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Educational attainment level has long been a strong predictor of adult health and longevity in the United States. Interestingly, the association between education and these outcomes has strengthened in recent decades. Since the 1980s, higher-educated adults have experienced favorable trends in health and longevity, while lower-educated adults have experienced stagnation or unfavorable trends. Studies have provided important clues about why the association between education and health and longevity has strengthened over time. However, explanations remain incomplete and contested. This article discusses key findings and debates about why the association has become stronger and offers recommendations to advance robust explanations. Two key recommendations call for a fundamental shift in how researchers conceptualize and study the increasingly strong association. These include (a) reconsidering which education groups should be viewed as normative in analyses of the trends and (b) elevating attention on contexts, institutions, and actors that have had an outsized influence on the trends. [ABSTRACT FROM AUTHOR]

Objectives. To identify relationships between US states' COVID-19 in-person activity limitation and economic support policies and drug overdose deaths among working-age adults in 2020. Methods. We used county-level data on 140 435 drug overdoses among adults aged 25 to 64 years during January 2019 to December 2020 from the National Vital Statistics System and data on states' COVID-19 policies from the Oxford COVID-19 Government Response Tracker to assess US trends in overdose deaths by sex in 3138 counties. Results. Policies limiting in-person activities significantly increased, whereas economic support policies significantly decreased, overdose rates. A 1-unit increase in policies restricting activities predicted a 15% average monthly increase in overdose rates for men (incident rate ratio [IRR] = 1.15; 95% confidence interval [CI] = 1.09, 1.20) and a 14% increase for women (IRR = 1.14; 95% CI = 1.09, 1.20). A 1-unit increase in economic support policies predicted a 3% average monthly decrease for men (IRR = 0.97; 95% CI = 0.95, 1.00) and a 4% decrease for women (IRR = 0.96; 95% CI = 0.93, 0.99). All states' policy combinations are predicted to have increased drug-poisoning mortality. Conclusions. The economic supports that states enacted were insufficient to fully mitigate the adverse relationship between activity limitations and drug overdoses. (Am J Public Health. 2024;114(7):714–722. https://doi.org/10.2105/AJPH.2024.307621) [ABSTRACT FROM AUTHOR]

In this paper, we test whether the Affordable Care Act Medicaid expansions are associated with maternal morbidity. The ACA expansions may have affected maternal morbidity by increasing pre‐conception access to health care, and by improving the quality of delivery care, through enhancing hospitals' financial positions. We use difference‐in‐difference models in conjunction with event studies. Data come from individual‐level birth certificates and state‐level hospital discharge data. The results show little evidence that the expansions are associated with overall maternal morbidity or indicators of specific adverse events including eclampsia, ruptured uterus, and unplanned hysterectomy. The results are consistent with prior research showing that the ACA Medicaid expansions are not statistically associated with pre‐pregnancy health or maternal health during pregnancy. Our results add to this story and find little evidence of improvements in maternal health upon delivery. [ABSTRACT FROM AUTHOR]

Policy PointsThe 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. [ABSTRACT FROM AUTHOR]

Over the past half century the gap in mortality across education levels has grown in the United States, and since the mid-1980s, the growth has been especially pronounced among white women. The reasons for the growth among white women are unclear. We investigated three explanations--social-psychological factors, economic circumstances, and health behaviors--for the widening education gap in mortality from 1997 to 2006 among white women aged 45 to 84 years using data from the National Health Interview Survey Linked Mortality File (N = 46,744; 4,053 deaths). Little support was found for social-psychological factors, but economic circumstances and health behaviors jointly explained the growing education gap in mortality to statistical nonsignificance. Employment and smoking were the most important individual components. Increasing high school graduation rates, reducing smoking prevalence, and designing work-family policies that help women find and maintain desirable employment may reduce mortality inequalities among women. (Contains 3 tables and 5 notes.)

In the United States, a woman's health insurance coverage is largely determined by her employment and marital roles. This research evaluates competing hypotheses regarding how the combination of employment and marital roles shapes insurance coverage among Mexican-origin, non-Hispanic white, and African American women. We use data from the 2004 and 2006 March Supplements to the "Current Population Surveys". Results show that these roles largely substitute for each other among non-Hispanic white and African American women, although marriage generally increases the odds of coverage slightly more than employment among non-Hispanic white women. In contrast, these roles cumulatively increase those odds among Mexican-origin women. Yet neither employment, nor marriage, nor their combination assures their coverage. Married Mexican-origin women are particularly disadvantaged. As women increasingly spend a smaller fraction of their lives in marriage, and as relatively few women are in benefits-rich occupations, stable and equitable coverage may require a universal health insurance system. (Contains 3 tables and 2 figures.)

