Trending politics, trending health: How divergent developments in welfare states explain diverging mortality profiles in wealthy nations

Mortality trends in the United States are increasingly diverging from mortality trends in other wealthy nations. Prominent explanations, some drawn from life-course perspectives, emphasize health-related behavior such as smoking, diet, and exercise. Surprisingly, very little research traces these divergent trends in population health to divergent trends in politics – especially divergent trends in the development of social policies that together constitute the welfare state. This is surprising for several reasons, one of which is the fact that premature mortality in the United States and other wealthy countries is concentrated among cohorts who came of age during a period of radical change in the welfare state. Over the so-called “golden age” of welfare-state expansion, which spans roughly the 1945-1975 period, Western democracies developed varying complexes of citizenship rights, and differences among welfare-state regimes were cemented. Our paper develops a theoretical approach to trends in population health that foregrounds politics, and explains why it is that politics and political institutions (broadly: the “rules of the game”) should shape population health. Our specific aim is to develop a new approach to understanding why trends in mortality in the US are increasingly diverging from other wealthy nations. Our evidence draws on several sources of data and published research, including new cross-nationally and historically comparative analyses of population health that develop and test political-institutional hypotheses, as well as focused case-studies of interventions that shed light on several causal mechanisms that connect politics, institutions, and population health.