A recent study published in Health Affairs Scholar highlights a significant relationship between political ideologies at the state level and health outcomes across the United States. Analyzing data from 2012 to 2024, researchers found that states with more conservative political metrics tend to experience worse health outcomes, including higher rates of infant mortality, premature deaths, and food insecurity.
The research team, led by Nancy Krieger of the Harvard T.H. Chan School of Public Health, sought to better understand how political dynamics at the state level influence public health outcomes in the United States. While public health research has traditionally focused on specific policies, such as Medicaid expansion or public health regulations, there has been little attention paid to the political ideologies of elected officials and the concentration of political power within state governments.
These elements, the researchers argue, are key drivers of policy decisions that ultimately shape the social and economic conditions affecting population health. By examining these political metrics alongside health outcomes, the study aimed to uncover broader systemic relationships that might otherwise go unnoticed.
To explore whether the ideological orientation of state governments had a measurable impact on the pace of health improvements or declines over time, the researchers analyzed data collected in the United States from 2012 to 2024. They examined four political metrics: the political ideology of elected officials based on voting records, the concentration of political power in state trifectas (where one party controls the executive and legislative branches), state policy indices reflecting liberal or conservative leanings, and voter political lean as measured by the Cook Partisan Voting Index.
The researchers linked these political metrics to eight health outcomes, selected for their importance as public health indicators and their ability to respond quickly to changes in societal conditions. These outcomes included infant mortality, premature mortality (death before age 65), health insurance coverage for working-age adults (35–64 years), childhood immunization rates, flu vaccination rates for older adults, COVID-19 booster uptake among adults aged 65 and older, food insecurity, and the prevalence of maternity care deserts.
The researchers found consistent and significant associations between higher state-level political conservatism and worse health outcomes. For instance, states with Republican trifectas had a premature mortality rate that was 25.49 deaths per 100,000 person-years higher compared to states with Democratic trifectas. Similarly, infant mortality rates were 0.94 deaths per 1,000 live births higher in Republican trifecta states. These disparities persisted even after adjusting for poverty.
States with more conservative elected officials also demonstrated significant disparities in food security and health insurance coverage. The percentage of uninsured adults aged 35 to 64 was 2.76% higher in Republican trifecta states compared to Democratic trifecta states. Food insecurity followed a similar pattern, with Republican trifecta states reporting a 0.68 percentage-point higher rate of households facing food insecurity.
Vaccination rates provided further evidence of the influence of political context. States with more liberal political metrics reported a 5.95% higher rate of COVID-19 booster uptake among adults aged 65 and older compared to more conservative states. Childhood immunization rates were also significantly higher, with a 3.06 percentage-point advantage in Democratic trifecta states. Similarly, flu vaccination rates for seniors were 4.35% higher in Democratic trifecta states, highlighting how state policies and governance affect preventive health measures.
To explore temporal trends, the researchers conducted joinpoint regression and spline modeling, which allowed them to identify inflection points in health outcomes and assess changes over time. Between 2018 and 2021, the rise in premature mortality rates was significantly steeper in conservative states. For example, the rate of premature mortality in the most conservative states increased by 29 deaths per 100,000 person-years during this period, compared to a rise of 17.6 deaths per 100,000 person-years in the most liberal states.
Similarly, the percentage of uninsured adults declined less in conservative states. Following the introduction of Medicaid expansion in 2014, states with more liberal political contexts achieved greater reductions in uninsured rates. By 2020, Republican trifecta states had an uninsured rate that was 7.2 percentage points higher than that of Democratic trifecta states, illustrating the policy impact of political ideologies on healthcare access.
The study also found that the two political metrics less commonly used in public health research—elected officials’ political ideology and state trifectas—were the most strongly associated with health outcomes. This suggests that focusing solely on voter leanings or enacted policies may overlook critical drivers of public health disparities, such as who holds political power and their ability to implement their ideological agendas.
The researchers also highlighted that the findings are especially relevant given the emergence of a Republican trifecta at the national level and shifts in state governance following the 2024 elections.
“If indeed political conservativism is causally associated with worse health outcomes and reduced access to health care, the election results may foretell (1) worsening health profiles in states with high or rising conservatism and (2) potential challenges to maintaining or improving the better health outcomes in more liberal states, given the national Republican trifecta,” the researchers wrote. “What actually transpires, however, will, of course, depend on the actions of elected officials, judges, government agencies, civil society organizations, and social movements, at the national, state, and local levels. A sobering question to consider is: If state health profiles worsen, who will be blamed, by whom?”
The study, “Politicians, power, and the people’s health: US elections and state health outcomes, 2012–2024,” was authored by Nancy Krieger, Soroush Moallef, Jarvis T. Chen, Ruchita Balasubramanian, Tori L. Cowger, Rita Hamad, Alecia J. McGregor, William P. Hanage, Loni Philip Tabb, and Mary T. Bassett.
