50 States, 50 Pathways to Health

With all eyes on federal policy changes, research on state-level laws may provide alternate routes to improving population health. In a recent Columbia Population Research Center panel, Mailman School faculty made a case that state laws and policies, even those not directly related to health, affect the health of immigrants and other vulnerable groups.

Jennifer Hirsch, professor of Sociomedical Sciences, presented her research on people living in states with inclusionary and exclusionary immigration policies. The study, published in Social Science and Medicine, found that Latinos in states with a more exclusionary policy climate had more days of poor mental health than those in more supportive states. (Hirsch puts the study in context in an op-ed just published in The Hill.)

Combining information on 14 policies with provisions affecting immigrants, from access to healthcare and social services, to rules around voter IDs and driver’s licenses, Hirsch and colleagues developed an index that assessed the overall policy climate. They then used the index to assess the impact of that climate on Latinos in 31 states with large or growing Hispanic populations. They observed significant policy differences state to state: For example, New Mexico and Washington grant licenses to undocumented immigrants; Alabama, Missouri, and Oklahoma do not.

“Even state policies that aren’t explicitly about health matter for the health of people living there,” said Hirsch. Latinos, who felt the brunt of the laws and related bias, saw the biggest health declines, but everyone in the states suffered. “An exclusionary policy climate is bad for everyone.”

Of course, immigrants aren’t the only group for whom the state-level policy context matters. Take LGBT populations: According to data compiled by the Human Rights Campaign, only 20 states and the District of Columbia prohibit discrimination related to sexual orientation and gender identity, and only 16 states and the District of Columbia have a law that addresses hate or biased crimes based on sexual orientation or gender identity. One of Hirsch’s collaborators, Mark Hatzenbuehler, associate professor of Sociomedical Sciences, presented his own research finding higher rates of mood and anxiety disorders in lesbian, gay, and bisexual adults in states without these protections compared to those in states with these protections.

Hatzenbuehler also presented a separate study finding a 37-percent hike in mood disorders among LGB adults after their state passed bans on same-sex marriage, results of which have been cited in several court cases. Intriguingly, he also found signs that mood disorders declined somewhat among LGB adults in states that did not impose a ban.

With all the research on the health effects of various policies, are policymakers actually paying attention to the evidence? Under what circumstances does science get a seat at the table?

Seeking to answer these questions, Constance A. Nathanson, professor of Sociomedical Sciences, and collaborators interviewed legislators at four state capitals. They identified two broad styles of governance, “individualistic” and “collaborative.”  The former style inclines legislators to create personal networks of trusted experts, exchanging authoritative policy-related information largely out of the public eye.  By contrast, in states with “collaborative” networks, policies are hashed out with all stakeholders present.  Policymakers consider research-based evidence under both systems, according to Nathanson, but collaborative systems are less reliant on the personalities and preferences of individual legislators.

The power of individual states extends beyond the laws they pass. In the case of the federal WIC nutrition program for low-income mothers and children under age 5, state officials are free to tailor the federally mandated food packages for the types of foods available and preferred by families in their state. They can also be creative in how they counsel and support women to introduce their children to healthy lifestyles. 

According to Sally Findley, professor in the Departments of Population and Family Health and Sociomedical Sciences, in January 2009 New York was the first state to roll out the revamped healthy WIC food package, adding choices for fresh fruits, vegetables, and low-fat milk. The state also changed its style of educating WIC participants to emphasize peer counseling around issues like breastfeeding and physical activity. Findley and collaborators at New York State’s Division of Nutrition found that between 2009 and 2014 women reported significant increases in their children’s healthy eating and time in “active play,” along with decreases in television viewing and consumption of sugar-sweetened beverages, all contributing to  a statewide decline in early childhood obesity.

Looking ahead, Hirsch says researchers should examine whether states and cities can provide a buffer against the impacts of the rapidly changing federal policy landscape. Public health advocates too may want to cast a more careful eye to the state and municipal level, and focus on policies—even policies that they might not initially consider to be within the domain of public health, like driver’s licenses for undocumented immigrants.