Mapping Mental Health Across US States: the Role of Economic and Social Support Policies

Mental health (e.g., anxiety, depression) continues to be a major public health concern in the United States that impacts millions of individuals, their families, and communities. Approximately 21% of adults 18 years and older, or 55 million adults, reported symptoms of recent depression in 2022, demonstrating the wide reach of mental health challenges.¹ Moreover, rates of depression and anxiety spiked at the onset of the COVID-19 pandemic and have not fully recovered to prepandemic levels, indicating that mental health will continue to be a major concern for population health.^1–3 In addition to the impacts on individuals and their families, mental health challenges have vast economic and social costs. For instance, estimates suggest that depression accounted for $83 billion in costs in 2000,⁴ and suicide and nonfatal self-harm injuries, which are linked to mental health, cost the United States over $500 billion annually from 2015 to 2020.⁵

However, significant variation in mental health exists across states, pointing to states as an important contextual environment to consider. In this perspective, we propose a theoretical perspective that examines how state-level variation in mental health is shaped by clusters of state policies, especially economic and social support policies. To this end, we first describe patterns of population mental health at the national and state level. We then argue that differences in state policy contexts contribute to different rates of mental health outcomes (e.g., depression, anxiety) across states. We conclude by recommending key areas for future research on state policy contexts and mental health that can yield greater insight into potential policy solutions to improve mental health.

Population Mental Health: Variation Across US States

Mental health is a critical dimension of well-being that is strongly linked to physical and cognitive health risks, as well as mortality risks, throughout the life course. Specifically, substantial research documents a strong association among depression and anxiety with chronic health conditions, disability, and mortality risk in midlife and older adulthood.^6,7 Therefore, mental health is not only a key facet of quality of life and well-being but also a salient determinant of population health. As such, there is a critical need to understand geographic variation in mental health as well as the determinants of mental health that may contribute to geographic variation.

Inequalities in mental health across the United States are stark. Figure 1 presents the age- and gender-adjusted prevalence of frequent mental distress across states based on pooled cross-sectional data (2015–2019) from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance Survey. Individuals experience frequent mental distress if they report feeling mentally unhealthy (e.g., sad, anxious, troubled) for at least 14 of the previous 30 days.⁸ Frequent mental distress ranged from a low of 8.2% in South Dakota to a high of 16.7% in West Virginia from 2015 to 2019. In general, the highest rates of distress were in the South and mid-Atlantic states, as well as Oregon, Michigan, and some northeastern states, with some variation in other regions.

Figure 1.

Predicted Probability of Frequent Mental Distress by State, 2015–2019 Authors’ calculations are based on pooled, cross-sectional data from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance Survey (2015–2019). The estimates from models include age and gender.

These inequalities in mental health across states reflect the growing importance of state contexts for adult health and well-being. A robust line of research points to state contexts as important macro-level determinants of physical health, mortality risk, and life expectancy.^9–11 Specifically, researchers have pointed to the significant shift in policymaking power from federal to state governments as the driving force behind the relevance of state contexts for population health. This shift in policymaking has been fueled by the devolution and preemption movements, resulting in an overall consolidation of policymaking power in state governments. Moreover, increased political polarization has led to the bundling of policies within states, with states looking increasingly different from one another as politics and policies diverge. Lastly, the rate of policy enactment at the state level has soared over the past four decades, highlighting the growing importance of state policy contexts for health.¹²

Extending prior work on state context and physical health, a growing body of research shows that state policy contexts are also tied to differences in mental health outcomes across states.^13–19 These researchers have often pointed to the importance of robust economic (e.g., paid sick leave) and social support (e.g., unemployment insurance) policies as salient predictors of mental health. Economic and social support policies provide additional economic support and assurance to individuals, especially those who are more vulnerable to economic shocks and financial precarity, in ways that lower risk of depression and anxiety. Specifically, these types of state policies can impact wages, affect the risk of exposure to poverty, and help individuals avoid financial hardship (e.g., food insecurity, housing insecurity), all of which are risk factors for depression, anxiety, and other mental health challenges. However, much more research is needed to understand the role of states in determining mental health outcomes, including the bundling of policies within states and the specific mechanisms linking state policies and mental health.

