By Steven H. Woolf, MD, MPH; Heidi Schoomaker, MAEd
JAMA, November 26, 2019
Abstract
Importance: US life expectancy has not kept pace with that of other wealthy countries and is now decreasing.
Objective: To examine vital statistics and review the history of changes in US life expectancy and increasing mortality rates; and to identify potential contributing factors, drawing insights from current literature and an analysis of state-level trends.
Evidence: Life expectancy data for 1959-2016 and cause-specific mortality rates for 1999-2017 were obtained from the US Mortality Database and CDC WONDER, respectively. The analysis focused on midlife deaths (ages 25-64 years), stratified by sex, race/ethnicity, socioeconomic status, and geography (including the 50 states). Published research from January 1990 through August 2019 that examined relevant mortality trends and potential contributory factors was examined.
Findings: 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, caused by drug overdoses, alcohol abuse, suicides, and a diverse list of organ system diseases. The largest relative increases in midlife mortality rates occurred in New England (New Hampshire, 23.3%; Maine, 20.7%; Vermont, 19.9%) and the Ohio Valley (West Virginia, 23.0%; Ohio, 21.6%; Indiana, 14.8%; Kentucky, 14.7%). The increase in midlife mortality during 2010-2017 was associated with an estimated 33 307 excess US deaths, 32.8% of which occurred in 4 Ohio Valley states.
Conclusions and Relevance: US life expectancy increased for most of the past 60 years, but the rate of increase slowed over time and life expectancy decreased after 2014. A major contributor has been an increase in mortality from specific causes (eg, drug overdoses, suicides, organ system diseases) among young and middle-aged adults of all racial groups, with an onset as early as the 1990s and with the largest relative increases occurring in the Ohio Valley and New England. The implications for public health and the economy are substantial, making it vital to understand the underlying causes.
From the Introduction
Life expectancy at birth, a common measure of a population’s health, has decreased in the United States for 3 consecutive years. This has attracted recent public attention, but the core problem is not new—it has been building since the 1980s. Although life expectancy in developed countries has increased for much of the past century, US life expectancy began to lose pace with other countries in the 1980s and, by 1998, had declined to a level below the average life expectancy among Organisation for Economic Cooperation and Development countries. While life expectancy in these countries has continued to increase, US life expectancy stopped increasing in 2010 and has been decreasing since 2014. Despite excessive spending on health care, vastly exceeding that of other countries, the United States has a long-standing health disadvantage relative to other high-income countries that extends beyond life expectancy to include higher rates of disease and cause-specific mortality rates.
From the Discussion
Potential Explanations
The increase in midlife mortality after 1999 was greatly influenced by the increase in fatal drug overdoses.
However, the increase in opioid-related deaths is only part of a more complicated phenomenon and does not fully explain the increase in midlife mortality rates from other causes, such as alcoholic liver disease or suicides (85.2% of which involve firearms or other nonpoisoning methods).
The National Research Council examined the US health disadvantage in detail and identified 9 domains in which the United States had poorer health outcomes than other high-income countries: these included not only drug-related deaths but also adverse birth outcomes, injuries and homicides, adolescent pregnancy and sexually transmitted infections, HIV and AIDS, obesity and diabetes, heart disease, chronic lung disease, and disability.
Tobacco Use and Obesity
Although tobacco use in the United States has decreased, higher smoking rates in prior decades could have produced delayed effects on current tobacco-related mortality and life expectancy patterns, especially among older adults.
The obesity epidemic, a known contributor to the US health disadvantage, could potentially explain an increase in midlife mortality rates for diseases linked to obesity, such as hypertensive heart disease and renal failure.
However, neither smoking nor obesity can fully explain current mortality patterns, such as those among younger adults and increasing mortality from conditions without known causal links to these risk factors.
