Lane Kenworthy, The Good Society
Most of us would like a long life. Longevity isn’t necessarily the best indicator of health, but it’s surely among the ones we care about most. Our chief measure of longevity is life expectancy — the average number of years of life expected among the population.
Americans’ life expectancy is high and rising, which is good news. But three aspects of the longevity story in the United States are less encouraging. First, given our affluence and our heavy spending on healthcare, Americans’ life expectancy is surprisingly low compared to other rich nations, and it has risen very little. Second, the gap in longevity between Americans with more and less income has widened in recent decades. Third, since 1999 the death rate for middle-aged whites has increased.
LIFE EXPECTANCY IN THE US IS HIGH AND RISING
Figure 1 shows that life expectancy in the United States increased from 39 years in 1880 to 70 years in 1960 to just shy of 80 years in 2015. This doubling in a little more than a century is remarkable. And while the pace at which life expectancy rises has slowed, the rise has continued.
Figure 2 puts the rise in longevity in longer-term historical perspective by adding data for the United Kingdom going back to the 1500s. For most of human history, life expectancy likely was around 30 to 35 years. The dramatic rise has come entirely since the late 1800s. It is a product of clean water (via chlorination, filtration, and sewage rerouting), pasteurized milk, antibiotics, vaccines, other advances in medications and medical procedures, and the extension of access to healthcare to the full population. Progress in reducing the spread of infectious diseases was key, as this had been the most common cause of death, especially among newborns and children.1
Since the mid-1900s, the key advances have come in extending the lives of those who make it to middle age. Figure 3 shows trends over the past several decades in the ten most significant sources of death prior to age 75. We’ve made a good bit of progress in reducing premature mortality by the biggest sources — heart disease, cancer, and accidents — as well as by lung disease, stroke, and homicide.2
AMERICANS DON’T LIVE AS LONG AS THEY SHOULD
As a country gets richer, its citizens tend to live longer.3 Apart from oil-rich Norway, the United States is the most affluent of the world’s longstanding-democratic nations.4 Yet when it comes to length of life, we fare poorly compared to these other nations. As figure 4 shows, as recently as 1980 we were in the middle of the pack among this group. Since, then, however, life expectancy for Americans has increased at a slower pace than in any other rich nation, and as of 2013 (the most recent year of comparable data) we stood last in line, with a life expectancy more than a year below that of the next-lowest country.
The gap in life expectancy between the US and the leading nations — Japan, Spain, Switzerland, and Italy — is about four years. Is that a lot, or is it not worth worrying about? Two comparisons may add some perspective. First, a gap of four years is about the same as the current gap between white and black Americans (see below). Second, the National Center for Health Statistics estimates that eliminating cancer as a cause of death would raise life expectancy in the United States by three years.5
Our low life expectancy is particularly startling given how much money we spend on healthcare. On average, more spending on healthcare is associated with higher life expectancy.6 The United States is the exception to the rule. Figure 5 shows that healthcare expenditures as a share of national income (GDP) are far higher in the US than in any other rich democratic country, and they’ve increased the most over the past half century. Yet our longevity has increased the least.
Is isn’t clear what accounts for this.7 One contributor is our comparatively high infant mortality rate, shown in figure 6. A second is the sizable number of Americans without health insurance. Recent studies estimate this may cause approximately 36,000 deaths per year.8 A third likely contributor is deaths from opioid addiction and overdose, though this isn’t a factor until the late 1990s (see below).
Other hypothesized culprits don’t fit well with the data. The United States is in the middle of the pack for most of the main causes of death, including cancer, heart disease, and accidents, and our improvement in recent decades has been on par with that of most other rich nations.9 Cigarette smoking has decreased as rapidly as in most other countries, from 42% of American adults in 1965 to 17% in 2014.10 Suicide, a significant and underappreciated cause of death, hasn’t declined; but that’s true in a number of other rich nations too, and our suicide rate is about average among those countries.11 Our homicide rate is much higher than that of other affluent countries, but it has decreased more rapidly than in most others.12 Obesity is more common in the US than in any other rich nation, and it has increased quite rapidly, but analysts aren’t sure how much this contributes to premature death.13
What is clear is that, in terms of longevity, Americans tend to get comparatively little bang for their buck.