Economic Policies, Social Support Policies, and Mental Health

A growing body of research provides evidence that state economic and social support policies impact population mental health. For instance, prior research documents that increases in state minimum wage can improve the mental health of lower-skilled workers for women, but these findings were not replicated for men.¹⁸ Similarly, policies that expand Supplemental Nutrition Assistance Program (SNAP) eligibility (e.g., elimination of asset tests and increases in income limits) contributed to decreased rates of major depressive episodes.¹³ Moreover, there is substantial evidence that state policies that improve economic security, such as minimum wage laws, unemployment benefits, and paid sick leave, are associated with suicide mortality.²⁰ The theoretical underpinning of many of these studies is that the state policies of interest improve economic outcomes and reduce stress exposures, with benefits for mental health given robust links between stress exposure and mental health.²¹ However, more research is needed to examine how economic and social support policies bundle within states to impact population mental health. We focus on the implications of state policies for dimensions of mental health and well-being that impact broad swaths of the population (e.g., depressive symptoms and probable depression).

In this perspective, we build on these prior studies and propose a conceptual framework based on three primary ways that state economic and social support policies can shape mental health (see Figure 2). In general, these state policies can 1) improve wages and reduce the risk of experiencing poverty, 2) minimize exposure to economic hardship (e.g., food and housing insecurity), and 3) weaken the link between economic hardship and its associated stressors with mental health. Here, economic hardship is considered the inability to pay for basic needs such as rent or mortgage, utilities, food, and medical care, whereas wages and poverty status reflect a household’s income and economic standing. Although these concepts are related, people can experience economic hardship without living below the poverty line, especially in the context of soaring housing, food, and childcare costs in the United States. In the following paragraphs, we expand the conceptual framework surrounding these three pathways.

Figure 2.

Conceptual Framework Linking State Economic and Social Support Policies With Mental Health Outcomes. Dashed lines reflect moderation.

First, economic and social support policies may impact mental health outcomes by improving wages and reducing poverty exposure, especially for lower-income workers. For instance, state economic policies such as state earned income tax credits (EITC) have the potential to reduce poverty, and policies related to minimum wage and collective bargaining can increase wages among workers. One study found that higher rates of state-level unionization were associated with lower rates of working poverty, above and beyond the effects of the state’s economic performance and social policies.²² Similarly, one estimate suggests that raising the minimum wage to $15 across the United States would lift nearly 40 million workers out of poverty.²³ Social support policies related to cash assistance and unemployment insurance also increase household income and reduce the risk of poverty.²²

Second, economic and social support policies may minimize the likelihood of experiencing economic hardship itself, which has robust associations with adverse mental health outcomes.²⁴ For instance, evidence suggests that access to paid sick leave (an economic policy) reduced economic hardship among service sector workers.²⁵ At the same time, social support policies provide needed resources to help individuals pay for critical expenses such as rent, utilities, and food, which can decrease the likelihood of experiencing economic hardship related to food and housing insecurity. For example, cash assistance programs may help lower-income households pay for typical household expenses such as rent, utilities, clothing, and more; SNAP benefits can help with food purchases; and expanded Medicaid eligibility promotes access to lower-cost health care. We consider Medicaid as a social support policy because it may reduce stress related to forgone medical care, and it may lower medical care costs so that it does not contribute (as much) to economic hardship. Together, these resources have the potential to alleviate economic hardship by providing additional resources to afford daily necessities with benefits for mental health.

Third, state policies have the potential to minimize the adverse mental health effects of economic hardship on mental health by providing needed support to help individuals and families weather difficult times. That is, in addition to reducing the risk of experiencing economic hardship in the first place, state policies can offset some of the adverse mental health outcomes stemming from economic hardship if it occurs. For instance, cash or near-cash assistance programs, rental assistance programs, and Medicaid generosity can provide tangible resources to financially vulnerable households and can weaken the perception of stress by conveying a sense of security during difficult times. These economic and psychosocial resources likely improve mental health outcomes among those experiencing financial hardship and any concomitant stressors. Indeed, an emerging line of research documents how specific state policies (e.g., unemployment insurance, eviction moratoria, paid sick leave) can reduce the adverse mental health consequences of acute and chronic stressors such as income loss^15,26 and financial hardship.^14,16 For example, in the case of involuntary job loss, social support policies such as unemployment insurance can be a tangible resource that may minimize the adverse effects of income loss and limit the negative impact on mental health.

