The state of the union’s health

Despite a post-Covid jump in life expectancy in 2023, the U.S. remains far behind other advanced industrial nations.

For the second year in a row, I begin the New Year by revisiting a handful of key public health indicators. How is the U.S. faring when it comes to longevity, infant mortality, health insurance coverage and obesity prevalence? How do we compare to our peer (i.e., relatively rich) nations throughout the advanced industrial world?

Changes to the core measures of public health are glacial. Progress is invariably slow and incremental, and sometimes nonexistent. Upon occasion, conditions deteriorate.

During the second half of the Biden administration, the U.S. made significant progress. The uninsured rate hit a record low. Longevity is rebounding after the sharp setback during the COVID-19 pandemic.

Will the incoming Trump administration extend those trends? While most of my readers will likely chime in here with an “I doubt it,” the fact is that the future direction of many (but not all) core indicators of public health are influenced just as much by macroeconomic and cultural trends as by policy shifts in Washington.

Moreover, when it comes to public health, there is usually at least a year’s lag in the officially reported data. Most of the data I’ve compiled over the past few weeks covers 2023. We won’t begin seeing 2024 data until later this year with most coming in mid-to-late 2026 — just in time for the mid-terms.

With that caveat in mind, let’s begin.

Longevity

When it comes to longevity, the U.S. suffered two major setbacks over the past decade. First was an exponential increase in opioid overdoses and suicides — the “deaths of despair” epidemic that added rural and small town America to the roster of afflicted neighborhoods and regions. Then came the COVID-19 pandemic, where a fragmented U.S. public health system, a general lack of preparedness, and widespread resistance to common-sense precautions killed off 1.2 million Americans, more than any other nation.

But now, finally, drug overdose deaths are on the decline. The most recent annual data showed a 14% drop to just under 100,000 a year. And the CDC reports the U.S. is recovering from the pandemic-driven downturn in life expectancy. It gained nearly a full year in 2023 from 2022.

But that gain is hardly restorative. This is a case where the nation that fell farthest had the most ground to make up. If we take a decade-long view (see the chart below), the U.S. not only still trails other advanced industrial nations, the gap between them has grown. It is the only country where life expectancy remains below where it stood a decade earlier.

What accounts for the U.S.’s ongoing failure to match its peers in life expectancy? The short answer is class, race and government policy.

The most widely-used proxy for class in the U.S. is educational attainment. Those with one or more college degrees — about a quarter of the adult population — live to 83 on average (2021 data). Those with lesser education live to 75, a shocking 8 years less.

This represents a dramatic shift in the fortunes of working class Americans. A quarter century ago, the gap between the highly educated and the rest was just two years (79 and 77, respectively).

There are multiple explanations for this growing differential: the hardships of working class life; the uptick in drug, alcohol and smoking abuse; growing economic inequality; social decay from rising economic stress. Government policy clearly played a role, too. In Europe, where there are more extensive social safety net programs, the difference in life expectancy between the highly educated and less educated is just half the U.S. level — about four years.

Moreover, when looking at Europe, one has to differentiate between east and west. In Eastern Europe, which is poorer and has a weaker social support system, overall life expectancy in most countries is about the same or a bit lower than the U.S. Not surprisingly, the difference in life expectancy between educational levels is similar to the U.S. — about eight years. But in Scandinavia, it is just two years — half the European-wide average.

The U.S. also has a glaring racial gap in longevity, which was exacerbated by the pandemic. In 1970, at the dawn of the post-civil rights era, the longevity gap between African-Americans and white Americans stood at 7.6 years. By 2010, after three decades of growth in the number of black, college-educated citizens, the overall black-white gap had fallen to 3.8 years (although in many left-behind inner city neighborhoods, the black-white “death gap” reached a stunning 15 to 20 years). The gap between college-educated whites and blacks fell to around 2.2 years.

But over the past decade, progress stalled. And then, during a pandemic that took its heaviest toll in minority communities, the overall black-white longevity gap grew to 4.0 years, reversing many of the gains of the previous two decades.

The next few years’ data will reveal if the recovery from the pandemic will help blacks as much on the upside as it hurt on the downside. If it doesn’t, the post-pandemic Trump era will be remembered as the time when a half century of progress in narrowing the racial longevity gap came to an end.

Health insurance coverage

The starting point for anyone needing health care services is having some form of health insurance. As the recent uproar over exorbitant out-of-pocket costs revealed, insurance is no longer a guarantee of affordability. But it is a necessary precondition.

For the first decade of the Affordable Care Act’s life, Republicans on Capitol Hill fought to prevent enactment of its coverage expansions. They failed. But a compliant Supreme Court allowed states to opt out of the law’s Medicaid expansion. Nine states still haven’t expanded the program to cover people earning up to 138% of poverty wages.

The year after Trump won the White House in 2016, his appointed officials used their executive powers to limit sign-ups on the insurance exchanges set up by the law. They reduced the number of navigators that provided technical help for the mostly lower-income clientele who wanted to sign up for plans. They eliminated advertising. The number of uninsured rose steadily during his first three years in office.

It was only bipartisan emergency legislation passed during the first COVID-19 shutdown that stabilized the program. The bill postponed the annual Medicaid reauthorization test for program beneficiaries, allowing millions of low-wage workers to remain in the program after starting jobs that didn’t provide coverage.

