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.

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[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

To improve health the US must spend more on social services

That the US spends far more, in total and per capita, on health care than any other country is a well-established fact which no one bothers to deny. That this expenditure has not brought us greater health is also established fact, although many still find this hard to believe, or don’t want to believe it. That we do not have the “best health care system in the world”, or even close, or even, actually, a health care system at all, is also demonstrably true. This does not stop a larger percent of the population, and particularly the very privileged sector represented by politicians, from maintaining that untruth.

However, in a provocative op-ed in the New York Times (“To fix health care, help the poor”), Elizabeth H. Bradley and Lauren Taylor argue that it is only when health care is viewed in its most narrow sense that the US spends more than other countries. Their study of 30 countries expenditures, “Health and social services expenditures: associations with health outcomes”[1], “…broadened the scope of traditional health care industry analyses to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.”

Essentially, their data shows that having services available to people that improve the quality of their lives, or, more important, decrease the negative health impact of the adverse circumstances into which they are born, develop, and live, lessens disease burden and improves health. This then decreases the costs of providing medical care to them. For example, they note, “The Boston Health Care for the Homeless Program tracked the medical expenses of 119 chronically homeless people for several years. In one five-year period, the group accounted for 18,834 emergency room visits estimated to cost $12.7 million.”

Bradley and Taylor indicate that among industrialized countries, the US ranks #10 in total health + social service spending , and is one of only 3 that spend more on health care than on all other social services. This means that, in addition to not getting the preventive or early-intervention health care that they need, Americans are at higher risk of illness and more ill when they come to medical attention. They may not be homeless, although obviously this dramatically increases their risk. People may not have adequate food, not have adequate warmth (see the discussion of “excess winter deaths” in Michael Marmot, the British Medical Association, and the Social Determinants of Health, November 1, 2011), not had a safe environment. They likely had far too little income. Many of them are children, and many of those, and often their parents before them, have had an inadequate education. A large number of the determinants of health are antenatal, and many more are in the early years of life. The other group at high risk of both adverse health outcomes and the poverty-related social deficits that influence them, are the elderly. So what do we see in the US? Threats to cut Medicare, cut Social Security, cut education.

This wouldn’t affect everyone equally, of course. Only the most vulnerable. Or, at least, the more vulnerable. The wealthy, of course, are unlikely to be inadequately housed, inadequately nourished, inadequately educated, and, in a tautology, inadequately employed. Another recent study, from the Organization for Economic Cooperation and Development (OECD), called “Divided we stand: why economic inequality keeps rising”, demonstrates rising inequality in income as indicated by the difference between the income of the top 10% and bottom 10%. “The income gap has risen even in traditionally egalitarian countries, such as Germany, Denmark and Sweden, from 5 to 1 in the 1980s to 6 to 1 today. The gap is 10 to 1 in Italy, Japan, Korea and the United Kingdom, and higher still, at 14 to 1 in Israel, Turkey and the United States. In Chile and Mexico, the incomes of the richest are still more than 25 times those of the poorest, the highest in the OECD, but have finally started dropping. Income inequality is much higher in some major emerging economies outside the OECD area. At 50 to 1, Brazil's income gap remains much higher than in many other countries, although it has been falling significantly over the past decade.”

 

In the report’s “country note” on the US, it observes that “The United States has the fourth-highest inequality level in the OECD, after Chile, Mexico and Turkey. Inequality among working-age people has risen steadily since 1980, in total by 25%. In 2008, the average income of the top 10% of Americans was 114 000 USD, nearly 15 times higher than that of the bottom 10%, who had an average income of 7 800 USD. This is up from 12 to 1 in the mid 1990s, and 10 to 1 in the mid 1980s….Income taxes and cash benefits play a small role in redistributing income in the United States, reducing inequality by less than a fifth – in a typical OECD country, it is a quarter. Only in Korea, Chile and Switzerland is the effect still smaller.” Of course, comparing deciles is deceiving; as the Occupy Wall Street movement emphasizes, the concentration of wealth is in the top 1%, and economist and NY Times columnist Paul Krugman (“We are the 99.9%”, November 24, 2011) and others point out that most of that wealth in the US is in the top 0.1%! The wealthiest 400 families in the US own as much as the bottom 50% of the population.

 

One obvious result of the rising inequality in the US is the increase in the overt control that this wealthy class exerts over the political process, through direct lobbying, political contributions, employment after and between stints of government service, and control of media. The “corporate personhood” decision by the US Supreme Court in Citizens United simply codified and protected this inequality. But income inequality in itself is not sufficient to lead to the destruction of the social safety net that exposes increasing numbers and percents of people to ravages that adversely affect their health. It also requires extreme selfishness and disrespect, so that billionaire people and corporations pay little in tax, and governments are purposely squeezed so that they have neither the will nor the resources to provide services.

 

The findings of Bradley and Taylor are not news to the public health community, of course, which is very familiar with the social determinants of health and the positive impact that investment in basic social supports has on the health outcomes of both populations and individual people. Investment is required to see future benefit, and the investment that we need, and are not making, is in education, is in nutrition, is in housing. It is far more than a shame. It is shameful.  

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[1 Bradley EH, Elkins BR, Herrin J, Elbel B.,Health and social services expenditures: associations with health outcomes, BMJ Qual Saf. 2011 Oct;20(10):826-31. Epub 2011 Mar 29