What causes differences in population health across states? A comprehensive examination of potential determinants of health

Background: With support from the Robert Wood Johnson Foundation, we undertook a comprehensive examination of available data to document differences in health status by state and to identify potential explanatory factors. The project was inspired by a 2013 National Research Council/Institute of Medicine study, which used a similar framework to explain the U.S. health disadvantage relative to other high-income countries.

Methods: Following a socioecological model, state-level data were collected on indicators for health outcomes (53 indicators) and five domains of potential health determinants: health systems (26 indicators), health behaviors (35 indicators), socioeconomic factors (40 indicators), the physical and social environment (49 indicators), and public policies/spending (35 indicators). The analysis was restricted to reputable public sources that offered data for at least 45 states, to the most current year with available data, and to indicators that best captured place-based influences at the community/neighborhood level. More than 1100 variables, including covariates, were examined.

Results: Large disparities in health outcomes by state, and regional patterns of poor health (e.g., Deep South), were pervasive across multiple metrics and tracked closely with similar differences in a range of health determinants. Potential explanations for state-level health disparities included not only familiar socioeconomic determinants (e.g., education, income) but also less recognized factors amenable to actionable solutions. State-level health disparities also showed some association with important upstream macrostructural factors, such as public policies and spending priorities.

Conclusions: The health of state residents is shaped by social conditions outside the health sector that influence socioeconomic wellbeing, the physical and social environment, and health behaviors.