2024 年选举版图揭示的美国死亡率鸿沟：特朗普州与哈里斯州差异扩大至 19.2%

In this 2026 midterm election season, health care ranks third on voters’ minds. That’s no surprise: U.S. life expectancy persistently lags those in comparable countries despite substantially greater spending on health care. As health and health care become increasingly political, we asked whether the leading drivers of mortality looked different by political geography in the United States.

In 2024, the mortality rate, adjusted for differences in age composition, was 19.2% higher in states that voted for Donald Trump than in states that voted for Kamala Harris. As the Make America Healthy Again (MAHA) agenda continues to shape U.S. health policy, the causes for these differences deserve close attention.

The political mortality divide in the U.S. is a relatively new phenomenon. In 2001, mortality rates adjusted for age were just 2% higher in counties where the plurality voted for a Republican presidential candidate versus a Democratic candidate.

By 2019, that relative difference had widened to 16.1%. The widening gap followed slower declines in mortality rates in Republican versus Democratic plurality counties (-11.1% versus -21.9% from 2001 to 2019, respectively).

To better understand this divergence and its more recent evolution, we compared publicly available mortality rates (measured in deaths per 100,000 people in the population and adjusted for age) between states that by plurality voted for Trump and those that voted for Harris in the 2024 presidential election over the period 2016 to 2024.

Stark differences in mortality rates between states that went for Trump and those that went for Harris have persisted and widened. When Trump won his first presidential election in 2016, mortality from all causes was 17% higher (776 versus 664 per 100,000) in the states that eventually went for him in 2024 compared with those that went for Harris. By 2024, that difference had widened to 19.2% (774 versus 649 deaths per 100,000).

This reality in 2024 reflects modest improvement from when the gap was even wider in 2021, largely because of. Covid-19. Covid-19 mortality peaked in 2020 at 86 per 100,000 people for states that went for Harris, while Covid-19 mortality in states that went for Trump continued climbing to 122 per 100,000 in 2021.

Yet Covid-19 played just one part in a more widespread phenomenon. We also examined deaths from the leading causes in the U.S.: heart disease and cancer. Whereas heart disease mortality decreased 9.1% in states that went for Harris from 2016 to 2024, it decreased only 2.9% in states that went for Trump.

Similarly, cancer mortality decreased 12.9% in states that went for Harris but only 9.1% in states that went for Trump. The persistence of these differences beyond the pandemic points to chronic disease, not Covid-19 alone, as a key component of the political mortality divide.

Drug overdose mortality tells a different story. In 2016, drug overdose mortality was 18% (or 3.4 per 100,000) higher in states that went for Trump; in 2024, it was estimated to be 2% (0.4 per 100,000) higher in states that went for Harris. Beginning in 2023, estimated drug overdose mortality rates in states that went for Trump fell below those in states that went for Harris, following an earlier peak in 2021 for Trump states (35 per 100,000) compared with 2022 for Harris states (32.5 per 100,000).

In the nine years leading up to the second Trump administration, trends in mortality portray two increasingly disparate mortal Americas — one with persistently higher mortality from heart disease and cancer independent of higher Covid-19 mortality burden and another with a widening lead in overall mortality but slower to bend the curve in drug overdose deaths.

Politics play an influential role in health policy and access to health care likely play a part. Medicaid expansion under the Affordable Care Act has been associated with lower mortality, yet 10 states have not adopted expansion. All 10 of these states went for Trump in 2024.

Coverage losses have also been greater in non-expansion states during Medicaid unwinding, and policy changes related to Medicaid work requirements and reverification could further affect continuity of coverage.

Beyond insurance coverage, access to care is increasingly challenging in rural communities, which have historically voted Republican, with disproportionate hospital closures as just one example.

Policy responses to health events can shape mortality. Differences in political priorities could explain some of the higher Covid-19 mortality rates in states that went for Trump, recognizing that policies meant to save lives also bring collateral effects.

With the drug overdose epidemic, mortality rates from drug overdose between states that went for Trump over Harris have converged. An epidemic once thought to predominantly affect distressed rural and de-industrializing communities has spread to and persisted in coastal and urban communities, where political debates continue regarding harm reduction policies versus enforcement.

Beyond health care policy, social factors shape the environment in which health is determined. Education — a predictor of health risk factors including smoking, obesity, cardiovascular risk, and preventive screening rates — has become increasingly aligned with political geography. Differences in economic opportunity, access to necessities such as healthy food and internet access, and exposure to media and popular culture can also shape health behaviors, with downstream effects on mortality.

Finally, differences in mortality from Covid-19 raise concern about an increasingly troubling phenomenon: the stark polarization of trust in health care and public health institutions across political lines. Marked differences in vaccination rates between states that went for Trump and those that went for Harris serve as a salient marker of its health effects.

“Making America healthy again” requires confronting the realities of disproportionate chronic disease-related mortality in states that went for Trump, an evolving opioid epidemic with shifting burden toward states that went for Harris, and communities vulnerable to novel infectious disease along with growing mistrust in science.

Addressing these challenges will entail sustained investment in the conditions that shape health, such as expanding access to affordable health care, closing educational gaps, strengthening rural and behavioral health infrastructure, and rebuilding trust in public health.

Policymakers ought not treat “red” and “blue” states as fixed categories of health risk but instead tackle the drivers of preventable deaths across these diverse communities. Doing so involves communities and their elected leaders bringing lived and technical expertise together to find solutions rooted in truth, evidence, and a shared conviction that while death may be more certain than taxes, disparities in when and why Americans die are not.

Brandon Yan, M.D., M.P.H., is a physician and public health researcher affiliated with the University of California San Francisco Philip R. Lee Institute for Health Policy Studies. Maddie Feldmeier, B.S., is a medical student at the UCSF School of Medicine. Renee Y. Hsia, M.D., M.Sc., is professor and vice chair of health services research of the UCSF Department of Emergency Medicine. She is also a core faculty member of the Philip R. Lee Institute for Health Policy Studies.