With its economic and military might, America is hard to beat on technological wonders, space exploration, and top-notch universities. But when it comes to health, a fundamental prerequisite to a fulfilling life, the US isn't delivering and hasn't been for a long time. Researchers now find that the big picture of health failings is even graver than we already knew.
Piles of studies have called attention to the fact that in the country ranking number one in healthcare spending per capita, people are living shorter lives, feeling more depressed, and are more likely to skip treatment due to cost than in many developed nations. In a performance ranking of 11 high-income countries compiled by the Commonwealth Fund in 2021, the American healthcare system came in dead last, with the worst outcomes of any of the nations studied.
"The only wealth is life," wrote the nineteenth-century critic John Ruskin. Recent research indicates that America may be rich in dollars, but getting poorer in ways that matter most.
In a stunning new report, "Missing Americans: Early Death in the United States, 1933-2021," Boston University professor of global health and epidemiology Jacob Bor and colleagues pored over data from the CDC and a global mortality database. During the period investigated, they compared U.S. mortality rates with those of Canada, Japan, and 16 Western European countries. How many American lives would have been saved each year, asked the researchers, if U.S. mortality rates had matched those of other wealthy nations?
A staggering number, is the answer.
Millions Gone Missing
According to the researchers, the U.S. started out of the gate in 1933 as a global health frontrunner, showing a significant advantage in mortality rates over the peer countries studied. But starting in the 1970s, something went awry. Overall, Americans began to die at higher rates than their peers, a trend that grew steadily and picked up steam in the 2000s.
By the year 2019, the number of annual "excess deaths" had reached a stunning 656,353. Bor and his colleagues refer to these people who died as "missing Americans"--the friends, family members, and colleagues who would still be with us if only modern U.S. healthcare and social policy lived up to their early promise.
Consider, the figure of 656,353 missing Americans is the number of excess deaths just in the year 2019 alone. In a single year, we lost--needlessly--more than the population of Detroit, Las Vegas, or Baltimore. And this was before the pandemic. In 2021, the number of missing Americans swelled to 1,092,293--a whole lot more than you could put on milk cartons. More than Atlanta and Miami combined. Even worse: half of them were under age 65.
Bor and his fellow researchers found that on average, not only were there more Americans dying relative to their peers abroad, the deaths were becoming younger.
These are human beings who didn't have to leave us. People who had children, elders, and neighbors to look after. Contributions to make. Love and laughter to share. The researchers found a haunting way to help us envision the profound depth of the tragedy. Based on the age at which Americans succumbed and the number of years they could have been expected to live had they been born in Finland, Spain, Japan, or the other countries studied, Bor and colleagues tabulate that in a single year, 2021, America sustained 25 million years of life lost.
Again, the figure of 25 million years of life lost is only for the year 2021. In 2022, as even more people die at 60 instead of 80, millions more future years of life will never be lived. The coronavirus is supposed to prey most viciously on the elderly, but in America, people still in their working years have been dropping away at higher rates during the pandemic than in peer nations--as they have been for years. Unsurprisingly, Black and Native Americans make up a disproportionate share of those vanished years and lives.
What changed?
Why, in a country with so much to spend--and so much spent on medical care--are so many lives being cut short? How did we start out so well and end up so badly?
Bor notes that the American mortality advantage in the late 1930s and 1940s was impacted by the high death rates in peer countries due to WWII and that the disadvantage of much of Europe and Japan likely continued for about a decade after the war because of the widespread devastation. But he also points to several other factors that probably helped Americans live longer up into the 1950s, such as the relative strength of organized labor and consequent rising wages, plus the large public investments that helped boost the middle class, like the GI bill and the promotion of high home ownership (with the caveat that these advantages were primarily available to White Americans).
Bor observes that the later period of American mortality advantage was likely bolstered by President Johnson's War on Poverty and the marked expansion of the safety net by Medicare and Medicaid, as well as the racial integration of hospitals in 1963 and environmental regulation which made water and air healthier. "All of these programs and policies took some of the gains that occurred in the 1950s and expanded them so that it wasn't just people with middle-class incomes and White people who had access to the determinants of a healthy, long life," he explains.
Yet even during the period of relative mortality advantages, America's inequality and structural racism likely held back the country's longevity record from being as good as it could have been. Older populations in the U.S. have tended to have better mortality outcomes relative to peer countries than younger groups. Bor cites the fact that Americans have to reach the age of 65 before benefits like universal health care kick in as negatively impacting younger peoples' life expectancy. This age-related trend shifted somewhat from 1980 to 2000, but the researchers found that in the 2000s, the age-related mortality picture is clear: the story of the U.S. disadvantage is primarily about people under 65 dying at higher rates than in peer countries.
The year when America's overall mortality numbers diverged from other wealthy nations is 1980, according to the researchers' findings. If the name Ronald Reagan comes to mind, you're not alone: Bor notes that a Twitter discussion of the team's work has homed in on this association. However, he emphasizes that the story is more complicated than one man's presidency and its attendant policy changes, citing multiple factors such as the rise in opioid-related deaths in the 2000s, as well as increasing deaths due to obesity, diabetes, and metabolic syndrome. Gun violence has also increased America's relative death toll.
