Context: This project investigates the role of state-level institutions in explaining variation in population health in the American states. Although cross-national research has established the positive effects of democracy on population health, little attention has been given to subnational units. The authors leverage a new data set to understand how political accountability and a system of checks and balances are associated with state population health.
Methods: The authors estimate error correction models and two-way fixed effects models to estimate how the strength of state-level democratic institutions is associated with infant mortality rates, life expectancy, and midlife mortality.
Findings: The authors find institutions that promote political accountability are associated with lower infant mortality across the states, while those that promote checks and balances are associated with longer life expectancy. They also find that policy liberalism is associated with better health outcomes.
Conclusions: Subnational institutions play an important role in population health outcomes, and more research is needed to understand the link between democracy and health. The authors are the first to explore the link between democratic institutions and population health within the United States, contributing to both the social science literature on the positive effects of democracy and the epidemiological literature on subnational health outcomes.