The Decline In US Life Expectancy; The Nation’s Choice

The Decline In US Life Expectancy; The Nation’s Choice unknown

Nearly 10 years have passed since a 2013 Institute of Medicine report drew attention to the US health disadvantage. For decades, the report explained, Americans had experienced poorer health, higher mortality rates, and shorter life expectancy than populations in other countries. The report warned that, “other countries have gained life years even faster, and our relative standing in the world has fallen over the past half century.” Conditions worsened after that report; US life expectancy plateaued and then decreased for three consecutive years (2014–17), while lifespans in other countries continued their climb.

The US health disadvantage was thus decades old in 2020, when COVID-19 arrived, and the disadvantage turned catastrophic. US COVID-19 mortality rates were among the world’s highest. US life expectancy experienced its largest decrease since World War II, exceeding losses in other high-income countries. When COVID-19 vaccines arrived in 2021, life expectancy increased in many countries, but US life expectancy decreased further. The pandemic will end, but the US health disadvantage will persist unless its root causes are addressed.

Falling Behind

In July 2022, the United Nations (UN) Department of Economic and Social Affairs released life expectancy estimates for 238 countries, covering 1950–2021. These data suggest that the US disadvantage is worse than the literature suggests. For example, most studies of the US health disadvantage draw comparisons with 15–30 “peer countries,” mostly Western European or Anglo-Saxon. However, according to the UN data, as many as 66 countries had higher life expectancy than the United States in 2020—including 45 populous countries (populations greater than 500,000, with more stable life expectancy estimates). These countries spanned the globe, from East Asia to Central and South America, Eastern Europe, and the Middle East. The literature usually measures US outcomes against high-income countries, but more than 20 countries that surpassed US life expectancy were middle-income or communist countries at the time.

Most studies date the onset of the US health disadvantage to the 1980s or 1990s, but it started earlier. According to the Human Mortality Database, in 1943, during World War II, eight countries had higher life expectancy than the United States. Although industrialized countries saw life expectancy increase, the UN data show that US increases slowed in the 1950s–60s. By 1968, 36 populous countries, including six then-Soviet Eastern Bloc states, had higher life expectancy. The US temporarily regained its pace in the 1970s, but advances in life expectancy stalled again in the early 1980s and have never recovered. Since 2010, 12 more countries surpassed the United States, half during the COVID-19 pandemic. Between 1983 and 2020, the gap between the highest life expectancy in a populous country and US life expectancy grew from 2.6 to 7.8 years (exhibit 1). Since 1950, 15 populous countries have outperformed the United States for more than 50 years.

Exhibit 1: US life expectancy disadvantage relative to populous countries, gap and rank, 1950–2021

Source: Population Division, Department of Economic and Social Affairs, United States. File GEN/01/REV1: Demographic indicators by region, subregion and country, annually for 1950–2021 (data accessed September 16, 2022). Notes: Populous countries: population greater than 500,000. Bars plot the difference in life expectancy between the United States and the populous country with the highest life expectancy in the given year. The country with the highest life expectancy was Norway in 1950–62 and 1976–77, Sweden in 1963 and 1965–75; Netherlands in 1964; Japan in 1978–2007; Macao in 2008–10; and Hong Kong in 2011–21. Line graph plots US rank relative to other populous countries, with higher rank denoting lower life expectancy.

Critics of US comparisons to countries with homogenous populations such as Norway and Japan note the racial diversity of the US population and the higher mortality rates they experience. However, even the US White population experiences higher mortality rates than White populations in peer countries. The US White population experienced the largest increases in midlife mortality during 2010–19 and the largest decreases in life expectancy in 2021 during the COVID-19 pandemic. Some blame specific health risks that predominate in the United States—such as the opioid epidemic, obesity, and firearm ownership, for example—but none of these explain the breadth of the US disadvantage: across dozens of health outcomes, ranging from preterm births to motor vehicle fatalities, other countries outperform the United States.

This pervasiveness suggests a systemic cause, such as deficiencies in the US health care system. However, health care accounts for only 10–20 percent of health outcomes. Another systemic problem is socioeconomic adversity, especially among the poor and middle class. The United States is wealthy in aggregate but also has enormous income inequality, having the highest concentrated wealth in the Organization for Economic Cooperation and Development (OECD) and the highest poverty rate. Education, the primary pathway for escaping poverty, is also inequitable. For example, in 2018, US students ranked 32nd in math performance at age 15.

Policy Choices

Slumping metrics in so many domains does not occur by chance. It reflects policy choices. For example, the United States lacks universal health care. It has the highest college tuition and offers the least financial aid in the OECD. All other OECD countries but the United States offer paid parental leave. Public spending on US families ranks 37th in the OECD. Other countries do more to prohibit corporate interference with elections and policy making, regulate industry to protect public health and safety, and ban marketing of dangerous products such as opioids and firearms. These policy choices likely exert individual and collective effects on population health and exacerbate health inequities.

Life expectancy variation across US states also reflects, in part, their policy choices. Since the 1990s, state policies have grown more polarized, and state life expectancy trajectories have diverged. In 1990, New York State’s life expectancy was lower than in Oklahoma (74.6 and 75.0 years, respectively). By 2019, life expectancy had increased by 6.6 years in New York State but only 1.1 years in Oklahoma. Studies show that states that adopted more conservative policy orientations were more likely to experience stagnant or decreasing life expectancy. States with policies that curbed growth in life expectancy effectively applied a brake to US life expectancy, helping other countries to surpass the United States.

In particular, “red” states in Appalachia, the Deep South, and Southern Plains experienced the least growth in life expectancy and thus played the largest role in slowing growth in US life expectancy from the 1980s onward. When US life expectancy stagnated after 2010, the largest contributors were New Mexico and states in Northern New England, the Ohio valley, and the Dakotas. In 2020–21, excess deaths from COVID-19 in conservative states with lax public health policies, such as Florida, Georgia, and Texas, helped push US death rates above those in other countries. The recent escalation in efforts by governors and legislatures to enact more polarized policies on issues affecting health (for example, abortion, gun control, climate policy) portend a future in which state capitols will be exerting even greater influence on national health trends.

The better outcomes that other countries have achieved—in some cases for more than 50 years—suggest that the US health disadvantage is a matter a choice. Dozens of large democracies have demonstrated sustained success in achieving higher life expectancy, better education, and less poverty, despite having less wealth than the United States. The US health disadvantage persists not for lack of policy solutions but for lack of political will. Policies known to improve population health are unpopular in US society for ideological, political, or financial reasons, or are opposed by special interests. Less clear is whether Americans know the price they are paying—in greater illness and earlier deaths—to uphold the status quo. That so many other countries enjoy better health may not be common knowledge.

Even knowing this, Americans may decide that the freedoms and other benefits of existing policies outweigh better health, but that should be an informed decision. More likely, public complacency and inaction, even as the nation loses ground to peer countries, is less a conscious choice to let the crisis proceed than unawareness that a crisis exists. Educating the public about the US health disadvantage is therefore vital so that policy makers and voters can make informed choices about their priorities. Absent any changes, Americans are likely to continue dying earlier than their peers, and the nation’s rankings will continue to fall.