Taken together, because lower socioeconomic status and greater economic hardship increase the risk of depression, anxiety, and other mental health challenges,^24,27,28 economic and social policies may improve mental health to the extent that they improve economic standing, minimize economic hardship, and weaken the adverse effects of economic hardship if it occurs. Notably, these economic and social support policies vary considerably across states and may contribute to differences in household income, poverty rates, and economic hardship.²⁹ Moreover, as noted above, policies tend to cluster along political lines such that states with generous unemployment insurance tend to have higher minimum wage, refundable EITC, generous Medicaid programs, and paid family/sick leave. On the other hand, states that are less generous in one area tend to be less generous across the board. The bundling of policies within states has accelerated in recent years, leading to a drastic divergence in state policy contexts over the past few decades that reinforce and exacerbate differences in health and well-being based on state of residence.

A Comparative Example: Minnesota and Mississippi

Table 1 contrasts two states with different economic and social support policies: Minnesota and Mississippi. We primarily focus on policy data from 2019 to capture the pre-COVID-19 pandemic landscape, although we also note relevant COVID-19-related policies. In addition to different policy contexts, Minnesota and Mississippi have notably different profiles of mental health. Rates of frequent mental distress in 2019 were 9.1% in Minnesota compared with 14.4% in Mississippi. These differences in mental health persisted during the COVID-19 pandemic. Rates of probable depression and anxiety were 17.8% and 23.9%, respectively, in Minnesota compared with 26.9% and 32.0% in Mississippi from 2020 to 2023. We argue that these differences in population mental health are likely due, in part, to vastly different economic and social support policies across these two states.

Table 1.

State Policy Contexts and Mental Health: A Comparison of Minnesota and Mississippi

	Minnesota	Mississippi
Mental health
Frequent mental distress, 2019 (%)	9.11	14.43
Probable depression, 2020–2023 (%)	17.8	26.9
Probable anxiety, 2020–2023 (%)	23.9	32.0
Economic policies (2019)
Minimum wage ($)	10	7.25
Offers state EITC	Y	N
State EITC rate as percentage of federal credit (%)	35	0
Right-to-work law present	N	Y
Paid sick leave	N	N
Economic preemption
States preempt localities from:
Raising minimum wage	N	Y
Requiring paid sick leave	N	Y
Total economic-related preemption laws (range 0–6)	0	4
Social support policies (2019)
UI amount (max $)	717	235
UI duration (max wk)	26	26
SNAP allotment for 4-person family (max $)	642	642
Expanded Medicaid eligibility under ACA	Y	N
Medicaid generosity scorea	67.51	38.53
COVID-19 social support policies
Eviction moratorium	Y	Y
Eviction moratorium expiration date	6/1/2022	6/1/2020
Utility shutoff moratorium	Y	Y
Reinstated work search requirement for UI	N	Y
P-EBT nutrition benefits for children 2020–2021 SY	Y	N

ACA, Affordable Care Act; EITC, earned income tax credits; N, no; P-EBT, pandemic electronic benefit transfer; SNAP, Supplemental Nutrition Assistance Program; SY, school year; UI, unemployment insurance; Y, yes.

Data are from State Policy and Politics Database.³⁰

^aThe Medicaid generosity score is an index of four elements of Medicaid: income eligibility, administrative burden, immigrant benefits, and Medicaid benefits.

When considering economic policies, Mississippi maintains the federal minimum wage ($7.25 per hour), does not offer a state EITC, has right-to-work laws that undermine the power of unions, and does not mandate paid sick leave. Minnesota, on the other hand, has a $10 per hour minimum wage, offers a state EITC with a credit of 35% of the federal EITC, does not have right-to-work laws, and did not mandate paid sick leave as of 2019. We note that Minnesota’s paid sick leave law was enacted in 2024.

