TLHLIM

All told, there is strong empirical support for the notion that specific healthrelated policies and behaviors differ across states, and that these differences matter for mortality. But quantifying how much of the total rise in state-level mortality dispersion can be explained by a health-capital model is more ambitious due to the long lags between investments and outcomes and the myriad types of policies and behaviors that might be relevant. It is even more difficult to quantify the separate contributions of policies versus behavior, given the likely feedback between these two “inputs” into the health-capital framework.
 
Even so, the health-capital model can help us understand some puzzles in the empirical literature. For example, one type of behavior—smoking—typically has a far larger effect on mortality than its direct clinical impact would predict (Cutler et al. 2011). Consistent with a broad health-capital model, Montez et al. (2019) observe that the outsized effect of smoking on health in area-level regressions can be understood by noting that changes in smoking behavior are often correlated with changes in health-related policies, including policies unrelated to smoking.
 
In New York, for example, smoking rates in 1992 were 22.1 percent, about the same as North Dakota (21.9 percent) and only slightly below Mississippi (23.6 percent). By 2016, smoking had fallen to 9.2 percent in New York, compared to significantly smaller decreases in North Dakota (14.0 percent) and Mississippi (16.6 percent). Since the early 1980s, New York has imposed a substantial excise tax on cigarettes, which reached $4.35 per pack in 2016. But as Montez et al. argue, the higher cigarette tax in New York was part of a bundle of initiatives which, to one extent or another, tended to improve public health. For example, New York also participated in Medicaid expansion, implemented its own earned income tax credit, and set a minimum wage above the federal level ($9.00 per hour in 2016). In contrast, Mississippi has a negligible cigarette tax ($0.68 per pack in 2016), opted out of Medicaid expansion, does not offer its own earned income tax credit, and defaulted to the federal minimum wage. In addition, Mississippi has preempted local governments from implementing health-promoting legislation, such as paid sick days, a higher minimum wage, stricter firearm regulations, and nutrition labeling in restaurants.
 
To explore the plausibility of this explanation, we experimented with regressions with state-level mortality as the dependent variable and various explanatory variables, including smoking and obesity rates. To capture state-level economic factors, we include state-level income, poverty rates, and manufacturing employment shares. We also include rates of prescribing effective or risky drugs, intended to capture health-care quality in 2008–2010 (Munson et al. 2013). Of course, these regression results should not be viewed as causal, and even interpreting the coefficients is tricky given the well-understood risks of using aggregated data to make inferences about individual causal factors.9 Details of these regressions and the underlying data sources are available in the online Appendix.
 
Here, we simply note two general patterns that emerge. First, consistent with our earlier results on state-level income and mortality, income has a strong negative correlation with mortality in 2016 but no particular relation in 1992. However, when we include the additional control variables, the later income coefficient becomes much less negative. This reduction suggests that high-income states differ from lowincome states along a variety of dimensions relevant for health, which are being captured in some ways by the additional controls.

Second, we find that the importance of smoking in these regressions is rising over time, even after controlling for income.10 This is consistent with interpreting the state-level smoking rate as a “sentinel measure” of midlife mortality, with lower smoking rates reflecting a variety of public health efforts to encourage more healthy behavior. Indeed, one might view these evolving health-related factors proxied for by smoking as the dynamic equivalent of the static Utah-Nevada comparison by Fuchs (1974), in which behavior is influenced by policies, and vice versa
 
We have documented a sharp increase in state-level disparities in midlife mortality, a result consistent with an emerging epidemiological literature (Vierboom, Preston, and Hendi 2019; Montez et al. 2019). This divergence has contributed to a more unequal America; West Virginia’s midlife mortality rate is nearly double that in Minnesota. These widening geographic disparities in state-level mortality cannot be attributed to changing spatial patterns in education levels, income inequality, or rising deaths of despair. Instead, rising spatial inequality in midlife mortality results from some states experiencing dramatic overall declines in mortality across educational groups, while other states have experienced at best only modest progress.

The first-order question is why high-income states have done so much better. Our review of the evidence indicates that differential adoption of policies such as tobacco taxes, Medicaid expansions, and income support in high-income but not low-income states, have led to both widening spatial disparities in mortality and to an increasingly close negative association between income and mortality. These policies are distinct from but complementary to health-related behaviors that also differ across states.
 
nsacpi said:
In New York, for example, smoking rates in 1992 were 22.1 percent, about the same as North Dakota (21.9 percent) and only slightly below Mississippi (23.6 percent). By 2016, smoking had fallen to 9.2 percent in New York, compared to significantly smaller decreases in North Dakota (14.0 percent) and Mississippi (16.6 percent). Since the early 1980s, New York has imposed a substantial excise tax on cigarettes, which reached $4.35 per pack in 2016. But as Montez et al. argue, the higher cigarette tax in New York was part of a bundle of initiatives which, to one extent or another, tended to improve public health. For example, New York also participated in Medicaid expansion, implemented its own earned income tax credit, and set a minimum wage above the federal level ($9.00 per hour in 2016). In contrast, Mississippi has a negligible cigarette tax ($0.68 per pack in 2016), opted out of Medicaid expansion, does not offer its own earned income tax credit, and defaulted to the federal minimum wage. In addition, Mississippi has preempted local governments from implementing health-promoting legislation, such as paid sick days, a higher minimum wage, stricter firearm regulations, and nutrition labeling in restaurants.
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So you believe increasing taxes on something is designed to create less of that something?
 
life expectancy by race

Asian Americans (85.2 years) having the highest, followed by Hispanic (81.3), White (78.4), Black (74), and American Indian/Alaska Native (AIAN) (70.1) populations

Seems pretty straight forward to me guys
 
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Two proponents of the importance of institutions in development have observed that “England in the nineteenth century was . . . a very unhealthy place, but the government gradually invested in clean water, in the proper treatment of sewage and effluent, and eventually in an effective health service” (Acemoglu and Robinson 2012, p. 51). The authors interpret these improvements not as the cause of England’s rapid economic growth, but instead as a consequence of its economic success. Lessons from this literature on institutions have an encouraging policy implication: Although states with high income have shown the way, states with lower income capacity are not inexorably constrained to rates of midlife mortality that rank among the worst in developed countries.
 
I agree with this final observation by the authors. Red states are not fated to forever fall behind. But it doesn't happen by magic. It happens through the adoption of better policies. There are some ideological barriers to this but they are not impermeable.
 
Tapate50 said:
life expectancy by race

Asian Americans (85.2 years) having the highest, followed by Hispanic (81.3), White (78.4), Black (74), and American Indian/Alaska Native (AIAN) (70.1) populations

Seems pretty straight forward to me guys
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And the income disparities make those even worse.
 
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