Failing Population Health: US Life Expectancy Falling Behind

Health in the United States is failing by most metrics that demographers use to monitor the well-being of populations. In 2020, life expectancy at birth declined to a level last observed nearly two decades earlier.¹ Infant mortality ranks worst among peer countries, and maternal mortality is triple the Organisation for Economic Co-operation and Development (OECD) average.² Mortality among individuals in midlife has been increasing, for several decades among some groups.³ Americans not only live shorter lives, but our lives are also less healthy on average, with rising rates of diabetes, hypertension, obesity, and mental health conditions.² While troubling in their own right, these trends also diverge from most of the global community, which has seen continual improvements in population health. As Woolf describes in this issue of AJPH (p. 970), the United States continues to fall behind other countries, moving from 12th to 46th in terms of rank over the period from 1950 to the present.

US HEALTH POOR AND UNEQUAL

The ranking and trends in US life expectancy belie important heterogeneity that clarify US population health not just as poor and declining but also as characterized by stark inequalities.⁴ Indeed, Woolf highlights the role of geography, replicating the well-established disadvantage of states in the US South and Midwest. Additional differentiation by age, race/ethnicity, and socioeconomic status further demonstrates the current state of US population health as determined by social and structural factors that disproportionately shorten the lives of our country’s marginalized populations.

The overall trend of deteriorating population health in the United States is particularly worrisome when we understand that rising midlife mortality is responsible for declines in life expectancy and causing the United States to fall behind other countries.⁵ The midlife period (ages 25–64 years) should be characterized by relatively good health and low risk of death, with chronic conditions typically accumulating toward the end of this life stage and death forestalled until old age. Yet, midlife health in the United States is facing a uniquely disturbing crisis, with individuals dying well before old age and of causes that are largely preventable, such as suicide, chronic liver disease, and accidental poisoning.³ The fact that these causes of death are avoidable points to systemic failures that exclude individuals from successful social integration and cause individuals to detach from social institutions.⁶

In addition to the role of preventable causes of death, part of what made rising midlife mortality so striking was that it was observed among a population that is typically advantaged in the United States—non-Hispanic White adults.⁷ This fact, coupled with the narrowing of the Black‒White mortality gap over the last several decades, may have given the false impression that racial and ethnic health disparities were no longer cause for concern. Yet, Black and Hispanic individuals experienced similar if not higher rates and trajectories of substance use behaviors and mental health problems across adolescence, early adulthood, and as they entered midlife.^8,9 Moreover, starting about a decade ago, midlife mortality also began to rise among minoritized racial and ethnic groups, oftentimes outpacing increases among non-Hispanic White adults.¹⁰ Finally, the disproportionate burden and impact of the COVID-19 pandemic erased nearly all of the previous progress in reducing racial/ethnic health disparities.¹¹

Even as overall US life expectancy declined, individuals with high socioeconomic status, measured in terms of education, income, or occupation, continued to extend their longevity.³ The result is a steepening of the socioeconomic gradient in health and mortality, with the differences between the advantaged and disadvantaged now even more pronounced. As Woolf mentions, this mirrors other social and economic trends of increasing inequality.

PERSISTENT AND GROWING EDUCATIONAL DISPARITIES

Educational attainment specifically plays an increasingly important role,⁴ the effects of which can be observed across the life course. In a nationally representative and diverse sample of US individuals born 1974 to 1982, the National Longitudinal Study of Adolescent to Adult Health (Add Health), I measured six physical and mental health and health behavior outcomes. This cohort was initially interviewed in adolescence in 1994 (ages 13–20 years) and followed up over four additional collection waves, most recently in 2016 to 2018 (ages 33–43 years). I present in Figure A (available as a supplement to the online version of this article at https://ajph.org) the median level or prevalence of each condition at each age, separately for those with and without a college degree, using cubic splines to flexibly fit the age pattern. We see the divergence in health between those with and without a four-year college degree, starting early in the life course and persisting or widening as individuals age into midlife.

We also see evidence of an increasing burden of poor health as individuals age into midlife, consistent with the observed trends in midlife health and mortality.³ With body mass index (BMI) and self-rated health in particular, we see worsening physical health as individuals age into midlife. After an initial peak in late adolescence, depressive symptoms follow a similar pattern, with increases across early and into mid-adulthood. Suicidal ideation, heavy drinking (more than the recommended daily limit on average), and any marijuana use in the last year all share a similar peak in adolescence or early adulthood, reaching relative stability across the late 20s and 30s. Even as the prevalence of health behaviors plateaus, the differentiation between educational groups remains or even widens.

As population health scholars and policymakers continue to work on documenting, understanding, and addressing declines in US life expectancy, future explanations and solutions must attend to the role of midlife health and the persistence and widening of health inequities by race, ethnicity, and socioeconomic position. Promising directions for future effort would interrogate how such inequalities contribute to the international and intranational patterns documented in Woolf’s work. Such comparative work illuminates our current position as historically and politically situated and highlights the possibility and promise of alternative population health futures rather than failures.