For Americans of a certain age, recent news has been grim. In November, economists Anne Case and Angus Deaton pointed out that middle-aged whites are dying faster than they were 15 years ago. That fact becomes even more startling when the United States is compared to other countries, where the mortality rate has been steadily declining for middle-aged people. In America, the misfortune has been distributed unequally — death rates increased the most for middle-aged whites with low levels of education.
Inequality was the theme of another high-profile study in April, from Stanford economist Raj Chetty and a team of researchers, who showed a widening gap in life expectancy between rich 40-year-olds and poor 40-year-olds. From 2001 to 2014, top earners at age 40 saw their expected lifetimes increase by nearly three years. The lowest earning Americans saw their expected lifetimes increase by only few months.
Together these studies have spawned dozens of investigations and essays trying to understand what’s ailing middle-aged America. But it’s important to remember that things haven’t been getting worse for everybody. In fact, there’s a lot to be optimistic about if you look at the big picture, says Janet Currie, a professor of economics at Princeton.
“There has been so little attention paid to some really huge declines in mortality, especially among young people and African Americans,” Currie says.
In a new paper published in the journal Science, Currie and her co-author Hannes Schwandt, an assistant professor at the University of Zurich, show that death rates have fallen dramatically for children and teens of all races over the past 20 years. Not only that, but death rates have fallen the most for children who live in the poorest counties. While health inequality between rich adults and poor adults seems to have increased, health inequality between rich kids and poor kids has narrowed.
"The health of the next generation in the poorest areas of the United States has improved tremendously," Schwandt says. "It is surprising how little anyone has paid attention to this health success story."
These 19 charts tell the story. Each chart shows the death rates for a certain age group. On each chart, there are blue triangles and green dots. The blue triangles represent death rates in 1990. The green dots represent death rates in 2010.
The economists took all the counties in the United States and ordered them left-to-right on each chart by the poverty rate. For instance, the left-most triangle on each chart represents the death rate in the richest counties in the U.S. in 1990. The right-most triangle represents the death rate in the poorest counties in the United States in 1990.
For young Americans, not only has the death rate declined everywhere over the past 20 years, but the difference between the death rates in rich counties and poor counties has also narrowed. This good news has been largely overlooked because recent research has focused on older Americans. But it’s a particularly important development, the researchers say, because good health at young ages predicts good health at older ages.
“There appears good reason to hope that today’s young will also be healthier when they reach old age and that inequality in mortality will decrease among these elderly in the future,” the researchers write.
In a follow-up paper released Monday by the National Bureau of Economic Research, the researchers show even more dramatic declines for black Americans. For instance, between 1990 and 2010, the death rate for black men aged 20-49 dropped by half. It used to be that white men living in the poorest counties lived longer than black men living in the richest counties — but by 2010, the gap between white men and black men had narrowed to almost nothing.
To look at the data another way: black men living in the poorest countries today are less likely to die before the age of 49 than black men living in the richest counties 20 years ago.
The reasons for these developments are still unclear. Currie and Schwandt believe that the declines in mortality among poor young people were caused by improvements in the social safety net — poor children are much more likely to have health insurance these days, thanks to federal programs. Better nutrition thanks to food stamps and school lunches may have also played a role; air and water pollution, which harms poor children the most, has also abated in many places in recent decades. The Centers for Disease Control and Prevention says that reductions in the number of people dying of heart disease, cancer and HIV are the top reasons black Americans are closing the life expectancy gap with white Americans.
It’s important to talk about these successes in public health because they give us hints about what the nation is doing right, especially for the most vulnerable. “This really does drive public policy discussion in a lot of ways,” Currie says. “People think everything is getting worse for poor people, and that’s just not true. There’s a lot of nuance.”
In recent years, economists have trumpeted the fact that income and wealth inequality are increasing in America. It is tempting, then, to assume that health inequalities must be on the rise as well. But the connection between these two different kinds of inequality is not all that clear, the researchers say, and there's a lag. It's important to remember that a person's health reflects not only their current circumstances, but the sum of their experiences since birth. An adult's health is a record of the past several decades of their life.
Chetty and his team have shown that inequality in life expectancy increasing between rich middle-aged people and poor middle-aged people. Something terrible might happen between youth and adulthood that sends middle-aged Americans, particularly whites, down a dark path of painkiller addiction and alcoholism. But those differences may also in part be the result of historical disparities in health care or childhood nutrition causing problems that are only surfacing now. Many health researchers believe, for instance, that smoking patterns partially explain why health inequality is increasing — rich people started to avoid smoking much earlier than poor people, and they are now starting to reap the rewards in middle age. But as smoking rates fall among the poor as well, the life expectancy gap may begin to close in the future.
That's why the statistics on young people are so heartening, because they give us a read on what's happening right now. Even though income inequality and wealth inequality has been increasing, the disparities in child death rates have still been shrinking. That suggests that recent policies are working to save the lives of poor kids. "The health of children is a sensitive indicator of recent social developments," Schwandt says, "The next step is to identify which policies are responsible, so we can scale them up."