Friday, November 29, 2019

Decreasing life expectancy in the US: A result of policies fostering increasing inequity

Four years ago, in 2015, economists Anne Case and Angus Deaton published a landmark article in which they documented decreasing life expectancy for white Americans, specifically those aged 45-54, which I discussed on November 14, 2015 in  Rising white midlife mortality: what are the real causes and solutions? This was somewhat shocking data, for it was the first time in decades that a decrease in life expectancy for a group in the US was seen. For a century, life expectancy had been rising.

Although the decrease in life expectancy was in whites of middle age (and lower income), and especially for low-income women (amazingly, low income women born in 1950 had, at the age of 50, a lower life expectancy than their mothers born in 1920!), it was important to remember that life expectancy for African-Americans and some other  minority groups still fell far short of that for whites. This decrease in life expectancy was not the case for other developed countries; it is a uniquely American characteristic – and obviously not a desirable one.

It is, thus, all the more depressing to have a comprehensive new study that finds that not only white people, but all Americans in the 25-64 year old age range have increasing mortality. “Life Expectancy and Mortality Rates in the United States, 1959-2017”,[1] by Steven H. Woolf and  Heidi Schoomaker, just published in JAMA, found that

Between 1959 and 2016, US life expectancy increased from 69.9 years to 78.9 years but declined for 3 consecutive years after 2014. The recent decrease in US life expectancy culminated a period of increasing cause-specific mortality among adults aged 25 to 64 years that began in the 1990s, ultimately producing an increase in all-cause mortality that began in 2010. During 2010-2017, midlife all-cause mortality rates increased from 328.5 deaths/100 000 to 348.2 deaths/100 000. By 2014, midlife mortality was increasing across all racial groups.

This new study confirms that a large part of the increase in middle-age mortality comes from what Case and Deaton called “deaths of despair”: suicide, drug overdoses, and alcoholism. But there was also a large contribution from “traditional” diseases such as heart disease, chronic lung disease, and stroke. People suffering from these conditions may increasingly be unable to receive adequate medical care for them, because they are uninsured or underinsured or because their out of pocket costs in co-payments and deductibles are unaffordable for them, and even because they live in the wrong places, rural areas far from hospitals. This is very different situation from that in other developed countries which, essentially universally, have universal health care. The New York Times article by Gina Kolata and Sabrina Tavernise quotes Dr. Woolf as saying “The whole country is at a health disadvantage compared to other wealthy nations…We are losing people in the most productive period of their lives. Children are losing parents. Employers have a sicker work force.”

Dr. Woolf also notes that “death rates are actually improving among children and older Americans,” unsurprisingly, “because they may have more reliable health care — Medicaid for many children and Medicare for older people.” Yes. Having health coverage and being able to access health care may actually make a difference, especially with treatment of chronic disease. And if there were adequate treatment for mental health and substance abuse, it could be even better.

Of course, increasing mortality is not just about access to health care. It is mainly about the overall lives many people in the US live. Working-class and formerly-working class people who often no longer have jobs, or at least good jobs, and have given up hope of getting them and re-creating their vision of the American dream, have joined the long-term disenfranchised, underserved, and underemployed. This is a common narrative provided for white working-class people who have turned to Donald Trump because of his (empty) promises to bring back manufacturing and mining jobs to the US. And it is the lack of any reasonable set of social services to prevent large swaths of the American population, of all races and colors and ethnicities, from going hungry, or being homeless or inadequately sheltered, or having heat in the winter and education (and thus hope) for their children.

This is another major issue; the US spends a much lower percent of its GDP on social services of all kinds than do other Western nations. If we add in the money spent on “health care” the gap narrows, but most of that money is being spent on medical care, and medical care often for those with far advanced conditions and a lot of money and/or good insurance, and much of that expense going into health system, insurance company, and pharmaceutical company profit. This was documented by Elizabeth Bradley and Lauren Taylor in 2011 (see To fix health care, help the poor, NY Times and my blog post To improve health the US must spend more on social services, December 18, 2011).

Dr. Woolf says “We need to look at root causes. Something changed in the 1980s, which is when the growth in our life expectancy began to slow down compared to other wealthy nations.” He, of course, knows what changed, and so do we. It was the election of Ronald Reagan and the rapid elimination of the social safety net that had developed in the New Deal, and a move toward greater economic aggrandizement of the already richest and most powerful at the expense of the poorest and least empowered, a trend that accelerated under both the Bush administrations, was only slightly slowed by the Clinton and Obama administrations, and has taken off full steam under our current President.

Yes, there is also an opioid crisis, brought on by not just despair but aggressive marketing by pharmaceutical companies such as the Sacklers’ Purdue. Yes, there is, as the Times article notes, a dramatically higher mortality with powerful synthetic opiates like fentanyl. But this is not a root cause. When you died from an episode of pneumonia complicating your lung cancer, it is misleading to say your death was from pneumonia; the real cause was your lung cancer. Ultimately all deaths are caused by cardiopulmonary arrest (your heart and lungs stopping working), but this is a mechanism, not a cause. Similarly, opioid deaths are the mechanism of death, but the cause is a very inequitable and unjust society. And this is the biggest difference between the US and other wealthy nations.

Ironically, some would say, the parts of the US that are most affected by the increasing death rates are those that not only supported, and are likely to again support, President Trump, but those that provided – and may again provide – the electoral vote margin for him. In addition to northern New England (Vermont, New Hampshire and Maine), the hardest hit states are Ohio, West Virginia, Indiana, and Kentucky. A third of all the excess deaths in the US are concentrated in four Ohio Valley states: Ohio, Pennsylvania, Kentucky, and Indiana. One commentator notes that there are “bright spots”: ‘Life expectancy in the coastal metro areas — both east and west — has improved at roughly the same rate as in Canada.’ But I don’t see this as a bright spot, I see the desperation and death and increasing mortality in the rest of the US as the sore spot. We could do better, but we haven’t; as I noted above even the 16 years of Democratic presidency (admittedly, often with a GOP-controlled Congress) have been more focused on meeting the desires of the wealthiest than the needs of most Americans.

We need to do better, and despite the fact that the Trump administration is the least likely to do so in recent history, it may well be re-elected because of the failure of “mainstream” opposition to come up with effective solutions.

[1] Woolf SH and Schoomaker H, Life Expectancy and Mortality Rates in the United States, 1959-2017. JAMA. 2019;322(20):1996-2016. doi:10.1001/jama.2019.16932


Anonymous said...

Clearly, the Medicare for All program, and also the plans for increased socioeconomic equity, proposed by presidential candidates Bernie Sanders and, to a lesser extent, Elizabeth Warren could quickly reverse this decline in mortality. I hope you will address this in a future posting before the primaries.

Josh Freeman said...

Dear Anonymous:
I like your comments; I wish I knew who you were!
Anyway, I have frequently (maybe too often!) expressed my strong support for Medicare for All, and for Bernie Sanders (although I like the Jayapal House bill better than his Senate bill).
I am flattered that you think my endorsement might have any affect whatever on the primaries, but I am sure it won't.

Unknown said...

Don't sell yourself short. I can see you've had >850,000 page views. You might have more of a voice than you think.

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