In 2015, a pair of economists received widespread attention for their study showing that since the late 1990s the death rate has been rising for middle-aged white Americans.
Now a new analysis by the same Princeton University team has identified which part of that population was driving that trend: people without college degrees.
White men and women in every age group between 25 and 64 who did not have college degrees saw their mortality rates increase between 1998 and 2015. Those with degrees saw their mortality rates decrease.
"There are two Americas," said Anne Case, who conducted the research with her husband, Angus Deaton, a Nobel laureate. "There's an America for people who have gotten a college degree, and an America for people who have not gotten a college degree. And if you had a checklist of well-being, the people without college degrees are getting worse and worse, and people with college degrees are doing very well."
The analysis, published Thursday in the Brookings Papers on Economic Activity, found that the problem appears to be distinctly American. In Europe, mortality rates for people with low levels of education are falling more rapidly than for those with more education.
In every age group the researchers examined, white Americans with a high school education or less now fare worse than blacks as a whole — a reversal of the situation in 1999.
Blacks and Latinos have seen steady improvement in mortality rates as whites without college degrees have been going in the other direction as a result of drug overdoses, alcoholism and suicide and a recent halt in a decline in deaths due to heart disease. The nation's opioid abuse epidemic played a major role.
But the authors said an underlying culprit is the widespread erosion of institutions that provided stability in American life for much of the 20th century: the manufacturing industry, the church, unions and stable marriage.
"A long-term process of decline … began for those leaving high school and entering the labor force after the early 1970s," and "traditional structures of social and economic support slowly weakened," the authors wrote.
"These changes left people with less structure when they came to choose their careers, their religion, and the nature of their family lives," they wrote. "When such choices succeed, they are liberating; when they fail, the individual can only hold him or herself responsible."
The result, the authors conclude, is a "recipe for suicide," adding that other risks include alcohol abuse, drug use and overeating.
The authors touch on themes of working-class white disenfranchisement that became a major undercurrent in the 2016 presidential campaign and turned "Hillbilly Elegy," a book by J.D. Vance about hope and hopelessness within rural America, into a bestseller.
The book focused on Appalachia, but Case says the problem stretches all over America, not just in rural areas, and may explain why voters were so interested in political outsiders like Donald Trump on the right and Bernie Sanders on the left.
"There's just a sea of despair; there's an enormous amount of pain," she said, describing "wages that don't rise with experience" and "an inability to create and keep stable marriages" among working-class whites. "There's a lot of lack of structure in people's lives that give balance and meaning."
Case said the situation may continue to worsen. "People just entering the labor market now without a college degree are getting hammered even more," she said. And older whites won't see comprehensive government relief in retirement, Case said.
"Social security is not going to magically wave its wand and make you whole again," Case said.