODS

This observational study included cancer death records of individuals aged ≥20 years from 2018 to 2021 in the United States. County-level characteristics were ascertained through the linkage of multiple national administrative and community surveys. We estimated age-standardized mortality rates (ASR) and rate ratios. We calculated the adjusted relative risks by county-level SDoH (geographic region, rurality, household income, income inequality, health insurance, and education) and other factors using age-adjusted multivariate quasi-Poisson regression.

RESULTS

In 2018-2021, approximately 2.4 million cancer deaths occurred in the United States. We observed important declines in the Black-White disparities, from 16.6% in 2018 (ASR = 289.9 vs 248.6 per 100,000) to 12.1% in 2021 (281.1 vs 250.8) in the Delta region and from 15.9% (254.9 vs 219.9) to 10.7% (240.6 vs 217.3) in the non-Delta region, though Black men in the Delta region remained the highest rate (ASR2021 = 346.9 per 100,000). County-level analyses provided strong evidence of geographic inequality and the role of SDoH, particularly education and income inequality.

CONCLUSIONS

Unfavorable SDoH are associated with increased cancer death risk. Region-specific health policies and interventions in the Delta region are essential to advance cancer health equity.

State-level association between income inequality and mortality in the USA, 1989-2019: ecological study

BACKGROUND

Prior studies have shown a positive relationship between income inequality and population-level mortality. This study investigates whether the relationship between US state-level income inequality and all-cause mortality persisted from 1989 to 2019 and whether changes in income inequality were correlated with changes in mortality rates.

METHODS

We perform repeated cross-sectional regressions of mortality on state-level inequality measures (Gini coefficients) at 10-year intervals. We also estimate the correlation between within-state changes in income inequality and changes in mortality rates using two time-series models, one with state- and year-fixed effects and one with a lagged dependent variable. Our primary regressions control for median income and are weighted by population.

MAIN OUTCOME MEASURES

The two primary outcomes are male and female age-adjusted mortality rates for the working-age (25-64) population in each state. The secondary outcome is all-age mortality.

RESULTS

There is a strong positive correlation between Gini and mortality in 1989. A 0.01 increase in Gini is associated with more deaths: 9.6/100 000 (95% CI 5.7, 13.5, p<0.01) for working-age females and 29.1 (21.2, 36.9, p<0.01) for working-age males. This correlation disappears or reverses by 2019 when a 0.01 increase in Gini is associated with fewer deaths: -6.7 (-12.2, -1.2, p<0.05) for working-age females and -6.2 (-15.5, 3.1, p>0.1) for working-age males. The correlation between the change in Gini and change in mortality is also negative for all outcomes using either time-series method. These results are generally robust for a range of income inequality measures.

CONCLUSION

The absence or reversal of correlation after 1989 and the presence of an inverse correlation between change in inequality and change in all-cause mortality represents a significant reversal from the findings of a number of other studies. It also raises questions about the conditions under which income inequality may be an important policy target for improving population health.

Changing relationship between income inequality and mortality

The recent paper by Dunn et al showed that the positive relationship between US state-level income inequality and mortality was small in the 1950s, rose to a large value around 1990 but had largely disappeared by 2019. We consider these findings in the context of the mechanisms that have been advanced for reasons why a positive relationship might be expected, and in relation to studies using alternative methods included in systematic reviews that fail to confirm an independent inequality/mortality relationship. Ecological studies, such as by Dunn et al, using subnational data have advantages compared with similar studies using cross-national data, but controls are typically confined to those available from sources such as decennial census, so scope for incorporating lagged effects and life course factors is limited. However, they are often the only studies with the statistical power to identify subnational differentials and time trends so they are complementary to rarely available sources such as high-quality long-term individual-level microdata data required for causal analyses. Income equality can arise not only due to citizens' positive preferences but also to external choices such as economic decline and globalisation, so examining the wider context is important when explaining excess levels of 'deaths of despair' in low-inequality US states. The apparent increasingly strong association between income levels and low mortality with a weakening inequality/mortality relationship has implications for policy recommendations.

Association Between Neighborhood Deprivation and Number of Ophthalmology Providers

PURPOSE

The Area Deprivation Index (ADI) is a quantitative measurement of neighborhood socioeconomic disadvantage used to identify high-risk communities. The distribution of physicians with respect to ADI can indicate decreased healthcare access in deprived neighborhoods. This study applies ADI to the distribution of ophthalmologists and demonstrates how practice patterns in the national Medicare Part D program may vary with ADI.

