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Research Special Paper

Political environment and mortality rates in the United States, 2001-19: population based cross sectional analysis

BMJ 2022; 377 doi: (Published 07 June 2022) Cite this as: BMJ 2022;377:e069308

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Politics and mortality in the United States

  1. Haider J Warraich, assistant professor of medicine123,
  2. Pankaj Kumar, internal medicine intern4,
  3. Khurram Nasir, chief of Division of Cardiovascular Prevention and Wellness56,
  4. Karen E Joynt Maddox, co-director of Center for Health Economics and Policy7,
  5. Rishi K Wadhera, section head of health policy and equity research38
  1. 1Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, MA, USA
  2. 2Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
  3. 3Harvard Medical School, Boston, MA, USA
  4. 4Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
  5. 5Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA
  6. 6Center for Outcomes Research, Houston Methodist, TX, USA
  7. 7Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
  8. 8Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
  1. Correspondence to: H J Warraich hwarraich{at}
  • Accepted 17 May 2022


Objective To assess recent trends in age adjusted mortality rates (AAMRs) in the United States based on county level presidential voting patterns.

Design Cross sectional study.

Setting USA, 2001-19.

Participants 99.8% of the US population.

Main outcome measures AAMR per 100 000 population and average annual percentage change (APC).

Methods The Centers for Disease Control and Prevention WONDER database was linked to county level data on US presidential elections. County political environment was classified as either Democratic or Republican for the four years that followed a November presidential election. Additional sensitivity analyses analyzed AAMR trends for counties that voted only for one party throughout the study, and county level gubernatorial election results and state level AAMR trends. Joinpoint analysis was used to assess for an inflection point in APC trends.

Results The study period covered five presidential elections from 2000 to 2019. From 2001 to 2019, the AAMR per 100 000 population decreased by 22% in Democratic counties, from 850.3 to 664.0 (average APC −1.4%, 95% confidence interval −1.5% to −1.2%), but by only 11% in Republican counties, from 867.0 to 771.1 (average APC −0.7%, −0.9% to −0.5%). The gap in AAMR between Democratic and Republican counties therefore widened from 16.7 (95% confidence interval 16.6 to 16.8) to 107.1 (106.5 to 107.7). Statistically significant inflection points in APC occurred for Democratic counties between periods 2001-09 (APC −2.1%, −2.3% to −1.9%) and 2009-19 (APC −0.8%, −1.0% to −0.6%). For Republican counties between 2001 and 2008 the APC was −1.4% (−1.8% to −1.0%), slowing to near zero between 2008 and 2019 (APC −0.2%, −0.4% to 0.0%). Male and female residents of Democratic counties experienced both lower AAMR and twice the relative decrease in AAMR than did those in Republican counties. Black Americans experienced largely similar improvement in AAMR in both Democratic and Republican counties. However, the AAMR gap between white residents in Democratic versus Republican counties increased fourfold, from 24.7 (95% confidence interval 24.6 to 24.8) to 101.3 (101.0 to 101.6). Rural Republican counties experienced the highest AAMR and the least improvement. All trends were similar when comparing counties that did not switch political environment throughout the period and when gubernatorial election results were used. The greatest contributors to the widening AAMR gap between Republican and Democratic counties were heart disease (difference in AAMRs 27.6), cancer (17.3), and chronic lower respiratory tract diseases (8.3), followed by unintentional injuries (3.3) and suicide (3.0).

Conclusion The mortality gap in Republican voting counties compared with Democratic voting counties has grown over time, especially for white populations, and that gap began to widen after 2008.


  • Contributors: HJW and PK contributed equally. HJW is the guarantor. All authors contributed to drafting the manuscript and provided critical revisions. PK performed the statistical analysis and all authors contributed to data interpretation. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: None received.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: HW is an advisor for Embrace Prevention Care; RW receives research support from the National Heart, Lung, and Blood Institute (grant K23HL148525-1); KEJM previously did contract work for the US Department of Health and Human Services; no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • The lead author (HJW) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Dissemination to participants and related patient and public communities: We plan to share our results on social media platforms and through potential author opinion pieces in mainstream publications that reflect and expand on the findings. We will also share this paper with our media relations team to share with outlets and prepare a press release.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

This analysis was performed using publicly available databases. Contact the corresponding author (hwarraich{at} for queries about the analysis and statistical code.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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