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January 13, 2020
State Health Policy Leadership Population Health
Christopher F. Koller, President
Back to President’s Blog: The View from Here
This guy— I will call him “Kurt”—came shambling around the corner while my buddy and I were chatting in the street in downtown Providence, Rhode Island. My friend, who works in health care as well, and I had just finished breakfast but weren’t quite done reforming Rhode Island’s health system, so our conversation had continued outside.
Over my colleague’s shoulder, I watched Kurt approach like a small storm cloud while we discussed payment reform and the calculus of provider consolidation. His gait was leisurely but grew more purposeful as he drew near.
He dove in: “Excuse me, gentlemen, for interrupting because I can see you are engaged in a spirited and meaningful conversation, undoubtedly of great importance.” Kurt apologized again, noted his own eloquence (for which he acknowledged he was well-known), and with a third apology and a wry smile, got to his main purpose: hitting us up for some spare change. Once he achieved this goal, he wished us happy holidays and continued strolling down the street.
As I watched him go off, I found myself wondering about the rest of his day and what he did when he was not playing the court jester. I figured his life was pretty fractured and included some underlying chronic health conditions, likely with a behavioral health or substance abuse component. Still, I had not taken it upon myself to raise, during our brief exchange, the salutary benefits of Medicaid expansion or routine visits to a primary care physician, preferably one with integrated behavioral health care services.
Even before we met, Kurt was in some ways a part of our breakfast conversation. People working in health care regularly lament the abysmal overall job the US industry does. We have now reached the point where life expectancy in the US has declined for three years running, despite the gobs of money the industry consumes. That morning our discussion touched on new verses in that lament: research by Steven H. Woolf and Heidi Schoomaker in the Journal of the American Medical Association that sheds some light on what is driving those drops in life expectancy.
The researchers’ first insight is that this decline was a long time coming. The article looks at data going back to 1959 and finds that the increases in life expectancy have been moderating since 1979, with further flattening since 2003 and 2011. There is real bad news for Kurt: victims in this moderation and decline were adults aged 25 to 64 dying from drug overdoses, alcohol abuse, suicides, and a variety of organ system diseases. Worse news for him, while the increases were not confined to particular races or ethnicities, they were disproportionately prevalent among men.
Woolf and Schoomaker also found that Kurt could have picked a better place to live. When it comes to longevity, as in real estate, location matters. The researchers estimated that “excess deaths” resulting from declining life expectancy were concentrated primarily in East-North-Central states (Indiana, Illinois, Michigan, Ohio, and Wisconsin) and New England. That does not mean the rest of the country is off the hook, as figure 8 from the study shows.
Looking across states, it appears that midlife mortality was worse in rural areas than urban ones, but the researchers found great variation in these rural rates, indicating other factors were at play.
Woolf and Schoomaker conclude by hypothesizing increased adult midlife mortality is driven largely by four factors: tobacco use and obesity, deficiencies in health care, psychological distress, and socioeconomic conditions.
These factors don’t have to determine destiny. Federal policy can address them but instead is apparently exacerbating them. And state-level life expectancy is moderating at different rates; the resulting state-level variation in excess deaths is worth investigating. It points not only to variations in the factors that are driving life expectancy (Hawaii may be a less stressful place to live than Mississippi) but to possible changes in those factors over time—changes due, at least in part, to policy decisions made by states. California and Wyoming are rarely mentioned in the same breath when it comes to state health policy, but both were at or below national life expectancy averages in 1959 and well above them in 2016 (See figure).
What, if anything, did policymakers do in California and Wyoming that had an impact on life expectancy? The policy actions those states took that led to improvements in life expectancy were likely not in health care but in other social policy arenas. Moreover, these decisions were made for other reasons, with only dim appreciation of the ripple effects on lifespan. So is it about who pays how much in taxes? What and how to invest in childcare and education? How to prevent and treat childhood trauma? The extent and nature of work available? Environmental protection? Woolf and other researchers are continuing to study these questions. We, at least, have plenty of evidence in the US that spending more money on health care does not help and may even be harmful.
Or maybe it is not about specific policies but the values that guide their prioritization and development. Long and healthy lives for all is perhaps the ultimate measure of social policy effectiveness. All of our social policies should contribute to that goal. If other concerns are prioritized, however, or policies are developed in ways that prioritize the interests of a powerful few, the health of many suffer.
For all Kurt’s charms, it is safe to say that he would rather not be walking the streets in winter and hitting up strangers for spare change. We know how stories like his often end: with an unfulfilled life and an earlier death. The new research shows that more people across the country are experiencing untimely deaths and points to the places and people affected most. The research also shows that it doesn’t have to be this way. That kind of change is possible, too.
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