Five Out-of-the-Box Ideas For Turning Around Falling US Life Expectancy Rates

By JEFF GOLDSMITH Ph.D. (15)

The Miniature Coffins via The National Museum of Scotland

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.

15 thoughts on “Five Out-of-the-Box Ideas For Turning Around Falling US Life Expectancy Rates

  1. On my list would be nutrition education for physicians and their offices, so they would do more for their patients to reverse hypertension and diabetes, which can both be controlled by diet and exercise.

    Diet and exercise are also good for mental health, which is finally coming out of the closet as a subject for discussion. Mental health issues lead to drug addiction, as do Averse Childhood Experiences.

    Some states (Arizona) offer double food stamps (SNAP) for people who shop at farmers’ markets.

    More pressure on the industrial food industry to stop loading its products with sugar, oil and salt.

    And of course more for people to live for –more opportunity to make a difference in the world.

    We are a nation that has stopped educating its citizens in ways to live fulfilling lives. Better education, better conversation, better motivation.

    I say this as a 77 year old plant-based woman who eats no processed food and never did. (Well, maybe canned tuna). When you get into looking at food labels you realize why lifespan and health span are both declining.

    My compatriots in the food as medicine movement (if there is such a thing) have all studied the “Blue Zones,” areas of the world where people live to be centenarians. Read the book.

    1. Good article Jeff. I start to wonder if the root causes that you speak of are really healthcare or societal. For example, in my recently chosen field of employee wellbeing, I believe the core issue is workplace culture–not health promotion programs. With a supportive culture, good programs work; with a toxic workplace culture, good programs do not work.

      What Jeff speaks of is far beyond healthcare. We rely far too much on healthcare to solve our real root-core societal ills.

      That being said, they’re real ills. And government is doing more harm than good. We are spending our money in the wrong areas, expecting silver bullets, when this is all about the basics. Poverty; education; family; employment. I really don’t see healthcare in those four. So I agree–blaming our admittedly less than perfect healthcare delivery system for this is inappropriate.

    1. Here’s my question

      I’ve been hearing complaints from sources for years about the increasing politicization of the CDC and political appointees throwing their weight around. Heard the same things in the Obama years. Under the circumstances, it seems reasonable to ask how reliable the CDC’s numbers are.

      How vulnerable are these statistics to manipulation? What political interests and policies are tied to them?

      Given what we know about the Trump administration’s record in other areas, this seems a fair question to ask.

      1. Excellent piece. We’ve been grossly underspending on public health for decades. Through D and R administrations. Why is baffling, but one reason is it got conflated with prevention. An effort to put PH on the political agenda this year seems important. John’s point about CDC is valid.

      2. There is no reason to believe that CDC’s data on morbidity and mortality have been compromised by political forces.

    2. Jeff misses the elephant in the room. US is spending more than double on healthcare than other rich economies. If close to $2 Trillion were available for food, housing, education, and parks our life expectancy would track other countries. Shifting the chairs around on the deck of the Titanic will not change the outcome.

      1. Thought provoking piece!

        I agree with Adrian –four words that are shocking, but true. In fact, my take on the importance of housing on health of people has already been shared with my community: https://www.kitsapsun.com/story/opinion/columnists/2018/11/09/niran-al-agba-why-affordable-housing-matters-your-health-care/1936034002/

        The third (predictable) drop in life expectancy has nothing to do with physicians, nurses, or even insurers and hospitals. It is about social determinants of health –access to healthy food, education, and housing. Until we see the forest for the trees, nothing is going to change.

      2. That was my point about spending in the wrong areas. We could come up with a list in addition to waste in healthcare. Focused spends on education and infrastructure seems like a common sense course, but….

      3. This is truly thought-provoking and somewhat terrifying – I’m certain the same decline in life expectancy will be observable over here in the UK, and for exactly the same reasons.

        We’ve always known that the biggest improvements in life expectancy, health, and quality of life came from improvements in housing conditions, reducing overcrowding, better sanitation, education, and reliable public utilities. Societal and public health interventions.

