Posts Tagged ‘life expectancy’

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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.

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According to a new report on inequality in the Brazilian city of São Paulo, compiled by Rede Nossa São Paulo (pdf, in Portuguese), the gap in the average age of death between the poorest and richest districts of the city is almost 24 years. Thus, for example, the average age of death in Jardim Paulista is 79.4 years while that of residents of Jardim Ângela is only 55.7 years.

This should come as no surprise since Brazil is one of the most unequal countries on the planet.

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However, lest we forget, the United States is also characterized by levels of inequality that are comparable to those in Brazil: in 2014, the top 1 percent of Americans captured 20.2 percent of pre-tax income, while their Brazilian counterparts managed to take home 27.6 percent. Perhaps even more damning, the share of income of the bottom 50 percent of both countries—while rising in Brazil and continuing to fall in the United States—was only 12.5 percent in 2014.

As it turns out, the obscene levels of inequality in the United States have resulted in a life expectancy at birth that is lower than most other high-income countries—and the gains in future years are expected to lower than in most other countries.

According to a an article published earlier this year in the British health journal Lancet,

Notable among poor-performing countries is the USA, whose life expectancy at birth is already lower than most other high-income countries, and is projected to fall further behind such that its 2030 life expectancy at birth might be similar to the Czech Republic for men, and Croatia and Mexico for women. The USA has the highest child and maternal mortality, homicide rate, and body-mass index of any high-income country, and was the first of high-income countries to experience a halt or possibly reversal of increase in height in adulthood, which is associated with higher longevity. The USA is also the only country in the OECD without universal health coverage, and has the largest share of unmet health-care needs due to financial costs. Not only does the USA have high and rising health inequalities, but also life expectancy has stagnated or even declined in some population subgroups. Therefore, the poor recent and projected US performance is at least partly due to high and inequitable mortality from chronic diseases and violence, and insufficient and inequitable health care.

In the case of both Brazil and the United States, the poor will continue to die younger unless and until the fundamental causes of economic inequality are eliminated.

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I find myself thinking more these days about the fairness of Social Security and other government retirement benefits.

One reason, of course, is because I’m getting close to retirement age—and, as I discover each time I raise the issue with students, young people don’t think about it much.* Another reason is because Social Security (in addition to Medicare, Disability, and other programs) is the way the United States creates a collective bond between current and former workers, by using a portion of the surplus produced by current workers to provide a safety net for workers who have retired.

That represents a kind of social fairness—that people who have spent a large portion of their lives working (most people need 40 credits, based on years of work and earnings, to qualify for full Social Security benefits) are eligible for government retirement benefits provided by current workers. Another aspect of that fairness is the system should and does redistribute from those with high lifetime incomes to those with lower lifetime incomes. While that makes the actual “rates of return” unequal across groups, it’s designed to provide a floor for the poorest workers in society.

Many people consider the U.S. Social Security system fair on those two grounds. That’s true even though some people, by random draw, may live longer than others. However, as Alan J. Auerbach et al. (pdf [ht: lw]) report, that fairness may be put into question if there are identifiable groups that vary in life expectancy, “as this introduces a non-random aspect to the inequality.”

Here’s the problem: retirement benefits in the United States are increasingly unequally distributed on a non-random basis. As I’ve written about many different times (e.g., here, here, and here), there’s a gap in life expectancies between those at the bottom and top of the distribution of income. And the gap has been growing over time.

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That result is confirmed by Alan J. Auerbach et al.: for the male birth cohort of 1930, life expectancy at age 50 rises from 26.6 to 31.7—a difference of 5.1 years. For the 1960 cohort, the lowest quintile has a slightly lower life expectancy than the 1930 cohort but then rises a level of 12.7 years higher for the top quintile, “indicating a very large increase in the dispersion.”

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Not surprisingly (since benefits rise with earnings), Social Security benefits also rise with income quintiles. Thus, for example, for men in the 1930 cohort, workers in the lowest quintile can expect to receive, on average, $126 thousand in benefits over the rest of their lives (discounted to age 50), while workers in the top quintile can expect to receive $229 thousand, or 82 percent more than the lowest income workers.

What is particularly troubling is how the results change when we move to the 1960 cohort. The additional 6-8 years of life expectancy for the top three quintiles lead to large increases in expected Social Security benefits, with benefits for the top quintile reaching $295 thousand. The difference between the highest and lowest quintiles is then expected to be $173 thousand, or 142 percent of the lowest income workers’ benefit.

According to the authors of the study,

These results suggest that Social Security is becoming significantly less progressive over time due to the widening gap in life expectancy.

Not only does the growing gap in life expectancies undermine the basic fairness of the Social Security system. It calls into question capitalism itself.

 

*For understandable reasons. I certainly didn’t think about retirement at that age. (I barely thought about getting a job. I just presumed I would—and would be able to—at some point.) However, when students are induced to do think about retirement, as I’ve written before, most take it for granted that Social Security is doomed. While they expect to pay into Social Security, they don’t expect to receive any Social Security benefits when they retire. Then, of course, I explain to them that making only one change—raising the taxable earnings base—would eliminate the projected deficit and keep Social Security solvent forever.