NARROWING AND WIDENING LONGEVITY GAPS
Race has long been among America’s most pronounced, and most troubling, axes of inequality, and that’s as true for longevity as for other aspects of well-being. At the beginning of the twentieth century, African Americans lived, on average, about fifteen years less than whites.14 This gap diminished over the course of the century. As figure 7 shows, in 1980 it was seven years. By 2014 it had decreased to four years — about the same as the gap between the US and Japan (figure 4 above). Deaths from most major sources have been falling faster among black Americans than among whites.15
Longevity also differs by income, and here the gap has been growing over time rather than shrinking. Figure 8 shows the trend since 1980 in life expectancy by income group (for males at age 50). Americans in the top two income quintiles have seen significant gains in life expectancy, while those in the bottom two haven’t. In 1980 the gap between Americans in the top quintile and those in the bottom was five years. By 2010 it had jumped to thirteen years.
It isn’t a surprise that people with more income tend to live longer than those with less. Income is correlated with a variety of health behaviors that matter for longevity: higher-income individuals are less likely to smoke, they tend to have better diets, and they exercise more. They also tend to experience less stress. The quantity and quality of medical services to which people have access also varies by income.16
What’s less clear is whether, and how much, these differences have increased over the past generation, and what effect that has had on the income gap in longevity.17 The rate of smoking has fallen less rapidly among lower-income Americans than among those with higher incomes.18 Opioid addiction and overdose has increased more rapidly among Americans with less education and income.19 The income disparity in medical care very likely has increased; between 1980 and 2010 the share of Americans without health insurance increased, and most of those lacking insurance have low to moderate income.20 Differences in healthcare provision between more-affluent urban areas and poorer rural areas appear to have widened. And the gap in income itself has grown, though mostly between those at the very top and everyone else.21 Yet not all health determinants have diverged according to income. While lower-income Americans are more likely to be overweight or obese than those with higher incomes, the income gap in obesity actually has shrunk in recent decades.22
The gap in longevity also has been growing between places. In recent decades, life expectancy has increased more rapidly in states that are heavily urban than in those with a larger rural population, as we see in figure 9. This is partly, perhaps mainly, due to the sharp rise in opioid-related deaths in rural regions of the country (see below).
THE DEATH RATE FOR MIDDLE-AGED WHITES HAS INCREASED
Death rates have been falling over time. Although the rate of decrease has varied across countries and groups, all have experienced an absolute improvement. Around 1999, however, the fall in mortality reversed course among middle-aged whites in the United States. Figure 10 shows data from a paper by Anne Case and Angus Deaton published in 2015 that first brought this to public attention.23 During the 1990s the death rate for non-Hispanic white Americans aged 45-54 fell, as it did for similarly-aged persons in other affluent nations and for Hispanics in the US. But then, at the end of the 1990s, it began to rise (slowly), and that rise continued for the remainder of the period shown in the chart. A similar but weaker shift occurred among 35-to-44-year-olds and 55-to-59-year-olds.24
Case and Deaton find that the death rate from many key sources, such as heart disease and cancer, continued to decline. But beginning in the late 1990s this was offset by a large increase in mortality due to accidental poisoning, and to a lesser extent to suicide and liver disease.25
Why did this happen?
One hypothesis points to rising economic insecurity.26 For middle-aged whites, particularly those with limited education, the period since the turn of the century has featured stagnant or falling employment, wages, and household income. However, economic insecurity seems unlikely to have been a significant contributor, for a number of reasons.27
Trends in wages, household incomes, and economic security in the US were about the same from 1979 to 1995 as they were in the 2000s.28 Yet the death rate for middle-aged whites increased only in the latter period, not in the former.
Since the late 1970s, wages and household incomes have increased more rapidly among Americans with a four-year college degree than among those with less education, but there was no break in this pattern around the turn of the century. For mortality, however, we do observe a break; the mortality rise since 1999 has been much larger among those with less education.29
Around 80% of middle-aged whites are homeowners. From 1999 to 2006, the first half of the period in which the white mortality rate increased, home values appreciated rapidly. So even though many were experiencing job insecurity and wage and income stagnation, quite a few also enjoyed a significant increase in wealth.30 Yet the rise in the death rate among middle-aged whites was, if anything, faster during this period than in the period of falling home prices after 2006.
The Great Recession of 2008-09 increased economic insecurity among middle-aged whites. Employment rates dropped, and household incomes shrank.31 Yet there was no acceleration in the increase in middle-aged white deaths.
Whites, African Americans, and Hispanics have experienced similar trends in wages, household incomes, and income instability since the late 1990s.32 But while the death rate among the middle-aged has risen for whites, it has fallen sharply for blacks and Hispanics.
Comparing across US counties, Christopher Ruhm finds only a weak association between changes in economic conditions and changes in drug-related death rates. He concludes that economic factors account for less than one-tenth of the rise, and that even this minor effect may actually owe to other causes.35
Finally, economic insecurity isn’t confined to the United States. Young labor market entrants, former manufacturing workers, residents of declining regional economies, and others have experienced rising precarity and/or falling living standards in the United Kingdom, France, Canada, and elsewhere. Yet only in the US has there been a shift in mortality rates (figure 10).