METHODS

The Centers for Medicare and Medicaid Services Data "Medicare Part D Prescribers by Provider" data for 2021 was analyzed. Geocodio identified ADIs corresponding to the practice addresses listed in the dataset. The national rank ADIs were compared against the number of ophthalmologists. Spearman's correlation test and one-way ANOVA determined statistically significant differences in Medicare data extracted between quintiles of ADI ranks.

RESULTS

We identified 14,668 ophthalmologists who provided care to Medicare beneficiaries. Each time ADI increased by 10, there was an average 9.4% decrease in ophthalmologists (p < 0.001). The distribution of ophthalmologists practicing throughout the United States by increasing ADI quintile are: 32%, 23%, 19%, 16%, and 9%. Providers practicing in neighborhoods in the first-ADI quintile were more likely to see Medicare beneficiaries compared to providers in the fifth-ADI quintile (p < 0.001).

CONCLUSION

The lack of ophthalmologists in high-ADI areas results in reduced eye care access in deprived neighborhoods. Many factors contribute to these disparities including limited access to metropolitan areas/academic institutions and fewer residency programs. Future programs and policies should focus efforts on creating an even distribution of ophthalmologists across the United States and improving access to eye care.

Are the geographic disparities in U.S. violent crime rising?

Inequality in economic and social outcomes across U.S. regions has grown in recent decades. The economic theory of crime predicts that this increased variability would raise geographic disparities in violent crime. Instead, I find that geographic disparities in homicide rates decreased. Moreover, these same decades saw decreases in the geographic disparities in policing, incarceration, and the share of the population that is African American. Thus, changes in policing, incarcerations, and racial composition could have led to a decrease in inequality in homicide rates. Moreover, the joint provision of law enforcement by local, state, and federal authorities may have reduced the impact of economic distress on violent crime.

Call for Action to Target Interhospital Variation in Cardiovascular Mortality, Readmissions, and Length-of-Stay: Results of a National Population Analysis

BACKGROUND

Excessive interhospital variation threatens healthcare quality. Data on variation in patient outcomes across the whole cardiovascular spectrum are lacking. We aimed to examine interhospital variability for 28 cardiovascular All Patient Refined-Diagnosis-related Groups (APR-DRGs).

METHODS

We studied 103,299 cardiovascular admissions in 99 (98%) Belgian acute-care hospitals between 2012 and 2018. Using generalized linear mixed models, we estimated hospital-specific and APR-DRG-specific risk-standardized rates for in-hospital mortality, 30-day readmissions, and length-of-stay above the APR-DRG-specific 90th percentile. Interhospital variation was assessed based on estimated variance components and time trends between the 2012-2014 and 2016-2018 periods were examined.

RESULTS

There was strong evidence of interhospital variation, with statistically significant variation across the 3 outcomes for 5 APR-DRGs after accounting for patient and hospital factors: percutaneous cardiovascular procedures with acute myocardial infarction, heart failure, hypertension, angina pectoris, and arrhythmia. Medical diagnoses, with in particular hypertension, heart failure, angina pectoris, and cardiac arrest, showed strongest variability, with hypertension displaying the largest median odds ratio for mortality (2.51). Overall, hospitals performing at the upper-quartile level should achieve improvements to the median level, and an annual 633 deaths, 322 readmissions, and 1578 extended hospital stays could potentially be avoided.

CONCLUSIONS

Analysis of interhospital variation highlights important outcome differences that are not explained by known patient or hospital characteristics. Targeting variation is therefore a promising strategy to improve cardiovascular care. Considering their treatment in multidisciplinary teams, policy makers, and managers should prioritize heart failure, hypertension, cardiac arrest, and angina pectoris improvements by targeting guideline implementation outside the cardiology department.

The Great Schism Trend, life expectancy, and politics

The SchwartzReport tracks emerging trends that will affect the world, particularly the United States. For EXPLORE it focuses on matters of health in the broadest sense of that term, including medical issues, changes in the biospere, technology, and policy considerations, all of which will shape our culture and our lives.

