As the federal government debates the financial stimulus needed to address the economic fallout from the coronavirus pandemic, the last recession offers an important reminder of the long-term health effects of a slow and uneven recovery. As large parts of the U.S.—particularly rural areas—failed to fully recover economically following the Great Recession, they experienced markedly different health fortunes from areas that experienced a robust recovery. If the pandemic exacerbates these economic trends, we may be left with an even greater disparity in the health and well-being of Americans living in different parts of the country.

The decade following the Great Recession saw the average life expectancy of Americans decline for the first time since the Spanish Flu pandemic of 1918. Studies have noted the rise in so-called “deaths of despair,” or deaths from substance abuse and suicide, particularly among the middle-aged white population during this period. The decline in deaths from heart disease, one of the major health advancements of the second half of the 20^th century, has also slowed down, and may now be rising again.

What is driving these troubling trends? My colleagues and I published a new study in the Journal of the American Medical Association, in which we found that the diverging economic fortunes of different parts of the country in the post-recession period were linked to differing death rates from heart disease and stroke among middle-aged Americans.

After examining nearly all deaths for middle-aged adults from 2010 to 2017, we noted that death rates from heart disease and stroke continued to decline in areas of the country that prospered economically, but remained flat where the economy faltered (Figure 1). In 2010, counties that had the greatest increase in economic prosperity over this period had, on average, 14 fewer deaths from heart disease for every 100,000 middle-aged residents compared to counties that had the greatest decrease in prosperity. By 2017, this gap had increased to 21 deaths for every 100,000 middle-aged adults. The more an area prospered economically, the greater the decline in death rates from heart disease.

These deaths were not confined to the so-called American “stroke belt,” a swath of southern states with the highest levels of stroke and heart disease in the U.S. Instead, the counties that experienced worsening heart disease deaths predominantly were in rural areas throughout the U.S. Rural communities have had a slow, yet steady, economic decline for decades and many have not recovered from the Great Recession. On top of issues such as closing rural hospitals, the ongoing pandemic, particularly in its later stages, has also disproportionately impacted rural areas. Although the economic disruptions brought on by the pandemic may be unique and could be followed by a robust economic recovery with the availability of vaccines and improved treatments, there is already evidence that the economic brunt is being disproportionately felt by people who were already on the lower end of the socioeconomic spectrum.

How should policymakers respond to these trends? Given the connection between economic prosperity and health, policies that aim to ensure the financial stability of people and their communities may translate into improved health outcomes for years to come. In a prior study, we found that expansion of Medicaid under the Affordable Care Act has reduced the number of people dying from heart disease and related disorders. Several other studies have also shown how Medicaid expansion led to improvements in different health outcomes. However, 12 states, including Texas and Florida, have yet to expand Medicaid. Other researchers have found that more generous unemployment benefits may lessen the impact of job losses on health.

Our study demonstrates some of the important health consequences of an uneven economic recovery. If the economic fallout from the pandemic is left unchecked, the disparities seen after the last recession will continue to grow and the health impacts will be felt for years to come.

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The study, Association Between County-Level Change in Economic Prosperity and Change in Cardiovascular Mortality Among Middle-aged US Adults, was published in JAMA on February 2, 2021. Authors include Sameed Ahmed M. Khatana, Atheendar S. Venkataramani, Ashwin S. Nathan, Elias J. Dayoub, Lauren A. Eberly, Dhruv S. Kazi, Robert W. Yeh, Nandita Mitra, S. V. Subramanian, and Peter W. Groeneveld.