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Suicide, substance abuse not only cause of ‘mortality gap’ for middle-aged white Americans

Source: Commonwealth Fund
The "Mortality Gap" for middle-aged whites was particularly large in parts of the South.

Last fall, a Princeton University study made international headlines when it reported that the death rate for middle-aged white Americans — those aged 45 to 54 — has been steadily increasing over the past 15 years.

The study’s authors suggested three main reasons for that startling trend: accidental poisonings (mostly overdoses from opioids and heroin), suicides and chronic liver diseases (associated with alcohol consumption).

But, according to a new, provocative report from the Commonwealth Fund, those factors do not explain all — or even most — of the recent increase in the death rate among middle-aged white Americans.

The prime reason middle-aged whites are dying at greater-than-expected rates in the U.S., says the report, is because that demographic is no longer progressing in its fight against common causes of death, such as heart disease, diabetes and respiratory disease.

Most of that stalled progress, the report adds, has occurred in states that have failed to expand their Medicaid program to all low-income adults.

‘A mortality gap’

The report was co-authored by the Commonwealth Fund’s president, Dr. David Blumenthal, and one of its senior researchers, David Squires. Using data collected by the Centers for Disease Control and Prevention, they compared U.S. death rates with expected death rates from 1968 to 2014. They also examined the causes of deaths for working-age adults during that period.

Blumenthal and Squires found that death rates in the United States have been declining since 1968 by an average of about 2 percent per year. The decline has occurred across most age groups, as well as across most racial and ethnic groups.

Other high-income countries, they point out, have experienced similar drops in their death rates, and in many of those countries the declines have actually appeared to speed up since 1998.

But, like the Princeton researchers before them, Blumenthal and Squires uncovered one major exception in the U.S. to this trend: white, working-age adults, particularly those at midlife. Instead of declining, the death rate for this group has significantly increased.

Indeed, for every 100,000 middle-aged white adults, there were more than 100 extra deaths in 2014 than historical trends would have predicted, according to the Commonwealth Fund’s analysis.

Familiar causes

Blumenthal and Squires acknowledge that about 40 percent of this “mortality gap” can be explained, as the Princeton researchers suggested, by substance abuse and suicides. But the rest of the gap, they say, is linked to illnesses that are among the most common causes of death in the U.S., such as heart disease, diabetes and respiratory disease.

Their analysis revealed that although fewer middle-aged white Americans are dying from these diseases than in the 1960s, that downward trajectory has stalled — or even reversed — since the late 1990s.

“Heart disease, the second-leading cause of death for middle-aged whites in the United States, is illustrative,” write Blumenthal and Squires. “After rapidly declining between 1968 and 1998, mortality from heart disease essentially leveled off for this population between 1999 and 2014. (For blacks and Hispanics, heart disease death rates continued their rapid decline.)”

“This leveling-off in improvement was as important as the rise in drug overdoses in explaining the gap between observed and expected mortality among middle-aged whites,” they add.

Minnesota’s gap

Blumenthal and Squires also found regional variation in the mortality gap. In seven states — West Virginia, Mississippi, Oklahoma, Tennessee, Kentucky, Alabama and Arkansas — the gap in 2014 between the actual and the expected death rates for middle-aged whites exceeded 200 deaths per 100,000 people.

In Minnesota, the gap was smaller but still significant: 59 extra deaths per 100,000 people. Minnesota is doing better on this front, however, than almost anywhere else in the country. Only two other states  — New York (49) and New Jersey (57) — had smaller gaps.

As Blumenthal and Squires point out, many of the states with the worst mortality trends have failed to expand their Medicaid program to all low-income adults.

Those states also have some of the highest levels of poverty in the country, as well as some of the highest rates of negative health indicators, such as smoking and obesity.

Trend needs reversing

“We are accustomed as a nation to making steady progress in the area of health,” write Blumenthal and Squires. “Even when looking at death rates over the past 15 years, there is still plenty of support for that optimism. Mortality has continued to decline at relatively rapid rates for many age groups, both in white and minority populations (though this progress has not eliminated racial disparities). But for working-age whites — especially 45-to-54-year-olds — we are witnessing regression that has little precedent in the industrialized world over the past half-century.”

“The notion that changing social and economic forces are a possible explanation does not mean that white middle-aged adults are suddenly worse off than other groups, especially minorities,” they add. “Rather, it suggests that their lives have changed in unexpected ways in recent years. … Reversing their current mortality trend should be an urgent priority, as should reducing other health disparities associated with race and income.” 

FMI: You can read the full report on the Commonwealth Fund’s website. The Commonwealth Fund is a private, nonpartisan, philanthropic organization that conducts research on health and social policy issues.

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