The dark side of American exceptionalism: shorter lives

The Centers for Disease Control and Prevention (CDC) recently updated its estimates of how the COVID-19 pandemic affected life expectancy in the United States, and the news is not good. We were already aware that 2020, the first year of the pandemic, was catastrophic in the United States, causing more deaths than in any other country. The decline in U.S. life expectancy in 2020 was the largest the nation has experienced since World War II. The CDC now reports that U.S. life expectancy declined further in 2021. Taken together, the two years produced a 2.7-year decrease in life expectancy, the largest decline in a century.

The decrease in U.S. life expectancy in 2021 was avoidable. We know this because no other high-income country experienced such losses. In fact, many countries saw their life expectancy increase. Throughout the COVID-19 pandemic, Americans have died at much higher rates than people in other rich countries. According to one study of the United States and 19 peer countries, U.S. life expectancy decreased by 1.9 years in 2020, compared to an average loss of 0.6 years in the other countries.

In 2021, when COVID-19 vaccines became available, most countries recovered their losses, and life expectancy increased an average of 0.3 years, but U.S. life expectancy continued to plummet.  

The poor performance of the United States in 2021 could have multiple explanations. Some countries performed better in distributing and administering COVID-19 vaccines and in maintaining pandemic control measures, such as wearing masks. Their populations were often more compliant, whereas many Americans resisted such measures. Many governors overtly blocked pandemic control measures.

Americans lack universal access to the health care system, which was overwhelmed by surges, affecting not only the treatment of COVID-19 but also other medical problems. According to the CDC, only 74 percent of the decline in U.S. life expectancy in 2020 was due to COVID-19. Deaths from chronic illnesses, like heart disease and diabetes, also increased during the pandemic. Drug overdose deaths broke records.

It’s tempting to view this calamity as a one-time anomaly and to assume, now that the pandemic seems to be waning, that U.S. health outcomes will return to normal. Eventually, U.S. life expectancy will return to pre-pandemic levels, but returning to “normal” leaves the United States in a precarious place.

The tragedy of Americans dying at higher rates than people in peer countries is hardly a new phenomenon. It began decades ago. Although life expectancy has been increasing over the past century, the increase began to slow in the United States in the 1980s. U.S. life expectancy fell below the average for high-income countries in the 1990s, plateaued in 2010 and then began to decline — while it continued to climb in other countries.

According to one study, the gap in the life expectancy between the United States and 16 peer countries grew from 1.9 years in 2010 to 3.1 years in 2018. The U.S. death toll during the COVID-19 pandemic further widened the gap. According to another study, by 2021 the gap between the U.S. and 19 peer countries had widened to 5.3 years.

The U.S. health disadvantage is not limited to life expectancy. Death rates from many diseases and injuries are higher in the United States, as is the prevalence of obesity, chronic diseases, and disability. Racial and ethnic health disparities are unacceptably large, but the poor U.S. health standing is not being driven by marginalized groups. White Americans die at higher rates than white people in other countries, as do rich Americans. Unhealthy eating, obesity, the opioid epidemic and guns all contribute to the U.S. health disadvantage, but no single cause explains the breadth of the U.S. health disadvantage.

The root cause is likely systemic. We must look upstream to explain the deteriorating health of Americans. Potential contributors include not only deficiencies in the U.S. health care system but also socioeconomic conditions, especially those facing the American middle class and low-income communities, as well as unhealthy conditions in the physical and social environment.

Perhaps the most fundamental contributors to the U.S. health disadvantage are policy and politics. In contrast to policies in other countries with better health outcomes, the United States provides weaker support for education, health care, affordable housing and the economic wellbeing of families — all of which profoundly influence health. U.S. employers are less likely to offer livable wages, paid leave and other benefits that workers enjoy in healthier countries. U.S. regulators are less likely to restrict industries that can threaten public health or to limit the marketing of dangerous products, from opioids to assault weapons. And U.S. society is less committed than more inclusive societies to confronting systemic barriers to opportunity based on race, ethnicity and other biases.

Federalism and the devolution of power to the states are also contributors. The gap in life expectancy across the 50 states has been widening since the 1990s. Growing political polarization, particularly in the last decade, has led states with progressive and conservative orientations to take very different approaches to policies that affect health and safety, from Medicaid expansion to tobacco control.

We saw this vividly during the COVID-19 pandemic, when state policy responses divided sharply across party lines. Republican governors demonstrated their partisan bona fides by questioning scientific evidence and resisting mandates.

While other countries can implement a national plan to address health issues, pandemics included — federalism forces the United States to mount 50 response plans.

Americans experience fragmented health care, labor policies, taxes and welfare support — and now the polarization is extending to abortion policy, gun control and even what students learn in the classroom.

Solving the U.S. health disadvantage can seem overwhelming, especially given the deeply entrenched root causes. But other countries have demonstrated what is possible. The better health and longer lifespans enjoyed by large democracies across the globe, from Australia and Canada to dozens of countries in Europe and East Asia, provide evidence that the poor health of Americans is a matter of choice. Policymakers and voters can choose to alter policies, but that requires political will. It requires decisions about how to prioritize health over competing personal, political and corporate interests.

As with most challenges, the first step is to acknowledge the problem, which has yet to occur. The U.S. health disadvantage is not common knowledge. Many Americans live with misconceptions and are unaware that their children are destined to live shorter lives. In 10 U.S. states, life expectancy is lower than in countries like Bosnia, Cuba and Iran. Palestinians have longer life expectancy than people in West Virginia and Mississippi.

The COVID-19 pandemic was a wakeup call that exposed a dark side of American exceptionalism that puts lives at risk. Americans deserve to know the facts and make informed choices when they are facing policy and electoral decisions that could affect their health and survival.  

Steven H. Woolf, who has authored more than 200 publications, is a professor at Virginia Commonwealth University School of Medicine, the director emeritus of its Center on Society and Health, and a member of the National Academy of Medicine. Follow Woolf on Twitter: @shwoolf.