Americans' Drinking, Drug Use, Despair Wiping Out Life Expectancy Gains

Drinking, drug use, obesity, isolation, and related ills are rolling back a half-century of gains in life expectancy in the United States—and these trends started so long ago they may be hard to reverse, according to a sobering analysis appearing today in JAMA.¹

Three straight years of declining life expectancy—from 2014 to 2017—have roots that go back to the 1980s, when “US life expectancy began to lose pace with other countries,” say Steven H. Woolf, MD, MPH; and Heidi Schoomaker, MAEd, both of the Center on Society and Health at Virginia Commonwealth School of Medicine.

Using nearly 60 years of data from the US Mortality Database and CDC (1959-2017), Woolf and Schoomaker paint a grim picture of how certain causes of death have climbed among Americans at midlife—those between age 25 and 64, before they become eligible for Medicare. Their findings amplify the data first highlighted by Princeton’s Anne Case and Angus Deaton, who coined the term “deaths of despair” in reporting the uptick in deaths from opioid and alcohol abuse and suicide.

Today’s JAMA report confirms the rise in those causes, especially since the 1990s, but adds to them deaths from obesity, hypertension, and renal failure—all related to poor nutrition and lack of exercise that have been public health officials’ radar for some time. And the report adds social isolation—identified by health plans as a leading cause of morbidity and mortality—as an additional culprit; an accompanying editorial cites a study that found it increased the risk of death by 29%.

For decades, the authors say, this quilt of morbidity has created an undercurrent in the US healthcare landscape, while official US life expectancy continued to rise due to advances in other areas—better treatments for heart disease and cancer, and declining smoking rates, especially among those with better access to education and insurance.

But Woolf and Schoomaker note that the triple wave of the opioid crisis—first oxycodone (OxyContin), then heroin, and now fentanyl—a slowdown in the health gains in other areas, and a rise in chronic stress and suicide have finally exposed what they call the “the US health disadvantage.”

Rising midlife mortality is strongly tied to income, and the analysis reveals both a strong rural-urban divide as well as shifting fortunes over time for some parts of the country. The authors note that in 1959, Kansas had the nation’s highest life expectancy at 71.9 years, but it ranked 29th in 2016. Among other findings:

• Life expectancy increased from 1959 to 2014, from 69.9 years to 78.9 years, but has declined for the past 3 years.
• The drop in life expectance followed increases in cause-specific mortality among those aged 25 to 64 that began in the 1990s, and led to an increase in all-cause mortality in 2010.
• During 2010-2017, midlife all-cause mortality rates rose from 328.5 deaths per 100,000 to 348.2 deaths per 100,000.
• While there has been much focus on the increased mortality among whites at midlife, the increases since 2014 have occurred among all racial groups, due to a combination of drug overdoses, alcohol abuse, suicides, and various organ system failures.
• States in the Northeast and the Ohio Valley have seen the highest relative increases in midlife mortality; from 2010-2017 there were 33,307 excess deaths at midlife, 32.8% of which occurred in 4 Ohio Valley states: West Virginia, Ohio, Indiana, and Kentucky.

Is healthcare access a factor?

“Although the US healthcare system excels on certain measures, countries with higher life expectancy outperform the United States in providing universal access to healthcare, removing costs as a barrier to care, care coordination, and amenable mortality,” Woolf and Schoomaker write. However, they state that US physicians also contributed to the opioid epidemic by writing prescriptions, and they say systemic deficiencies alone cannot explain why midlife mortality rates rose for some chronic disease while falling for others, such as heart disease and HIV.

Chronic stress and rising income inequality were discussed as potential factors. The healthcare divide between the haves and have nots—which started in the 1980s and took off in the 1990s—tracked “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.” The healthcare disadvantage, the authors say, fell hardest on those with the least education, including women, and was concentrated in areas where jobs fled, including rural areas and the Midwest.

“One theory for the larger life expectancy gains in metropolitan areas is an increase in the population with college degrees,” Woolf and Schoomaker wrote.

The authors, as well as commentators in an editorial, say the policy implications are significant and challenging. The editorial by authors from the Harvard T.H. Chan School of Public Health² note that the effects of obesity were predicted 15 years ago, but today 80% of adults do not meet US physical activity guidelines. Half of adults have hypertension, mostly uncontrolled. After years of progress on fighting tobacco, the rise of e-cigarettes presents a new health challenge.

And rising despair and suicide rates—85% of which are by a firearm or “non-poisoning”—point to the challenge of fully integrating mental health into the care landscape after decades of stigma and sectoring it out of the rest of most health plans. Medicare and Medicaid should lead the way, the editorial states.

“Bridging health policy, social policy, and financing debates can leverage multisectoral approaches to reverse declining life expectancy,” the editorial states. Setting a new life expectancy goal is one approach, and alternative payment models can be used to address the nonclinical areas that must be part of the solution.

“Otherwise,” write Koh et al, in the editorial, “the nation risks life expectancy continuing downward in future years to become a troubling new norm.”

References

1. Woolf, Schoomaker. Life expectancy and mortality rates in the United States, 1959-2017. JAMA. 2019;322(10):1996-2016.
2. Koh HK, Parekh AK, Park JJ. Confronting the rise and fall of US life expectancy. JAMA. 2019;322(10):1963.