Higher-than-expected death rates among middle-aged white Americans are largely being driven by stagnant progress against heart disease and other common illnesses, according to new research into a crisis that is increasingly worrying healthcare officials and policymakers.
The unexpectedly high mortality — which sets the U.S. apart from other developed nations — has come into focus recently amid a rising toll of drug deaths and suicide.
But the new report from the New York-based Commonwealth Fund suggests that drugs and suicides are only a part of the problem. The full cause of the disturbing trend is likely broader and involves failures in the medical system and profound changes in the economy.
"We are accustomed to making progress against diseases. We learn how to prevent them and how to treat them and, as we do that, fewer people die from them," said Dr. David Blumenthal, a coauthor of the study and president of the fund.
"For middle-aged whites, that progress has stalled and even reversed for some conditions. We need to find out why this is happening."
The problem was worst in several states stretching from Appalachia south and west across the Deep South.
Mortality rates were 60% to 76% higher than they would have been if the trends of the 1980s and 1990s had continued in West Virginia, Kentucky, Tennessee, Alabama, Mississippi, Arkansas and Oklahoma.
By contrast, the gap between expected and actual mortality rates was smallest in New York, New Jersey, California, Connecticut, Minnesota, Massachusetts and Illinois.
"There is clearly something going on that is troubling," said Samuel Preston, a University of Pennsylvania demographer who headed a 2011 National Academy of Sciences panel that looked at life expectancies in high-income countries. "It points to a serious national problem."
Evidence has been emerging for years about worrying life expectancy trends in the U.S., as women and men in some parts of the country died younger than their counterparts did a generation ago.
The focus on middle-aged whites intensified when a pair of Princeton University economists — Nobel laureate Angus Deaton and Anne Case — published a blockbuster article last year showing that since 1999, death rates had increased specifically among non-Latino white Americans ages 45 to 54.
Researchers have not found a similar problem among African Americans and Latinos, though a health gap between whites and nonwhites remains.
Nor has problem emerged among working-class residents of Western Europe or other industrialized nations.
"The question is: Is it social safety net?" Case said in an interview. "Are working-class people more protected in Europe? Is it universal healthcare?"
To explain the reversal in decades of progress among whites, Deaton and Case pointed to a dramatic increase in deaths attributed to drug poisoning, suicide and alcohol-related liver disease, which killed twice as many working-age whites in 2014 as in 1999.
The increase in deaths among whites from drug abuse, alcohol and suicide was so large that it "bears a resemblance" to trends seen "during the height of the AIDS epidemic," Case and Deaton concluded in their paper, published in the Proceedings of the National Academy of Sciences.
The Commonwealth Fund researchers, working with the same data from the U.S. Centers for Disease Control and Prevention, looked beyond those causes, however.
They found a marked slowdown in what had been a steady improvement in death rates linked to illnesses including heart disease, diabetes and respiratory disease.
For example, from 1983 to 1998 there was a 41% decline in mortality linked to heart disease. By contrast, the death rate fell by 11% from 1999 to 2014.
"Mortality rates for middle-aged whites have stopped declining — or actually increased — across a broad range of health conditions, including most of the leading causes of death," the authors wrote.
The states showing the worst trends have high rates of poverty as well as some of the highest rates of smoking and obesity in the country.
They also historically have had among the weakest healthcare systems, with high rates of people lacking insurance and poor access to medical care.
Some of these shortcomings may be addressed in some states by the Affordable Care Act. Arkansas, Kentucky and West Virginia have expanded their Medicaid safety nets through the law, a step that other research suggests should have health effects over the longer term.
The remaining states with the biggest health gaps continue to resist the law and do not guarantee health coverage.
But Blumenthal and coauthor David Squires note that broader trends affecting middle-aged whites may explain much of the worsening of death rates.
They point to an "increasing disengagement from the mainstream economy" on the part of less-educated workers, declining rates of marriage and falling incomes.
"We are witnessing regression that has little precedent in the industrialized world over the past half century," the authors concluded.