Americans die younger than people in nearly every other wealthy democracy.
A study published in September by Steven Woolf of Virginia Commonwealth University traces America's mortality crisis. In 1980, only 13 countries with populations over one million had longer life expectancy than the United States. By 2023, 37 did. People in 60 countries now have a better chance of surviving to age 40.
Young adults have suffered the greatest losses. Between 2010 and 2021, mortality among Americans aged 25 to 44 rose 71.2 percent. Drug overdoses drove much of that increase. Deaths from hypertension, metabolic disorders and alcoholic liver disease also rose. For children and teenagers, car crashes, homicide and suicide added to the toll. In 2023, 4,455 Americans aged 1 to 19 died from firearm injuries, according to a research letter published this year in the New England Journal of Medicine.
Woolf identifies familiar causes: opioids, firearms, obesity, chronic illness and an inadequate health care system. He also identifies the obstacle to fixing them. It is not a lack of solutions but a lack of political will.
He is right. But why?
Americans do not want to die young. Red America does not want its children to overdose. Blue America does not want its neighbors to go without care. The will is missing because our political system turns questions of life and death into battles in America's ongoing cold civil war.
Start with COVID-19. Yale researchers compared voter-registration and death records in Ohio and Florida. Before vaccines became widely available, registered Republicans and Democrats had similar excess-death rates. After vaccines became widely available, deaths among Republican voters were 25.8 percent higher than expected, compared with 18.1 percent among Democrats. The gap was greatest in counties with low vaccination rates.
Think about what happened. President Trump's Operation Warp Speed accelerated the development and production of COVID-19 vaccines. The first shots were administered before he left office. President Biden then expanded the rollout, delivering 200 million shots in his first 100 days. This was a medical achievement that crossed administrations. It should have crossed party lines.
Instead, vaccination became a test of which side a person trusted. Public-health guidance changed as scientists learned more about the virus, but those changes fell on a country already primed to distrust the other side. In February 2022, Pew found that roughly three-quarters of Republicans said changing recommendations had made them less confident in health officials. Researchers also found that showing Americans a video of Trump endorsing vaccination increased the number of shots administered. The messenger mattered.
This was not simply a failure of people who refused vaccination. It was a failure of a political system that made public-health officials and their recommendations part of the struggle for national power. Medical advice had become another message from the other side.
And the damage extended beyond COVID. In a study published this May in Nature Human Behaviour, Elizabeth Elder and Neil O'Brian found that conservatives experienced worsening health during the 2010s and higher mortality in the early 2020s. In a separate survey, they found that Republicans and Trump voters were less willing to seek medical care, follow doctors' advice and trust medications, even for conditions unrelated to COVID.
That is how the cold civil war reaches into the examination room. Distrust does not stop at an election or a government agency. It follows people to their doctors and affects decisions about their own health. When one national government is the prize in a permanent cold civil war, everything it touches becomes contested ground. Even medicine.
Health coverage follows the same pattern.
The Affordable Care Act offered states federal funding to expand Medicaid to low-income adults. Economists Sarah Miller, Norman Johnson and Laura Wherry found that expansion reduced annual mortality by 9.4 percent among the low-income adults aged 55 to 64 most likely to gain coverage. They estimated that 15,600 deaths in non-expansion states from 2014 through 2017 would have been prevented had those states expanded coverage.
Ten states still have not adopted the expansion. Is that because voters in Red America reject coverage for the working poor? Look at what happened when voters decided for themselves. Idaho, Utah, Nebraska, Missouri, Oklahoma and South Dakota all approved Medicaid expansion at the ballot box, despite resistance from Republican leaders.
When the question was health coverage, voters said yes. When the question was Obamacare, partisan leaders said no. The difference was not simply policy. It was tribe.
Woolf documents how health outcomes have diverged as states have divided along partisan lines, especially since 2010. Congress enacted the Affordable Care Act, Republicans tried to repeal it, and the 2025 federal budget law imposed new Medicaid eligibility requirements, with major provisions scheduled for 2027. Hospitals, insurers and patients have spent years planning around a system that national politics keeps changing.
No one builds a durable health system on ground that shifts with every election. Escaping this cycle requires changing the political structure that sustains it.
Elsewhere I have proposed a reorganization of the United States into an American Union: two semi-autonomous democratic republics, one predominantly Red and one predominantly Blue, joined by a common defense, common currency, integrated markets and freedom of movement. Each would have its own modern constitution, with enforceable rights for its political minorities.
The goal is not to create two ideologically pure republics. It is to move the struggle over domestic policy out of a single national government that both sides are determined to control. Both republics would contain conservatives, liberals, independents and people who reject those labels. While neither would be ideologically uniform, each would be a more cohesive political community, with greater agreement about the basic role of government. Disagreements would continue, without every one of them becoming a fight for control of the entire country.
That would change the health care debate. A conservative in Red America would no longer see coverage for the working poor as a concession to Blue America. A progressive in Blue America would no longer see every market-based reform as a Red America scheme to strip away care. Each republic would confront the same question: how to keep its own people alive and well.
Other countries show how many answers that question has. Switzerland uses mandatory private insurance. Britain has a national health service. Canada provides public insurance through its provinces. Singapore combines mandatory health savings with basic insurance for citizens and permanent residents. All four have longer life expectancies than the United States. Their systems are different, but all provide a foundation of broad health coverage.
A Red republic would be free to build a market-driven system. A Blue republic would be free to build a more public one. Each would be accountable for the results. Each could learn from the other, adopt what works and discard what fails. Neither would need to defend a bad policy simply because the other republic opposes it.
Public health also depends on trust. People follow medical advice, get screened and vaccinate their children when they trust the institutions asking them to do so. In 1997, Ichiro Kawachi and his colleagues found that states with lower levels of social trust had higher mortality rates. A study of 177 countries published in The Lancet found that higher trust in government and other people was associated with more COVID-19 vaccination and fewer infections.
America is running out of that trust. Tell people for long enough that the other side threatens everything they value, and they stop trusting its leaders. They start doubting its doctors and scientists. Eventually, they lose confidence in institutions they need themselves.
An American Union would change the stakes. Two more cohesive political communities, each governing itself, would give Red and Blue Americans less reason to fear one another and more reason to make their own institutions work. They could disagree about health policy without treating every disagreement as a fight for national survival.
Woolf is right that we know many of the solutions. Other countries put them to work every day. What we lack is a political structure that lets us do the same. An American Union would let each republic stop asking how to defeat the other side and start asking how to keep its people alive.
Jordan Karp is a lawyer and writer based in New York with a keen interest in American political culture, institutional reform, and civic life.
