In 2020, Healthiest States Voted for Biden, Reported Superior COVID-19 Outcomes

In 2020, Massachusetts ranked as the healthiest state in the country for the first time, while for the second year in a row, Mississippi was found to be the unhealthiest state, according to a report published by Sharecare, a digital health company, in partnership with the Boston University School of Public Health (BUSPH).

The rankings were based on Sharecare’s Community Well-Being Index (CWBI), which consists of over 3 million surveys conducted over more than a decade. Marking the 13th generation of Sharecare’s state rankings, over 450,000 respondents aged 18 and older representing 50 states were included in the 2020 report, while 600 separate data sources were analyzed to assess social determinants of health (SDOH) associated with community health outcomes.

Although the year was marred with the health and economic challenges of the COVID-19 pandemic, community well-being did improve in certain respects throughout 2020, despite significant differences reported across state lines. Overall, “from 2019 to 2020, the nation’s CWBI score remained statistically unchanged, increasing slightly from 60.2 to 60.5,” the report reads.

The CWBI consists of 10 domains to identify individual health risk and opportunity (physical, financial, social, community, purpose) and to highlight risks tied to an individual’s environment or social health factors (health care access, food access, resource access, housing and transportation, economic security).

In addition to the COVID-19 pandemic, 2020 was also an election year and brought about a racial justice reckoning, prompting global protests and activism.

“This first analysis of 2020 data from Sharecare’s Community Well-Being Index paints an initial picture of the well-being landscape amid one of the most difficult years in recent memory,” said Kimberly Dukes, PhD, executive director of BUSPH’s Biostatistics & Epidemiology Data Analytics Center.

Notably, the index showed 9 of the 10 healthiest states in the country voted for President Joe Biden in the 2020 presidential election. The same proportion of the 10 least healthy states went to former President Trump.

Following Massachusetts in the top slot, Hawaii, New Jersey, Maryland, New York, California, Connecticut, Washington, and Colorado ranked among the healthiest, with Utah being the only state in that cohort that went to Trump.

These states all reported lower than average individual health risk factors in general and better than average SDOH. In contrast to the lower-ranked states, most residents in the healthiest states reported they “enjoy supportive relationships and love in their life; have the tools to manage their economic life to increase financial security and reduce stress, regardless of income; and have access to high-quality healthcare and jobs, on top of their better physical health,” the company said in a statement.

Indiana, Tennessee, Louisiana, Alabama, Oklahoma, Kentucky, West Virginia, New Mexico, Arkansas, and Mississippi made up the least healthy states. New Mexico was the only state in this cohort that went to Biden.

Among the top 25 healthiest states, just 5 voted for Trump in the 2020 election.

Other national trends included:

• A decline in financial well-being, dropping from 60.5 in 2019 to 58.4 in 2020
• An increase in national resilience (a subcategory of the physical well-being domain) including a 4.6-point year-over-year upward trend tied to Americans’ collective ability to manage condition burden, daily productivity, lifestyle behaviors, and mental health
• Trends tied to improvements across community, purpose, and social well-being

Improvements in social support are not unprecedented during disasters, as previous research shows social support and cohesion within communities affected by natural disasters were linked to a decreased likelihood of long-term depression symptoms.

In 2020, researchers found “strong relationships between the percentage who voted Republican at the state level and low overall CWBI scores.” Geographically, healthier states also tended to be in the East Coast Atlantic region of the country or Northeast, compared with the largely Southern least healthy states.

However, some states ranked highly overall were found to lack in key areas. For example, California was ranked in the bottom position for resource access, while—though not in the overall top 10 healthiest states—North Dakota ranked first for economic security.

Those residing in southern states reported the lowest levels of community well-being, while states like Georgia, Delaware, and Maryland all saw increases in rank for this category.

“Despite differing trends noted across states and regions, the latest Index results broadly demonstrate the resilience with which Americans responded to adversity,” said Elizabeth Colyer, senior vice president and head of the CWBI at Sharecare in a statement. “While financial well-being declined, community well-being held steady…demonstrating the positive influence that non-physical factors can have on individuals’ health, including the critical impact that outlook and leadership have on our subjective evaluation of health and well-being,”

Researchers also analyzed associations between states’ health ranking and their handling of the COVID-19 pandemic, finding:

• States in the top quintile of the CWBI broadly achieved better COVID-19 measures compared with states in the bottom quintile, seeing more than 20% lower incidence rates on average and more than 50% lower death rates in comparison to states assuming a bottom 10 spot
• States in the top quintile achieved higher levels of financial, physical, and social well-being, as well as broadly higher levels of social determinants across economic security and health care access, creating a possible buffer against COVID-19 incidence and case fatality levels experienced in states among the bottom 10

Specifically, Tennessee and Oklahoma were among the 10 states with the lowest CWBI scores and ranked among the top 10 for COVID-19 case counts. However, among the top 10 states, New York, New Jersey, and Massachusetts all reported the highest COVID-19 mortality rates making it difficult to draw definitive conclusions between CWBI scores and mortality trends.

For states that faired relatively well in the pandemic, factors like superior levels of physical health, lower levels of financial stress, and improved social connections could have all played a roll.

“While nothing causal can be drawn from correlations between CWBI scores and COVID-19 risk, these findings suggest that physical and financial resilience, strength in social networks, access to critical health care resources, and residing in a state with strong economic security may enhance COVID-19 resilience – and conversely for states at the bottom of the CWBI, poor measures in these domains may enhance risk,” authors wrote.

Breaking down results along population lines, on average, counties considered rural measured well-being scores 2 or more points lower than urban counties.

To help mitigate some of the glaring discrepancies illustrated in the report, authors recommend improvement must begin with assessing communities’ current status and establishing partnerships, followed by providing resources for individuals to ensure personal engagement, transforming communities via tailored programs, and finally measuring overall impact.

Sharecare and BUSPH plan to release 2020 figures specifically geared to metropolitan statistical areas and counties, and an additional analysis focusing on well-being outcomes for Black, Indigenous, persons of color (BIPOC) communities.