JAMA Forum: Declining US Life Expectancy and the 2020 Presidential Election

By Ali Bokhari, MPH, and Joshua Sharfstein, MD

Image: Getty Images/PeopleImages

The recent 3-year downturn in US life expectancy is the longest sustained decline in a century, when the nation experienced both World War I and the Great Influenza pandemic of 1918. The United States is now ranked 43rd among 195 countries and territories for life expectancy and projected to decline to 64th by 2040. There are major disparities in how long US citizens live, based on race, class, geography, and education, with the result that many children will not live as long as their parents.

One might imagine that these demoralizing statistics would be a key focus for candidates seeking the presidency. This is not the case. Not a single candidate, Democrat or Republican, has posted a comprehensive plan for reversing the trends in life expectancy. The topic arose just 3 times in 12 hours of Democratic debates to date. Responding to a question about private insurance, Sen Cory Booker (D, New Jersey) attributed the lower life expectancy for African Americans to poorer health care in lower-income communities. Two candidates—Andrew Yang, JD, and Gov Steve Bullock (D, Montana)—drew a contrast between the rise of the economy with the fall in life expectancy.

Also scarce are prominent mentions of life expectancy on campaign websites. The website of candidate Tom Steyer, MBA, references the life expectancy difference within zip codes of Fresno, California, as part of a discussion for clean air and water rights. Other candidates’ sites, including those of Rep Tim Ryan (D, Ohio) and Marianne Williamson, call the decline in life expectancy in the wealthiest country in the world as unacceptable. The site of Sen Bernie Sanders (I, Vermont) references gaps in life expectancy as a consequence of income inequality.

Why so little detail about a core measure of the health of the US population?

One reason may be that many candidates have focused their attention on plans to fix the health care system. These options include plans to close gaps in the Affordable Care Act, a public option, Medicare for all who want it, and Medicare for all in several variations. Some of these plans mention life expectancy in passing, such as when Andrew Yang’s Medicare-for-all plan states that by “providing holistic healthcare to all our citizens, we’ll drastically increase the average quality of life, extend life expectancy, and treat issues that often go untreated.” Many of the plans project their effects on key parameters such as coverage and cost; none set targets for the potential gains for life expectancy for the nation. The absence of this outcome may in part reflect the fact that access to health care only modestly contributes to longevity.  

A second reason for so little attention to life expectancy on the whole may be that candidates are focusing on specific contributors to increasing rates of death. For example, of 23 current Democratic and Republican candidates, 10 have posted plans to address the overdose epidemic, 7 have plans on suicide, 15 have plans on interpersonal violence, and 9 have plans on noncommunicable chronic diseases—each of which contributes to the decline in life expectancy. However, only 4 of the candidates—Sen Michael Bennet (D, Colorado), Andrew Yang, Sen Elizabeth Warren (D, Massachusetts), and South Bend, Indiana, Mayor Pete Buttigieg—expressly mention the potential benefits of tackling these issues for life expectancy.

A third reason may be that candidates are paying considerable attention to specific disparities in life expectancy, such as those by race, ethnicity, and geography. Of the 16 candidates who have posted plans on health disparities, 5 mention the potential benefits of tackling such issues for life expectancy: Warren and Buttigieg, along with former Maryland Rep John Delaney, former Texas Rep Beto O’Rourke, and former Pennsylvania Rep Joe Sestak. These candidates have plans to close gaps affecting African Americans, people living in rural areas, and Native American communities.

Eleven other candidates—Booker, Bullock, Steyer, Ryan, Williamson, and Sanders, along with Vice President Joe Biden, former US Secretary of Housing and Urban Development Julian Cástro, Sen Kamala Harris (D, California), Sen Amy Klobuchar (D, Minnesota), and President Donald Trump—have posted plans addressing specific contributors to disparities in mortality, such as elevated rates of suicide among veterans. However, these plans do not address the potential benefits of tackling these issues for life expectancy.

A Missed Opportunity
The 3 major topics overshadowing life expectancy in the Presidential campaign are all important. Improving the healthcare system, addressing specific causes of death, and tackling health disparities are also more tangible than trends in longevity for the entire population. Construal-level theory suggests that the farther removed a person feels from something psychologically, the more likely they will view the concept as abstract. The statistic of life expectancy at birth estimates the number of years people can expect to live if the age-specific death rates remain constant—hardly an intuitive concept. Individuals are naturally concerned about how long they themselves will live, but the average life expectancy in an area rarely rises to the level of a major community priority.

However, even if the campaigns’ reluctance to address life expectancy may not be a surprise, we believe it is a missed opportunity for the health of the nation.

Focusing on improving life expectancy as a top-line goal would lead to greater, high level appreciation of what is causing more young people to die. Most analyses find drug addiction, violence, and preventable chronic illness as 3 preventable causes across race, class, and geography. With the goal of saving lives in mind, policy options could be sorted by whether they are likely to have the desired effect. Among strategies that would rise to the top are common pathways of risk and social determinants of health. A national “why do we rank 43rd in the world” discussion would create a framework to consider solutions at every level of government and society.

Absent such a North Star measure, however, investments are more likely to remain driven by historical patterns and preexisting biases, not evidence. For example, some investments in traditional approaches to addiction are of little to no value, and many successful approaches to reducing gun violence have yet to penetrate through the political fog.

Politics of Life Expectancy
And what about the politics of life expectancy? Some analyses suggest that these might be quite potent. In the 2016 Presidential election, counties with stagnating or falling life expectancy were more likely to shift their votes to the Republican nominee. In fact, 1 study found that the best predictors of the vote in the last presidential election were the combined county-level variables of life expectancy with obesity, diabetes, alcoholism, and physical activity. Wider health inequities were also associated with shifting voting patterns. These types of analyses have even led some people to speculate that a modest decline in the prevalence of diabetes might have shifted the outcome of the election.

The stagnation and decline in US life expectancy offer a rare opportunity for common ground. Candidates who confront this problem may be able to speak to multiple constituencies at once—from rural voters affected by rising suicide rates to people with addiction in the suburbs and to individuals suffering from chronic illness in cities. The United States is suffering, and presidential leadership can create a path for saving many lives. The nation could do much worse than a broad and vigorous debate on how to reach a healthier future.

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About the authors:

Ali Bokhari, MPH, earned his Master’s degree in public health from Johns Hopkins University Bloomberg School of Public Health, is currently a medical student at New York Institute of Technology College of Osteopathic Medicine, and is the incoming president of the American Medical Student Association. He has worked on political campaigns for Democratic candidates at the presidential, congressional, and local levels, but does not have an official role nor has contributed to a Presidential candidate for the 2020 election. (Image: Austin Chan)

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Joshua M. Sharfstein, MD, is vice dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health. He previously served as secretary of the Maryland Department of Health and Mental Hygiene, as the principal deputy commissioner of the US Food and Drug Administration, and as commissioner of Health for Baltimore. He is also a consultant to Audacious Inquiry and to Sachs Policy Group. A pediatrician, he lives with his family in Baltimore. Other than providing comments on several campaign plans for Mayor Pete Buttigieg, he does not have an official role and has not contributed to a Presidential candidate for the 2020 election. (Image: Chris Hartlove).

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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