Is fair representation good for children? effects of electoral partisan bias in state legislatures on policies affecting children's health and well-being

Increasing evidence suggests that state policies impact constituents' health, but political determinants of health and health inequities remain understudied. Using state and year fixed-effects models, we determined the extent to which changes in electoral partisan bias in lower chambers of U.S. state legislatures (i.e., discrepancy between statewide vote share and seat share) were followed by changes in five state policies affecting children and families (1980-2019) and a composite of safety net programs (1999-2018). We examined effects on each policy and whether the effect was modified when bias was accompanied by unified party control. Next, we determined whether the effect differed depending on which party it favored. Less bias resulted only in higher AFDC/TANF benefits. Both pro-Democratic and pro-Republican bias was followed by decreased AFDC/TANF benefits and increased Medicaid benefits. AFDC/TANF recipients, unemployment benefits, minimum wage, and pre-K-12 education spending increased following pro-Democratic bias and decreased following pro-Republican bias. Estimated effects on the composite measure of safety net policies were all close to null. Some effects were modulated by unified party control. Results demonstrate that increasing fairness in elections is not a panacea by itself for increasing generosity of programs affecting children's well-being. Indeed, bias can be somewhat beneficial for the expansiveness of some policies. Furthermore, with the exception of unemployment benefits and AFDC/TANF recipients, Democrats have not been using the additional power that comes with electoral bias to spend more on major programs that benefit children. Finally, after decades in which electoral bias was in Democrats' favor, bias has started to shift toward Republicans in the last decade. This trend forecasts more cuts in almost all the policies in this study, especially education and AFDC/TANF recipients. There is a need for more research and advocacy emphasis on the political determinants of social determinants of health, especially at the state level.

Electoral Democracy and Working-Age Mortality

Policy Points The erosion of electoral democracy in the United States in recent decades may have contributed to the high and rising working-age mortality rates, which predate the COVID-19 pandemic. Eroding electoral democracy in a US state was associated with higher working-age mortality from homicide, suicide, and especially from drug poisoning and infectious disease. State and federal efforts to strengthen electoral democracy, such as banning partisan gerrymandering, improving voter enfranchisement, and reforming campaign finance laws, could potentially avert thousands of deaths each year among working-age adults.

CONTEXT

Working-age mortality rates are high and rising in the United States, an alarming fact that predates the COVID-19 pandemic. Although several reasons for the high and rising rates have been hypothesized, the potential role of democratic erosion has been overlooked. This study examined the association between electoral democracy and working-age mortality and assessed how economic, behavioral, and social factors may have contributed to it.

METHODS

We used the State Democracy Index (SDI), an annual summary of each state's electoral democracy from 2000 to 2018. We merged the SDI with annual age-adjusted mortality rates for adults 25-64 years in each state. Models estimated the association between the SDI and working-age mortality (from all causes and six specific causes) within states, adjusting for political party control, safety net generosity, union coverage, immigrant population, and stable characteristics of states. We assessed whether economic (income, unemployment), behavioral (alcohol consumption, sleep), and social (marriage, violent crime, incarceration) factors accounted for the association.

FINDINGS

Increasing electoral democracy in a state from a moderate level (defined as the third quintile of the SDI distribution) to a high level (defined as the fifth quintile) was associated with an estimated 3.2% and 2.7% lower mortality rate among working-age men and women, respectively, over the next year. Increasing electoral democracy in all states from the third to the fifth quintile of the SDI distribution may have resulted in 20,408 fewer working-age deaths in 2019. The democracy-mortality association mainly reflected social factors and, to a lesser extent, health behaviors. Increasing electoral democracy in a state was mostly strongly associated with lower mortality from drug poisoning and infectious diseases, followed by reductions in homicide and suicide.

CONCLUSIONS

Erosion of electoral democracy is a threat to population health. This study adds to growing evidence that electoral democracy and population health are inextricably linked.

Association of Place With Adolescent Obesity

Importance

Despite strong evidence linking place and obesity risk, the extent to which this link is causal or reflects sorting into places is unclear.

Objective

To examine the association of place with adolescents' obesity and explore potential causal pathways, such as shared environments and social contagion.

Design, Setting, and Participants

This natural experiment study used the periodic reassignment of US military servicemembers to installations as a source of exogenous variation in exposure to difference places to estimate the association between place and obesity risk. The study analyzed data from the Military Teenagers Environments, Exercise, and Nutrition Study, a cohort of adolescents in military families recruited from 2013 through 2014 from 12 large military installations in the US and followed up until 2018. Individual fixed-effects models were estimated that examined whether adolescents' exposure to increasingly obesogenic places over time was associated with increases in body mass index (BMI) and probability of overweight or obesity. These data were analyzed from October 15, 2021, through March 10, 2023.