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A new study by Barry Bosworth, Gary Burtless, and Kan Zhang (pdf, as discussed here) reveals that (looking at mid-career earnings) the life expectancy gap between those at the top and bottom of the distribution is growing.

For example (from the bottom half of the chart above), for 50-year old women in the top one-tenth of the income distribution, women born in 1940 could expect to live almost 6.4 years longer than women in the same position in the income distribution who were born in 1920. For 50-year old women in the bottom one-tenth of the income distribution, they found no improvement at all in life expectancy.

Longevity trends among low-income men were not much better: Men at the bottom saw only a small improvement in their life expectancy (of 1.7 years) compared to a much large increase for men at the top (8.7 years). So, the life-expectancy gap between low-income and high-income men increased just as fast as it did between low- and high-income women.

This growing gap in life expectancy has lots of different implications, such as the long-presumed progressivity of Social Security payouts (since low-wage contributors receive monthly checks that are a higher percentage of the monthly wages they earn during their careers than high-income participants). But, according to this and similar studies, we’re learning that the growing mortality differences between rich and poor are offsetting the redistributive tilt in Social Security’s benefit formula.

Perhaps even more important, the mortality gap is challenging our long-held expectation that successive generations live longer than the generations that preceded them. For the past three decades, however, improvements in average life spans at the bottom of the income distribution have been negligible while those at the top continue to grow.

What this finding suggests is that it’s not just income and wealth but life itself that has grown starkly more unequal in the United States.

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Special mention

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Earlier today, I referred to a recent study about inequality and life expectancy in the United States.

The chart above is from that study, “The Association Between Income and Life Expectancy in the United States, 2001-2014,” published by (and now available for free in) the Journal of the American Medical Association.

The upper panels, which illustrate race- and ethnicity-adjusted life expectancies for men and women by income quartile for each year from 2001 through 2014, show that there was a much larger increase in life expectancy for higher income groups during the 2000s. (For men, the mean annual increase in life expectancy from 2001 through 2014 was 0.20 years in the highest income quartile compared with only 0.08 years in the lowest income quartile. For women, the comparable changes were 0.23 years in the highest quartile and only 0.10 years in the lowest quartile.)

The lower panels, which illustrate the annual increase in race-adjusted life expectancy by income ventiles, show the large discrepancies in the annual increases in longevity between men and women at the top and bottom of the distribution of income. (The annual increase in longevity was 0.18 years for men, which translates to an increase of 2.34 years from 2001 to 2014, and 0.22 years for women, an increase of 2.91 years from 2001 to 2014 in the top 5 percent of the income distribution. In the bottom 5 percent of the income distribution, the average annual increase in longevity was 0.02 years, an increase of only 0.32 years from 2001 to 2014 for men and 0.003 years, an increase of 0.04 years from 2001 to 2014 for women.)

According to the authors, here are the two main conclusions of this portion of their study (citations omitted):

The first major conclusion is that life expectancy increased continuously with income. There was no dividing line above or below which higher income was not associated with higher life expectancy. Between the top 1% and bottom 1% of the income distribution, life expectancy differed by 15 years for men and 10 years for women.

These differences are placed in perspective by comparing life expectancies at selected percentiles of the income distribution (among those with positive income) in the United States with mean life expectancies in other countries. For example, men in the bottom 1% of the income distribution at the age of 40 years in the United States have life expectancies similar to the mean life expectancy for 40-year-old men in Sudan and Pakistan, assuming that life expectancies in those countries are accurate. Men in the United States in the top 1% of the income distribution have higher life expectancies than the mean life expectancy for men in all countries at age 40 years. . .

The second major conclusion is that inequality in life expectancy increased in recent years. Between 2001 and 2014, individuals in the top 5% of the income distribution gained around 3 years of life expectancy, whereas individuals in the bottom 5% experienced no gains. As a benchmark for this magnitude, the NCHS estimates that eliminating all cancer deaths would increase life expectancy at birth by 3.2 years.

You read that right: U.S. men in the bottom 1 percent of the income distribution have life expectancies similar to the mean life expectancy for men in Sudan and Pakistan! And the gap between those at the top and bottom is growing!

What we have then is technical chart with a very important political message: now more than ever, we need a radically different way of organizing economic and social life in the United States—unless, of course, we want to remain at the level of Sudan and Pakistan.

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No, that’s not the democratic socialist candidate for the Democratic nomination. It was actually Al Capone who once said that “Capitalism is the legitimate racket of the ruling class.”*

That racket—and, with it, challenges to the legitimacy of capitalism—was evident in a wide variety of news stories yesterday.

