• Lee Goldman, Maribel P Lim, Qixuan Chen, Peng Jin, Peter Muennig, and Andrew Vagelos.
• Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA. lgoldman@columbia.edu.
• J Gen Intern Med. 2019 Mar 1; 34 (3): 363371363-371.

BackgroundThe outcome of the 2016 presidential election is commonly attributed to socioeconomic and ethnic/racial issues, but health issues, including "deaths of despair," may also have contributed.ObjectiveTo assess whether changes in age-adjusted death rates were independently associated with changes in presidential election voting in 2016 vs. 2008.DesignWe used publicly available data in each of 3112 US counties to correlate changes in a county's presidential voting in 2016 compared with 2008 with recent changes in its age-adjusted death rate, after controlling for population and rural-urban status, median age, race/ethnicity, income, education, unemployment rate, and health insurance rate.Design SettingCross-sectional analysis of county-specific data.Setting/ParticipantsAll 3112 US counties.Main MeasuresThe independent correlation of a county's change in age-adjusted death rate between 2000 and 2015 with its net percentage Republican gain or loss in the presidential election of 2016 vs. 2008.Key ResultsIn 2016, President Trump increased the Republican presidential vote percentage in 83.8% of counties compared with Senator McCain in 2008. Counties with an increased Republican vote percentage in 2016 vs. 2008 had a 15% higher 2015 age-adjusted death rate than counties with an increased Democratic vote percentage. Since 2000, overall death rates declined by less than half as much, and death rates from drugs, alcohol, and suicide increased 2.5 times as much in counties with Republican gains compared with counties with Democratic gains. In multivariable analyses, Republican net presidential gain in 2016 vs. 2008 was independently correlated with slower reductions in a county's age-adjusted death rate. Although correlation cannot infer causality, modest reductions in death rates might theoretically have shifted Pennsylvania, Michigan, and Wisconsin to Secretary Clinton.ConclusionsLess of a reduction in age-adjusted death rates was an independent correlate of an increased Republican percentage vote in 2016 vs. 2008. Death rates may be markers of dissatisfactions and fears that influenced the 2016 Presidential election outcomes.

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