Exposure

Adult obesity rate in military parent's assigned installation county was used as a summary measure of all place-specific obesogenic influences.

Main Outcomes and Measures

Outcomes were BMI, overweight or obesity (BMI in the 85th percentile or higher), and obesity (BMI in the 95th percentile or higher). Time at installation residence and off installation residence were moderators capturing the degree of exposure to the county. County-level measures of food access, physical activity opportunities, and socioeconomic characteristics captured shared environments.

Results

A cohort of 970 adolescents had a baseline mean age of 13.7 years and 512 were male (52.8%). A 5 percentage point-increase over time in the county obesity rate was associated with a 0.19 increase in adolescents' BMI (95% CI, 0.02-0.37) and a 0.02-unit increase in their probability of obesity (95% CI, 0-0.04). Shared environments did not explain these associations. These associations were stronger for adolescents with time at installation of 2 years or longer vs less than 2 years for BMI (0.359 vs. 0.046; P value for difference in association = .02) and for probability of overweight or obesity (0.058 vs. 0.007; P value for difference association = .02), and for adolescents who lived off installation vs on installation for BMI (0.414 vs. -0.025; P value for association = .01) and for probability of obesity (0.033 vs. -0.007; P value for association = .02).

Conclusion and Relevance

In this study, the link between place and adolescents' obesity risk is not explained by selection or shared environments. The study findings suggest social contagion as a potential causal pathway.

Heterogenous Effects of Local Government Spending on Mortality Across Racial Groups Among Working-Age Adults in the U.S

Introduction

Mortality among working-age adults has been rising, but the underlying reasons are not fully known. Given the relationship between higher levels of public spending and better health outcomes, it is possible that differences in public spending may explain some of this trend. This study examined the association between county government spending and overall and race-specific mortality among working-age adults over time.

Methods

Hybrid random effects models, which specified separate within- and between-county effects, were used to assess the relationship between per capita county spending and overall and race-specific mortality rates from 1980 to 2019. All models controlled for median age, percentage of the population with at least a bachelor's degree, unemployment rate, and poverty rate.

Results

In the overall population, counties with higher k-12 education, library, and police spending were significantly associated with higher mortality rates. Among Black adults, counties with lower corrections spending, lower waste management spending, and higher highway spending had significantly higher Black mortality. Among White adults, counties with lower natural resource spending and higher police spending had higher White mortality.

Conclusions

This study showed that differences in public spending may explain the geographic and racial differences in mortality among working-age adults. Local governments should consider public spending as a tool to improve overall population health and address racial health inequalities in their jurisdictions.

Heterogeneity in place effects on health: The case of time preferences and adolescent obesity

We leverage a natural experiment in combination with data on adolescents' time preferences to assess whether there is heterogeneity in place effects on adolescent obesity. We exploit the plausibly exogenous assignment of military servicemembers, and consequently their children, to different installations to identify place effects. Adolescents' time preferences are measured by a validated survey scale. Using the obesity rate in the assigned installation county as a summary measure of its obesity-related environments, we show that exposure to counties with higher obesity rates increases the likelihood of obesity among less patient adolescents but not among their more patient counterparts.

US State Policy Contexts and Population Health

Policy Points This Perspective connects the dots between the polarization in US states' policy contexts and the divergence in population health across states. Key interlocking forces that fueled this polarization are the political investments of wealthy individuals and organizations and the nationalization of US political parties. Key policy priorities for the next decade include ensuring all Americans have opportunities for economic security, deterring behaviors that kill or injure hundreds of thousands of Americans each year, and protecting voting rights and democratic functioning.

Income Inequality and Population Health: Examining the Role of Social Policy

Studies of the relationship between income inequality and life expectancy often speculate about the role of policy, but direct empirical research is limited. Drawing on the neo-materialist perspective, we examine whether the longitudinal association between income inequality and life expectancy is mediated and moderated by policy liberalism in U.S. states (2000-2014). More liberal policy contexts are characterized by greater efforts to regulate the economy, redistribute income, and protect vulnerable groups and lesser efforts to penalize deviant social behavior. We find that state-level income inequality is inversely associated with policy liberalism and life expectancy. The association between income inequality and life expectancy was not mediated by policy liberalism but was moderated by it. The association is attenuated in states with more liberal policy contexts, supporting the neo-materialist perspective. This finding illustrates how states like New York and California (with liberal policy contexts) can exhibit high income inequality and high life expectancy.

