increasing disparities in life expectancy

The NY Times just featured an article on the growing longevity disparity associated with income disparity (see http://www.nytimes.com/2016/02/13/health/disparity-in-life-spans-of-the-rich-and-the-poor-is-growing.html?emc=edit_th_20160213&nl=todaysheadlines&nlid=67866768 ), based on a report released by the Brookings Institute. see http://www.brookings.edu/research/reports2/2016/02/life-expectancy-gaps-promise-social-security#recent/ for a brief review of the report and http://www.brookings.edu/~/media/Research/Files/Reports/2016/01/life-expectancy-gaps-promise-social-security/BosworthBurtlessZhang_retirementinequalitylongevity_012815.pdf?la=en for the full 174 page report. main points:

--in the early 1970s, a 60-year old man in the top half of the earnings' ladder had life expectancy 1.2 years longer than one in the bottom half. in 2001, the gap was 5.8 years

--the Brookings report found that, comparing life expectancy between those in the top vs bottom 10% of earners (data are based on life expectancy at age 50 yo):

        --for men born in 1920, there was a 6-year difference; for men born in 1950, there was a 14-year difference.

        --for women born in 1920, there was a 4.7-year difference; for women born in 1950, there was a 13-year difference.

        --in a separate analysis, the Brookings report noted that life expectancies in those born in 1920 vs 1940, comparing the bottom to the top 10% of mid-career income distribution were:

                    --those in the bottom 10%: 80.4 years for women (no change); 74.3 increasing to 76.0 in men

                    --those in the top 10%: 84.1 years for women increasing to 90.5!!!; 79.3 increasing to 88.0!!! in men

--why are the differences so great and getting dramatically greater? hard to pinpoint exactly (and studies looked at different endpoints), but some differences:

        --cigarette smoking: decreased more in wealthy, could explain 1/5 to 1/3 in the gap between men with college degrees vs those with high school degrees; 1/4 of the gap in women

        --obesity: rates of obesity between rich and poor narrowed from 1990-2010, when 37% of poorer and 31% of richer adults were obese

        ​--prescription drug abuse has disproportionately increased mortality in poor communities

        --of note, limited access to care was not found to play much of a role (they reference an article by Steven Schroeder: N Engl J Med 2007; 357:1221), stating that only 10% of the disparity has to do with medical care [note that this statement was not footnoted, so i cannot check on the reliability of it].

--one side note is that wealthier people live longer and therefore collect more years of social security payments as well as longer utilization of Medicare services, disproportionate financial benefits for the wealthy, 

--these longevity disparities are not necessarily reflected in other countries: in Canada, men in the poorest urban areas had the largest declines in heart disease mortality from 1971-1996, and the overall gaps in longevity decreased over this time period. cancer survival rates in low-income residents in Toronto were significantly better than in Detroit, yet there was no difference for middle- and high-income residents (see Am J Public Health. 1997; 87(7): 1156)

--the Brookings report also commented on the fact that higher wage earners are retiring later (they attribute this to the fact that their jobs are higher-paying which is especially important since most jobs now do not come with a pension or guaranteed income after retirement, the jobs usually are more rewarding, and social security benefits were pushed up a year to age 66). lower age workers tend to retire earlier with only 13.8% getting social security at age 66.  they do not comment explicitly (so, i will): the increase in age for social security from 65 to 66 is much less significant for an office worker than someone doing hard manual labor, where they likely have chronic musculoskeletal pains/problems, and the possibility of extending the work-life another year may be painful and undoable. but getting social security early adds to income inequality, since the payout is much less/yr.

----------------------------------------------------------------------------------------

in a (somewhat) related recent article (see life expectancy injury JAMA2016 in dropbox, or JAMA. 2016;315(6):609), researchers looked at life expectancy from birth (vs from age 50 in above), as a means to evaluate mortality in younger people, where both the major causes of death are different from those >50yo (more from injury/trauma/drugs), and the impact is greater (more years of expected life are lost). they focused on motor vehicle traffic crashes (MVT), firearm injuries, and drug poisonings (eg overdoses). the table below shows the contribution of these injuries/traumas to the life expectancy of men and women, also comparing the US rates to those of a variety of other countries. from this data, overall death from injury accounted for 48% of the longevity gap in men (1.02 years of the 2.15 years of the all-cause difference), with firearm-related injuries accounting for 21% of the overall gap, drug poisonings 14% and MVT crashes 13%. for women injuries/traumas accounted for 19% of the gap, with 4% from firearms, 9% from drug poisonings, and 6% from MVT crashes. Overall, the impact of these injuries in the US is far greater than in a combination of other countries. the other table (not shown) details the specifics per country, showing for example that although Portugal is the only country in the list with an overall death rate higher than the US, their death rate from injuries is much lower than the US, so that Portugal still has a life-expectancy 0.5 years longer than the US (ie, because there are fewer injuries/overdoses which disproportionately affect younger people). a caveat here is that they are relying on death coding across different countries.

a few comments:

--there are very real reasons why lower wage earners have lower life expectancy, as noted in many prior blogs. obesity is a major problem but is exacerbated by lack of access to good, affordable foods. doing exercise can be an obstacle when people live in unsafe neighborhoods. manual laborers tend to have more disabilities (i'm not sure i have met any construction workers, masons, plumbers, etc who do not have significant musculoskeletal problems by the age of 40). air quality tends to be worse in poor neighborhoods. general stress tends to be higher.

--i do have concerns about writing off access to medical care as not much of a factor in the longevity discrepancy.  it is clear that inadequate access to care is an issue for the poor only. and there are huge discrepancies within that group. if you happen to live in Massachusetts, access is generally quite good. if you live in rural Mississippi or Louisiana, access is terrible/can be effectively nonexistent. 

--though i do think that, overall, the predominant issue is that, though we spend lots of $$ in the US on health care, unlike other countries (including many with far fewer resources than in the US), we spend the vast majority on "medical care" (where in other countries a higher % of health care money goes to making sure people have good food, housing, jobs, and an array of social services --see The American Health Care Paradox, by E Bradley and L Taylor, published in 2013, noting that:

    --we spend almost twice as much money as the next most expensive health care system; yet we have really terrible comparable health outcomes, eg ranking 26th in life expectancy

    ​--countries with far better health outcomes spend much more money on social services to enhance well-being, such as "investments in housing, nutrition, education, the environment and unemployment support" (which dovetails with the way the World Health Organization defines health as "a state of complete physical, mental and social well-being"); we spend dramatically less than other countries on these social services

    ​--and, if you add up the strictly medical as well as the social costs invested by different countries for health care, the US is somewhere in the middle of the pack in terms of per capita spending

--so,  i think this is why longevity of wealthier people in the US (who need fewer social services) is pretty much as good at those living in the highest ranking countries (Japan, Iceland), but poorer people have the life expectancy of those in Poland and the Czech republic

--there are several reports finding a temporal relationship between divergences in income inequality and longevity inequality over the past 40 years.

--and the JAMA study reinforces the overall importance of traumatic or drug-related deaths overall (which is largely missed in the Brookings analysis), and especially in the young