Who should we vote for to promote health and well-being?

For better or worse, the US has a two-party political system. This means that when a voter enters a voting booth, they often must choose between a member of the Republican party or the Democratic party. Given this system, most people are “partisan” in the sense that they vote exclusively for one party or the other. Choosing between the two parties suggests a comparison between Democratic liberal policies and Republican conservative policies. Such a comparison should help us navigate politics and make decisions when we’re in the voting booth.

While it’s true that the parties are constantly being compared with one another, much of this often operates as political noise. The fraught and seemingly broken political environment has led many people to see very little difference between the parties. In the political center many people feel that both sides, particularly the extremes, are comparably unreasonable and bad-faith. People often feel like they should be somewhere between the two parties to be “reasonable” or “free-thinking.” People on the far ends of the political spectrum mock this position as “enlightened centrism” and argue that their opponents at the opposite side of the political spectrum are clearly worse. Interestingly, many people on the far left/right can reach a similar perspective that “both sides are equally bad.” In my experience this is often leftists being critical of the “voting for the lesser of two evils” model of democracy and refusing to vote for the Democrats because they are “just another conservative party.” This is all to say, there are many people who do not think there are meaningful differences between the parties. But, one’s views on this topic can have important implications for voting, democracy, and policy.

As an evidence-based voter, my vote would be strongly influenced if there is robust empirical and scientific evidence that one political party’s policies are associated with important outcomes. The outcomes I’ll be considering here are in regard to life, death, health and illness. There are a few types of evidence to consider. At a basic level, if Democratic policies are superior to Republican policies, we would expect to see a robust correlation between liberal policies and health and wellbeing. Ideally, we would also know how different policies have better or worse effects. In other words, a correlation is great, but we would also want evidence that liberal policies cause better outcomes, and the correlation isn’t due to other factors like liberal places being wealthier (for example). 

This can all be pretty difficult for scientists to work out. We don’t do experiments where we randomly assign policies or political leadership. When political leadership correlates with so many important things, like wealth, educational outcomes, geography, and history, it can be difficult to disentangle how health is related to policy. But the scientists who study this use sophisticated methods and go through rigorous peer review processes to come to humanity’s best understanding of these issues. As a young policy scholar, I welcome corrections and notes from policy experts who take issue with any of my analysis throughout this article. With all that said, what follows is my attempt to evaluate the scientific evidence about whether US-based liberal vs conservative policies are better for physical and mental health.

Which party’s policies are associated with health and well-being?

We are in our third year of a global pandemic which has killed 6.3 million worldwide and 1 million in the US alone. This situation provided an important test case of how different policy approaches resulted in different outcomes. One difference between the two parties during the pandemic was how they responded to public health guidance. Republican leaders were less likely to promote mask wearing and vaccination. People who listened to and endorsed Trump were less likely to receive vaccinations. These differences in messaging mattered. Republicans in general were less likely to engage in social distancing to reduce spread and less likely to be vaccinated relative to their liberal counterparts. But there were also policy differences beyond messaging. Areas of the country that rolled out liberal policies like shutdowns and mask mandates ultimately had lower numbers of COVID-19 infections which likely saved lives. Medicaid expansion also reduced COVID-19 cases when re-openings occurred and likely mitigated risks to low income families. On the other hand, conservative voting restriction legislation (no doubt unintentionally) resulted in higher county-level COVID cases and mortality rates during voting seasons. A review of the relevant research is pretty clear, liberal policies are associated with better health outcomes during the pandemic: lower case numbers and less deaths.

Let’s set aside the current COVID pandemic (and likely future pandemics) though and consider health more broadly. What do researchers find when they evaluate the differences in health outcomes between liberal and conservative areas of the country? There are many studies here that all point in the same direction. One simple but important variable to consider here is mortality rate, or how often people die in the population over time. More specifically, researchers focus on “age-adjusted mortality rates” because differences in population age can significantly influence how much people die. 

A very recent study using data from 99% of the US population found that age-adjusted mortality rates are different across counties depending on if they are liberal or conservative. The age adjustment is important, because liberals are, in general, younger than conservatives. The research team evaluated mortality across five presidential elections, from 2000 to 2019. Fortunately, they found that health outcomes have been improving across the board in Democratic counties and Republic counties (Go Science!). But their main findings compared Democratic to Republican areas and found that the improvements were not equally distributed. There was a growing gap in mortality such that Democratic counties had increasingly lower age-adjusted mortality relative to Republican counties. Further, they found that the pattern was consistent across different identity groups (race, ethnicity, urban-rural location, sex). The gap between Republican and Democratic counties grew six-fold from 2001 to 2019, mostly due to changes in deaths due to “heart disease, cancer, lower respiratory tract diseases, unintentional injuries, and suicide.”

