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