Policy PointsThis 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The contextual predictors of mortality in the United States are well documented, but the COVID-19 pandemic may have upended those associations. Informed by the social history of disease framework (SHDF), this study examined how the importance of county contexts on adult deaths from all causes, drug poisonings, and COVID-19-related causes fluctuated during the pandemic. Using 2018 to 2021 vital statistics data, for each quarter, we estimated associations between county-level deaths among adults ages 25 to 64 and prepandemic county-level contexts (economic conditions, racial-ethnic composition, population health profile, and physician supply). The pandemic significantly elevated the importance of county contexts—particularly median household income and counties’ preexisting health profile—on all-cause and drug poisoning deaths. The elevated importance of household income may be long-lasting. Contextual inequalities in COVID-19-related deaths rose and then fell, as the SHDF predicts, but rose again along with socio-political disruptions. The findings support and extend the SHDF. [ABSTRACT FROM AUTHOR]

Introduction: The goal of this study was to estimate how state preemption laws that prohibit local authority to raise the minimum wage or mandate paid sick leave have contributed to working-age mortality from suicide, homicide, drug overdose, alcohol poisoning, and transport accidents.Methods: County-by-quarter death counts by cause and sex for 1999-2019 were regressed on minimum wage levels and hours of paid sick-leave requirements, controlling for time-varying covariates and place- and time-specific fixed effects. The model coefficients were then used to predict expected reductions in mortality if the preemption laws were repealed. Analyses were conducted during January 2022-April 2022.Results: Paid sick-leave requirements were associated with lower mortality. These associations were statistically significant for suicide and homicide deaths among men and for homicide and alcohol-related deaths among women. Mortality may decline by more than 5% in large central metropolitan counties currently constrained by preemption laws if they were able to mandate a 40-hour annual paid sick-leave requirement.Conclusions: State legislatures' preemption of local authority to enact health-promoting legislation may be contributing to the worrisome trends in external causes of death. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives. It is often documented that the educational gradient of mortality is steeper for men than for women; yet, the explanation remains a matter of debate. We examine gender differences in the gradients within the context of marriage to determine whether overall differences reflect gender differences in health behaviors or a greater influence of men's education on spousal health. Methods. We used data from the 1986 through 1996 National Health Interview Survey Linked Mortality Files for non- Hispanic White adults aged 55-84 years at the time of survey. We estimated Cox proportional hazards models to examine the gradients (N=180,208). Results. The educational gradient of mortality is marginally steeper for men than for women when aggregating across marital statuses; yet, this reflects a steeper gradient among unmarried men, with low-educated never married men exhibiting high levels of mortality. The gradient among unmarried men is steeper than unmarried women for causes that share smoking as a major risk factor, supporting a behavioral explanation for differences in the gradient. No gender difference in the gradient is observed for married adults. Discussion. Low education and unmarried status exert a synergistic effect on men's mortality. Unmarried, low-educated men may lack social supports that encourage positive health behaviors. Key Words: Education--Gender--Gradient--Marriage--Mortality.

Objectives. To estimate total life expectancy (TLE), disability-free life expectancy (DFLE), and disabled life expectancy (DLE) by US state for women and men aged 25 to 89 years and examine the cross-state patterns. Methods. We used data from the 2013–2017 American Community Survey and the 2017 US Mortality Database to calculate state-specific TLE, DFLE, and DLE by gender for US adults and hypothetical worst- and best-case scenarios. Results. For men and women, DFLEs and DLEs varied widely by state. Among women, DFLE ranged from 45.8 years in West Virginia to 52.5 years in Hawaii, a 6.7-year gap. Men had a similar range. The gap in DLEs across states was 2.4 years for women and 1.6 years for men. The correlation among DFLE, DLE, and TLE was particularly strong in southern states. The South is doubly disadvantaged: residents have shorter lives and spend a greater proportion of those lives with disability. Conclusions. The stark variation in DFLE and DLE across states highlights the large health inequalities present today across the United States, which have significant implications for individuals' well-being and US states' financial costs and medical care burden. [ABSTRACT FROM AUTHOR]

Health, Aging, Geographic contexts, Disparities, Policy. [Extracted from the article]