A second hypothesis focuses on the reference groups that shape people’s perception of their economic well-being. Andrew Cherlin explains the reasoning36:
“When whites without college degrees look back, they can often remember fathers who were sustained by the booming industrial economy of postwar America. Since then, however, the industrial job market has slowed significantly. The hourly wages of male high school graduates declined by 14 percent from 1973 to 2012, according to analysis of data from the Economic Policy Institute. Although high school educated white women haven’t experienced the same major reversal of the job market, they may look at their husbands — or, if they are single, to the men they choose not to marry — and reason that life was better when they were growing up.
“African-Americans, however, didn’t get a fair share of the blue-collar prosperity of the postwar period. They may look back to a time when discrimination deprived their parents of equal opportunities. Many Hispanics may look back to the lower standard of living their parents experienced in their countries of origin. Whites are likely to compare themselves to a reference group that leads them to feel worse off. Blacks and Hispanics compare themselves to reference groups that may make them feel better off.”
This hypothesis too doesn’t square well with the data. The General Social Survey asks a question about how people perceive their own standard of living compared to their parents’ standard of living when they were a similar age. Figure 11 shows the share of non-Hispanic whites, African Americans, and Hispanics responding that their standard of living is much worse or somewhat worse than their parents’. Following Cherlin’s lead, I include only persons aged 25-54 and without a college degree.37 If the reference group hypothesis is correct, we would expect to see a divergence between the two racial groups beginning in 2000. Instead, there is no noteworthy separation until 2010, long after the divergence in mortality commenced.
The explanation that best fits the evidence focuses on white Americans’ growing use of opioid pain relievers. These pain relievers — oxycodone, hydrocodone, codeine, morphine, fentanyl — became increasingly available via prescription beginning in the late 1990s. Purdue Pharma, the maker of OxyContin, the most popular of these drugs, aggressively marketed it to primary care physicians and hospitals, urging them to prescribe it more frequently and in larger quantities. As opioid pain relievers became more widely available in a nonstigmatized (prescription) form, more Americans began to use them. Because opioids are addictive, more people got hooked and became regular users. Some overdosed on the pain reliever itself, some created a toxic mix by combining it with another drug (such as a sleep aid), and some switched to heroin and eventually overdosed on that.38
What is the evidence? First, as noted earlier, the chief source of the rise in mortality among middle-aged whites is an increase in accidental poisonings.
The timing fits. Prescriptions issued for opioid pain relievers increased gradually in the 1990s and then doubled from 1999 to the peak in 2011. Sales of opioid prescription drugs quadrupled from 1999 to 2014. As figure 12 shows, overdose deaths involving prescription opioids quadrupled between 2000 and 2014. In 2010, Oxycontin was reformulated to make it more resistant to overdose (by making it difficult to crush into a powder). This helped to reduce overdoses from prescription opioids, but in response heroin overdose deaths shot up.39
This explanation helps to account for the racial difference. Though we don’t have good information about the over-time trends, 5% of whites report nonmedical use of prescription pain relievers in the past year, versus 3% of blacks, and overdose deaths involving prescription opioids are more common among whites than among blacks or Latinos.40
This hypothesis also helps to account for the fact that the death rate has increased more for women than for men. Women are more likely to have chronic pain, to be prescribed prescription pain relievers, to be given higher doses, and to use them for lengthier periods than men. And women tend to become dependent on prescription pain relievers more quickly than men.41
The limited available cross-country data also are consistent with the opioid pain reliever hypothesis. Americans consume a much larger quantity of opioids than their counterparts in other rich nations.42 Figure 13 shows the over-time trend in the death rate from accidental poisoning in these countries. The rise in the United States beginning around 1999 stands out (along with Ireland and Norway). Middle-aged whites in the US would stand out even more; the poisoning death rate among whites aged 45-54, for instance, jumped from 8 per 100,000 in 1999 to 30 in 2013.43
Was there some deeper underlying cause of middle-aged whites’ turn to opioid pain relievers? Not necessarily. Lots of Americans experience pain. On average, we have nine surgeries during our lives.44 One in four each year experience back or neck pain significant enough to see a doctor for help, and two in three will at some point in their life.45 One in ten has kidney stones.46 In this context, the growing availability of opioid pain relievers in a nonstigmatized form (prescription pills), coupled with their addictiveness, may have been enough to launch the epidemic.