Again this is just one of many studies on this topic. This paper cites half a dozen other studies by different research groups converging on similar conclusions. A 2021 paper found that Republican counties have had lower increases in life expectancy over time. Which was a continuation of a trend found in a 2020 paper which found that if US states adopted more liberal policies (more economic regulations and protections of marginalized groups) on average women would live 2.8 years longer and men would live 2.1 years longer. This just replicates a 2017 paper finding that Trump 2016 votes coincide with declining or stagnating life expectancy. Ironically, other researchers suggest that these declines in healthcare are associated with subsequent increases in vote shares for Trump and the Republican party, the very group that rejects policies that would alleviate health declines.

If you are politically inclined to dismiss these findings, you might be thinking, “well sure, it’s because Democratic counties are more urban/wealthy/educated, this is all just correlational!” Fortunately, experts in these areas check those sorts of other explanations. The findings I have discussed very often account for such things as best they can by including these factors in their statistical models. Many of the models also evaluate changes over time so that they can see how policy shifts precede shifts in health and well-being. But we need not only rely on correlational papers, there is more research that tries to evaluate the mechanisms or reasons why liberal policies lead to better health outcomes. 

On the topic of mortality, liberal gun policies are associated with lower suicide rates and lower numbers of mass shootings. For health more broadly, another large study using data from all 50 states across 10 years found that progressive tax structures used to fund generous education spending and lenient welfare programs predicted improvements to population health. These programs counteract the negative health consequences of inequality through government programs like unemployment, worker’s comp, public assistance programs, disability programs, educational spending, and financial aid for low income people. One particular set of studies focused on LGB folks (they didn’t investigate trans people) really exemplifies why liberal policies outperform conservative policies in terms of health and wellbeing. The 2014 study found that liberal LGB protections like anti-discrimination laws, gay marriage rights, and hate crime statutes prevent mental health issues. LGB folks in liberal areas with these protections were about 2.5 times less likely to have mental health issues and had about 12 years added to their life span due to lower instances of suicide or prejudiced violence.  

This is really what the mechanism is: harm reduction. Liberal policies, for all their flaws and imperfections, reduce harm much more than their conservative alternatives. With more protections for people and stronger safety nets, people can weather difficult times using government services, they can avoid harmful discrimination, they can access healthcare, and they can get a quality education. All of this results in a healthier and happier population of people that live longer lives. Public policy folks know this. A 2021 Lancet review of Trump-era conservative health policies extensively documented the utter failure of conservative policies to maintain or improve health from 2016 through 2020.

Many liberal policies are not the BEST, they’re just better than their conservative alternatives

And yet, all of this does not suggest that liberal policies are the pinnacle of human society. Experts know what needs to be done, and it often extends beyond what Democrats and American liberal politics has on offer. For example, the ACA (American Care Act or “Obama Care”) and Medicaid expansion helped the US progress towards goals around AIDS prevention and treatment, but it hasn’t been enough. Similarly, we know how to address the factors that underlie racial disparities in health, but liberals have not made these changes a priority. The obvious systemic change we need is universal healthcare, but this policy was still not part of the Democratic party platform in 2020. We are the only high-income nation without a universal healthcare system and we lag behind other countries in our healthcare outcomes and affordability. Contrary to the findings of some (often conservative) analyses, a recent systematic review of a wide array of fiscal analyses of a single-payer healthcare system found the projected costs are entirely feasible. The fact that both political parties refuse to support this evidence-based policy doesn’t change how effective it would be. We should not feel constrained by the current zeitgeist of our political system when thinking about what is best for our country.

Nevertheless, until we reform the two party system or a viable third party emerges, every two years we will have a decision to make. Very often we will have to choose between a liberal and a conservative, a Republican and a Democrat. The choice is really about who we want our adversaries in public office to be. Do we want a conservative who is against government programs generally, or a liberal who can be more easily lobbied to support effective public policy? We should keep in mind the empirical, demonstrable, and robust findings that relative to conservative policies, liberal policies save lives, increase life spans, decrease illness, slowed the pandemic, improve mental health, decrease suicides, and on and on. Politics is full of flashy and noisy distractions, but this is a clear evidence-based signal though all that noise.

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