Dying too young

from David Ruccio

If there ever was an argument in support of Medicare for All it’s this: despite spending more on health care than any other country, the United States has seen increasing mortality and falling life expectancy for people ages 25 to 64, who should be in the prime of their lives.

A new report published in the Journal of the American Medical Association paints a bleak picture: overall life expectancy in the United States, which had increased for most of the past 60 years, has actually fallen for three consecutive years. But this is not just a recent trend. U.S. life expectancy began to lose pace with other countries in the 1980s, and, by 1998, had declined to a level below the average life expectancy among Organisation for Economic Cooperation and Development countries. While life expectancy in these countries has continued to increase, American life expectancy stopped increasing in 2010 and has been actually decreasing since 2014.*

The recent decrease in U.S. life expectancy was largely related to increases in all-cause mortality among young and middle-aged adults, as against other groups (infants, children, and the elderly) for whom mortality rates have declined. For individuals aged 25 to 64 years all-cause mortality rates were in decline in 2000, reached a nadir in 2010, and increased thereafter.

But the roots of the crisis in U.S. life expectancy go back further in time. Midlife mortality rates for a variety of specific causes (e.g., drug overdoses and hypertensive diseases) began increasing earlier. But they weren’t reflected in all-cause mortality trends because they were offset by large, simultaneous reductions in mortality from ischemic heart disease, cancer, HIV infection, motor vehicle injuries, and other leading causes of death. However, increases in cause-specific mortality rates before 2010 slowed the rate at which all-cause mortality decreased (and life expectancy increased) and eventually culminated in a reversal. The end result was that all-cause mortality increased after 2010 (and life expectancy decreased after 2014).

The authors of the report make it clear that deficiencies in the healthcare system explain increased mortality from at least some conditions.

Although the US health care system excels on certain measures, countries with higher life expectancy outperform the United States in providing universal access to health care, removing costs as a barrier to care, care coordination, and amenable mortality.

Radically transforming the way healthcare is financed, such as is proposed in the U.S. Medicare for All Act of 2017 Health Insurance Program, would go a long way to reversing the decline in life expectancy in the United States. It would eliminate the financial barriers to decent healthcare, providing everyone with access to hospitalization, primary and preventative services, prescription drugs, and other services (such as oral health, audiology, and vision services), and so on.

But, we have to admit, universal health insurance is not by itself going to solve the problem in the United States. One reason, of course, is that one cause of the decrease in life expectancy is the surge in drug overdose deaths that began in the 1990s, which came out of the private, profit-seeking U.S. healthcare industry itself.**

The increasing mortality and falling life expectancy among young and middle-aged Americans were exacerbated by other dimensions of U.S. capitalism. We know, for example, that, since the late 1970s, income inequality widened, surpassing levels in other countries, concurrent with the deepening U.S. health crisis. Moreover, those most vulnerable to the new economy (e.g., adults with limited education and younger men) experienced the largest increases in death rates as did those who worked in areas suffering economic dislocation, such as rural U.S. areas and the industrial Midwest. While the authors admit that the causal links have not been firmly established, they do observe that “Socioeconomic pressures and unstable employment could explain some of the observed increases in mortality spanning multiple causes of death.”

It’s not just a matter of absolute income or net worth. According to the report, the causes of economic despair may be more “nuanced,” stemming from “perceptions and frustrated expectations” within the American working-class. Whatever hope was tied in with the American Dream has been undermined as economic inequality reached obscene levels and intergenerational mobility declined.

Moreover, these potential causes are probably not independent and may, together and in complex ways, shape mortality patterns.

major contributors like smoking, drug abuse, and obesogenic diets are shaped by environmental conditions, psychological distress, and socioeconomic status. The same economic pressures that force patients to forego medical care can also induce stress and unhealthy coping behaviors and can fracture communities.

Americans are faced, then, with an enormous problem: an economic system that, especially in recent decades, has caused mortality to rise and life expectancy to fall among young and middle-age workers; a private healthcare system that has both been inadequate to the task of caring for these people and in, the case of certain classes of pharmaceutical drugs, made the problem worse; and a system of health insurance that has left millions of people without access to healthcare.

Medicare for All represents a real solution to one dimension of the problem. But not to the other two. Unless and until the U.S. economic system (including the way healthcare is provided) is radically transformed, Americans will continue to die much too young.

 

*According to the report, Life expectancy began to advance more slowly in the 1980s and plateaued in 2011. U.S. life expectancy peaked in 2014 and subsequently decreased significantly for 3 consecutive years, reaching 78.6 years in 2017.

**It started with the introduction of OxyContin in 1996; was followed by increased heroin use, often by patients who had become addicted to prescription opioids; and then was subsequently aggravated by the emergence of potent synthetic opioids, which triggered a large post-2013 increase in overdose deaths.