. %  W  i  t  h  A  c  c  e  s  s  -1  9  %  -2  4  %  -1  9  %  -2  5  %  1  .  3  E  -2  7  -1  .  1  E  +  0  1  C  l  i  n  i  c  a  l  C  a  r  e   %  V  a  c  c  i  n  a  t  e  d  -6  %  -5  %  -4  %  -8  %  3 . There is a clear relationship between the obesity rate, physical inactivity rate, smoking rate, and life expectancy and the Republican margin shift in these states. The copyright holder for this this version posted August 11, 2020. ; http://dx.doi.org/10.1101/2020.08.05.20169003 doi: medRxiv preprint different demographics: the average "% 65 and older" in Republican counties was 19.68% higher compared to Democratic counties; the average "% Non-Hispanic White" in Republican counties was 50.20% higher; the average "% Rural" in Republican counties was 93.91% higher; and the average "% with Some College" in Republican counties was 8.51% lower. These demographic differences are also driving healthcare differences. For example, Republican counties received 52% of Medicare funding (of which patients over 65 account for 85% 24 The median Republican county had 11% fewer residents who completed some college and the bottom and top quartiles were 6% and 11% less respectively. Table 2 shows percent differences between the 1 st quartile, median, 3 rd quartile and means for different health-related variables as well as t-statistics and p-values. The median Republican county had a 17% higher . CC-BY 4.0 International license preprint (which was not certified by peer review) is the author/funder. It is made available under a The copyright holder for this this version posted August 11, 2020. ; http://dx.doi.org/10.1101/2020.08.05.20169003 doi: medRxiv preprint " injury death rate" and a 26% higher " % Disconnected Youth" rate. The median Republican county had a 50% higher rate of coal workers' pneumoconiosis, 25% higher rate of chronic respiratory diseases, and a 32% higher rate of chronic obstructive pulmonary disease. The mortality risk was higher in every age group for the median, and bottom quartile counties, and lower for the age groups less than 65. The healthcare costs per capita were higher in Democratic counties (including Imaging Costs per Capita, Procedures Per Capita Actual Costs, Tests Per Capita Actual Costs, and Actual Costs per capita). There were consistently higher Medicaid participation rates among Democratic counties. The median uninsured % and uninsured % among individuals with less than 138% of the poverty line were higher in Republican counties by 2% and 11%, respectively. The insurance rates were much higher in Democratic counties among those with and without a high school education. The median Republican county had 2% lower life expectancy overall and 3% lower life expectancy among whites. Cancer rates were higher in most Republican counties than Democratic counties, with the exceptions of prostate, liver, and stomach cancers.
The median Republican county has a 13% higher obesity rate, a 21% higher diabetes rate, 19% higher physical inactivity rate, a 24% higher opioid prescribing rate, and a 6% higher smoking rate. Republican counties are older, with the median Republican county having 21% more individuals in the % 65 and over demographic. They are also whiter, with the median Republican county having a 69% greater rate in the % Non-Hispanic White demographic.
Republican counties are more rural (median % rural rate is 234% higher for Republican counties), and access to care decreases in these counties accordingly: the primary care physician rate (ratio of population to primary care physicians) is 37% lower in the median Republican . CC-BY 4.0 International license preprint (which was not certified by peer review) is the author/funder. It is made available under a The copyright holder for this this version posted August 11, 2020. ; http://dx.doi.org/10.1101/2020.08.05.20169003 doi: medRxiv preprint counties. Some of these health behavior, life expectancy, and health insurance rate differences presented in Table 2 are visualized in Figure 1 . . CC-BY 4.0 International license preprint (which was not certified by peer review) is the author/funder. It is made available under a The copyright holder for this this version posted August 11, 2020. ; http://dx.doi.org/10.1101/2020.08.05.20169003 doi: medRxiv preprint
In this retrospective cohort study, we found statistically significant relationships between a number of health measures and the political voting patterns of counties in 2016 and over the last three decades. By calculating the median difference between counties that voted Democrat or Republican in the 2016 election, we found that residents of counties that voted Republican in the last presidential election have increased median incidence cardiovascular disease (11% median difference), diabetes (21%), obesity (13%), self-harm (22%), decreased median life expectancy (2%), and physical activity (19%) compared to residents of counties that voted Democrat.
Collectively, these data indicate that counties that voted Republican in the 2016 election are
The trends in Fig 2 show increases over time in counties that voted Republican in 2016 compared to Democrat in negative health outcomes such as diabetes and obesity concomitantly with decreases in life expectancy. This indicates that these counties have experienced an overall worsening in quality of health over time. It is important to note that these are not necessarily counties that have voted Republican in previous elections. The Affordable Care Act (ACA) was the signature legislative accomplishment of the Obama administration. Yet during his presidency, counties that ultimately voted Republican in the 2016 election continued to experience an overall worsening of healthcare measures, despite improved insurance rates. This worsening in the context of the ACA may be one of a number of factors contributing to individual voting decisions for Trump in 2016. 25 As the incidence of these chronic diseases grows, so does the overall cost of treating them. 90% of the nation's annual healthcare expenditures of $3.5 trillion is for people with chronic and/or psychiatric conditions. Diabetes accounts for $237 billion every year, with 30 million Americans affected and 84 million with prediabetes; obesity directly costs $147 billion a year; lack of physical activity costs $117 billion annually; smoking leads to $170 billion in direct medical costs; and heart disease and stroke cost $199 billion per year and lead to $131 billion in lost productivity. 26 As patients live with these chronic diseases for longer, the number of complications for which treatment will be necessary will increase, further increasing costs. As these costs rise, it is likely that attempts will be made to curb healthcare spending. This will trap patients in these vulnerable counties in a vicious cycle: lack of access will lead to increased incidence of chronic disease, which will increase healthcare costs per patient, which will further increase total healthcare expenditure. In light of proposed measures amounting to healthcare . CC-BY 4.0 International license preprint (which was not certified by peer review) is the author/funder. It is made available under a The copyright holder for this this version posted August 11, 2020. ; http://dx.doi.org/10.1101/2020.08.05.20169003 doi: medRxiv preprint austerity, as well as the evidence of the deleterious effects of austerity on health in general, more targeted and effective healthcare spending (rather than cuts) is warranted. 27 The majority of Medicare funds (52%) go to counties that voted Republican in 2016.