Minnesota and Mississippi also have different preemption laws, especially related to economic policies. For instance, in Mississippi, states can preempt localities from raising the minimum wage or implementing a mandatory paid sick leave policy; whereas, in Minnesota, localities are allowed to adopt their own minimum wage and paid sick leave policies. When examining the total number of economic preemption laws (e.g., related to minimum wage, fair scheduling, project labor agreements, prevailing wage, paid leave, and gig economy regulations), Mississippi had four (out of six) preemption laws, whereas Minnesota had zero.

Similar differences emerge when examining state social support policies. For example, Mississippi allows a maximum monthly unemployment insurance amount of $235, did not expand eligibility for Medicaid under the Affordable Care Act (ACA), and has a Medicaid generosity score of 38.53 (higher values represent more generosity). In contrast, Minnesota allows a maximum unemployment insurance of $717 per month, expanded eligibility for Medicaid under the ACA, and has a Medicaid generosity score of 67.51.

Moreover, states tend to respond differently to large-scale crises, which impacts how residents are able to cope in times of crisis. Indeed, state policy differences between Minnesota and Mississippi were amplified during the COVID-19 pandemic. For example, Mississippi implemented a short-lived eviction moratorium that expired in June 2020 as well as a brief moratorium on utility shutoffs. In Minnesota, the utility shutoff moratorium lasted through August 2021, and the eviction moratorium lasted until June 2022. Minnesota also adopted waivers that removed requirements related to unemployment insurance, SNAP benefits, and other social support programs to make them more easily and quickly accessible during this tumultuous period. Mississippi did not. Overall, the differences in economic and social support policies between Mississippi and Minnesota demonstrate two vastly different types of state policy environments.

Key Policy Successes and Failures

We posit that the different mental health outcomes between states like Minnesota and Mississippi are due, in part, to their vastly different economic and social support policies. Moreover, Minnesota and Mississippi illustrate key successes and failures related to state economic and social support policies implemented in the past ten years that may impact mental health outcomes. When considering key successes, Minnesota has joined other states in implementing economic and social support policies that likely benefit population mental health. For instance, Minnesota was an early adopter of expanded eligibility for Medicaid under the ACA in 2014, and they are now joined by 39 other states.³¹ Minnesota also began incrementally increasing the state’s minimum wage above the federal minimum wage starting in 2014 and allows higher minimum wages in cities such as Minneapolis and St. Paul.³² For instance, starting in January 2025, the minimum wage in Minnesota increased to $11.13, with a minimum wage of almost $16/hour in Minneapolis and St. Paul.³² As of 2024, Minnesota is one of 30 states with a minimum wage higher than the federal minimum wage of $7.25 (which, notably, has not increased since 2009).³² Minnesota recently joined 14 other states in mandating paid sick leave (with three additional states enacting paid sick leave in 2025), most of whom have adopted policies in the past five years.³³

These are just a few examples of successful state-level policies that states like Minnesota have implemented over the past decade. Notably, many of these policies are quite popular among voters across party lines.³⁴ As an example of this bipartisan support, the three most recent states to pass state paid sick leave laws in November 2024 are solidly conservative states (Alaska, Missouri, Nebraska). Two of these states (Alaska, Missouri) also passed minimum wage increases, both of which will reach $15 per hour by 2026 (Missouri) or 2027 (Alaska).³⁵ Many of these successes in conservative states have been the result of ballot initiatives. Missouri voters, for example, have voted to expand Medicaid eligibility, implement paid sick leave, increase minimum wage, and repeal right-to-work laws in recent years. State failures, then, are marked by state policymakers not implementing and/or not putting on the ballot economic and social support policies that are popular, effective, and beneficial to mental health.

