By Laudan Aron and Gavin Yamey
Life expectancy in America fell sharply in 2020. It fell again in 2021. The COVID-19 pandemic certainly played a role, but that’s not the whole story. During this same time period, eight of the ten leading causes of death also increased. Even maternal and child and adolescent mortality increased. In August 2022, federal health officials released new data showing that across all demographic groups, Americans are dying younger.
Ten years ago, a landmark report called “Shorter Lives, Poorer Health” documented for the first time a widespread “U.S. health disadvantage,” a shortfall in the health and survival of Americans relative to other high-income countries [Aron was the report’s study director]. On some measures, such as violent deaths among males aged 15-24, the divergence from other rich countries began growing as early as the 1950s. The report showed that the U.S. had the lowest life expectancy among peer countries and higher rates of injury, illness, and death from dozens of causes. Evidence of this disadvantage was found for young and old, rich and poor, men and women, and Americans of all races and ethnicities.
Another seminal report released in 2021, called “High and Rising Mortality Rates Among Working-Age Adults,” showed that U.S. mortality rates have been increasing in mid-life (ages 25-64), the prime years for family formation, childrearing, caregiving, and employment. More surprisingly the rising mortality among U.S. children and youth between 2019 and 2021 represents a profound crisis. Although not predictive of future mortality conditions, which are likely to change, current survival rates mean that one in 25 American five-year olds will not reach their 40th birthday.
The reasons behind these disturbing trends are many, and one might argue, uniquely American. Here are five:
A poor start in life for many young Americans
Beyond the latest data on rising pediatric mortality rates, it is clear that the U.S. is failing its youngest citizens on multiple fronts. For at least a decade now, cross-national comparisons of child and adolescent wellbeing in rich countries show that the U.S. ranks at or near the bottom on most measures. Such measures include material wellbeing, health and safety, behaviors and risks, education, housing, family friendly policies, and social protection. Further, careful analyses of overall levels of social spending by country show that, compared to other high-income nations, the U.S. is distinct in how it spends, not how much it spends. American spending is much less redistributive, with fewer benefits going to children, families, and the disadvantaged. In addition to high rates of infant and maternal mortality, the latest data show that U.S. children are in the midst of a deepening mental health crisis, with increased access to firearms and opioids driving up rates of suicide, homicide, and overdoses. In 2020, firearm-related injuries surpassed motor vehicle crashes to become the leading cause of death among young Americans ages 1-19.
A dysfunctional and costly healthcare system
Among the many factors driving health and survival is healthcare. The U.S. has long been known for having one of the most complex, fragmented, and expensive healthcare systems in the world. For millions of Americans, quality, affordable, accessible healthcare is simply out of reach (and the uninsured are more likely to die young than the insured), or it is effectively unavailable, or disappearing due to political pressures, as in the case of sexual and reproductive healthcare. The U.S. healthcare system, its high costs, and its poor health outcomes, start to “make sense” when viewed through a business case lens, and its optimization of revenue and profits, rather than health and wellbeing. As Dr. Elisabeth Rosenthal, editor-in-chief of KFF Health News, says about the U.S. medical market, “a lifetime of treatment is preferable to a cure” and “prices will rise to whatever the market will bear.” It should come as no surprise then that that the U.S. healthcare system is one driver of the poor health and survival of Americans, many of whom are uninsured, underinsured, medically undertreated or overtreated, distrustful of the system, and drowning in medical debt. Finally, the astounding $4.3 trillion (or $12,914 per person) spent annually on healthcare in the U.S. far exceeds spending in other countries around the world, and crowds out other social investments that matter to human development, protection, and flourishing.
Societal systems that undermine wellbeing and accelerate inequality
Beyond healthcare, many other aspects of life and the policy-driven systems that underpin them are compromising the health and wellbeing of Americans. Lives are diminished and lost because of the U.S. approach to food and nutrition, housing and civic infrastructure, education and training, employment and entrepreneurship, crime and safety, economic and community development, credit and financial services, social protection and safety nets, and environmental conditions. Deep dives into most of these systems often reach two strikingly consistent conclusions: (1) they are perpetuating or accelerating inequality, and (2) they are working as designed, meaning their seemingly perverse effects are a feature, not a bug. These systems reflect both historical factors and ongoing choices by policymakers and private sector interests. The good news here is that other countries are making different choices, which (in theory) means the U.S. can too. We can rein in negative commercial determinants of health (private sector activities affecting health) and instead build genuine care systems and adopt a health-in-all-policies agenda, defined by the CDC as “a collaborative approach that integrates and articulates health considerations into policymaking across sectors to improve the health of all communities and people.”
An inadequate policy response to growing inequality and precarity
The large and growing U.S. disadvantage in health and survival is, in part, a reflection and accelerant of economic inequality and precarity. U.S. income and wealth inequality is high, has risen substantially over recent decades, and exceeds levels in other advanced democracies. Some might argue that high levels of inequality are acceptable as long opportunity and socioeconomic mobility remain high. But such opportunity and mobility have seen a dramatic reduction in the last half century, with only half of children today earning more than their parents did, compared to 90 percent of children born in 1940. Equally importantly, Americans greatly underestimate actual levels of wealth inequality and still prefer that wealth be more equitably distributed. The conditions producing such high levels of inequality — and ways of mitigating or reversing them — are of course matters of public policy. In addition to more progressive tax and transfer policies, which also affect many middle-class entitlements, any policy that expands access to the social determinants of health – nutrition, education, employment, housing, transportation, safety, justice, caregiving – will in turn improve population health and wellbeing. Policymakers influence their availability, accessibility, and affordability. One reason other high-income nations outperform the U.S. on health and survival is because the many resources that matter to health and wellbeing are distributed (or redistributed) more equitably and they have stronger systems of social care and protection.
Structural racism, racial capitalism, and their attendant injustices
Although the U.S. health disadvantage affects all Americans, even privileged ones, the most marginalized communities have always paid a much higher cost. The latest data on U.S. life expectancy by race/ethnicity confirm this and are a powerful reminder of the ongoing influence of systemic racism in the American landscape. As Dr. Camara Jones, past president of the American Public Health Association, explains, racism is “a system of structuring opportunity and assigning value based on the social interpretation of how one looks (what we call ‘race’), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.” By unfairly structuring opportunity and allocating access to the resources that matter to health and survival, structural racism, racial capitalism (the interlinkages between capital accumulation and racial exploitation), and other forms of injustice directly influence population health. It is critical to acknowledge these root causes of the U.S. disadvantage in health and survival, rather than fall prey to overly simplistic narratives that blame individual people and places for their poor health. Ostensibly race-neutral policies and practices often perpetuate an enduring legacy of racism, protecting the health of some communities at the expense of others. One fascinating example is when the Florida Department of Agriculture banned sugar growers from burning sugar cane “when the wind blows east” in an effort to protect wealthier, whiter communities from their toxic fumes.
Declining life expectancy in the U.S., and especially rising deaths rates of children and adolescents, should be a loud wake-up call for the nation. The more hopeful but still urgent news is that we can change this reality: conditions of life and death are direct reflections of our values and priorities and the policies we choose to govern our communities and the nation as a whole. If we are to enjoy a level of health, wellbeing, and survival similar to those in other advanced democratic nations, Americans will need to make a fundamentally different set of policy choices.
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