It’s about behavior more than policy

Americans aren’t living as long as we used to. A child born in 2021 can expect, on average, to live to the age of 76.1. That’s a decline of nearly a year from 2020, according to the CDC, and a nearly three-year decline from 2019. The last time life expectancy was this low was 1996.

Most of the world, of course, saw a sharp drop in life expectancy in 2020, largely because of the Covid pandemic. But while life expectancy rebounded in 2021 in most similarly developed countries, it continued to fall in the United States. In fact, Americans have lived less long on average than their developed-world peers for decades — at least since the 1980s, by some estimates.

This disparity has long enabled political posturing. Liberal critics of the United States, and particularly advocates of government-funded health care, point to the disparity as evidence of America’s basic failures in comparison with our more enlightened European peers. That the Republican-voting states of the Deep South have particularly low life expectancies is taken by some as evidence of the particular deadliness of conservative policies.

But that’s not the full story. While America’s stagnating life expectancy is a real cause for concern, in the long run our underperformance has had more to do with the risky behaviors of America’s young adults than with our less socialized health-care system. And while policy can reduce those behaviors, there’s no silver bullet for making Americans live longer.

Compared with historical norms, Americans live much longer than they did in decades past. The average child born in the year 1900 could expect to live to about age 47, according to CDC statistics. Nowadays that figure is 77. Some of that gain is attributable to reductions in childhood mortality, but not all of it. In 1960, for example, a 40-year-old could expect to live another 34 years. In 2020, the Berkeley Mortality Database estimates, that number rose to 39 years. Even 80-year-olds can expect to live longer than they did in 1960 — about two years longer, again per the Berkeley data.

While these figures represent a remarkable accomplishment, they are an expected by-product of technological development, including innovations in sanitation, disease prevention, and medical care. Worldwide, life expectancy has doubled since 1900. So in some regards, it would be more remarkable if American life expectancy hadn’t risen steadily.

The data shown above are what make recent trends in the United States so notable and alarming. They compare U.S. life expectancy since 1980 with that of other highly developed countries — Canada, Japan, and the nations of Western Europe. Three things stick out.

First, the United States has been an outlier from its similarly developed peers since at least the 1980s. Second, the United States experienced a particularly large decline in life expectancy in 2020 and, as mentioned above, did not get the rebound in 2021 that many other nations enjoyed. Third, U.S. life-expectancy growth has been stagnant since around 2010, widening the gap between us and the rest of the developed world.

The recent drop in U.S. life expectancy, in other words, is both particularly large by international standards and part of a longer-term underperformance compared with our peers. This underperformance is seen both in absolute terms — how long Americans live — and in the rate at which our life expectancy grows. But what explains this divergence, both now and historically? And what, if anything, can government do to remedy it?

Life expectancy declined in the United States, indeed almost everywhere, in 2020 because Covid caused hundreds of millions of lost years of life worldwide. That effect is quantifiable: The CDC estimates that about 74 percent of the life-expectancy decline in 2020, and about half of the decline in 2021, is attributable to Covid.

Covid also explains why the U.S. had a larger life-expectancy decline than similarly developed nations. In cumulative excess mortality per capita, the U.S. is behind only Italy among similar countries, according to the website Our World in Data. A larger fraction of people died of Covid in America, that is, than in peer countries in 2020 and 2021.

America’s higher Covid death rates could be attributable to variations in health-care policy or vaccine usage. On such indicators, the United States is generally middle-of-the-pack — not best, not worst. According to the most recently available figures from Our World in Data, for example, about 80 percent of Americans were vaccinated against Covid, putting it squarely in the middle of peer countries. On a nine-item “stringency index” that Our World in Data calculated to track the strength of government responses, America has similarly been about as aggressive on average as peer countries. (Such measures are always imperfect, particularly given the federalist patchwork of policy responses in the U.S.)

At the same time, part of our high death rate likely stems from differences between the population of America and those of its peer countries that affect the populations’ susceptibility to disease. Americans are (infamously) fatter than their developed-country peers, and obesity is a well-established risk factor for Covid death. We are younger on average, however, and smoke much less than peer countries, both factors that might suggest a lower Covid death rate.

The distinction of policy versus demographics is at play in debates about the broader decline in life expectancy as well. Is America’s lower-than-our-peers life expectancy the result of something different about our population or about our policy?