The United States currently ranks last among high-income countries for life expectancy. Since 2014, U.S. life expectancy has declined. By now, these alarming trends are well known to researchers, the public, and policymakers. Nevertheless, there is no consensus among researchers on the causes of the trends, and there has been no serious and effective bipartisan effort to solve the problem. The dominant narrative has implicated Americans' behaviors, such as smoking, illicit drug use, and suicide; yet, this narrative is misguided and counterproductive. It also exonerates the key structural drivers of behaviors and health, namely the U.S. policy context and the outsized influence of corporations and big donors on those policies. The U.S. policy context has changed dramatically since the 1970s, particularly at the state level. State policies have hyperpolarized along partisan lines. These changes have likely had a profound impact on nearly every aspect of Americans ' lives, cutting short many of them. Consequently, this Essay argues that state policies increasingly affect life and death in the United States. It raises concerns about how the polarization of state policies will further deteriorate the health of many Americans, It points to three significant forces behind the polarization and the growing importance of state policy contexts on Americans ' lives--(1) New Federalism; (2) the new type of state preemption laws; and (3) the emergence of organizations, such as the American Legislative Exchange Council, through which corporations and big donors influence policies. [ABSTRACT FROM AUTHOR]

To understand the education-mortality association among U.S. adults, recent studies have documented its national functional form. However, the functional form of education-mortality relationship may vary across geographic contexts. The four U.S. Census regions differ considerably in their social and economic policies, employment opportunities, income levels, and other factors that may affect how education lowers the risk of mortality. Thus, we documented regional differences in the functional form of the education-mortality association and examined the role of employment and income in accounting for regional differences. We used data on non-Hispanic white adults (2,981,672, person years) aged 45-84 in the 2000-2009 National Health Interview Survey, with Linked Mortality File through 2011 (37,598 deaths) and estimated discrete-time hazard models. The functional form of education and adult mortality was best characterized by credentialism in the Midwest, Northeast, and for Western men. For Western women, the association was linear, consistent with the human capital model. In the South, we observed a combination of mechanisms, with mortality risk declining with each year of schooling and a step change with high school graduation, followed by steeper decline thereafter. Our work adds to the increasing body of research that stresses the importance of contexts in shaping the education-mortality relationship. [ABSTRACT FROM AUTHOR]

Since the mid-1980s differences in mortality risk across education levels have widened considerably among non-Hispanic white women. For example, while mortality has "declined" among college-educated women, it has remained fairly "stable" among women with a high school credential or some college education and "increased" among women without a high school credential. The reasons for the growing mortality gap are poorly understood. The authors investigated whether the widening gap reflected a growing importance of educational attainment for economic well-being (e.g., employment, income), psychosocial resources (e.g., marriage, mental health), or health behaviors, such as avoiding tobacco and maintaining a healthy body weight. Key findings are presented and policy implications are discussed.

Objectives. To examine how disparities in adult disability by educational attainment vary across US states. Methods. We used the nationally representative data of more than 6 million adults aged 45 to 89 years in the 2010-2014 American Community Survey. We defined disability as difficulty with activities of daily living. We categorized education as low (less than high school), mid (high school or some college), or high (bachelor's or higher). We estimated age-standardized disability prevalence by educational attainment and state. We assessed whether the variation in disability across states occurs primarily among low-educated adults and whether it reflects the socioeconomic resources of low-educated adults and their surrounding contexts. Results. Disparities in disability by education vary markedly across states--from a 20 percentage point disparity in Massachusetts to a 12-point disparity in Wyoming. Disparities vary across states mainly because the prevalence of disability among loweducated adults varies across states. Personal and contextual socioeconomic resources of low-educated adults account for 29% of the variation. Results. Disparities in disability by education vary markedly across states--from a 20 percentage point disparity in Massachusetts to a 12-point disparity in Wyoming. Disparities vary across states mainly because the prevalence of disability among loweducated adults varies across states. Personal and contextual socioeconomic resources of low-educated adults account for 29% of the variation. [ABSTRACT FROM AUTHOR]

Functional limitations and disability declined in the US during the 1980s and 1990s, but reports of early 21st century trends are mixed. Whether educational inequalities in functioning increased or decreased is also poorly understood. Given the importance of disability for productivity, independent living, and health care costs, these trends are critical to US social and health policies. We examine recent trends in functional limitations and disability among women and men aged 45–64. Using 2000–2015 National Health Interview Surveys data on over 155,000 respondents, semiparametric and logistic regression models visualize and test functioning trends by education. Among women and men with at least a college degree, there was no change in disability and mild increase in limitations over time. All other education levels experienced significant increases in functioning problems ranging from 18% higher odds of functional limitations in 2015 compared to 2000 among men with some college to about 80% increase in the odds of disability among women and men with less than high school education. The similar trends for both genders suggest common underlying causes, possibly including the worsening economic well-being of middle- and working-class families. The pervasive growth of functioning problems is a cause for concern that necessitates further scholarly investigation. [ABSTRACT FROM PUBLISHER]