HIGH AND RISING MORTALITY RATES
AMONG WORKING-AGE ADULTS
Kathleen Mullan Harris, Malay K. Majmundar, and Tara Becker, Editors
Committee on Rising Midlife Mortality Rates
and Socioeconomic Disparities
Committee on Population
Committee on National Statistics
Division of Behavioral and Social Sciences and Education
A Consensus Study Report of
THE NATIONAL ACADEMIES PRESS
Washington, DC
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This activity was supported by contracts between the National Academy of Sciences and the National Institute on Aging of the National Institutes of Health (HHSN263201800029I/HHSN26300036), and the Robert Wood Johnson Foundation (#75873). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-0-309-68473-6
International Standard Book Number-10: 0-309-68473-0
Digital Object Identifier: https://doi.org/10.17226/25976
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. (2021). High and Rising Mortality Rates Among Working-Age Adults. Washington, DC: The National Academies Press. https://doi.org/10.17226/25976.
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COMMITTEE ON RISING MIDLIFE MORTALITY RATES AND SOCIOECONOMIC DISPARITIES
KATHLEEN MULLAN HARRIS (Chair), Department of Sociology and Carolina Population Center, University of North Carolina at Chapel Hill
MICHAEL E. CHERNEW, Department of Health Care Policy, Harvard Medical School
DAVID M. CUTLER, Department of Economics, Harvard University
ANA V. DIEZ ROUX, Dornsife School of Public Health, Drexel University IRMA T. ELO, Department of Sociology, Population Studies Center, University of Pennsylvania DARRELL J. GASKIN, Bloomberg School of Public Health, Johns Hopkins University
ROBERT A. HUMMER, Department of Sociology and Carolina Population Center, University of North Carolina at Chapel Hill
RYAN K. MASTERS, Department of Sociology, University of Colorado Population Center, Institute of Behavioral Science, University of Colorado Boulder
SHANNON M. MONNAT, Department of Sociology and Lerner Center for Public Health Promotion, Syracuse University
BHRAMAR MUKHERJEE, School of Public Health, University of Michigan
ROBERT B. WALLACE, College of Public Health, University of Iowa
STEVEN H. WOOLF, Department of Family Medicine and Population Health, Virginia Commonwealth University School of Medicine
Staff
MALAY K. MAJMUNDAR, Study Director
TARA BECKER, Program Officer
ELLIE GRIMES, Senior Program Assistant
MARY GHITELMAN, Senior Program Assistant
COMMITTEE ON POPULATION
KATHLEEN MULLAN HARRIS (Chair), Department of Sociology and Carolina Population Center, University of North Carolina at Chapel Hill
EMILY M. AGREE, Department of Sociology and Department of Population, Family, and Reproductive Health, John Hopkins University
DEBORAH BALK, Marxe School of Public and International Affairs and CUNY Institute for Demographic Research, Baruch College of the City University of New York
NANCY BIRDSALL, Center for Global Development (President Emeritus), Washington, DC
ANN K. BLANC, Social and Behavioral Science Research, Population Council, New York, NY
COURTNEY C. COILE, Department of Economics, Wellesley College
DANA A. GLEI, Research Consultant, Georgetown University
ROBERT A. HUMMER, Department of Sociology and Carolina Population Center, University of North Carolina at Chapel Hill
HEDWIG (HEDY) LEE, Department of Sociology, Washington University in St. Louis
JENNIFER J. MANLY, Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Department of Neurology, Columbia University
ANNE R. PEBLEY, Department of Community Health Sciences, Department of Sociology, California Center for Population Research, Bixby Center on Population and Reproductive Health, University of California, Los Angeles
ISABEL V. SAWHILL, The Brookings Institution, Washington, DC
DAVID T. TAKEUCHI, School of Social Work, University of Washington
REBECA WONG, Health Disparities, University of Texas Medical Branch at Galveston
MALAY K. MAJMUNDAR, Director
COMMITTEE ON NATIONAL STATISTICS
ROBERT M. GROVES (Chair), Office of the Provost, Georgetown University
LAWRENCE D. BOBO, Department of Sociology, Harvard University
ANNE C. CASE, Woodrow Wilson School of Public and International Affairs (Emerita), Princeton University
MICK P. COUPER, Institute for Social Research, University of Michigan
JANET M. CURRIE, Woodrow Wilson School of Public and International Affairs, Princeton University
DIANA FARRELL, JPMorgan Chase Institute, Washington, DC
ROBERT GOERGE, Chapin Hall at The University of Chicago
ERICA L. GROSHEN, The ILR School, Cornell University
HILARY HOYNES, Goldman School of Public Policy, University of California, Berkeley
DANIEL KIFER, The Pennsylvania State University
SHARON LOHR, School of Mathematical and Statistical Sciences (Emerita), Arizona State University
JEROME P. REITER, Duke University
JUDITH A. SELTZER, University of California, Los Angeles
C. MATTHEW SNIPP, School of the Humanities and Sciences, Stanford University
ELIZABETH A. STUART, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health
JEANNETTE WING, Data Science Institute, Columbia University
BRIAN A. HARRIS-KOJETIN, Director
CONSTANCE F. CITRO, Senior Scholar
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Preface and Acknowledgments
The year 2017 marked the third year in a row that life expectancy in the United States had fallen, the longest sustained decline in life expectancy in a century (since the influenza pandemic of 1918–1919). Already ranked relatively low in life expectancy (26th) in 2015 among the 35 countries that make up the Organisation for Economic Co-operation and Development, the United States would lose even more ground in its global position in national health and well-being. Research had already uncovered some troubling mortality trends and disparities before 2015 and was focused on the search for explanations. Early findings pointed to rising mortality rates among middle-age White adults, although the trends soon revealed that younger adults were also at risk, as were other racial/ethnic groups, such that premature mortality in the working ages of 25–64 was becoming more common in the United States than in prior years and in comparison with its international peers.
