By JEFF GOLDSMITH Ph.D. (15)
After last Thanksgiving, the US Centers for Disease Control reported that US life expectancy declined again in 2017, after falling in 2015. The last time the US experienced a two-year decline in life expectancy was during the early 1960’s, before Medicare and Medicaid, and before much of modern medicine! The last three-year decline was a century ago- a result of the Spanish flu epidemic in the aftermath of World War I. Spread over a population of 327 million, the drop of 0.3 years in American life expectancy since 2014 represents a loss of almost 100 million life years! For a country with a nearly $20 trillion economy and that is spending more than $3.5 trillion annually on healthcare, this is both a disgrace and an international embarrassment.
Health analysts pointed to the epidemic of drug deaths as the principal cause. (And it wasn’t just opiates that did the damage; more than 24 thousand of the more than 70 thousand overdose deaths in 2017 were from methamphetamine and cocaine, problems that many lay observers may believe we put in the rear-view mirror years ago). Suicides claimed 47 thousand Americans in 2017, a 33% increase since the turn of the millennium! So between suicides and drug overdoses, which are really a form of suicide, American lost 117 thousand people in 2017.
However, in the background, a more ominous development was the end of a more than forty-year trend in declining deaths from strokes and heart disease, almost certainly due to obesity. Add all these causes together and they are evidence of a slow brewing multi-factor public health crisis. A rising number of Americans are slowly or rapidly killing themselves.
This slow-motion carnage is not randomly distributed among the generations. Life expectancy of children and teens has improved since 2014, as has health of older Americans. The deterioration in health status is concentrated in midlife Americans (most of Generation X and the younger edge of the boomers) and is more pronounced among men of all racial backgrounds than among women. And thanks to overdose deaths, Millennials, that is young people aged 25–34, saw their risk of dying rise ten percent from 2015 to 2017!
The death rate changes are also not randomly distributed geographically. There is a six-year gap between states with the highest and lowest life expectancy. Though the most recent (e.g. 2017) report did not break out individual states’ performance, states with most significant long term rise in death rates have been in greater Appalachia and the deep South, areas with persistent long-term economic problems. There are also hot spots in the near and far West, concentrated in native American reservations and mining communities.
It is time for an honest societal conversation about what to do about this spreading humanitarian catastrophe, a significant challenge given our polarized, blame-infested political climate. Both political parties’ “experts” on health policy decry the rise in health spending. Both wings of the community seem to gravitate toward moral failure as the main driver.
If the population is getting sicker, as appears to be the case, blaming doctors and hospitals, as has been the fashion recently among many of healthcare’s progressive policy experts, is not productive. If we just found the right “operant conditioning schedule” for hospital and physician payment, the argument runs, the care system could take care of this problem.
Conservative policy experts blame moral failure of individuals for rising healthcare use and costs. If only people, particularly the poor, just had more “skin in the game”, they would take better care of themselves, and “shop” for the care they need. The cure, analogous to prescribing bleeding for cancer, is to shift more of health costs to individuals and families, on the unproven assumption that more exposure to the cost of care will lead to better health habits and more responsible consumer behavior.
While behavioral factors certainly play a role in rising mortality- lack of exercise and hypertension are the strongest proximate predictors of rising death rates- the root cause appears to be poverty — and the despair that finds root in it. Indeed, the percentage of a county’s population in poverty was the most powerful demographic predictor of a given county’s death rate . This makes intuitive sense. As an astute colleague, Alexandra Drane, said once, “If your marriage is failing, and you are losing your job and are four months behind on your mortgage, lowering your hemoglobin A1c score may not be your number one priority.”
The societal conversation about how to reverse this trend begins by answering some tough questions. Here is only a sample:
- Can we do a more effective job of stimulating economic development in struggling areas than laying on large corporate tax cuts and pining for a resurgence of 1940’s industries like coal mining, tobacco and dairy, and steel manufacturing? Or does it make sense to pay people who presently live in those areas to relocate to areas where there are more economic opportunities and shortages of workers?
- Can we rapidly retool low skill workers who did not attend college to address a growing skilled labor shortage?
- What role can more generous and more effective mental health coverage play in reversing what Angus Deaton has called the rise in “deaths of despair”- particularly suicide and drug overdoses?
- Can we do a more effective job of supporting families, and sustaining marriages, which appear to be protective both from suicide and drug deaths?
- What risk factors can the care system most productively address on its own (hint: hypertension appears to be the leading candidate, followed closely by diabetes)?
One thing seems likely. Last year, 2018, and next year 2019, will probably bring America yet more life expectancy reductions. The issue seems almost certain to raise its ugly head in the 2020 Presidential campaign, which is not shaping up to be an exercise in substantive, real world type health policy discussion, but rather a war among dueling “bumper stickers” (“Single payer”! “Socialized Medicine!”, etc.) Not clear yet is how many combatants will mention the niggling $85 billion a year that we are spending on public health in the midst of a public health crisis. It would be great for prospective Presidential candidates to bring us some real answers.
Jeff Goldsmith Ph.D. is a veteran health industry analyst. He is National Advisor to Navigant Healthcare, and President of Health Futures, Inc, a strategic consultancy.