(with J Bound, AT Geronimus, T Waidmann), Health Affairs, 2015, 34 (12), 2167-2173

Independent researchers have reported an alarming decline in life expectancy after 1990 among US non-Hispanic whites with less than a high school education. However, US educational attainment rose dramatically during the twentieth century; thus, focusing on changes in mortality rates of those not completing high school means looking at a different, shrinking, and increasingly vulnerable segment of the population in each year. We analyzed US data to examine the robustness of earlier findings categorizing education in terms of relative rank in the overall distribution of each birth cohort, instead of by credentials such as high school graduation. Estimating trends in mortality for the bottom quartile, we found little evidence that survival probabilities declined dramatically. We conclude that widely publicized estimates of worsening mortality rates among non-Hispanic whites with low socioeconomic position are highly sensitive to how educational attainment is classified. However, non-Hispanic whites with low socioeconomic position, especially women, are not sharing in improving life expectancy, and disparities between US blacks and whites are entrenched. Findings underscore the urgency of an agenda to equitably disseminate new medical technologies and to deepen knowledge of social determinants of health and how that knowledge can be applied, to promote the objective of achieving population health equity.

(with JA Tapia Granados), 2015, Health Policy 119 (7), 941-953

Reports have attributed a public health tragedy in Greece to the Great Recession and the subsequent application of austerity programs. It is also claimed that the comparison of Greece with Iceland and Finland—where austerity policies were not applied—reveals the harmful effect of austerity on health and that by protecting spending in health and social budgets, governments can offset the harmful effects of economic crises on health. We use data on life expectancy, mortality rates, incidence of infectious diseases, rates of vaccination, self-reported health and other measures to examine the evolution of population health and health services performance in Greece, Finland and Iceland since 1990–2011 or 2012—the most recent years for which data are available. We find that in the three countries most indicators of population health continued improving after the Great Recession started. In terms of population health and performance of the health care system, in the period after 2007 for which data are available, Greece did as good as Iceland and Finland. The evidence does not support the claim that there is a health crisis in Greece. On the basis of the extant evidence, claims of a public health tragedy in Greece seem overly exaggerated.

Social Science and Medicine, 2018, 200, 36-43

Individuals participate in politics to influence the politicians that prescribe the policies and programs that distribute the public goods and services that shape the social determinants of health. But the opportunity to participate in politics is conditional on survival, and in the U.S., the haves enjoy a significant survival advantage over the have-nots. This process can be detected looking at the relationship between age and participation: It is inflated by the fact that, as time progresses, a higher proportion of low-SES, low-level participation individuals die and are therefore excluded from the available pool of participants faster than high-SES, high-level participation individuals. We analyze this mechanism applying propensity scores matching and multivariate regressions on data from MIDUS I (Midlife in the United States: A National Study of Health and Well-being) and its 10-year mortality follow-up. Results show that health differences between 10-year survivors and non-survivors explain 56% of their differences in socio-political participation. Survivors participate at higher levels than non-survivors across all age groups and SES levels; without detrimental differences in health, individuals would participate 28% more as they age. The same disadvantaged individuals whose increased participation would pressure for redistributive policies are those who die off from the available pool of participants at much higher rates than socioeconomically advantaged individuals. The proposed conceptual model helps to explain how, through the early disappearance of the poor, continuing socio-political participation of high-SES survivors helps to perpetuate inequality in the status quo.

(with AT Geronimus, J Bound, D Dorling), Social Science & Medicine, 2015, 136, 193-199

Excess mortality in marginalized populations could be both a cause and an effect of political processes. We estimate the impact of mortality differentials between blacks and whites from 1970 to 2004 on the racial composition of the electorate in the US general election of 2004 and in close statewide elections during the study period. We analyze 73 million US deaths from the Multiple Cause of Death files to calculate: (1) Total excess deaths among blacks between 1970 and 2004, (2) total hypothetical survivors to 2004, (3) the probability that survivors would have turned out to vote in 2004, (4) total black votes lost in 2004, and (5) total black votes lost by each presidential candidate. We estimate 2.7 million excess black deaths between 1970 and 2004. Of those, 1.9 million would have survived until 2004, of which over 1.7 million would have been of voting-age. We estimate that 1 million black votes were lost in 2004; of these, 900,000 votes were lost by the defeated Democratic presidential nominee. We find that many close state-level elections over the study period would likely have had different outcomes if voting age blacks had the mortality profiles of whites. US black voting rights are also eroded through felony disenfranchisement laws and other measures that dampen the voice of the US black electorate. Systematic disenfranchisement by population group yields an electorate that is unrepresentative of the full interests of the citizenry and affects the chance that elected officials have mandates to eliminate health inequality.

(with J Bound, AT Geronimus), International Journal of Epidemiology, 2014, 43 (3), 818-826

Infant mortality rates in the US exceed those in all other developed countries and in many less developed countries, suggesting political factors may contribute. Annual time series on overall, White and Black infant mortality rates in the US were analysed over the 1965–2010 time period to ascertain whether infant mortality rates varied across presidential administrations. Data were de-trended using cubic splines and analysed using both graphical and time series regression methods. Across all nine presidential administrations, infant mortality rates were below trend when the President was a Democrat and above trend when the President was a Republican. This was true for overall, neonatal and postneonatal mortality. Regression estimates show that, relative to trend, Republican administrations were characterized by infant mortality rates that were, on average, 3% higher than Democratic administrations. In proportional terms, effect size is similar for US Whites and Blacks. US Black rates are more than twice as high as White, implying substantially larger absolute effects for Blacks. We found a robust, quantitatively important association between net of trend US infant mortality rates and the party affiliation of the president. There may be overlooked ways by which macro-dynamics of policy impact microdynamics of physiology, suggesting the political system is a component of the underlying mechanism generating health inequality in the USA.

