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Cross-state differences in health

Do U.S. States' Socioeconomic and Policy Contexts Shape Differences in Adult Disability?

Jennifer Karas Montez, Mark D. Hayward, Douglas A. Wolf


In recent decades, the United States has experienced a sharp fall in its international ranking in life expectancy.  Thanks to several recent studies, it is now known that part of this fall is due to large, and growing, differences in life expectancy across U.S. states.  Less is known, however, about states’ differences in other health outcomes.  For instance, while we know that women outlive men across states in the U.S., it is not known whether women experience better or worse health outcomes than men across states.  In addition, it is not known if any state differences in health outcomes are due to states’ population characteristics (e.g., residents’ race/ethnic or educational composition) or due to the states’ economy and policies.

The authors address these issues by exploring adult disability in the U.S.  Specifically, they ask: (1) Does adult disability vary across U.S. states? (2) Are there differences by gender and age?  (3) If differences exist, do states’ socioeconomic and policy contexts explain the variability?

Using nationally-representative data from the American Community Survey that includes over 5.5 million U.S.-born adults 25-94 years of age, the authors apply the World Health Organization’s (WHO) socio-ecological framework to determine if differences in disability exist across states and, if so, what are possible explanations for those differences.  The WHO framework posits that structural determinants—defined as socioeconomic and policy contexts that create stratified systems of economic resources across gender, race/ethnicity, and education level—differentially expose individuals to health risks and health resources.  Therefore, in addition to analyzing individual characteristics (gender, age,  race/ethnicity, and education level), the authors examine the following state-level factors:  economic output (how economically healthy is the state), income inequality (do more or fewer people share in a state’s prosperity), years with the state supplemental Earned Income Tax Credit (a social policy that benefits lower-income workers), cigarette taxes per pack (a public health policy known to positively impact health), and Medicaid program score (a measure of access to health care for low-income and disabled residents).

Key Findings

  • Disparities in adult disability across U.S. states are substantial. In many states as much as 20-30% of working-age adults report a disability. See figure
  • A substantial fraction of disparities in disability across states arises from “extra-individual” factors (e.g., economic or social policies) at the state level. Among older adults, the fraction was one-half.
  • In contrast to mortality, disability differences across states are similar for women and men.
  • Living in a state with strong economic output and a population that shares more equally in those fortunes are associated with substantially lower disability rates.

Age-Standardized Disability Prevalence for Adults Aged 24-94 Years and Born in Their State of Residence

College of Liberal Arts

This caption describes the image above.

This map shows that the percentage of adults aged 25-94 years with a disability varies widely in the U.S.  For example, in many states in the south, nearly 24% of adults report a disability while several states in the Midwest have less than 15% of adults with a disability.

Policy Implications

States' investments in their populations through policies and strategies that encourage economic growth and reduce income inequality may lower the prevalence of disability in those states. An example of a state investment that is especially salubrious is Earned Income Tax Credit (EITC). Living in states with a long history of offering an EITC appears to lower the chances of disability in later life. Disability-related benefits of EITC accrue over the life course and manifest most prominently after decades of exposure. Moreover, the benefits of living in a state with EITC are not limited to EITC recipients. To the extent that EITC increases employment, raises incomes, reduces risky behaviors, and improves health as studies suggest, the benefits may reverberate across family members, friends, communities, and state budgets.

In sum, states differ dramatically in their levels of disability. A substantial portion of these differences reflect states’ investments in their populations that promote prosperity and reduce inequality.


Montez, J. K., Hayward, M. D., & Wolf, Douglas A. (2017). Do U.S. states’ socioeconomic and policy contexts shape adult disability? Social Science & Medicine 178, 115-126.

Suggested Citation

Montez, J. K., Hayward, M. D., & Wolf, Douglas A. (2017). Do U.S. states’ socioeconomic and policy contexts shape differences in adult disability? PRC Research Brief 2(3). https://doi.org/10.15781/T2HX15W5J

About the Authors

Jennifer Karas Montez is an assistant professor and Gerald B. Cramer Faculty Scholar of Aging Studies in the Department of Sociology and a faculty associate of the Aging Studies Institute, Syracuse University; Mark D. Hayward is a professor in the Department of Sociology, Centennial Commission Professor in the Liberal Arts; faculty research associate, Population Research Center, and director, Population Health Initiative, The University of Texas at Austin; Douglas A. Wolf is a professor in the Department of Public Administration and International Affairs; faculty associate of the Aging Studies Institute; director, Center for Aging & Policy Research; and senior research affiliate, Center for Policy Research and Aging Studies Institute, Syracuse University.


This study was funded in part by the Fund for the Advancement of the Discipline Award supported by the American Sociological Association and the National Science Foundation, as well as center grant 5 R24 HD042849 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development awarded to the Population Research Center at the University of Texas at Austin.