Life expectancy in the United States has increased significantly over the past century, due to reductions in many of the major sources of premature death. Yet given our national affluence and heavy spending on healthcare, Americans’ life expectancy is surprisingly low — the lowest among the world’s rich democratic nations — and it has increased comparatively little over the past generation. We don’t have a good explanation for why.
There’s a sizable gap in longevity between white and black Americans, but it has shrunk considerably in recent decades. The gap between Americans with more and less income, by contrast, has increased. Here too scientists haven’t yet figured out the main determinant(s).
Since 1999, the death rate among middle-aged whites has increased, in contrast to that of African Americans, Hispanic Americans, and similarly-aged persons in most other affluent countries. The growing availability of opioid pain relievers appears to be the chief cause.
- Angus Deaton, The Great Escape, Princeton University Press, 2013, ch. 2. ↩
- Deaton, The Great Escape, ch. 4. ↩
- Hans Rosling, “200 Years, 200 Countries, 4 Minutes,” Gapminder; Deaton, The Great Escape; OECD, Health at a Glance, 2015, ch. 3. ↩
- Lane Kenworthy, “America Is Exceptional … and Ordinary,” The Good Society. ↩
- Elizabeth Arias, Melonie Heron, and Betzaida Tejada-Vera, “United States Life Tables Eliminating Certain Causes of Death, 1999-2001,” National Vital Statistics Reports 61-9, 2013. ↩
- OECD, Health at a Glance 2017, ch. 2. ↩
- James S. House, Beyond Obamacare: Life, Death, and Social Policy, Russell Sage Foundation, 2015; Austin Frakt, “Medical Mystery: Something Happened to U.S. Health Spending After 1980,” New York Times, 2018. ↩
- One death per 800 uninsured persons. Benjamin D. Sommers, Atul A. Gawande, and Katherine Baicker, “Health Insurance Coverage and Health — What the Recent Evidence Tells Us,” New England Journal of Medicine, 2017; Steffie Woolhandler and David U. Himmelstein, “The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?,” Annals of Internal Medicine, 2017. ↩
- OECD, Health at a Glance, 2015, ch. 3. ↩
- Centers for Disease Control, National Center for Health Statistics, Health, United States, 2015, table 47, using National Health Interview Survey data; OECD, Health at a Glance, 2015, figure 4.1. ↩
- Lane Kenworthy, “Mental Health,” The Good Society. ↩
- Lane Kenworthy, “Safety,” The Good Society. ↩
- Lane Kenworthy, “Weight Moderation,” The Good Society. ↩
- Centers for Disease Control, National Center for Health Statistics, “United States Life Tables, 2011,” National Vital Statistics Reports, 2015, table 19. ↩
- National Center for Health Statistics, “Special Feature on Racial and Ethnic Health Disparities,” Health, United States, 2015; Sabrina Tavernise, “Blacks See Gains in Life Expectancy,” New York Times, 2016. ↩
- Michael Marmot, The Health Gap, Bloomsbury Press, 2015. ↩
- Beth C. Truesdale and Christopher Jencks, “The Health Effects of Income Inequality: Averages and Disparities,” Annual Review of Sociology, 2016. See also Congressional Budget Office, “Growing Disparities in Life Expectancy,” Economic and Budget Issue Brief, 2008; Christopher Jencks, “The Poor Die Young: What’s Killing Them?,” unpublished, 2009; S. Jay Olshansky et al, “Differences in Life Expectancy Due to Race and Educational Differences Are Widening, and Many May Not Catch Up,” Health Affairs, 2012; Annie Lowrey, “Income Gap, Meet the Longevity Gap,” New York Times, 2014. ↩
- Ronald Lee et al, The Growing Gap in Life Expectancy by Income, National Academies Press, 2015, figure 3-6, using National Health Interview Survey data. ↩
- See below. ↩
- Lane Kenworthy, “Stable Income and Expenses,” The Good Society. ↩
- Lane Kenworthy, “Income Distribution,” The Good Society. ↩
- Lane Kenworthy, “Weight Moderation,” The Good Society. ↩
- Anne Case and Angus Deaton, “Rising Morbidity and Mortality in Midlife among White Non-Hispanic Americans in the 21st Century,” PNAS, 2015. See also Case and Deaton, “Mortality and Morbidity in the 21st Century,” Brookings Papers on Economic Activity conference, 2017. ↩