The Biden administration reversed many of those policies. It also increased subsidies for those earning up to 400% of poverty wages. The result? By the end of 2023, the U.S. had the lowest uninsured rate and lowest number of uninsured in its history. However, the end of the Covid emergency meant Medicaid reauthorizations resumed. As a result, we’re likely to see a slight uptick in the ranks of the uninsured in 2024.

Source: U.S. Census Bureau

This is clearly the one area where changes in policy have a major impact. If the incoming Republican-run Congress gets its way, the higher subsidies for individual plans will end (they run out at the end of September unless extended). Medicaid may be turned into a block grant, which will incentivize Republican-run state legislatures to drop expanded coverage in that program.

Robert M. Kennedy, Jr. and Dr. Mehmet Oz, Trump’s nominees to run the Health & Human Services Department and the Centers for Medicare and Medicaid Services, respectively, have been noticeably silent on the issue. If Congress passes and the president signs legislation that undercuts the ACA, we’re likely to see a significant drop in the number of insured and a rise in the uninsured rate as early as next January.

Infant mortality

To its great shame, the U.S. consistently posts one of the worst records in the industrialized world for protecting the life of the child from birth to age one. While losing one out of every 185 live births may not seem like a lot, it is three times higher than the one in 588 babies lost in Japan, the world leader in protecting the lives of newborns.

Moreover, while infant mortality has been dropping around the world, the U.S. has made much less progress. For the first time in decades, things appear to be getting worse.

In 2022, the infant mortality rate ticked up to 5.6 deaths per 1,000 live births. Since 2000, when the U.S. infant mortality rate stood at 7.1 deaths per 1,000 births, the U.S. infant mortality rate has risen from 12th highest to 5th highest among the 38 countries belonging to the Organization for Economic Cooperation and Development. Who does worse? Only Costa Rica, Turkey, Colombia and Mexico.

The failure is systemic. Many pregnant women have inadequate access to high quality prenatal and postnatal care, especially if they are poor. State Medicaid programs, which cover over 40% of pregnancies and childbirths in the U.S., has failed to conduct adequate outreach to low-income and poorly educated mothers, whose newborns suffer a disproportionate share of early childhood deaths.

The U.S. also has a higher number of preterm births compared to other advanced industrial countries. Preemies are much more likely to die in the first year. Finally, the U.S. has an uneven and inadequate support system for new mothers, who are much less likely to enjoy paid leave from employers or social support from the government compared to other countries.

Will any of that change under a Republican administration and Congress? While the GOP made protecting fetuses central to its political mission, few of its members on Capitol Hill have joined their Democratic colleagues in promoting policies that would help expectant mothers or their newborn children.

Obesity

Obesity is America’s number one public health problem. While HHS nominee Kennedy may be a flawed messenger, he is onto something when he attacks the food and restaurant industries for purveying processed foods that expand both America’s waistline and its health care costs.

People who are chronically obese are far more likely to contract diabetes, heart disease and cancer, all of which are expensive to treat. They are far more likely to miss work after coming down with minor illnesses, which drains U.S. productivity. Their bodies give out at a younger age and are more likely to require expensive operations to replace worn out knees and hips.

While rising obesity is a worldwide problem (in part because U.S. fast food emporiums and industrial agriculture have spread across the globe), the U.S. is among the worst. Obesity is defined as someone with a body mass index over 30 (weight in kilograms divided by height in meters squared). Translation: Someone who is 5’10’’ and weighs over 209 pounds is considered obese. Over 40% of the U.S. population is now obese, according to data from the World Obesity Federation. In most western European countries, the percentage of people considered obese is in the high teens.

The U.S. health care system fails to help people lose weight. Once-a-year office visits that give patients nothing more than encouraging words to slim down and exercise more never worked. Proven programs like the Diabetes Prevention Program that offer overweight and obese people ongoing counseling, group sessions and free gym memberships hasn’t gotten much takeup despite being approved as a Medicare benefit.

Count me among the skeptics who question whether the pharmaceutical industry will ride to the rescue with its new class of medications, the GLP-1 inhibitors that tamp down appetites. With one in 8 Americans already having tried the drugs, adult obesity rates fell “last year for the first time in more than a decade,” economics columnist Catherine Rampell wrote enthusiastically in the Washington Post. “Drugs such as Ozempic and Zepbound are already reshaping Americans’ waistlines.”

I checked out the study she cited. It reviewed de-identified medical records for over 16 million patients in Optum’s database. Optum is a subsidiary of UnitedHealth. It wasn’t a study of whether the drugs worked. Its authors didn’t divide that large group into those who took the drugs and those who didn’t. It merely looked at the weight loss or gain of the entire group.

And here’s what it found: “The mean body mass index (BMI) plateaued in 2022 (at) 30.24, and decreased slightly in 2023 (to) 30.21.” Data translation: That’s a decrease of three one-hundredths of an index point or a decrease of one-tenth of one percent in body weight.

I think I’ll wait a few more years before declaring that the $15,000-a-year pricetag for these drugs is the most effective and cost-effective way to address America’s bulging waistline.

In a future post, I’ll take a look at some of the social indicators that drive ill-health in American society with the goal of setting a baseline for the “social determinants of health.” Do health outcomes move up or down in tandem with improvements or declines in housing and food insecurity, real wages and income inequality?

Note to enterprising scholars out there: It would be nice to know.