Red State Blue State

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The United States has concluded a divisive election and one key question that looms is: just how deep are our differences? The lay press enjoyed a long and sometimes comical run of comparisons between the demographics of Red vs. Blue States, with reported differences ranging from religious beliefs (more evangelical Christians in Red States) to education (more college graduates in Blue States) to breakfast choices (donuts in Red States vs. bagels in Blue States). But are there other, more substantive differences between Red States and Blue States, perhaps even related to health outcomes?

As emergency physicians, injuries are among our favorite outcomes to study. We chose to evaluate injury fatalities as the outcome because injuries represent an area where public health interventions through legislation could make (and have made) a difference, including but not limited to those such as speed limits, seatbelt usage, and firearm restrictions. So how do injury fatalities associate with state-based political outcomes of the 2012 election? We compared injury mortality rates in states based on whether they voted for Barack Obama (Blue) or Mitt Romney (Red) in the 2012 presidential election, using 2010 data from the Web-based Injury Statistics Query and Reporting System (WISQARS) and the U.S. Census Bureau. Indeed, we found a political-injury divide. Among the 10 states with the lowest overall injury fatality rates (range 37.6/100,000 individuals to 50.6/100,000 individuals), nine voted for Obama. Among the 10 states with the highest overall injury fatality rates (range 74.8/100,000 to 91.0/100,000), nine voted for Romney (Data Supplement S1, available as supporting information in the online version of this paper). Of the 10 states with the lowest motor vehicle fatality rates (range 5.5/100,000 to 8.7/100,000), all 10 voted for Obama, while all 10 of the states with the highest motor vehicle fatality rates (range 17.3/100,000 to 23.0/100,000) voted for Romney. Similarly, all 10 of the lowest firearm fatality rate states voted for Obama (range 3.2/100,000 to 7.9/100,000), while seven out of 10 of the states with highest firearm fatality rates voted for Romney (range 14.5/100,000 to 20.5/100,000; see Data Supplement S2, available as supporting information in the online version of this paper, for breakdown by state).

Clearly, voter choices do not lead to injury deaths. And just because a majority voted for one party or another, there can be dramatic voting differences across a state: for instance, 2012 Blue States such as Pennsylvania and Colorado have Democratic pockets in populous urban areas but have large swaths of Red counties. Thus, facile comparisons based on potentially specious political observations do not tell the entire story.

But just because the political theory does not really bear weight, or at least is more complex than two colors, the fact remains that there are significant state-based differences in health outcomes, in this case injury mortality. As we further explored what potential factors could explain these differences, we came up with the ultimate predictor: poverty. In fact, the real Red State–Blue State divide appears to be based on poverty, with eight out of 10 of the states with the lowest percentages of people living in poverty having voted for Obama (8.3% to 11.6% of the states' population living below poverty) and eight out of 10 of states with the highest percentages of people living in poverty having voted for Romney (17.9% to 22.4% living below poverty). So our Red State vs. Blue State divide was likely more a Poor State vs. Rich State divide.

Poverty, in fact, is likely the greatest overall public health problem in this country—the public health issue that affects all other outcomes. And we have many public health outcomes to tackle in our country. The Kaiser Family Foundation[1] demonstrates substantial state-based differences in infant fatality, obesity, and life expectancy—all outcomes that should be modifiable in an industrialized nation with considerable resources and the infrastructure to make large-scale public health interventions. Whether or not we can work together to modify these outcomes by attacking the inequities and risk factors that underlie them remains to be seen.

That is not to say politics and lawmaking do not play a large role in public health. We have recently shown that booster seat legislation is associated with decreased fatalities in children 4 to 7 years of age.[2] Other important legislation in the past few decades that has greatly improved public health outcomes include seatbelt laws,[3] driving-under-the-influence laws,[4] and smoking restrictions,[5] among a host of others. All of these legislative acts faced significant political hurdles in both Red and Blue States, but slowly have become national standards. Drunk driving, which used to be considered acceptable behavior, is now no longer socially acceptable after considerable legislative and public health efforts over the past four decades. Such paradigm shifts are possible, but require tenacity and a long-term perspective. Firearm legislation, a lightning rod issue in the current political environment, also offers the potential to reduce firearm fatalities in the United States, which are among the highest in the world.

The bottom line is this: Red State or Blue State aside, there are huge health inequities in this country, many of which are associated with poverty. While the current political discourse rallies behind taxing (or not taxing) the wealthy, much more attention needs to be dedicated to solutions aimed at reducing poverty and the associated preventable adverse health outcomes. When fatality rates vary as much as sixfold across states, it is time to recognize that the politics of health have their own cliff.

Ancillary