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March 11, 2022

The Growing Influence of State Governments on Population Health in the United States

Author Affiliations
  • 1Center on Society and Health, Virginia Commonwealth University, Richmond
JAMA. 2022;327(14):1331-1332. doi:10.1001/jama.2022.3785

For decades, the population of the US has experienced shorter life expectancy and higher disease rates than populations in other high-income countries. The gap in life expectancy between the US and 16 peer countries increased from 1.9 years in 2010 to 3.1 years in 2018 and 4.7 years in 2020.1 The US health disadvantage is even worse in certain states, with states such as Alabama and Mississippi having the same life expectancy as Latvia (75 years).2,3

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2 Comments for this article
Health Disparities
Paul Nelson, MS MD | Family Health Care PC, Retired
Health disparities in the US are even worse than indicated in this Viewpoint. In comparison with OECD nations involving Western Europe and Scandinavia, excess health spending as a portion of our economy vs theirs was 1 trillion USD in 2019. Improvements in our nation's longevity stopped 10 years ago. Our nation's maternal mortality rate continues to worsen unabated, as it has since 1970; we would need to reduce it by 70% to rank among the OECD nations cited previously. Early childhood obesity continues to worsen without any nationally recognizable or remedial cause.

It is likely that an underlying factor
is our nation's steadily declining social cohesion, a sleeping giant if there ever was one.

Diagnosis means going beyond the symptoms
Jeoffry Gordon, MD, MPH | Retired
While the Viewpoint by Woolf clearly describes the tragic response of the United States to the covid-19 pandemic, it is not adequate to focus on the results (symptoms) without explicitly identifying the causes (pathophysiology). The root cause is not obscure. For generations, "states rights" has been a political euphemism for racism. In medical services, federalized Medicare not only avoided this curse, it took active steps to remediate it. At the same time Medicaid devolved to the states and for over 50 years has supported a second class health system for the poor, especially dire in the former Confederate states, creating racial disparities which were well established and described before covid-19. The deferral of federal pandemic management to the states has been proven to be both dysfunctional and tragic as Woolf demonstrates.

Indeed, the recent lively domestic polarization and turmoil unleashed by contemporary federal political leaders not only affects pandemic response and morbidity and mortality generally, it threatens the fundamental pillars of democracy and re-enforces many other discriminatory public policies, especially at the state level. Unfortunately, treating this disease will be especially difficult, because the pathophysiology (political philosophy) has been firmly implanted in the Supreme Court.

Recently, the American Medical Association explicitly rejected its sad historic ties to states rights and racism. This was an important step forward. I would suggest that JAMA stop publishing articles (research and Viewpoints) which document the effects of racial animus without explicitly recognizing the the social pathophysiology that lies behind these morbidities.