New York Times columnist Paul Krugman, for example, recently argued that state-to-state variations in life expectancy were attributable to policy choices. States where people lived less long also tended to vote for the GOP, which in turn invested less in health- and life-promoting policies. As Krugman noted, there is “a strong correlation between how much a state’s life expectancy rose from 1990 to 2019 and its political lean, as measured by Joe Biden’s margin over Donald Trump in the 2020 election.”

This argument isn’t completely without merit. Medicaid expansion, for example, probably reduces risk of death for beneficiaries, so states that take it — which are more likely to lean Democratic — may see some marginal gain in life expectancy. But more generally, this argument misses the character of the deaths that were already driving the stagnation of life expectancy before Covid.

Specifically, America did so poorly compared with other rich countries because of rising death rates among the nonelderly and for nonmedical reasons. As my Manhattan Institute colleague Chris Pope, a health-care scholar, once put it: “Take out [obesity], car accidents and gun violence, [and] the difference in life expectancy disappears entirely.” Such deaths, it turns out, have a far more complicated relationship to policy than Krugman’s argument might lead one to believe.

As the Financial Times’ John Burn-Murdoch has shown, most of the United States’ underperformance in life expectancy does not show up among the elderly, who die at rates similar to those of their same-age peers in other developed countries. Rather, the biggest gaps are in the death rates of young and middle-aged adults. Younger deaths, Burn-Murdoch notes, have a larger impact on life expectancy than deaths among the elderly because the former represent more life-years lost.

Younger people, all else equal, are much less likely to die from medical problems — heart disease, cancer, etc. — and more likely to die from external causes. So it’s important to pay attention not just to the provision of health care but to the spectrum of risky behaviors.

The broad category of “injury deaths” is, after Covid, the leading cause of the recent decline in life expectancy, accounting for 16 percent of the drop in 2021, according to the CDC. “Unintentional injury” covers a broad swath of deaths, from car accidents to fires. But the biggest share in recent years has been drug overdoses, which in 2021 in the United States exceeded 100,000 for the first time ever. The surge in these deaths, along with a dramatic increase in homicides, is so large that U.S. life expectancy declined in 2020 even if Covid deaths are removed from the calculation, Burn-Murdoch finds.

These kinds of nonmedical deaths have, moreover, been holding down life expectancy since well before Covid. In a widely cited 2015 paper, Princeton economists Anne Case and Angus Deaton identified the particular prevalence of suicide, drug overdose, and alcohol deaths among middle-aged non-Hispanic whites as a driver of the decline in life expectancy among that group in particular. These “deaths of despair,” as they were soon labeled, have been linked to the declining fortunes of the white middle class generally.

“Deaths of despair” are, of course, only part of the life-expectancy puzzle. Homicides (and, to a lesser extent, car crashes) are concentrated among young people; that we have many more of each than our peer countries is a major reason we lose many more years of life than they do. The problem is particularly acute for men, among whom one 2022 paper suggests that “drug overdose, firearms, and car accidents” make up a large share of the “life expectancy shortfall.”

Does this mean that there is some unifying factor that makes young adulthood and middle age in the United States particularly bad? This is certainly the implication of the “deaths of despair” thesis, which many commentators have seized upon as evidence that collective spiritual malaise is behind our life-expectancy woes. There’s some evidence to back this supposition. A recent analysis found, for example, that the decline in religious attendance since the early 1990s explains a small but significant percentage of the increase in external-cause deaths. But there are important differences that should give us pause here. Is it really plausible to say, for example, that the same factor causes high black homicide rates and high white suicide rates but relatively low incidences of the converse in each group?

Rather, it is worth investigating why the different contributors to America’s injury-death problem vary from those of Europe. Even a quick overview suggests a diversity of problems, with no silver-bullet solution available.

Perhaps the most straightforward contributor to America’s life-expectancy gap is drug overdose. The U.S. drug-overdose-death rate has risen steadily since the turn of the century, driven by successive crises of opioid-painkiller addiction, heroin addiction, and finally the adulteration of the U.S. drug supply with uber-potent synthetic opioids such as fentanyl. Our peer nations have not seen the same surge: The European Monitoring Centre for Drugs and Drug Addiction estimates that roughly 6,000 people died of drug overdoses in Europe in 2020, compared with 96,000 in the United States.