Mortality inequalities in France since the 1920s: Evidence of a reversal of the income gradient in mortality

Many recent studies show that Europe has had a lower mortality inequality for most ages than the United States over the last thirty years. However, the evolution of the income gradient in mortality all along the twentieth century remains poorly understood. This article uses a unique dataset that gives the annual lifetables and fiscal income for the 90 administrative regions of mainland France from 1922 to 2020. The income gradients in mortality are computed across regions using a traditional method with calendar ages and, alternatively, with mortality milestones to control for the increase in life expectancy over time. The study reveals a systematic reversal of the gradient that occurred around the 1970s for both sexes and all ages or mortality groups when calculated at an aggregated level. Inequality in mortality amongst the oldest age groups has however returned to a level observed at least ten years earlier because of Covid-19, even after controlling for mortality improvements over the period.

U.S. state policy contexts and mortality of working-age adults

The rise in working-age mortality rates in the United States in recent decades largely reflects stalled declines in cardiovascular disease (CVD) mortality alongside rising mortality from alcohol-induced causes, suicide, and drug poisoning; and it has been especially severe in some U.S. states. Building on recent work, this study examined whether U.S. state policy contexts may be a central explanation. We modeled the associations between working-age mortality rates and state policies during 1999 to 2019. We used annual data from the 1999-2019 National Vital Statistics System to calculate state-level age-adjusted mortality rates for deaths from all causes and from CVD, alcohol-induced causes, suicide, and drug poisoning among adults ages 25-64 years. We merged that data with annual state-level data on eight policy domains, such as labor and taxes, where each domain was scored on a 0-1 conservative-to-liberal continuum. Results show that the policy domains were associated with working-age mortality. More conservative marijuana policies and more liberal policies on the environment, gun safety, labor, economic taxes, and tobacco taxes in a state were associated with lower mortality in that state. Especially strong associations were observed between certain domains and specific causes of death: between the gun safety domain and suicide mortality among men, between the labor domain and alcohol-induced mortality, and between both the economic tax and tobacco tax domains and CVD mortality. Simulations indicate that changing all policy domains in all states to a fully liberal orientation might have saved 171,030 lives in 2019, while changing them to a fully conservative orientation might have cost 217,635 lives.

Educational disparities in adult health across U.S. states: Larger disparities reflect economic factors

Introduction

Education level is positively associated with adult health in the United States. However, new research shows that the association is stronger in some U.S. states than others, and that states with stronger associations also tend to have poorer overall levels of health. Understanding why educational disparities in health are larger in some states than others can advance knowledge of the major drivers of these disparities, between individuals and states. To that end, this study examined how key mechanisms (economic conditions, health behaviors, family, healthcare) help explain the education-health association in each state and whether they do so systematically.

Methods

Using data on over 1.7 million adults ages 25-64 in the 2011-2018 Behavioral Risk Factor Surveillance System, we estimated the association between education level and self-rated health in each state, net of age, sex, race/ethnicity, and calendar year. We then estimated the contribution of economic, behavioral, family, and healthcare mechanisms to the association in each state.

Results

The strength of the education-health association differed markedly across states and was strongest in the Midwest and South. Collectively, the mechanisms accounted for most of the association in all states, from 55% of it in North Dakota to 73% in Oklahoma. Economic (employment, income) and behavioral (smoking, obesity) mechanisms were key, but their contribution to the association differed systematically across states. In states with stronger education-health associations, economic conditions were the dominant mechanism linking education to health, but in states with weaker associations, the contribution of economic mechanisms waned and that of behavioral mechanisms rose.

Discussion

Meaningful reductions in educational disparities in health, and overall improvements in health, may come from prioritizing access to employment and livable income among adults without a 4-year college degree, particularly in Southern and Midwestern states.

On the frontlines : An exploratory analysis of unequal exposure to air pollution and COVID-19 in the United States

Recent literature has suggested a link between poor air quality and worse COVID-19 outcomes. In the United States, this link is particularly noteworthy because of residential sorting along ethnic lines within the US population; minorities are disproportionately exposed to health hazards, including air pollution. The impacts of the COVID-19 pandemic have also been disproportionately concentrated amongst minorities. We explore the association between air quality and COVID-19 outcomes, using county level data for the United States from the first wave of the pandemic in 2020, and test whether exposure to more polluted air can account for some of the observed disparities in COVID-19 outcomes among minorities.