Another notable policymaking success was the expansion of the social safety net at the federal and state levels in response to the COVID-19 pandemic. In particular, given the soaring rates of unemployment at the start of the COVID-19 pandemic,³⁶ the social safety net expanded in a way that was not tied to employment, which stands in stark contrast to the shift toward tax-based transfers for working families since (at least) the 1990s.³⁷ Moreover, the federal government implemented sweeping policies at the national level, such as expanded unemployment insurance, stimulus payments, a national eviction moratorium, access to paid sick leave for many employees, and the expanded child tax credit. Evidence suggests that many of these policies were effective. For instance, the expanded child tax credit and stimulus payments helped to slash child poverty rates to their lowest levels in over 50 years.³⁸ Moreover, the massive legislative action lifted approximately 18 million Americans out of poverty.³⁹

Whereas the expansion of many policies in the COVID-19 pandemic era represented a big step forward for economic and social support policies, two notable failures stand out. First, although many of the economic and social support policies that were implemented at the federal and state levels were popular and effective, policymakers allowed for their expiration. Subsequently, economic hardship soared and the progress toward reducing poverty levels was wiped out. For instance, child poverty rates doubled in 2022 following the expiration of these policies.³⁸ The expiration of such policies may partially explain why rates of depression and anxiety have not returned to prepandemic levels.¹

Second, despite a few major federal policy changes, states were still the primary site of policymaking during the pandemic. Although many states, even conservative-leaning states, initially implemented social support policies (e.g., eviction moratoria) and adjusted requirements to make benefit programs (e.g., unemployment insurance, SNAP) more accessible, the longevity of these policies was short lived in some states, reinforcing geographic variation in economic and social support policies. Moreover, states—primarily conservative states—relied on preemption to restrict localities from implementing beneficial economic and social support policies during the pandemic. As a result, COVID-era policies became hyperpolarized and perhaps even accelerated the hyperpolarization of policies in the 21st century. This hyperpolarization of policies across states, especially during a large-scale crisis, has the potential to fuel differences in mental health simply based on where people live.

Implications for Research

Mental health will likely continue to be a major population health concern in the coming decades. Barring a substantial reversal in the political organization of policy creation and implementation in the United States, state governments will also likely have a greater role in enacting policies that affect the health and well-being of their residents. Therefore, understanding the role of state policies for mental health is paramount to improving population health in the United States. To this end, there are three key aspects of state policy contexts and mental health that need further description, theorization, and empirical evaluation: 1) the role of state policies within the larger political and socioeconomic context, 2) heterogeneity in the impacts of state policy contexts at key life-course stages and their cumulative toll on mental health across the life course, and 3) the impact of state policies on mental health for different sociodemographic groups.

First, the ascendancy of states as key determinants of population health has occurred alongside macro-level economic changes (e.g., globalization, neoliberalism) that heighten the vulnerability of individuals. That is, the federal government’s role in establishing economic and social support policies is diminishing while economic uncertainty is growing. As an example of growing economic uncertainty, income inequality in the United States has reached historic levels in recent years, surpassing levels not seen since the 1880s. In 2016, the top 1% of adults earned approximately 20% of all income.⁴⁰ At the same time, inequality among poor households has increased since the 1990s, largely as a result of a shift in antipoverty efforts from the federal to state governments.³⁷ In addition to skyrocketing income inequality, real wages have stagnated for middle-wage workers and declined for low-wage workers,⁴¹ cost-of-living continues to increase,⁴² and corporations have increased their power (and profits) at the expense of workers.¹⁰ Therefore, future research should aim to understand the increased role of state government alongside the macro-level changes that increase uncertainty in people’s lives. That is, at a time when economic and social support policy needs are increasing, there are fewer political or institutional opportunities to address them, potentially leading to growing mental health challenges in the population even among states with more generous economic and social support policies. Thus, more research should consider how macro-level economic and political environment may be stifling social support policy advancements even among the states with the most robust social safety nets.

Second, state policies are likely to impact the mental health of their residents differently depending on their age. For example, policies that guarantee access to food may reduce hunger and improve the mental health of people at all ages; however, these policies may be especially important among children whose learning and development may be sensitive to regular, reliable access to food. Work-related policies, such as unemployment insurance and paid sick leave, may lessen the stress of working age adults from the anticipation of job loss or job loss itself. Lastly, policies that provide supports for older adults, such as additional health care coverage (including coverage of prescription medications or other costs not fully covered by Medicare), may improve their mental health by addressing medical needs without having to endure pain or discomfort for fear of not being able to afford medical bills (or limitations in coverage). Despite these clear theoretical connections and the growing literature focused on these policies, more research is needed that incorporates a life-course perspective on how policies differently shape mental health across ages and the impact of long-term exposure to policy environments on trajectories of mental health across the life course.