Nevertheless, the Trump administration is mulling large cuts to Medicare and other entitlement programs. 28 Additionally, the majority of individuals with preexisting conditions live in states that voted Republican in 2016 (55.5%), running counter to the Trump administration's policies that weaken laws protecting those with pre-existing conditions. 29 Our analysis showed trends between voting patterns and health outcomes, but it is also important to study patterns between health policy and political party affiliation. One direct consequence of political party affiliation on health policy is Medicaid expansion, which many more Democratic states adopted. All together, our data indicate that the health needs of certain areas are not being adequately addressed by their elected officials. States that expanded Medicaid were associated with a number of positive health measures, including improved access to care, better glucose monitoring in diabetes, better hypertension control, reductions in rates of major postoperative morbidity, and reductions in preventable hospitalizations. 303132 35 In light of these data, as well as those indicating states that had Medicaid expansion showed improved health measures, it is clear that states that did not . CC-BY 4.0 International license preprint (which was not certified by peer review) is the author/funder. It is made available under a The copyright holder for this this version posted August 11, 2020. ; http://dx.doi.org/10.1101/2020.08.05.20169003 doi: medRxiv preprint expand Medicaid harm their constituency by failing to do so. The impact of health has been previously shown to affect political participation, with people in poor health being less likely to vote. 36 Researchers have also looked at the public health voting patterns in the US senate and found that Democratic senators averaged 59.1% points higher in voting accordance with public health policy recommendations compared to Republican Senators, suggesting that Republican senators diverge significantly from the recommendations of the American Public Health Association (APHA). 37 Given the large the differences in health behaviors of Democrat and Republican counties with respect to physical inactivity, obesity, and smoking, the policy differences should be fully examined. It is worth systematically exploring the extent to which political party affiliation affects public health policymaking and the impact this has on public health.
As of late May 2020, the COVID-19 pandemic has affected Democratic and Republican counties differently. The most cases and deaths from the virus have occurred in dense urban areas, which lean Democrat, including the epicenter in New York City. The New York Times estimated that counties Trump won in 2016 reported 27 percent of the cases and 21 percent of the deaths. 38 This divide is further highlighted by the partisan nature of policies implemented by elected officials (i.e. governors) in response to the crisis.
Healthcare is arguably the central topic of the 2020 election, with COVID-19 serving as an avatar for the politicization of healthcare. Medical care during the pandemic, risk of complications during the pandemic, perceptions of the pandemic, behavior change during the pandemic, the government response during a pandemic, and the social safety net during the pandemic, have all been divided along partisan lines.
. CC-BY 4.0 International license preprint (which was not certified by peer review) is the author/funder. It is made available under a The copyright holder for this this version posted August 11, 2020. ; http://dx.doi.org/10.1101/2020.08.05.20169003 doi: medRxiv preprint This study has several limitations. The first is that we cannot attribute voting behavior to individual Democrat and Republican voters. While we have examined the voting patterns at the county level, it is true that voter turnout in the United States is low (55.7% in the 2016 election) compared to other developed countries and varies between demographics, so whether the results in a given county reflect the true preferences of its residents is questionable. Similarly, the majority of lower socioeconomic individuals do not vote, which skews the data towards those who can, who may also be healthier on average. These data do not indicate the healthcare differences between individual voters and should not be understood as a reflection on individual party members.
Here we find strong relationships between voter party affiliation and health outcomes.
These outcomes stem from both individual mechanisms (like the self-expressed lower priority of health issues in republican voters) as well as institutional aggregate measures (e.g. ACA and
Medicare expansion choices falling along party lines). Although polarization and partisanship are increasing in western democracies, the link between partisanship and health is particularly strong in the US, and our work suggests that it is in the public interest to further study the mechanisms that link partisanship to health outcomes in an attempt to decouple political affiliation and health in the future.
The analysis and code from this manuscript can be found at the following link: https://github.com/tymor22/Health-and-Politics/. All of the data analyzed in this manuscript is available at the following link: https://zenodo.org/record/3936108#.Xyc5O_hKh_Q with the DOI number 10.5281/zenodo.3936108.
. CC-BY 4.0 International license preprint (which was not certified by peer review) is the author/funder. It is made available under a The copyright holder for this this version posted August 11, 2020. ; http://dx.doi.org/10.1101/2020.08.05.20169003 doi: medRxiv preprint . CC-BY 4.0 International license preprint (which was not certified by peer review) is the author/funder. It is made available under a The copyright holder for this this version posted August 11, 2020. ; http://dx.doi.org/10.1101/2020.08.05.20169003 doi: medRxiv preprint