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First, there was the issue of health. Once again, we’re learning that the capitalist racket is affecting health. In particular, the gap in life span between rich and poor is widening. The top 1 percent among American men live 15 years longer than the poorest 1 percent; for women, the gap is 10 years. These rich men and women have gained three years of longevity just in this century.

And for some groups—especially white working-class men and women—death rates are actually rising.**

Public health experts say the rising white death rate reflects a broader health crisis, one that has made the United States the least healthy affluent nation in the world over the past 20 years. The reason these early deaths are so conspicuous among white women, these experts say, is because in the past the members of this comparatively privileged group have been unlikely to die prematurely. . .

[Anne] Case said that the whites who are dying are not America’s elites.

“They may be privileged by the color of their skin,” she said, “but that is the only way in their lives they’ve ever been privileged.”

Second, consider the problem of international trade. Michael Riordan challenged Carrier Corporation’s recent decision to transfer its Indianapolis plant’s manufacturing operations and about 1,400 jobs to Monterrey, Mexico.

The transfers of domestic manufacturing jobs to Mexico and Asia have benefited Americans by bringing cheaper consumer goods to our shores and stores. But when the victims of these moves can find only lower-wage jobs at Target or Walmart, and residents of these blighted cities have much less money to spend, is that a fair distribution of the savings and costs?

Recognizing this complex phenomenon, I can begin to understand the great upwelling of working-class support for Bernie Sanders and Donald J. Trump — especially for the latter in regions of postindustrial America left behind by these jarring economic dislocations.

And as a United Technologies shareholder, I have to admit to a gnawing sense of guilt in unwittingly helping to foster this job exodus. In pursuing returns, are shareholders putting pressure on executives to slash costs by exporting good-paying jobs to developing nations?

Even Lawrence Summers, desperate (like most mainstream economists) to maintain free international trade and global integration, had to admit that the globalization agenda has been a racket by and for those at the very top:

The core of the revolt against global integration, though, is not ignorance. It is a sense — unfortunately not wholly unwarranted — that it is a project being carried out by elites for elites, with little consideration for the interests of ordinary people. They see the globalization agenda as being set by large companies that successfully play one country against another. They read the revelations in the Panama Papers and conclude that globalization offers a fortunate few opportunities to avoid taxes and regulations that are not available to everyone else. And they see the kind of disintegration that accompanies global integration as local communities suffer when major employers lose out to foreign competitors.

Finally, when coupled with the revelations in the Panama Papers, there’s the growing suspicion that the 1 percent are both abandoning the rest of society (by hiding their money and avoiding taxes) and remaking the rules of the game (by using their money to influence elections and legislation). As Aditya Chakrabortty explains,

the Panama Papers confirm that the super-rich have effectively exited the economic system the rest of us have to live in. Thirty years of runaway incomes for those at the top, and the full armoury of expensive financial sophistication, mean they no longer play by the same rules the rest of us have to follow. Tax havens are simply one reflection of that reality. Discussion of offshore centres can get bogged down in technicalities, but the best definition I’ve found comes from expert Nicholas Shaxson who sums them up as: “You take your money elsewhere, to another country, in order to escape the rules and laws of the society in which you operate.” In so doing, you rob your own society of cash for hospitals, schools, roads…

But those who exited our societies are now also exercising their voice to set the rules by which the rest of us live. The 1% are buying political influence as never before. Think of the billionaire Koch brothers, whose fortunes will shape this year’s US presidential elections. In Britain, remember the hedge fund and private equity barons, who in 2010 contributed half of all the Conservative party’s election funds – and so effectively bought the Tories their first taste of government in 18 years.

Capitalism, of course, has always been a racket of the ruling class. Now, it seems—with revelations about unequal health and life spans, the costs of globalization, the ability of a tiny group at the top to exercise both exit and voice, and much more—its legitimacy is being called into question.

 

*Chicago’s most famous gangster was no anticapitalist radical. On the contrary:

“Listen,” he said, “don’t get the idea I’m one of those goddam radicals. Don’t get the idea I’m knocking the American system. The American system…” As though an invisible chairman had called upon him for a few words, he broke into an oration upon the theme. He praised freedom, enterprise and the pioneers. He spoke of “our heritage”. He referred with contempuous [sic] disgust to Socialism and Anarchism. “My rackets,” he repeated several times, “are run on strictly American lines and they’re going to stay that way”…his vision of the American system began to excite him profoundly and now he was on his feet again, leaning across the desk like the chairman of a board meeting, his fingers plunged in the rose bowls.

“This American system of ours,” he shouted, “call it Americanism, call it Capitalism, call it what you like, gives to each and every one of us a great opportunity if we only seize it with both hands and make the most of it.” He held out his hand towards me, the fingers dripping a little, and stared at me sternly for a few seconds before reseating himself.

**Consider this extraordinary statistic:

Compared with a scenario in which mortality rates for whites continued to fall steadily after 1998, roughly 650,000 people have died prematurely since 1999 — around 450,000 men and nearly 200,000 women.

That number nearly equals the death toll of the American Civil War.