Of all the affluent nations in the world, the United States is the one whose citizens die youngest. Despite spending thousands of dollars more per capita on health care than any other country, Americans in 2019 nevertheless faced a relatively low life expectancy of 78.8 years, according to the National Center for Health Statistics. (Based on preliminary data from 2020, the pandemic knocked it down a full year.)
That may not seem tragically young. It’s certainly a vast improvement over the figure for 1919. Throughout the 20th century, lives grew longer across much of the world, rising by nearly a decade in the U.S. between 1959 and 2017. But the rise slowed here in the 1980s, finally plateaued in 2010, and declined for three consecutive years after 2014. Our peers continued to climb all the while, with Japan leading at 84.3 years and many others well above 80. On a list of countries ranked by life expectancy, the U.S. is ranked somewhere in the mid-40s, in the company of Ecuador, Turkey and Croatia.
It’s not a status befitting a developed country. So why does America lag so far behind the rest of the wealthy world? The problem can’t be pinned neatly on any one factor, but its clear that a few trends — smoking, obesity, suicide, homicide, drug overdose — are driving the excess deaths, particularly in young and middle-age adults.
Life expectancy has stagnated from coast to coast, compared with the top countries in the Organization for Economic Co-operation and Development. Even our healthiest regions, like California and the Pacific Northwest, still trail places like France, Germany and Sweden. But there are major differences between subsets of the U.S., and between individual states. Studies find that the industrial Midwest, the South and Appalachia have been hit hardest. Along racial lines, mortality rates have increased among white populations, but not as severely as they have for Native American and Black populations.
Poor in Wealth, Poor in Health
The trends listed above are all proximate causes. Many researchers argue they are symptoms of an underlying common denominator: the socioeconomic inequality that ripples through every aspect of life in this country, influencing health in subtle and complex ways from birth to untimely death.
Ample evidence suggests that low-income populations face a health disadvantage throughout life. They are more prone to smoking. They are less physically active, often living in landscapes unsuited to exercise. Those same environments may lack nutritious food, green space, clean air and other essential components of wellbeing. Many of the direct causes of premature death are individual choices, but research finds them associated with economic choices made, ultimately, by governments. “This is driven by pretty intentional decisions over time, in terms of our federal policies and state policies,” says David Rehkopf, a social epidemiologist at Stanford University.
Variations in life expectancy from state to state may also hint at the responsibility of state governments. Their decisions are likely guiding health all the time, but for blatant evidence, look no further than the pandemic. Governors often clashed with local authorities and sometimes overruled their health orders, leading to surges in infection. “We got vivid examples on our nightly news,” says Steven Woolf, a social epidemiologist at Virginia Commonwealth University. “The result was that you could see this tension between those competing policy agendas, and how that ended up affecting the health of the people in those communities.”
The great irony is how dramatically the U.S. outspends the rest of the world on health care (roughly $11,000 per capita; Switzerland is next in line, at $7,700, with a life expectancy of 83.5 years to show for it). Consequently, America truly does have the best doctors, the best hospitals and the best life-saving tools, Woolf says, “but our implementation is lousy. Most Americans are not getting that cutting-edge care.” The U.S. is “all breakthrough and no follow-through.”
In contrast, Rehkopf says, other wealthy countries have taken a proactive approach. “Instead of investing in technology, they invested in public health and prevention instead.” That investment takes diverse forms — universal health care, effective firearm restriction, urban design that encourages walking and biking. But many experts agree that some of the most important are social policies like early childhood education, income support, progressive taxation and housing assistance.
In other words, most well-heeled nations create systems that prepare the next generation for success and stand ready to help those in need. “That doesn’t sound like a doctor talking,” Woolf admits. “But part of the message here is that … our economy and our health are tied at the hip.” Tend to the first and the second comes more naturally.
One Crisis Ends, Another Resumes
Life expectancy did increase by a tenth of a year in both 2018 and 2019, but Woolf doesn’t view that uptick with optimism. More telling, in his opinion, was America’s pandemic trajectory. “Many of those same issues fed right into the catastrophe that we experienced in COVID,” he says. The past year exposed deep racial and economic disparities, as Black and Latino peoples were infected, hospitalized and killed by the virus at disproportionate rates.
This reveals the “social determinants of health,” as experts call them. “Our health inequities are shaped partially by health care,” Woolf says, “but also by the economic conditions in which we live, and what’s going on with our homes and communities.” And despite the pre-pandemic bump in life expectancy, Rehkopf says, “I haven’t seen anything getting better in terms of any of those risk factors. [...] We need to take action in a serious way if we want this to change.”
Woolf agrees. As the U.S. climbs out from the depths of COVID-19, he urges the nation to acknowledge that it has only begun to reckon with its fundamental health dilemma. “It'll be very easy for people to be lulled into a sense of complacency,” he says, “that the problem is behind us and we can get on with our normal lives, not realizing that we’re still in the middle of a crisis.”
