This entry was one of the winners of our Summer 2023 student blog contest!
Trends in Life Expectancy
The recent decline in life expectancy in the United States is largely attributed to the well-known COVID-19 pandemic and opioid epidemic. However, these recent crises are not the sole drivers of the stagnation and subsequent drop in life expectancy. Prior to 2010, life expectancy in the US was steadily increasing, similar to other high income countries. Yet, by 2010 a concerning shift occurred as life expectancy stagnated. In 2014, for the first time in decades, life expectancy in the United States began to decline [PDF].
While COVID-19, overdoses, cardiovascular disease, and mental or nervous system disorders have been emphasized in research and in news media as the primary causes of life expectancy declines, these explanations are incomplete. Notably, other high-income countries had continued growth in life expectancy during the 2010s, raising the question: why has the US performed so poorly in comparison?
The US consistently has higher mortality rates for many causes of death including overdoses, birth outcomes, injuries, homicides, pregnancy and childbirth, STIs, HIV and AIDS, diabetes, heart disease, lung disease, and disability compared to other high income countries. Scholars have noted a multitude of reasons for higher mortality rates in the US including, but not limited to, the healthcare system, socioeconomic factors, lifestyle factors, violence and injuries, and maternal and infant health.
Ultimately, these factors are rooted in how American society is structured. In the following paragraphs, we discuss some of the underlying causes of the US life expectancy decline. We discuss the social conditions limiting American health to increase awareness and progress toward fixing underlying structural causes.
The Healthcare System
The U.S. healthcare system consistently ranks last among high income countries. It is characterized by high costs, limited access, and fragmentation. It is worth noting that historically, the US outperformed almost all other countries in treating some fatal conditions, particularly cancer. However, in recent years, our cancer mortality rate has been comparable to other high-income countries. Additionally, the US still spends the most money per capita on cancer care, highlighting a key weakness. For example, recent research from Stanford University shows that one reason the United States spends more on healthcare but has worse health outcomes is due to high administrative costs. Clinics spend substantial funds on administrative systems due to the lack of centralized medical records systems.
Moreover, just because you have insurance in the US doesn’t mean that you will receive equitable healthcare. In fact, the fragmented and high-cost health system is responsible for increased mortality (an estimated 60,000 preventable deaths) and higher COVID case counts for people with poor insurance coverage. There are also other barriers to accessing care, like needing approval from insurance for medication, which results in frustrating communication, stress, and unnecessary complex processes.
Additionally, people with public insurance have different frustrations with the US healthcare system compared to those with private insurance. People with Medicaid face difficulty scheduling appointments [PDF] and experience longer wait times.[PDF] However, people with employer provided insurance experience higher cost of care and lower satisfaction. Cross-country comparisons compliment these findings. An analysis comparing countries’ health care systems revealed [PDF] that the top performing systems provide universal healthcare, invest in equitable primary care for all, reduce administrative barriers to care, and invest in social services—all areas that the US healthcare system needs to improve.
Socioeconomic Disparities and Lifestyle Factors
Socioeconomic disparities are evident in the US, with income and wealth inequality substantially greater than in other high-income nations. Indeed, while the American life expectancy shortfall is pervasive across all walks of life, historically oppressed groups are facing the brunt of the life expectancy crisis. American systems were made for and to benefit the elite, whether that be white, wealthy, heterosexual, abled, etc. persons. The hierarchical, unequal nature of American society has concentrated mental and physical illness among those who are poor and less educated, and among minority racial groups.
Those who are Black and of lower socioeconomic status are likely to have worse health and life expectancy than those who are white or richer. This was exemplified during the COVID-19 pandemic, when impoverished families and racial and ethnic minorities experienced the worst health outcomes. The socioeconomic disparities in the US undoubtedly contribute to the population’s declining life expectancy.
Lifestyle factors in the US are also a likely contributor to poor life expectancy. The ”default American lifestyle” relies upon individualism, inactivity, industrial food consumption, and medical dependency. In other words, American society is structured for poor health. The presence of greedy institutions has resulted in excessive work, increased individual and family responsibilities, rising financial insecurity and instability, and car-dependent infrastructure. These changes have amplified stress among all Americans. In turn, increased stress debilitates the body and encourages negative health behaviors, lowering life expectancy. The opioid crisis is just one example of how the American societal structure results in health-degrading lifestyle factors.
Violence and Injuries
Violence and injury-related deaths are common in the US. The high rate of violent and injury mortality in the US is unprecedented. The US consistently has the highest number of motor-vehicle deaths, gun deaths, and suicides per capita compared to other high-income countries. Similar to lifestyle factors, specific societal structures like car-dependent infrastructure and easy access to firearms contribute to violent mortality. For example, women who are pregnant or postpartum have a 16% higher homicide prevalence.
Additionally, violence and injuries are especially prevalent in the younger population. Young adults are keenly at risk for injury-related, preventable deaths, such as homicide, suicide, and substance abuse. Such high mortality among the younger population results in significant declines for US population life expectancy. Reducing structural factors like car dependency and gun accessibility could reduce the number of violent deaths.
Maternal and Infant Mortality
Socioeconomic disparities, poor prenatal care, preterm births, and lack of social support systems drive high maternal and infant mortality rates in the United States. Maternal mortality is stratified by race; pregnancy-related mortality is 4-5 times higher for black women compared to white women. Researchers argue that many of these maternal deaths are preventable, and are largely due to failures of US healthcare systems. These challenges were further exacerbated during the first year of the COVID-19 pandemic, when maternal mortality rates increased by 33.3%, mostly due to higher death rates of Black and Hispanic women. The wide income, race, and class inequalities in the United States are also contributing to higher maternal mortality.
While much research focuses on conditions during pregnancy, inequalities and injustices well before pregnancy begins have been linked to worse maternal and birth outcomes. Additionally, historical systemic inequalities also contribute to modern-day disparities in birth outcomes. For example, women who live in areas that were historically redlined have significantly higher risk of preterm birth[PDF]. While infant mortality has declined over the past century, disparities between black and white infants have widened. Reinvesting to support pregnancies and children is essential for revitalizing American population health.
What can we do?
How can we reimagine these structures in order to benefit the health of our society? The answer is nuanced. The United States is a unique country; it is difficult to compare our policies, systems, and structure to other nations. However, there needs to be recognition that the US is behind and falling further behind other high-income countries. As Steven Woolf, a lead scholar on life expectancy, commented, “It’s worth taking a look at what [other countries have] done and Americanizing it—you don’t have to take it right off the shelf.” We can even look within the US at different states. Research has shown that states with more liberal policies are faring much better in life expectancy than less liberal states:
US life expectancy is estimated to be 2.8 years longer among women and 2.1 years longer among men if all states enjoyed the health advantages of states with more liberal policies. This would put US life expectancy on par with other high-income countries.
Structural changes like introducing universal healthcare, reducing poverty, expanding the social safety net, decreasing car dependency, and investing in children may put us back in the running. It would be worthwhile to invest in prevention via social policy, particularly among children—the future population of the US.
