Primary Submission Category: Mortality
Electoral Democracy and Working-age Mortality
Authors: Jennifer Karas Montez Kent Jason Cheng Jacob M. Grumbach
Presenting Author: Jennifer Karas Montez*
Working-age mortality rates are rising in the U.S., an alarming trend that predates the COVID-19 pandemic. Reasons for the rise are not fully understood, although several have been hypothesized. The potential role of democratic erosion has been overlooked, despite warnings about the deleterious consequences. This study estimated the association between electoral democracy and working-age mortality within U.S. states and examined how economic, behavioral, and social factors contributed to the association. METHODS: We used the State Democracy Index (SDI), an annual summary of each state’s electoral democracy from 2000 to 2018. We merged the SDI with annual age-adjusted mortality rates for adults 25–64 years in each state. Regression models estimated the association between SDI and working-age mortality within states, using a 1-year lag and controlling for stable characteristics of states and annual measures of political party control, safety net policies, and share of the population that were immigrants. We examined how poverty, employment, alcohol consumption, sleep, marriage, violent crime, and incarceration may account for the association. RESULTS: Within a state, each unit increase in the SDI was associated with a significant 1.5% decrease in women’s mortality and 1.2% decrease in men’s mortality one year later, net of controls. Increasing the SDI from the 10th to 90th percentile of the SDI distribution may have resulted in 24,751 fewer deaths in 2019. Among the factors examined as contributors to the SDI-mortality association, only violent crime and incarceration rates were important. Taken together, those two factors accounted for 33% and 45% of the association among women and men, respectively. CONCLUSION: The erosion of democracy is a significant threat to population health. Improving electoral democracy could potentially avert many deaths among working-age adults.