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What the dip in US life expectancy is really about: inequality

While poor Americans are dying earlier, the rich are enjoying unprecedented longevity.

By Julia Belluz@juliaoftorontojulia.belluz@voxmedia.com Jan 9, 2018, 9:50am EST

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In 1980, the richest cohort of middle-age American men could expect to live until about 83 and the poorest, to 76. By 2010, the richest American males had gained six years in life expectancy, living to 89 on average, while life expectancy for the poorest men hadn't improved. Getty Images/Image SourceLiving in the US increasingly looks like a health risk. Average life expectancy here dropped for the second year in a row, according to recent data from the Centers for Disease Control and Prevention. The grim trend stems from a toxic mixture of more drug- and alcohol-related deaths and more heart disease and obesity in many parts of the country. And it puts Americans at a higher risk of early death compared to their counterparts in other wealthy countries.
But what's often lost in the conversation about the uptick in mortality here is that this trend isn't affecting all Americans. In fact, there's one group in the US that's actually doing better than ever: the rich. While poor and middle-class Americans are dying earlier these days, the wealthiest among us are enjoying unprecedented longevity.
So when we talk about life expectancy slipping, what we should also talk about is the growing problem of health inequality in America. And it's an increasingly urgent discussion, health researchers are warning, because of policy changes on the horizon that are poised to make the mortality gap even wider.
Some of these policies will hamper access to medical care (such as failing to fund CHIP, the health insurance program for low-income children) but others that aren't even directly related to health care like tax cuts may have even more insidious effects on the American mortality gap.

America's alarming life expectancy gap

The rich have long-enjoyed more longevity than the poor, but the gap in life expectancy has been widening in the US over the last few decades, along with other types of social and income inequality here.
The CDC's Division of Vital Statistics, which tracks mortality in the US, uses death certificates as the data source, and doesn't collect family income data. But we do have good data on the mortality gap and income from a study published in JAMAin 2016.
A group of researchers, led by Stanford University economist Raj Chetty, analyzed income data for the US population from 1.4 billion tax records between 1999 and 2014. They then compared it with mortality data from Social Security Administration death records. They found that, from 2001 to 2014, the richest Americans gained about five years of longevity, while life expectancy for the poor didn't budge:
Changes in race- and ethnicity-adjusted life expectancy by income group, 2001 to 2014. JAMAThey also found that men who were among the top 1 percent of income earners lived 15 years longer than men at the bottom 1 percent. For women at the extremes of the income distribution, life expectancy differed by 10 years. At Vox, we broke their data down by state, and you can see that wealthier Americans are living longer than poorer Americans all across the country. (Here's the data on men, but the same trends hold for women.)
Alvin Chang/VoxThis life expectancy divide between rich and poor Americans has been growing for decades. A report from the National Academies of Science looked at life expectancy by income groups between 1980 and 2010. In 1980, the richest cohort of middle-age American men could expect to live until about 83 and the poorest, to 76. By 2010, the richest American males had gained six years in life expectancy, living to 89 on average, while life expectancy for the poorest men hadn't improved. (The Washington Post has nice visualizations of the data in the report here.)
"Because we have widening income inequality and there's a bigger gap between haves and have nots," said Steven Woolf, a researcher at Virginia Commonwealth University who has been researching income and mortality. "We are seeing a bigger divide in mortality."

Tax reform and other Trump-era policies are expected to make the gap worse

This growing gap should be "a dramatic reminder of what actually affects our health," Woolf added.
We often think about health status in terms of access to doctors, hospitals, and medicines. But access to health care only accounts for about 10 to 20 percent of our health outcomes. Far more influential on our health is our socioeconomic status and certain health behaviors, like smoking, eating healthfully, and getting exercise.
In Chetty's study, for example, the researchers found that life expectancy among the poorest individuals was "significantly correlated" with health behaviors like smoking, obesity, and exercise. Poorer people are more likely to be overweight, smoke, and drink compared to their wealthier counterparts. Interestingly, these effects seemed to be mitigated in places that had enacted policies to curb poor health behaviors such as anti-smoking laws or trans fat bans in cities.
Right now, there are several policies on the horizon that are not only expected to hamper health care access, but exacerbate income inequality and widen the life expectancy disparity, David Blumenthal, president of the Commonwealth Fund, says. Blumenthal has written about the potential effects of the tax bill, which passed through the Senate in December, on low- and middle-income Americans in particular, and how it'll disproportionately ding them while rich Americans and corporations will enjoy tax breaks:

If the Senate tax legislation becomes law, Americans earning less than $75,000 would face higher taxes on average by 2027, according to the Joint Commission on Taxation's estimates of the bill's distributional effects. The bill has varying effects on different income groups in different years, but consistently cuts taxes for the richest Americans. For example, individuals earning less than $10,000 would see their federal taxes go up on average by $182 each year until 2027. People earning a million dollars or more would, on average, see their taxes fall by $6,800 annually over the next decade.

Blumenthal told Vox, "We can expect ... to see the gap in life expectancy and health care outcomes between low- and high-income Americans grow in coming years if gaps in income increase."
Vox's Dylan Scott and Alvin Chang have also argued that the tax bill because of its tax breaks for the rich "takes the wheel of America's already-dramatic income inequality and presses the accelerator." It'll also repeal Obamacare's individual mandate, resulting in an estimated 13 million fewer Americans with health insurance. That's not to mention Congress's failure to fund CHIP and its proposed cuts to Medicaid health insurance programs for low-income American children and adults both moves that have been endorsed by the Trump administration,
So instead of just focusing on the overall decline in life expectancy, we need to start talking about these links between policy, and worsening income inequality and its relationship to the growing mortality gap. If we don't, Woolf warned, we'll fail to see the solutions to America's early death problem.