The Great Divide: Education, Despair, and Death

Deaths of despair, morbidity and emotional distress continue to rise in the US, largely borne by those without a college degree, the majority of American adults, for many of whom the economy and society are no longer delivering. Concurrently, all-cause mortality in the US is diverging by education in a way not seen in other rich countries. We review the rising prevalence of pain, despair, and suicide among those without a BA. Pain and despair created a baseline demand for opioids, but the escalation of addiction came from pharma and its political enablers. We examine the "politics of despair," how less-educated people have abandoned and been abandoned by the Democratic Party. While healthier states once voted Republican in presidential elections, now the less-healthy states do. We review deaths during COVID, finding mortality in 2020 replicated existing relative mortality differences between those with and without college degrees.

The association between educational attainment and longevity using individual-level data from the 1940 census

We combine individual data from the 1940 full-count census with death records and other information available on the Family Tree at familysearch.org to create the largest individual dataset to date (17 million) to study the association between years of schooling and age at death. Conditional on surviving to age 35, one additional year of education is associated with roughly 0.4 more years of life for both men and women for cohorts born 1906-1915 and smaller for earlier cohorts. Focusing on the 1906-1915 cohort we find that this association is identical when we use sibling or twin fixed effects. This association varies substantially by place of birth. For men, the association is stronger in places with greater incomes, higher quality of school, and larger investments in public health. Women also exhibit great heterogeneity in the association, but our measures of the childhood environment do not explain it.

Urban scaling of opioid overdose deaths in the USA: a cross-sectional study in three periods between 2005 and 2017

OBJECTIVES

To describe the association between population size, population growth and opioid overdose deaths-overall and by type of opioid-in US commuting zones (CZs) in three periods between 2005 and 2017.

SETTINGS

741 CZs covering the entirety of the US CZs are aggregations of counties based on commuting patterns that reflect local economies.

PARTICIPANTS

We used mortality data at the county level from 2005 to 2017 from the National Center for Health Statistics.

OUTCOME

Opioid overdose deaths were defined using underlying and contributory causes of death codes from the International Classification of Diseases, 10th revision (ICD-10). We used the underlying cause of death to identify all drug poisoning deaths. Contributory cause of death was used to classify opioid overdose deaths according to the three major types of opioid, that is, prescription opioids, heroin and synthetic opioids other than methadone.

RESULTS

Opioid overdose deaths were disproportionally higher in largely populated CZs. A CZ with 1.0% larger population had 1.10%, 1.10%, and 1.16% higher opioid death count in 2005-2009, 2010-2014, and 2015-2017, respectively. This pattern was largely driven by a high number of deaths involving heroin and synthetic opioids, particularly in 2015-2017. Population growth over time was associated with lower age-adjusted opioid overdose mortality rate: a 1.0% increase in population over time was associated with 1.4% (95% CI: -2.8% to 0.1%), 4.5% (95% CI: -5.8% to -3.2%), and 1.2% (95% CI: -4.2% to 1.8%) lower opioid overdose mortality in 2005-2009, 2010-2014, and 2015-2017, respectively. The association between positive population growth and lower opioid mortality rates was stronger in larger CZs.

CONCLUSIONS

Opioid overdose mortality in the USA was disproportionately higher in mid-sized and large CZs, particularly those affected by declines in population over time, regardless of the region where they are located.

EDUCATION AND INCOME GRADIENTS IN LONGEVITY: THE ROLE OF POLICY

Education and income are strong predictors of health and longevity. In the last 20 years many efforts have been made to understand if these relationships are causal and what the possible role of policy should be as a result. The evidence from various studies is ambiguous: the effects of education and income policies on health are heterogeneous and vary over time, and across places and populations. I discuss explanations for these disparate results and suggest directions for future research.

U.S. State Policy Contexts and Physical Health among Midlife Adults

This study examines how state policy contexts may have contributed to unfavorable adult health in recent decades. It merges individual-level data from the 1993-2016 Behavioral Risk Factor Surveillance System (n=2,166,835) with 15 state-level policy domains measured annually on a conservative to liberal continuum. We examined associations between policy domains and health among adults ages 45-64 years and assess how much of the associations is accounted by adults' socioeconomic, behavioral/lifestyle, and family factors. A more liberal version of the civil rights domain was associated with better health. It was disproportionately important for less-educated adults and women, and its association with adult health was partly accounted by educational attainment, employment, and income. Environment, gun safety, and marijuana policy domains were, to a lesser degree, predictors of health in some model specifications. In sum, health improvements require a greater focus on macro-level factors that shape the conditions in which people live.