The Political Economy of Health: A Mixed-Membership Analysis of U.S. Mortality, 1999-2023

Abstract

A central task in social epidemiology is to clarify how “place” shapes health. Yet a gap persists between how “place” is theorized to affect population health and insights from a growing field of research in political science concerning the linkage between political and economic systems. Drawing on the American Political Economy (APE) framework, we conceptualize “place” as a jurisdictional context reflecting the country’s decentralized structure of governance that determines “who gets what, when, how, and where” (Hacker et al. 2022, p.2). Our conceptualization of “place” is organized along three interrelated dimensions: (1) sociopolitical and demographic structure of geographic localities (including racialized stratification), (2) economic and environmental conditions (material and environmental stratification), and (3) governance and institutional priorities (civic representation, fiscal organization, market organization, and local service systems). We illustrate our approach using U.S. counties, a key administrative spatial unit widely used for monitoring national health inequalities, and a territorialized and consequential jurisdiction through which authority, budgets, and service responsibilities are allocated. Chapter 1, “An Engine, Not A Vessel”: A Political-Economic Conceptualization of Place in Population Health,” develops the theoretical foundation of the dissertation. Drawing on structural epidemiology, relational place theory, and the APE framework to define U.S. counties as jurisdictional contexts, this chapter introduces the macro-meso-micro pathway and develops Bayesian mixed-membership models to estimate latent configurations of political-economic context. Using a cross-sectional, 51-indicator model derived from several national data sources, latent configurations were measured primarily between 2020-2023 across 3,108 contiguous U.S. counties. Chapter 2, “Place as Jurisdiction: County Context and U.S. Mortality,” examines how these latent configurations are associated with premature mortality, life expectancy, and years of potential life lost. By linking these archetypes to national mortality data, this chapter demonstrates how distinct political-economic organizations pattern survival inequities, revealing a profound 8-year gap in life expectancy between the most and least structurally advantaged county contexts. Chapter 3, “County Jurisdictional Contexts and the U.S. Drug Toxicity Crisis” extends our framework to investigate a specific, evolving, and longstanding public health emergency that has profoundly shaped U.S. mortality. A mixed-membership model specific to the drug toxicity crisis was developed to examine how local political-economic configurations conditioned successive waves of the drug toxicity crisis, particularly the period that coincided with the proliferation of synthetic opioids. Using Bayesian spatio-temporal models over a 25-year period, the results reveal how the proliferation of synthetic opioids (2013-) reordered the geography of fatal drug toxicity across the contiguous U.S., activating latent vulnerabilities in structurally disinvested urban counties, while more affluent diversified counties remained comparatively insulated. Together, the dissertation makes two primary contributions to population health research, one conceptual and one methodological. First, the conceptual contribution connects theories of structural epidemiology, health geography, and the American Political Economy framework to operationalize “place,” as a political-economic context. Second, the methodological contribution demonstrates how mixed-membership models can be used to operationalize this framework, providing a flexible, theory-informed statistical approach for estimating and mapping latent political-economic configurations of place onto geographic space. In doing so, this dissertation offers a complementary paradigm for social epidemiology to characterize geographic survival inequalities by the patterning of people and their political-economic contexts.