Is this because Europe has better drug policy? Maybe. But it’s also because fentanyl mostly seems not (yet) to have penetrated European markets. Most European illicit opioids are sourced from Afghanistan, while most American illicit opioids are sourced from Mexico. While traffickers moving product from Mexico have made or are making the shift to fentanyl, the heroin market remains functional enough in Europe that the switch hasn’t happened there.

This kind of detail illustrates how small differences between the U.S. and elsewhere can have large impacts on metrics such as life expectancy. It also suggests that reducing the life-expectancy gap will require stopping the fentanyl wave — something three successive presidential administrations have thus far failed to do.

Other differences in injury-death tendency mirror longstanding differences between the United States and other developed countries. America has one of the highest homicide rates, and by some measures the highest motor-vehicle-death rate, in the OECD. These may represent differences in behavior (Americans like driving fast and shooting more than non-Americans do) or differences in what we own (Americans have many more cars and guns than residents of most other developed countries).

But U.S. injury deaths have nonetheless shifted dramatically in recent years. Both homicides and car crashes spiked suddenly and precipitously in the summer of 2020, after the onset of the Covid pandemic and the protesting and riots set off by the murder of George Floyd. That suggests that short-run changes in the institutions of social control — the shuttering of schools and jobs, or a reduction in proactive policing–can appreciably contribute to changes in life expectancy.

Risky behaviors, it should be noted, can lead to declining life expectancy through medical causes of death. Cardiovascular disease has long been the leading cause of death both in the United States and worldwide, but American rates of heart disease are notably higher than those in Europe. While there is a lively debate over what exactly explains this disparity, dietary choices — in particular, the consumption of lots of foods that are super-rich in salt, fat, and sugar — contribute to Americans’ higher rates of obesity and, thereby, their heart-disease risk. Getting people to change their diet, it turns out, is much harder than treating them for the consequences of their overeating.

These disparate issues — drug use, murderousness, dangerous driving, gluttony — are, we might speculate, joined by a common tendency towards risky behavior that differentiates America from peer nations. But even if Americans are more risk-prone than other people, such riskiness is harder for policy to remedy than its specific manifestations.

What policy can do — and ought to do, if we want to help bring U.S. life expectancy up — is address particular expressions of our proneness to taking risks. That will look different in different cases. The rising deadliness of opioids can be addressed in the short run with wider distribution of the overdose-reversing drug naloxone (although research suggests this practice has had limited impact on overdose death rates in toto, possibly because it only prolongs drug use and so does not reduce aggregate death risk). It is just as important, if not more so, to make a large investment in treatment capacity. By one estimate, nearly 8 million Americans suffer from opioid addiction, while only 1 million are currently receiving gold-standard medication-assisted treatment, as many public and private facilities still fail to provide it.

Investment in treatment should be paired with active prevention. Three successive presidential administrations have failed to adequately communicate to the public that the drug supply is now poisoned. The current White House has also allowed the border crisis to run rampant, making it easier for traffickers to smuggle drugs into the United States. This sort of public-health messaging could also help combat obesity, although the jury is still out on both the causes of and the solutions to America’s weight problem.

Homicide, particularly gun homicide, is a uniquely American problem but not an insoluble one. We now have a set of evidence-based interventions that have dramatically reduced gun violence. “Hot spots” policing, for example, drives down crime by concentrating cops in the places where most offending occurs; “focused deterrence” strategies work similarly, by targeting for services or prosecution the small subset of the population that commits most of the violence. We also could use more police officers; as I showed in a recent Manhattan Institute report, police-staffing-to-population ratios have declined steadily since the Great Recession. More cops, decades of research has shown, means fewer homicides.

The car-crash problem, too, could improve with more-stringent enforcement. Robust research shows that when jurisdictions reduce traffic enforcement, traffic deaths go up; it’s a good reason not to “de-police” traffic. Traffic deaths can also be deterred by speed cameras, which are both cost-effective and underused in many jurisdictions. And better public-transit systems — cleaner, safer, and more widely available — can serve as an effective substitute for cars.

These are, in some senses, Band-Aid solutions to what may be a deeper cultural problem. But Band-Aids are useful — they help us stop the bleeding. Americans live fast and die young; there is not much that policy can do to change that. But it can rein in the worst excesses of that tendency while still respecting Americans’ freedoms.