In considering the widening gap between the US and peer countries in the 2000s, Bor points to the work of Princeton economists Anne Case and Angus Deaton on "deaths of despair"--the term for lives lost to preventable causes like suicide, drug overdose, and alcoholism. Researchers like sociologist Shannon Monnat, who has studied the opioid crisis, have built upon this work, trying to understand why these deaths occur so frequently in the US.
Bor mentions the combined stressors of economic dislocation due to globalization and the loss of jobs and economic opportunity in some parts of the country, especially among those lacking college degrees, and the social implications of these trends, such as increasing numbers of men without jobs who are no longer considered husband material and thus lose the social support that comes with marriage. Compounding the problem, in Bor's view, is "the failure of our politics to address it, or to even see it coming--and this was happening under both George W. Bush and Obama."
As Bor and his researchers note, inequality is surely a big part of the picture. In 2017, economist Peter Temin described how America began to diverge into what are essentially two separate nations in the 1970s. One nation--around 20% of the total population--boasts college educations, good jobs, and access to quality healthcare. The other nation, where the 80% majority resides, is stuck with low wages, insecure jobs, fewer education opportunities, and unaffordable and inadequate healthcare. These are the people getting sicker and dying younger than they used to. Temin observes that the US economic structure now looks a lot more like that of a developing nation than a wealthy superpower, which may help explain why the country's mortality rates as a whole can't compete with peer countries where such bifurcation is less pronounced. Thomas Ferguson, Director of Research at the Institute for New Economic Thinking (INET), has studied America's increasing turn to money-driven politics, which has resulted in public-minded policies giving way to free market-driven policies that do not consider the needs of the majority.
These two worlds, the high-income and low-wage sectors, interact less and less, which might explain why many affluent Americans, including the doctors who attend them, are unaware of how dire the country's overall health record has become or how many are dying young compared to peer nations.
But the low-wage world knows something about it first-hand. The Covid crisis has illustrated how many Americans are not simply ignored, but placed directly in harm's way--expected to sacrifice their very lives for the benefit of the affluent. This attitude was succinctly expressed by Dan Patrick, lieutenant governor of Texas, as the pandemic raged: "There are more important things than living," he stated. Like an economy that mostly benefits the few?
Bor acknowledges the need to discuss policies that would help the U.S. turn around its dismal mortality record, but he believes that the first step is to make the public aware of the urgency of the situation. Even he, an epidemiologist, has been taken aback by what he and his colleagues found. "What surprised me in this research is how huge the number of missing Americans is, and how little a part of our public conversation... I am sure if you did a survey, people would have no idea of the scale of excess mortality in the U.S. We're just way behind."
A turn for the worse?
Unfortunately, if America was a patient, the doctor would likely be predicting a turn for the worse.
For starters, the nation's pandemic response has been widely criticized, with data showing clearly that the U.S. record in saving people from the ravages of the virus is below average in the world and among the worst among developed and high-income nations. That's certainly not helping the mortality crisis.
In the broader view, the fracturing of the country into a dual economy is not improving. To add further stress, Peter Temin has illuminated in his most recent book that racial disparities in the U.S. economy appear to be getting worse, not better.
Unbridled capitalism is not good for life expectancy. For example, the increasing move of private equity into healthcare since the 1980s in the US has alarmed many experts, as INET has highlighted in research by Eileen Appelbaum and Rosemary Batt, and also in work by Thomas Ferguson, Paul Jorgensen, and Jie Chen on private equity's political contributions. A series of articles on the pressure put on emergency rooms by private equity to cut costs has further illuminated the danger to American lives from this rapacious part of the financial sector, which squeezes ever-steeper profits from human bodies.
Meanwhile, as the health of Americans is deteriorating, the Supreme Court attacks environmental regulation, gun protections, and delivers a shocking blow to women's health. If U.S. programs and policies of the 1960s expanded upon the gains that occurred in the 1950s, then many of those in the 2020s are doing the opposite--they are intensifying the failures of past decades.
"It's one of the tragic ironies of our era," says Bor. "Populations that have seen some of the worst trends in health outcomes over the last 40 years are electing leaders who will further exacerbate those trends through policies that are inimical to public health--whether that's a failure to expand Medicaid, failure to regulate guns, or abortion restrictions that will lead to negative short-term and long-term health consequences for women."
All of this points to the uncomfortable reality that US democracy is not functioning as it should. When elected officials do not reflect the will of the people, which surely, at a most basic level, is to live, then something has gone badly wrong. "The thing that I find most frustrating is that you'd expect in a democracy that the political system would respond when there's a mass health crisis, when peoples' material realities have been in decline," says Bor. "What you see is exactly the opposite. It seems very bleak but then you think, gosh, there has to be an opportunity for a new politics here."