(with J Bound, AT Geronimus), International Journal of Epidemiology, 2014, 43 (3), 831-834

(with AS Karlamangla, TL Gruenewald, D Miller-Martinez, SS Merkin, TE Seeman), Journal of Biosocial Science, 2019, 1-18

Social stratification is an important mechanism of human organization that helps to explain health differences between demographic groups commonly associated with socioeconomic gradients. Individuals, or group of individuals, with similar health profiles may have had different stratification experiences. This is particularly true as social stratification is a significant non-measurable source of systematic unobservable differences in both SES indicators and health statuses of disadvantage. The goal of the present study was to expand the bulk of research that has traditionally treated socioeconomic and demographic characteristics as independent, additive influences on health by examining data from the United States. It is hypothesized that variation in an index of multi-system physiological dysregulation – allostatic load – is associated with social differentiation factors, sorting individuals with similar demographic and socioeconomic characteristics into mutually exclusive econo-demographic classes. The data were from the Longitudinal and Biomarker samples of the national Study of Midlife Development in the US (MIDUS) conducted in 1995 and 2004/2006. Latent class analyses and regression analyses revealed that physiological dysregulation linked to socioeconomic variation among black people, females and older adults are associated with forces of stratification that confound socioeconomic and demographic indicators. In the United States, racial stratification of health is intrinsically related to the degree to which black people in general, and black females in particular, as a group, share an isolated status in society. Findings present evidence that disparities in health emerge from group-differentiation processes to the degree that individuals are distinctly exposed to the ecological, political, social, economic and historical contexts in which social stratification is ingrained. Given that health policies and programmes emanate from said legal and political environments, interventions should target the structural conditions that expose different subgroups to different stress risks in the first place.

Social Science & Medicine - Population Health , 2019, 8, 100440

We propose the politics hypothesis—i.e., the hypothesis that political forces comprise either a powerful predecessor of the social determinants of health or are essential social determinants of health themselves. We examine the hypothesis that political actors like presidents, their ideology, and institutions like the political parties they represent shape overall and race-specific health outcomes. Using census and Vital Statistics data among many other sources, we apply both theory- and data-driven statistical methods to assess the role of the president’s party and the president’s political ideology as predictors of overall and race-specific infant mortality in the United States, 1965–2010. We find that, net of trend, Republican presidencies and socially-conservative ideology of U.S. presidents are strongly associated with slower declines of infant mortality rates, overall and for white and black infants, compared to Democratic and socially-liberal presidents in the U.S. Approximately half (46%) of the white-black infant mortality gap, about 20,000 additional infant deaths, and most if not all the infant mortality rate gap between the U.S. and the rest of the developed world, can be attributed to the 28 years of Republican administrations during the study period. These findings are consistent with the politicization of public health and the conceptualization of politics as a powerful predecessor, in the causal chain, of the social determinants of health. Understanding the political ideological and institutional contexts in which health policies and healthcare and welfare programs are implemented, as well as how governments construct culture and social psychology, provide a more comprehensive framework for understanding and improving population patterns of disease, mortality, and entrenched racial disparities in health in the U.S.

(with D Cottrell, MC Herron, DA Smith), American Politics Research, 2019, 47(2), 195-237

On account of poor living conditions, African Americans in the United States experience disproportionately high rates of mortality and incarceration compared with Whites. This has profoundly diminished the number of voting-eligible African Americans in the country, costing, as of 2010, approximately 3.9 million African American men and women the right to vote and amounting to a national African American disenfranchisement rate of 13.2%. Although many disenfranchised African Americans have been stripped of voting rights by laws targeting felons and ex-felons, the majority are literally “missing” from their communities due to premature death and incarceration. Leveraging variation in gender ratios across the United States, we show that missing African Americans are concentrated in the country’s Southeast and that African American disenfranchisement rates in some legislative districts lie between 20% and 40%. Despite the many successes of the Voting Rights Act and the civil rights movement, high levels of African American disenfranchisement remain a continuing feature of the American polity.

(with AT Geronimus, J Bound, TA Waidmann, B Timpe), Journal of health and social behavior, 2019, 60 (2), 222-239

Discussion of growing inequity in U.S. life expectancy increasingly focuses on the popularized narrative that it is driven by a surge of “deaths of despair.” Does this narrative fit the empirical evidence? Using census and Vital Statistics data, we apply life-table methods to calculate cause-specific years of life lost between ages 25 and 84 by sex and educational rank for non-Hispanic blacks and whites in 1990 and 2015. Drug overdoses do contribute importantly to widening inequity for whites, especially men, but trivially for blacks. The contribution of suicide to growing inequity is unremarkable. Cardiovascular disease, non-lung cancers, and other internal causes are key to explaining growing life expectancy inequity. Results underline the speculative nature of attempts to attribute trends in life-expectancy inequity to an epidemic of despair. They call for continued investigation of the possible weathering effects of tenacious high-effort coping with chronic stressors on the health of marginalized populations.

(with A Pantoja, RA Jimeno), 2012, South Bend: University of Notre Dame Press, 130-148