Healthcare will remain on the front lines of the culture wars for the foreseeable future. Issues including abortion, Covid-19 mitigation and transgender care have clearly shown a red state– blue state divide. Doctors in one state can now face jail time for practices that are the standard of care in the state next door.
For millions of Americans, these fissures have engendered distrust of physicians, medical researchers and once-trusted institutions like the Centers for Disease Control and Prevention. While this trend is most noticeable on the far right, some groups—both liberal and libertarian— have also become increasingly skeptical of government health policies. In both red and blue states, political extremism degrades the quality of healthcare and medical research. Congress has exacerbated the divide by shifting health policy decisions to state legislatures and distributing funding for Medicare and other programs to states through unrestricted block grants. Further complicating matters, health insurance is regulated separately in all 50 states, with insurance commissioners or commissions determining where the money goes. Commissioners are appointed in 39 states and elected in 11, so healthcare decisions tilt with the political orientation in each state. This fragmentation could be resolved if the federal government set a national policy and provided every citizen the same healthcare services currently enjoyed by members of Congress.
We can expect distrust and partisanship among millions of Americans to continue in the near future, although the 2022 midterm election offered some tentative evidence that the majority of voters are tiring of politicians with the most extreme anti-science positions. The biggest change in the electorate was Gen Z, which turned out in larger-than-expected numbers and overwhelmingly backed progressive candidates, thwarting a widely anticipated “red wave.” But left-wing ideologues should take no comfort: Gen Z regards both major political parties as misguided. They’ll cross party lines to back policies and politicians they think will be most effective in addressing their major concerns: reproductive rights, climate change, racial and gender justice, and access to affordable, equitable healthcare.
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3 YEARSAverage difference in life expectancy between liberal and conservative states
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+ 30%Higher death rate from Covid-19 in red states vs. blue states
Politics and polarization have life-and-death consequences.
Jennifer Karas Montez
Professor of Sociology, Scholar in Aging Studies, Syracuse University
Data: Montez, J. et. al. 2020, ‘US State Policies, Politics, and Life Expectancy,’ The Milbank Quarterly, 04 August
* Liberal was defined as expanding state power for economic regulation and redistribution or for protecting marginalized groups, or restricting state power for punishing deviant social behavior; conservative was defined as the opposite.
To meaningfully improve the health of Americans, new policies must target all of the drivers of health, including education, economic stability, neighborhoods and environments, social and community well-being, and historic inequities.
Steven Woolf, MD, MPH
Professor of family medicine and population health, Virginia Commonwealth University School of Medicine
OUTCOMES: A LIFE AND DEATH GAP
The US is already a two-tier nation. Longevity and health studies show that people living in states where politics overrides science suffer from more chronic illness and have a lower life expectancy than those living in states with more progressive, science-driven policies. Blue states like Connecticut have health outcomes on par with European liberal democracies while others, like red state Oklahoma, tend toward outcomes seen in developing nations. The current difference in life expectancy between liberal and conservative states can be as high as seven years—with an average difference of nearly three years. During the pandemic, cumulative death rates from Covid-19 in red states were 30% higher than in blue states. We expect the longevity gap to widen, particularly when the next pandemic strikes.
States that politicize medicine and health policies will eventually face a backlash. Liberal cities within conservative states will attempt to adopt more progressive policies. Pro-choice advocates, for example, will try to circumvent state bans by creating sanctuary cities, funding travel for those seeking abortions and other procedures, and launching ballot initiatives to counter the laws passed in state legislatures. Far from fixing the problem, battles between the federal government, courts, states and cities will create an unstable and complex legal web for providers to navigate. This will add new levels of regulatory burdens to provider workloads and will increase burnout. (For more on provider burnout, see Tomorrow’s Careforce.)
CHANGES IN OVERALL POLICY ORIENTATION,1958–2018, & LIFE EXPECTANCY BY US STATE, 1970–2014
Data: Montez, J. et. al. 2020, ‘US State Policies, Politics, and Life Expectancy,’ The Milbank Quarterly, 04 August
When science becomes politicized and we don’t believe medical research or data because they come from people with different politics, we are in a very bad place. Politics is going to continue to rear its ugly head and impact healthcare, but at some point the common good has to prevail and we have to hold our leaders responsible.
Nancy Nielsen, MD, PhD
Senior Associate Dean for Health Policy, Jacobs School of Medicine and Biomedical Sciences
WHAT IF POLITICAL POLARIZATION GETS WORSE
Rising polarization will lead to greater gaps in health outcomes and life expectancy. Politicians will likely expand the list of banned or restricted procedures and healthcare options to include types of contraception, surrogate decision-making and end-of-life care. Imbalances in care will be accelerated as blue states become destinations for high-income patients seeking abortions, gender care and other procedures banned or limited in red states, and also for medical training in these fields. Lower-income patients who don’t have the funds to travel will go without treatment or seek potentially dangerous alternatives.
Some states will face boycotts by corporations, and by music and sports promoters. In addition, the most restrictive red states will see a brain drain of researchers and biomedical entrepreneurs.
IF WE BREAK THE IMPASSE
The political fever surrounding healthcare policies will break if voters reject politicians who sacrifice their constituents’ health outcomes for political gain.
Some likely scenarios:
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The voting-eligible Gen Z cohort that upended red-wave expectations of the 2022 elections represented less than half of their generation. Between now and 2030, eight more years’ worth of Gen Z will reach voting age. Politicians who want to attain—and retain—power would do well to cater to their pragmatic aims.
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Companies that have locations across the country will flex their economic muscle and demand more uniformity across state policies that better reflect the needs and wishes of their employees and shareholders. This includes insurers who will be under pressure from corporate clients and customers to reject healthcare that isn’t based on science. Hospitals and caregivers will use their considerable political and economic strength to actively advocate for pro-science and pro-patient policies.
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Citizens will realize that political polarization has delivered them poor health outcomes and shorter lives and will demand equity with other, healthier states. Less politicized and more civic-minded individuals will be motivated to run for office, participate in government committees and vote for policies that support science and improve medical outcomes.
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Lawmakers will find common ground on the issue that most impacts health: the economy. Studies suggest that a strong economy that lifts people from poverty overrides the impact of state policies in improving citizens’ health. For instance, red states with oil revenue show improved life expectancy compared to those without the revenue. Politicians may continue to disagree on health policies but may find common cause promoting policies that stimulate economic growth.