Third, state policies may vary in their relevance for mental health across sociodemographic groups beyond (or in addition to) age. That is, the impacts of economic and social support policies on the mental health of different groups are likely unequal, shaped by risk, rewards, and opportunities. Moreover, economic and social support policies unfold alongside other state policies that are relevant for mental health. For example, the reversal of Roe v. Wade in Dobbs v. Jackson Women’s Health Organization moved the policymaking authority of abortion restrictions to state governments. For some states, these restrictions were stringent, unclear when medical intervention was legal, targeted medical professionals, and have resulted in preventable deaths of pregnant women and infants.^43–45 These state policies, in turn, may uniquely impact the mental health of women of reproductive ages by affecting their anticipation of risks, sense of bodily autonomy, and devaluation of their own lives. In fact, emerging research shows strong evidence for an increase in depression and anxiety among women in states with trigger laws (i.e., abortions were immediately banned).⁴⁶ Notably, given the bundling of state policies, states with abortion restrictions are also the ones that are least likely to offer robust economic and social support policies. Additional research is needed to investigate the types and combinations of policies that impact mental health, as well as differences in the impacts of policies on mental health across groups. Understanding how the bundling of policies impacts mental health will shed light on the reasons for differences in mental health across states and lay the groundwork for understanding leverage points to improve population mental health.

Implications for Policy

Using Minnesota and Mississippi as examples, we noted key policy successes of the past decade, highlighting policies such as increased minimum wage and paid sick leave that are popular and effective and potential leverage points to improve population health, including mental health. We conclude with two overarching policy priorities for the future. First, state policymakers should prioritize scientifically supported policies that improve economic security such as raising the minimum wage, offering a refundable EITC, implementing paid sick leave, eliminating right-to-work laws, and expanding unemployment insurance and cash or near-cash assistance programs. Relatedly, policymakers should aim to reduce administrative burdens that prevent qualified individuals from accessing needed resources. At a time when political polarization and gridlock will impede progress at the federal level, state policymakers must fill the void by implementing robust economic and social support policies. Indeed, state policies will likely be increasingly salient determinants of mental and physical health in the context of political gridlock. Harnessing current bipartisan support for policies, such as paid sick leave and increased minimum wage, may be an effective entry point to making positive change at the state level.

Second, although employment-based economic and social support policies (e.g., state EITC, minimum wage) are beneficial and should be expanded as much as possible, a strong social safety net must include support for individuals regardless of employment status, especially because nonworking individuals may be some of the most vulnerable. For instance, because assistance is increasingly tied to employment, benefits have been redistributed from the poorest families to those with higher incomes near the poverty line.^37,47 Moreover, some of the most beneficial programs for the poorest households, such as SNAP benefits, have restrictions that limit their effectiveness at combatting economic hardship.⁴⁸ We suggest that policymakers prioritize economic and social support policies that help the poorest households achieve economic security, regardless of their employment status.

Conclusion

Overall, this perspective argues that economic and social support policies are key drivers of mental health outcomes, especially to the extent that they impact opportunities for economic security (e.g., avoidance of poverty and economic hardship). The bundling of policies within states has accelerated in recent years, leading to a drastic divergence in state policy contexts over the past few decades. Therefore, the polarization of state policies reinforces and exacerbates differences in health and well-being based on state of residence, including in mental health. For this reason, it is prudent that future research aims to better understand links between state policies and mental health outcomes to inform policymakers on how policies or clusters of policies may benefit their residents. In turn, policymakers will have the opportunity to improve the mental health and well-being of the US population.

Policy Points:

• This perspective argues that state economic and social support policies are key determinants of population mental health.

• Key policy successes of the past decade include state expansion of Medicaid eligibility, increase in minimum wage, and implementation of paid sick leave.

• Key policy priorities include the prioritization of evidence-based policies that improve economic security and the expansion of social support policies that are not tied to employment.