Almost 10 years have passed since a 2013 Institute of Medicine Report drew attention to the health disadvantage of the United States. For decades, the report explains, Americans have experienced poorer health, higher death rates and shorter life expectancies than people in other countries. The report warns that “other countries have gained years of life even faster, and our relative position in the world has fallen over the past half-century.” Conditions worsened after this report; Life expectancy in the United States plateaued, then decreased for three consecutive years (2014-2017)while lifespans in other countries continued to climb.
The health disadvantage of the United States therefore existed for decades in 2020, when COVID-19 arrived, and the disadvantage became catastrophic. Death rates from COVID-19 in the United States were among the highest in the world. Life expectancy in the United States has experienced its biggest drop since World War II, exceeding losses in other high-income countries. When the COVID-19 vaccines arrived in 2021, life expectancy has increased in many countries, but life expectancy in the United States has fallen further. The pandemic will end, but America’s health disadvantage will persist unless its root causes are addressed.
In July 2022, the United Nations (UN) Department of Economic and Social Affairs released life expectancy estimates for 238 countries, covering the period 1950-2021. These Data suggest that the American disadvantage is worse than the literature suggests. For example, most studies of health disadvantage in the United States draw comparisons with 15 to 30 “peer countries”, mostly Western European or Anglo-Saxon. However, according to UN data, as many as 66 countries had higher life expectancies than the United States in 2020, including 45 populous countries (populations over 500,000, with life expectancy estimates higher stable). These countries spanned the globe, from East Asia to Central and South America, Eastern Europe and the Middle East. The literature typically measures US outcomes relative to high-income countries, but more than 20 countries that have exceeded US life expectancies have been middle income or the communist countries of the time.
Most studies date the onset of health disadvantage in the United States to the 1980s or 1990s, but it started earlier. According to Human Mortality Database, in 1943, during World War II, eight countries had a higher life expectancy than the United States. Although industrialized countries have seen an increase in life expectancy, Once show that increases in the United States slowed in the 1950s-1960s. In 1968, 36 populous countries, including six then-Soviet Eastern Bloc states, had higher life expectancies. The United States temporarily picked up its pace in the 1970s, but progress in life expectancy stalled again in the early 1980s and never recovered. Since 2010, 12 other countries have passed the United States, half of them during the COVID-19 pandemic. Between 1983 and 2020, the gap between the highest life expectancy in a populous country and life expectancy in the United States grew from 2.6 to 7.8 years (Figure 1). Since 1950, 15 populous countries have outperformed the United States for more than 50 years.
Exhibit 1: United States life expectancy disadvantage relative to populous countries, gap and ranking, 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. The bars plot the difference in life expectancy between the United States and the populated 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; Macau in 2008–10; and Hong Kong in 2011-2021. The line chart plots the ranking of the United States against other populous countries, with a higher ranking indicating a lower life expectancy.
Critics of comparisons of the United States with countries with homogeneous populations like Norway and Japan note the racial diversity of the American population and the higher death rates they experience. However, even the The white American population is experiencing higher death rates than white populations in peer countries. The American white population experienced the largest increases in mid-life mortality from 2010 to 2019 and the largest declines in life expectancy in 2021 during the COVID-19 pandemic. Some blame specific health risks prevalent in the United States, such as the opioid epidemic, obesity, and gun ownership, for example, but none of these explain the extent of American disadvantage: on dozens of health problems, ranging from premature births to motor vehicle deaths, other countries outperform the United States.
This pervasiveness suggests a systemic cause, such as shortcomings in the US healthcare system. However, health care accounts for only 10-20% of health outcomes. Another systemic problem is socio-economic adversity, especially among the poor and middle class. The United States is wealthy overall, but also has huge income inequality, having the highest concentrated wealth within the Organization for Economic Co-operation and Development (OECD) and highest poverty rate. Education, the first route out of poverty, is also inequitable. For example, in 2018, American students ranked 32nd in math at 15.
The collapse of metrics in so many areas does not happen by chance. It reflects political choices. For example, the United States lacks universal health care. It has the highest university tuition and offers the least amount of financial aid in the OECD. All other OECD countries except the United States offer paid parental leave. Audience spending on American families ranks 37th in the OECD. Other countries are doing more to ban corporate interference in elections and policy-making, regulate the industry to protect public health and safety, and ban the marketing of dangerous products such as opioids and firearms. fire. These policy choices are likely to have individual and collective effects on population health and exacerbate health inequalities.
The variation in life expectancy between US states also reflects, in part, their political choices. Since the 1990s, state policies have developed more polarizedand the life expectancy trajectories of the states have diverge. In 1990, life expectancy in New York State was lower than Oklahoma (74.6 and 75.0 years, respectively). In 2019, life expectancy had increased by 6.6 years in New York but only 1.1 years in Oklahoma. Studies show that states that adopted more conservative policy orientations were more likely to experience a stagnant or decreasing life expectancy. States whose policies have dampened the growth of life expectancy have effectively dampened life expectancy in the United States, helping other countries to overtake the United States.
In particular, the “red” states of Appalachia, Deep South, and Southern Plains experienced the lowest growth in life expectancy and therefore played the largest role in slowing life expectancy growth. life in the United States from the 1980s. When American life expectancy stagnated after 2010, the biggest contributors were New Mexico and the northern New England states, the Ohio Valley, and the Dakotas. In 2020-2021, excess COVID-19 deaths in conservative states with lax public health policies, such as Florida, Georgia, and Texas, helped drive up death rates in the United States above those of other countries. The recent escalation of efforts by governors and legislatures to adopt more polarized policies on issues affecting health (e.g., abortion, gun control, climate policy) portends a future in which the capitals of States will exert an even greater influence on national health trends.
The best results achieved by other countries — in some cases for more than 50 years— suggest that US health disadvantage is a matter of choice. Dozens of major democracies have demonstrated sustained success in achieving higher life expectancies, better education, and reduced poverty, despite having less wealth than the United States. The health disadvantage of the United States persists, not for lack of political solutions, but for lack of political will. Policies known to improve population health are unpopular in American society for ideological, political, or financial reasons, or are opposed by vested interests. What’s less clear is whether Americans know the price they’re paying — in terms of more serious illnesses and earlier deaths — for maintaining the status quo. That so many other countries enjoy better health is perhaps not 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 if the nation is losing ground to peer countries, is less a conscious choice to let the crisis continue than ignorance that a crisis exists. Educating the public about America’s health disadvantage is therefore essential for policymakers and voters to make informed choices about their priorities. Without any change, Americans will likely continue to die earlier than their peers, and the country’s ranking will continue to drop.