Abstract

Geographic disparities are a defining feature of rising U.S. working-age mortality, with state policy contexts and county economic contexts identified as critical macro-level factors. However, neither factor fully explains geographic disparities on its own.

Using 30 years of linked data on state policy contexts, county economic contexts, and county mortality, we investigate joint associations between county and state contexts and all-cause mortality among U.S. adults aged 25‒64 from 1990 to 2019. The findings reveal that the lowest predicted mortality rates are consistently in counties with low economic insecurity that are also in states with liberal policy contexts.

Moreover, counties with conservative state policies generally have higher mortality than counties with liberal state policies, regardless of county economic context. For males, this holds except in the most economically vulnerable counties and in counties with the lowest labor force participation, where, regardless of state policy context, mortality rates are similarly high. For females, being in a county with high labor force participation somewhat equalizes mortality differences across policy contexts.

Taken together, the novel findings suggest that state and county contexts have synergistic associations with working-age mortality and that accounting for both greatly advances understanding of the large and widening disparities in county-level mortality.