Poor, rural, and less-educated Americans are most vulnerable to life expectancy declines in the U.S., experts told lawmakers on Wednesday during a Senate Health, Education, Labor, and Pensions subcommittee hearing.
A federal report issued Wednesday by the CDC’s National Center for Health Statistics reported that U.S. life expectancy in 2020 dropped by 1.5 years, driven primarily by the COVID-19 pandemic.
But what bothered Sen. Bernie Sanders (I-Vt.) was that even before the pandemic, smaller declines in life expectancy were already beginning, and tended to affect “working people” most — those with lower incomes or less education, and those living in rural areas.
“If you are upper income, if you have stable housing, if you have access to decent medical care, you’re doing fine,” he said.
Sanders offered a tale of two counties: one wealthy, one not. In Fairfax County, Virginia ($124,000 median household income, 6% poverty rate), a child born today can expect to live to be 85 years old. In Scott County, Indiana ($48,000 median household income, 14% poverty rate), life expectancy is 71 years.
“Imagine that, [a] 14-year discrepancy,” he said.
This is not a question of whose house is bigger or who drives the fancier car, said Sanders. “It’s a question literally of poverty and stress being a death sentence, and all of this is preventable,” he said.
Sanders highlighted what some experts are calling “deaths of despair” — drug overdoses, alcohol-related deaths, and suicides.
Hearing witness Kathleen Mullan Harris, PhD, chair of the National Academies of Sciences, Engineering, and Medicine’s (NASEM) Committee on Rising Midlife Mortality Rates and Socioeconomic Factors, and colleagues published a consensus study on this issue in March.
In the consensus study, life expectancy fell for 3 straight years (2014-2017), “the longest sustained decline in a century,” said Harris, who is also a professor of sociology at the University of North Carolina at Chapel Hill.
In trying to determine why more Americans ages 25 to 64 were dying, Harris and colleagues looked at trends from 1990-2017 and found three main drivers: deaths due to drug poisoning and alcohol, suicide, and cardiometabolic diseases — including diabetes, hypertension, and heart disease.
Drug and alcohol deaths were the primary reason for rising mortality rates, she said.
Poor government oversight, physician prescribing habits and actions by drug manufacturers played a role. Also a contributing factor was that certain populations — those without a college degree, and those living in places where mining and manufacturing jobs had dried up — saw increases in pain, psychological health problems, and long-term economic challenges.
While there wasn’t a single cause for declining life expectancy, three common factors linked each of the mortality trends: economic adversity, economic inequality, and vulnerability, Harris said.
Asked by Sanders, specifically about the factors that could lead a young person to a substance use disorder, Robert MacKenzie, chief of police for the Kennebunk Police Department in Maine, and a witness at the hearing, pointed to adverse childhood experiences (ACEs).
Children exposed to adverse experiences in their home — ranging from their parents’ separation or divorce, to mental illness, to domestic violence, or neglect or physical or sexual abuse — are more likely to have issues with suicide or substance use later in life.
“The more issues that they have … the more chances are that their life expectancy is going to be shorter,” he said.
A study of juvenile offenders in Florida found more than half had ACE scores of 4 or higher, making them 12 times more likely to attempt suicide, 7 times more likely to have an alcohol addiction and 10 times more likely to have injected “street drugs,” he said.
When Sanders asked whether a “livable wage,” “decent housing,” and offering “healthcare as a human right” could improve life expectancy, Harris agreed that it would.
Many people assume that life expectancy differences between the U.S. and other industrialized nations are purely a function of race and ethnic disparities, but even if those differences vanished, the U.S. would still lag behind other nations, because of “socioeconomic inequality, poor economic conditions, and the stress of living with those conditions,” she said.
“If everybody had a job that would provide them with a sense of meaning and dignity and purpose in life,” she said — one that let them care for their families and the opportunity for upward mobility — “I think that would really cut to the heart of helping us catch up to other rich nations and life expectancy.”
The NASEM committee also offered several concrete recommendations including:
- Improving regulation and oversight for prevention and treatment for substance use disorders
- Addressing the “economics and social strains” that left communities vulnerable to opioids and other drugs
- Implementing obesity prevention programs early in life that target low-income communities
- Balancing the rights of the food industry with public health priorities
- Expanding Medicaid eligibility in the 12 states that have yet to expand
Harris pointed out that death rates are lower in states that chose to expand their Medicaid program.
Hearing witness William Cooke, MD, owner and medical director of Foundations Family Medicine in Austin, Indiana, cited his grandfather who died in his 50s as an example of how poverty, toxic stress, and substance use can shorten lives. His aunt’s death at 39 years old from an overdose is another example, he said.
After graduating medical school and beginning work as a family physician, Cooke was shocked by the suffering he saw in rural America — “young people with late-stage diabetic complications, women dying of cervical cancer, and a man with a tumor on his tongue so large, he couldn’t even close his mouth,” he said.
Treatment Through Prevention
The problem, Cooke observed, is that medicine has been so focused on treating the ill that it’s forgotten to promote health.
Inequitable access to clean air and water, healthy food, safe housing, dependable transportation and a living wage — as well as a sense of belonging — place the entire country at a “health disadvantage,” said Cooke, citing the Surgeon General’s 2019 report “Community Health and Economic Prosperity.”
“We must move beyond the passive disease-oriented model of ‘do no harm’ to a proactive person-centered model of protect from harm,” he said, and primary care physicians have a special role in this effort.
Shifting to this person-centered model in his town of Austin has worked, Cooke said.
The city, which saw what Sen. Mike Braun (R-Ind.) called “the worst drug-fueled HIV outbreak in U.S. history,” has since seen case rates drop from 200 per year to one last year, Cooke said.
“We’ve also seen an explosion of people with substance use disorder entering into treatment and recovery, along with fewer diabetic complications, better pain management without the use of opioids, improved prenatal care, [and] fewer hospitalizations,” Cooke said.
The secret to Cooke and his colleagues’ progress has been to treat people where they are, using school, jail, and mobile clinics; working alongside the sheriff and the recovery community to quickly reach those experiencing overdose or other crises; and linking clinicians to specialized care using programs such as Project Echo.
Cooke also emphasized the importance of partnerships with nonprofit behavioral health systems as well as community, recovery and faith-based groups that help patients meet “basic human needs for food, safety, and belonging.”
He pointed out that our current fee-for-service payment system doesn’t reimburse for these types of interventions and encouraged a shift toward payment models that would.
“We must recognize the cumulative effect … of every person’s health on our nation’s health,” Cooke said. “By taking this crisis of health inequity and declining life expectancy on now, we can reestablish the United States as the healthiest place in the world to live.”