Deficiencies in Health Care
Deficiencies in the health care system could potentially explain increased mortality from some conditions. Although the US health care system excels on certain measures, countries with higher life expectancy outperform the United States in providing universal access to health care, removing costs as a barrier to care, care coordination, and amenable mortality. In a difficult economy that imposes greater costs on patients, adults in midlife may have greater financial barriers to care than children and older adults, who benefit from the Children’s Health Insurance Program and Medicare coverage, respectively. Although poor access or deficiencies in quality could introduce mortality risks among patients with existing behavioral health needs or chronic diseases, these factors would not account for the underlying precipitants (eg, suicidality, obesity), which originate outside the clinic. Physicians contributed to the overprescription of opioids, and iatrogenic factors could potentially explain increases in midlife mortality from other causes, but empirical evidence is limited. Nor would systemic deficiencies in the health care system explain why midlife death rates increased for some chronic diseases while decreasing greatly for others (eg, ischemic heart disease, cancer, and HIV infection).
Psychological Distress
Despair has been invoked as a potential cause for the increase in deaths related to drugs, alcohol, and suicide (referred to by some as “deaths of despair”).31,37,66,101 Some studies suggest that psychological distress, anxiety, and depression have increased in the United States, especially among adolescents and young adults.
Socioeconomic Conditions
Three lines of evidence suggest a potential association between mortality trends and economic conditions, the first being timing. The US health disadvantage and increase in midlife mortality began in the 1980s and 1990s, a period marked by a major transformation in the nation’s economy, substantial job losses in manufacturing and other sectors, contraction of the middle class, wage stagnation, and reduced intergenerational mobility. Income inequality widened, surpassing levels in other countries, concurrent with the deepening US health disadvantage. The second line of evidence concerns affected populations: those most vulnerable to the new economy (eg, adults with limited education, women) experienced the largest increases in death rates. The third line of evidence is geographic: increases in death rates were concentrated in areas with a history of economic challenges, such as rural US areas and the industrial Midwest, and were lowest in the Pacific division and populous states with more robust economies (eg, Texas, New York). One theory for the larger life expectancy gains in metropolitan areas is an increase in the population with college degrees.
Socioeconomic pressures and unstable employment could explain some of the observed increases in mortality spanning multiple causes of death. Financial hardship and insecurity limit access to health care and the social determinants of health (eg, education, food, housing, transportation) and increase the risk of chronic stress, disease, disability, pessimism, and pain.
Policy Considerations
Evidence-based strategies to improve population health seem warranted, such as policies to promote education, increase household income, invest in communities, and expand access to health care, affordable housing, and transportation. The increase in mortality from substance abuse, suicides, and organ system diseases argues for strengthening of behavioral health services and the capacity of health systems to manage chronic diseases.
Comment:
By Don McCanne, M.D.
The United States is an outlier amongst wealthy nations in that increase in life expectancy has not kept pace with the other nations and has actually declined for three consecutive years after 2014. Maybe our great nation is not so great after all.
The factors are complex, indicating the need to resist simple explanations such as those that “blame the victim.” But that certainly does not mean that we should walk away from potential remedies.
One obvious factor is the deficiencies in health care in what is the most expensive health care system on earth but one which is locked in mediocrity primarily because of our failure to implement public policies that would provide the nation with much better health care utilization and outcomes.
The authors conclude that we need strategies to improve population health such as policies to promote education, increase household income, invest in communities, and expand access to health care, affordable housing, and transportation, including the strengthening of behavioral health services and the capacity of health systems to manage chronic diseases.
For those who say that these policies should be initiated and implemented in the private sector, they will have to explain why the private sector is failing us and what they can do to get us back on track to improving population health.
But the old rule is that when the private sector fails us, we need to turn to the government – our democratically-elected government. In recent decades, the neoliberals have aligned themselves with the conservatives in conspiring to keep much of the control in the private sector with disproportionate benefit to the plutocrats over the people.
Education, income inequity, community investment, affordable housing, transportation, and especially health care are all arenas that cry out for public policy solutions. We will not see these improvements until we get past blaming the victims, which is ironic since we’re our own victims – a direct result of our citizen inaction.
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