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The positive association between educational attainment and adult health ("the gradient") is stronger in some areas of the United States than in others. Explanations for the geographic pattern have not been rigorously investigated. Grounded in a contextual and life course perspective, this study assesses childhood circumstances (e.g., childhood health, compulsory schooling laws) and adult circumstances (e.g., wealth, lifestyles, economic policies) as potential explanations. Using data on US-born adults aged 50-59 at baseline ( N =13,095) and followed for up to 16 years across the 1998-2014 waves of the Health and Retirement Study, this study examined how and why educational gradients in morbidity, functioning, and mortality vary across nine U.S. regions. The findings indicate that the gradient is stronger in some areas than others partly because of geographic differences in childhood socioeconomic conditions and health, but mostly because of geographic differences in adult circumstances such as wealth, lifestyles, and economic and tobacco policies.

Despite numerous studies on educational disparities in U.S. adult health, explanations for the disparities and their growth over time remain incomplete. We argue that this knowledge gap partly reflects an individualist paradigm in U.S. studies of educational disparities in health. These studies have largely focused on proximal explanations (e.g., individual behaviors) to the neglect of contextual explanations (e.g., economic policies). We draw on contextual theories of health disparities to illustrate how U.S. states, as institutional actors, shape the importance of education for health. Using two nationally-representative datasets and seven health measures for adults aged 45-89, we show that the size of the educational gradient in health varies markedly across states. The size varies because of variation in the health of lower-educated adults. We use state excise taxes on cigarettes to illustrate one way that states shape educational disparities in health. Our findings underscore the necessity of contextualizing these disparities.