America's Declining Well-Being, Health, and Life Expectancy: Not Just a White Problem

Peter A. Muennig, MD, MPH; Megan Reynolds, PhD; David S. Fink, MPH; Zafar Zafari, PhD; Arline T. Geronimus, ScD


Am J Public Health. 2018;108(12):1626-1631. 

In This Article

Alternative Stories

If longer-term trends toward social malaise, declining health, and increases in mortality preceded the opioid epidemic, we must explore other explanations for America's relative fall in health and global life expectancy rankings. The relative decline is likely to have many proximal and distal causes and cannot be explained by a single hypothesis. Moreover, the possibilities are nearly infinite and each upstream risk could lead to a cascade of downstream risks. These could include the increases in industrial chemicals in the environment, screen time, reliance on private automobiles, and mechanization of human tasks and worsening of the quality of the food supply chain. Virtually any social trend that might correlate over time with changes in health curves is a candidate. For the purposes of illustration, we describe some of the more popular or plausible explanations on the basis of our reading of the published research and feedback from scholars active in this area.

(1) Failure of democratic institutions and regulations might be making life more hazardous, particularly for Whites in red states.[31,32] Welfare programs are stronger in blue states. Blue states also tend to have stronger governance, stricter gun laws, safer roads, and more stringent environmental protections. Certainly, some of the regulatory standards from blue states spill over to red states (e.g., automobile standards and trans fat bans) because it is more expensive for companies to make different products for different markets. But many, such as Medicaid expansion, do not.[33]

Such variation in public investment also exists across countries. The United States is falling behind other nations with respect to educational performance, income equality, environmental protection, transportation, waste management, the rule of law, and private gun ownership regulations.[34] Many of the institutions that have long protected low-income Whites from abject poverty are now disappearing, particularly in those states and counties with the highest increases in mortality rates. There is some experimental evidence that welfare policies influence long-term health, but there is considerably more work that needs to be done to ascertain which policies work and for whom.[35–38]

(2) Economic stagnation since the 1980s for moderate-income households of all races/ethnicities could have adverse health implications apart from despair. As characterized by the John Henryism and weathering hypotheses and related empirical literature, the roles of chronic stressors and the tenacious coping needed to survive or overcome them have cumulative adverse health effects.[39,40] These are reflected in the early onset of life-threatening chronic diseases and in generally increased health vulnerability as body systems become dysregulated or exhausted by prolonged stress-mediated wear and tear.[41]

(3) Changing demographics may be inflating longevity losses in the United States by race, by county, or for the country as a whole. Some of the declining health and longevity in the United States has long been masked by immigration. Foreign-born Americans are generally much healthier than are native-born Americans of similar socioeconomic position.[42] It is possible that when immigration to the United States leveled off, immigrants stopped contributing to life expectancy gains and that this drove recent declines in overall life expectancy in the United States.[14] The migration story is supported by a relatively strong correlation between mortality and in-migration trends and the fact that areas without major urban centers that attract healthy international migrants have experienced a leveling off in life expectancy over the past decade.[43]

Internal migration may also play a role. This problem is best illustrated by a comparison between survival patterns in widely divergent labor markets. The "stroke belt," where employment opportunity has been contracting for some time, suffers from absolute increases in mortality, whereas urban innovation centers such as San Francisco, California; Portland, Oregon; and New York City show drops in mortality.[12] If healthy people leave poorer counties to seek job opportunities in larger, coastal, urban areas, this would create a statistical reduction in health quality and an increase in mortality in poorer geographic areas attributable purely to compositional, rather than intraindividual, change.

(4) Rising medical costs may be compromising Americans ability to satisfy basic needs. If there is anything to which one can point that makes the United States an outlier in global rankings of health measures, it is medical costs. In the early 1970s, medical costs in the United States were in line with those in other nations. They have since substantially outpaced increases in other nations and are now more than twice as high as the next biggest spender, Switzerland.[5] Out-of-pocket payments for insured people are rising sharply over time.[44] These costs are eating into middle-class American's disposable income. Whites are likely to be uniquely affected because they have historically been more likely to receive employer-based health insurance, which has seen rising copayments and deductibles. Those receiving Medicaid, on the other hand, have been somewhat shielded from these market-driven increases. Medicaid has, over time, become a benefit for low-income Americans in more diverse blue states.

(5) Earlier smoking among White women could be producing lagged mortality effects that are surfacing in middle and older ages. Wang and Preston find that the prevalence of smoking in the United States was much higher than in other nations, particularly among White women, and that the full effects of smoking on population health do not materialize for decades. Research has shown that smoking rates among White women did not peak until the 1960s and that they subsequently declined very slowly among low socioeconomic status White women relative to both high socioeconomic status women and men.[45] Additionally, smoking rates declined much faster in blue states with higher cigarette taxation. Because of the coincidence of smoking and drug use, it is quite possible that the contemporary effects of cigarette smoking overlap with the effects of the opioid epidemic.

These and other hypotheses warrant consideration alongside wage-driven White despair. In all likelihood, the answer rests in some combination of factors that include, but are not limited to, stagnating wages.[9] Any such analyses should factor in the weakening of democratic institutions and regulations, increased stress exposure and the high-effort coping it entails, rising medical costs, migration of healthy people, and gendered smoking patterns.