- Case and Deaton, “Rising Morbidity and Mortality in Midlife”; Andrew Gelman, “Death Rates Have Been Increasing for Middle-Aged White Women, Decreasing for Men,” Statistical Modeling, Causal Inference, and Social Science, 2015. ↩
- Case and Deaton, “Rising Morbidity and Mortality in Midlife,” figure 2. ↩
- Case and Deaton, “Rising Morbidity and Mortality in Midlife”; Nick Bunker, “Rising US Mortality and Its Potential Economic Causes,” 2015; Josh Zumbrun, “The Economic Roots of the Climbing Death Rate for Middle-Aged Whites,” Wall Street Journal, 2015; Shannon M. Monnat, “Deaths of Despair and Support for Trump in the 2016 Presidential Election,” Research Brief, Department of Agricultural Economics, Sociology, and Education, Penn State University, 2016. ↩
- Lane Kenworthy, “Is Economic Insecurity to Blame for the Increase in Deaths among Middle-Aged Whites?,” Consider the Evidence, 2015. ↩
- Lane Kenworthy, “A Decent and Rising Income Floor,” The Good Society; Kenworthy, “Shared Prosperity,” The Good Society; Kenworthy, “Stable Income and Expenses,” The Good Society. ↩
- Case and Deaton, “Mortality and Morbidity in the 21st Century.” ↩
- Lane Kenworthy, “Wealth Inequality,” The Good Society. ↩
- Bureau of Labor Statistics, “Labor Force Statistics from the Current Population Survey”; Economic Policy Institute, “Median Family Income,” The State of Working America. ↩
- Economic Policy Institute, “Hourly Wage Growth by Gender and Race/Ethnicity,” The State of Working America; Economic Policy Institute, “Median Family Income,” The State of Working America; Jacob S. Hacker, Gregory A. Huber, Austin Nichols, Philipp Rehm, Mark Schlesinger, Rob Valletta, and Stuart Craig, “The Economic Security Index: A New Measure for Research and Policy Analysis,” Review of Income and Wealth, 2013. ↩
- Economic Policy Institute, “Hourly Wages by Wage Percentile, Gender, and Education,” The State of Working America. ↩
- Gelman, “Death Rates Have Been Increasing for Middle-Aged White Women, Decreasing for Men.” ↩
- Christopher J. Ruhm, “Deaths of Despair or Drug Problems?,” Working Paper 24188, National Bureau of Economic Research, 2018. ↩
- Andrew Cherlin, “Why Are White Death Rates Rising?,” New York Times, 2016. ↩
- Cherlin, “Why Are White Death Rates Rising?” ↩
- Andrew Kolodny et al, “The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction,” Annual Review of Public Health, 2015; Daniel J. McGraw, “How Big Pharma Gave America Its Heroin Problem,” Pacific Standard, 2015; David A. Kessler, “The Opioid Epidemic We Failed to Foresee,” New York Times, 2016; Harriet Ryan, Lisa Girion, and Scott Glover, “‘You Want a Description of Hell?’ OxyContin’s 12-Hour Problem,” Los Angeles Times, 2016. ↩
- Nora M. Volkow, “America’s Addition to Opioids,” Senate testimony, 2014; Centers for Disease Control, “Prescription Opioid Overdose Data”; American Society of Addiction Medicine, “Opioid Addiction: 2016 Facts and Figures”; Wilson M. Compton, Christopher M. Jones, and Grant T. Baldwin, “Relationship between Nonmedical Prescription-Opioid Use and Heroin Use,” New England Journal of Medicine, 2016; Abby Alpert, David Powell, and Rosalie Liccardo Pacula, “Supply-Side Drug Policy in the Presence of Substitutes: Evidence from the Introduction of Abuse-Deterrent Opioids,” Working Paper 23031, National Bureau of Economic Research, 2017. ↩
- Centers for Disease Control, “Prescription Opioid Overdose Data”; American Society of Addiction Medicine, “Opioid Addiction: 2016 Facts and Figures”; Abby Goodnough, “How Race Plays a Role in Patients’ Pain Treatment,” New York Times, 2016. ↩
- Centers for Disease Control, “Prescription Painkiller Overdoses: A Growing Epidemic, Especially Among Women,” 2013. ↩
- International Narcotics Control Board, “Tables of reported statistics on narcotic drugs,” 2016, table XIV.1.a. ↩
- Case and Deaton, “Rising Morbidity and Mortality in Midlife,” figure 2. ↩
- Peter H.W. Lee and Atul A. Gawande, “The Number of Surgical Procedures in an American Lifetime in 3 States,” Journal of the American College of Surgeons, 2008. ↩
- Gallup, “One in Four Adults Sought Care for Neck/Back Pain Last Year,” 2016. ↩
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, “Kidney Disease Statistics for the United States.” ↩