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Why is life expectancy in the U.S. going down? A Q&A

In this Q&A, Stanford scholar Jay Bhattacharya provides context to understand the recent decline in life expectancy in the United States.

A recent report from the Centers for Disease Control and Prevention contained a sobering surprise: Life expectancy at birth in the U.S. declined a tenth of a year to 78.6 years. The update also included information on the leading causes of death.

Jay Bhattacharya, MD, PhD, a senior fellow of the Freeman Spogli Institute for International Studies, helped make sense of the findings:

Did anything surprise you about the studies?

The academic discourse around life expectancy in the past few years has really just been focused on looking for signs of a possible slowdown in the rate at which it has been increasing. What the CDC has now revealed is a real reduction in the anticipated life spans of human beings born today. Up until recently, we as demographers had been debating what the limits to human longevity might be, but now we're now being forced to answer a totally different question about why that positive trend, which we'd assumed was going to continue for a while, has been so suddenly thrown into reverse.

What possible reasons have been floated to explain this decline? 

A lot of the discussion in the media after the CDC released these reports was focused on increased deaths from opioid abuse and suicide. The theory goes that because of the increasing prevalence of suicide, depression, drug abuse, and so forth  --  which tend to begin in younger populations  --  that there's more of an impact on life expectancy relative to, for example, a disease hitting people who are 80- or 90-years-old.

But my personal view is that these factors, although they might have a particular political salience right now, aren't actually the main reasons for the decline that the CDC is reporting.

What alternative would you offer?

A lot of the previous demographic literature has focused on changes in chronic disease rates in the American population and in particular on obesity. There's been this enormous and persistent rise in the prevalence of obesity going back decades...

In the U.S. today, around 40 percent of the adult population is obese and correlates very strongly, causally even, with diabetes and all kinds of other chronic conditions that are not just expensive to treat but also lead to increased mortality.

How should we go about reversing these trends?

One thing that I think we need to be better at is distinguishing between primary prevention and secondary care. The latter we've gotten very good at, the former not so much. For instance, while chronic disease rates have risen dramatically in the U.S., disability from that chronic disease hasn't to the same extent. We're better at treating people who've had a heart attack or a stroke so that they don't end up seriously disabled, but in terms of preventing those primary health events from happening, by targeting risk factors like obesity, we're not doing enough.

How should we be spending health care dollars to maximize their positive impact on outcomes like life expectancy?

This is a tricky question, because it gets into the highly-political distributional questions around health care, as well as the way that these questions tie into other types of social inequality. When it comes to socioeconomic status, the lowest quintile has experienced almost no change in life expectancy over the last 20 years whereas as the highest quintiles experienced very substantial life-expectancy increases. In developed countries, it also tends to be the relatively poor who are most likely to be obese; about 1.5 times more likely in the U.S.

Exactly how we should go about addressing this imbalance isn't clear... Certainly though, we should be asking where the marginal value of health care dollars is highest and target those areas. For instance, the costs of preventative or primary medicine relative to rehabilitative or secondary care are much lower, so working on novel and effective ways to encourage people to take better care of themselves before they experience some kind of major illness will be critical.

A longer version of this piece was originally published by the Freeman Spogli Institute for International Studies. 

Photo by Stephen Leonardi

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