A comprehensive new study from the Yale School of Public Health highlights how drastically mortality rates can vary across U.S. states — a gap that researchers attribute largely to public policy, social conditions, and environmental factors.
Published in JAMA Network Open, the study is the first of its kind to analyze mortality trends across all 50 states and Washington, D.C., by birth cohort, covering more than 179 million deaths from 1969 to 2020.
“Where you are born shouldn’t determine how long you live, but in America, it still does,” said Dr. Theodore R. Holford, lead author and Professor Emeritus of Biostatistics at Yale. “This study shows how cumulative policy decisions and social environments shape health outcomes across generations.”
Geographic Inequities in Life Expectancy
Despite an overall national decline in mortality rates over the past 50 years, the study reveals a deeply uneven trajectory across states. Women in the West and Northeast states saw the highest life expectancy gains, while those in Southern states lagged far behind.
For example, in 2020, women in Hawaii had the highest life expectancy at 84.5 years, while women in Mississippi had the lowest at 75.6 years. The U.S. national average was 80 years for women. The disparity was even more pronounced over time: women born in some Southern states between 1900 and 2000 gained fewer than three years in life expectancy, compared to over 20 years for women in states like California and New York.
For men, similar trends emerged. Hawaii again led in 2020 with a male life expectancy of 77.4 years, while Mississippi recorded the lowest at 68.9 years. The national average stood at 74.3 years.
Notably, Washington, D.C., saw one of the most dramatic improvements. While it had the lowest life expectancy in the 1900 birth cohort, by 2000, life expectancy for females had increased by 30 years and for males by 38 years — a testament, the study suggests, to strategic investments in public health.
The Role of Policy, Poverty, and Public Health
The researchers emphasize that these disparities are rooted not just in health behaviors but also in systemic differences in socioeconomic status, access to healthcare, and the strength of public health infrastructure.
“States with fewer improvements in life expectancy often have higher poverty rates and weaker public health systems,” noted co-author Dr. Jamie Tam, assistant professor of health policy and management at Yale.
For example, California was highlighted as a model for proactive health policy. It implemented smoke-free workplace laws as early as 1995, encouraging generational shifts in smoking behavior and contributing to lower mortality rates. In contrast, Kentucky made little effort to reduce cigarette use, which the study links to its persistently higher mortality rates.
States such as West Virginia, Oklahoma, Arkansas, Tennessee, Louisiana, Mississippi, and Alabama followed similar patterns of high smoking prevalence and associated health outcomes.
A Call for Policy Reform
The researchers conclude that improving life expectancy across all states requires deliberate policy action. They point to disparities in vaccination access, sanitation, tobacco regulation, and environmental protections as contributing to long-term differences in health outcomes.
“The disparities we see today are the result of decades of cumulative effects — on smoking rates, healthcare access, environmental exposures, and public health investments,” said Holford. “Without conscious policy changes, these gaps will likely persist or even widen.”
The study’s authors argue that its findings should serve as a guide for policymakers, helping them allocate resources and design interventions aimed at closing the life expectancy gap across the United States.
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