https://jamanetwork.com/journals/jama/article-abstract/2790238
Disparities in health across the 50 states are growing, a trend that began in the 1990s.4 For example, in 1990, life expectancy in New York was lower than in Oklahoma, but the trajectories separated sharply in the 1990s and, by 2016, New York ranked third in life expectancy, whereas Oklahoma ranked 45th.2 By 2019, mortality rates at ages 25 to 64 years differed by a factor of 216% between the states with the highest mortality rate (565.1 per 100 000) and the lowest rate (261.9 per 100 000), up from 188% in 1999. The widening gap cannot be explained by changes in the racial and ethnic composition of states, because the same trend occurred within racial and ethnic groups. For example, among non-Hispanic White individuals, mortality rates at ages 25 to 64 years differed by a factor of 228% between the states with the highest mortality rate (571.7 per 100 000) and the lowest rate (250.2 per 100 000), up from 166% in 1999.5
Although the divergence in state health trajectories might reflect changes in demographic and socioeconomic characteristics, a more likely potential explanation is the growing polarization of public policies across states. States assumed increasing powers decades ago, when the Reagan administration in the 1980s and the US Congress in the 1990s promoted devolution, a policy aimed at shifting authorities and resources (eg, block grants) to the states.6
States with different political priorities and economic circumstances made diverse policy choices, widening the gap across the states in education, wages, taxes, social programs, corporate profits, wealth inequality, and infrastructure. Health outcomes changed as states took different approaches to Medicaid, workplace and product safety, the environment, tobacco control, food labeling, gun ownership, and needle exchange programs. These policies had predictable consequences. For example, states that raised cigarette taxes experienced fewer tobacco-related illnesses. Injury deaths increased in states that relaxed speed limits and motorcycle helmet laws.