        And similarly, as life expectancy goes down, it will be because of worsening inequality, declining living standards and housing conditions.

        What I would ask is: “Why is this happening?” is it purely the greed of the super-rich and corporations, driving down wages and starving public services of taxation funding? Or is it something more fundamental and less human-controlled – such as the effects of a Post-Peak-Oil world struggling to maintain the standards of living and populations it used to think it could sustain with what seemed in the 20th century to be ‘limitless’ oil?

      4. Welcome to my world….says the sociologist.

        Is anyone surprised that the primary solutions for societal problems are going to be economic and social. Healthcare costs (in the US) are very important, but even there, we should think more broadly. Consider the CDC’s budget for last year vs. just the food industry’s advertising budget. The food industry advt budget (mostly processed food) = $200 billion vs. CDC = $5.6 billion. By a coincidence, $5.6 billion is just what McDonald’s spent on advts in the US.

        And even if we think of health (not healthcare): the primary issues will be air, water, sanitation, housing, poverty, sense of purpose, smoking, food (enough, too much, bad for you), drinking, jobs, education, non-medical use of drugs, exercise, etc. Vaccines will by the first “medical” intervention (if we don’t count the role of medical knowledge to help with water purity).

        Yes, as Adrian notes: the 18% of GDP spent on healthcare – if cut by 50% — would free up a hell of a lot of resources for other uses. But with the current administration, assuming those other uses would be beneficial is a heck of an assumption.

      5. Per Ross’s comment, there are actually a lot of sociologists in the healthcare world: Steve Shortell at Berkeley, Rob Burns at Wharton, Paul Starr at Princeton, me at wherever- to mention only a few. We have been outshouted by the economists. Perhaps it is time for us to be less gentlemanly and raise our voices about the societal contribution to health status and expense. This piece was intended to start a conversation about the broader issues, and our flawed social accounting system. . .

  2. Let me suggest a symptom of the problem: In the years intervening from 2008, while employers and their upper third of employees (and senior management) did VERY well, the rank and file did not. Wages have been largely stagnant for 20 years, retirement plans gutted, and employee contributions to health insurance quintupled. Is there any wonder that the bottom half of the population, whether British or American, is less healthy, more stressed, and living shorter lives? Why couldn’t corporate America have shared the largess with the lower half of the employee base? Is the drive for ever increased profits and because they could. I blame boards more than anyone for this. What is the last Board that held its CEO every bit as accountable for the health and wellbeing of his/her employees as they do for profits?

    And I decidedly am not a liberal.

  3. Excellent article and I think Ross’s comments below are right on target. Poor health outcomes largely aren’t due to the healthcare system. But, ravenously resource intensive healthcare fed by an increasingly unhealthy society is a recipe for massive waste.

    Unfortunately, the premature deaths described below occur one by one and escape headlines. If they had some associated drama, like a plane crash or a terrorist event, there would be banner headlines, congressional hearings and the nation would rapidly be mobilized. Unfortunately, debating faux emergencies is the order of the day.

    Seriously addressing the deep seated national trends that are pushing mortality—environmental, educational, lifestyle, etc.—would require massive public investment coupled with an educational campaign. I’m doubtful that the country currently has the collective spirit to support such an effort. In 1961 JFK told us to “ask not what your country can do for you…” Twenty years later, Ronald Reagan asked, “are you better off than you were four years ago. “ That step away from a collective sense of our well-being has only become stronger in subsequent decades. Any attempt to recapture it will likely be denigrated as “socialism,” as we’ve recently been reminded. Unfortunately, those with the resources to protect themselves won’t see what’s in it for them.

    DS

  4. I’m glad to see that that the case for focusing on the social determinants of health is being made on economic terms now. Clinical focus alone won’t spark necessary changes to promote general health and wellness. A more holistic view of what keeps Americans secure and healthy is desperately needed so that we focus on prevention as much as treatment.

    Luckily, really good SDOH research and projects are being performed nationally (Texas, for one, seems to be doubling down on this). Question is whether gov’t and/or private health care actors have enough incentive to support and promote best practices nationally.

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