In this context, in 2018 the National Institute on Aging and the Robert Wood Johnson Foundation requested that the National Academies of Sciences, Engineering, and Medicine undertake a study on high and rising rates of midlife mortality and concomitant widening social differentials. In response to that request, the National Academies appointed the Committee on Rising Midlife Mortality Rates and Socioeconomic Disparities (under the standing Committee on Population) to carry out the task. Twelve scholars representing a broad array of disciplines—including demography, economics, epidemiology, medicine, public health, sociology,
and biostatistics—were included on the committee, which met six times in person over a 2-year period.
This report presents a considerable body of information. The committee decided to conduct its own analysis of the trends in working-age mortality by age, sex, race and ethnicity, and geography using the most up-to-date data to establish its members’ collective understanding of the main drivers of the rising trend and disparities in working-age mortality in the United States. Findings from the committee’s analysis are presented in Part I of this report. The committee then conducted a comprehensive review of the research on rising working-age mortality to evaluate evidence on what had changed in American society to bring about the change in mortality rates and how the patterns of change differed for population subgroups. Findings on the explanations for the rise in working-age mortality are presented in Part II of the report. The committee’s work was arduous because the amount of data was massive; the problem was complex; and the unique trends by age, sex, race and ethnicity, and geography multiplied that complexity. In this report, the committee attempts to communicate these complexities while at the same time identifying the main drivers of high and rising working-age mortality based on current research and their implications for the future. The committee was also very deliberate and conscientious in its recommendations for further data collection, research, and policy.
This study would not have been possible without the contributions of many people. Special thanks go to the members of the study committee, who dedicated extensive time, thought, and energy to this task. Committee members conducted extensive analysis in generating Part I of the report, often enlisting their students and research assistants to help. Julene Cooney (Syracuse University), Nick Graetz (University of Pennsylvania), Jermaine Heath (Harvard Medical School), Fitore Hyseni (Syracuse University), Jeron Impreso (Harvard Medical School), Sammer Marzouk (Harvard University), Harrison Mintz (Harvard Medical School), Rohan Shah (Harvard Medical School), and Yue Sun (Syracuse University) assisted the committee in analyzing mortality trends and assessing selected research literatures. Thanks are also due to Anna Mueller (Indiana University Bloomington), who provided valuable guidance to the committee on suicide deaths.
The committee received useful information and insights from presentations by outside experts at open sessions of committee meetings. We thank Erika Blacksher (University of Washington), Anne Case (Princeton University), Andrew J. Cherlin (Johns Hopkins University), Kathleen Frydl, Carol Graham (Brookings Institution), Christopher Ruhm (University of Virginia), and Jennifer Silva (Indiana University Bloomington).
Several staff members of the National Academies made significant contributions to the report. Ellie Grimes and Mary Ghitelman made sure
that the committee meetings ran smoothly, assisted in preparing the manuscript, and otherwise provided key administrative and logistical support; Kirsten Sampson Snyder managed the report review process; Yvonne Wise managed the report production process; and Brian Harris-Kojetin, director of the Committee on National Statistics, provided valuable guidance and oversight. We also thank Rona Briere for skillful editing.
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report: Andrew J. Cherlin, Department of Sociology, Johns Hopkins University; Sandro Galea, School of Public Health, Boston University; Mark D. Hayward, Population Research Center, University of Texas at Austin; Ichiro Kawachi, Department of Social and Behavioral Sciences, Harvard School of Public Health; Peter Muennig, Mailman School of Public Health, Columbia University; Samuel H. Preston, Population Studies Center, University of Pennsylvania; Albert L. Siu, Mount Sinai Medical Center; and Frank A. Sloan, Economics Department and Center for Health Policy, Law and Management, Duke University.
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by Bradford Gray, Urban Institute, and Eileen Crimmins, University of Southern California. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
Kathleen Mullan Harris, Chair
Malay K. Majmundar, Study Director
Tara Becker, Program Officer
Committee on Rising Midlife Mortality
Rates and Socioeconomic Disparities
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Contents
Individual and Societal Implications of Rising Mortality Among Working-Age Adults
Impact of the COVID-19 Pandemic on Working-Age Mortality
Study Methods and Limitations of the Evidence Base
2 U.S. Mortality in an International Context
Life Expectancy at Birth in the United States Versus Peer Countries
The U.S. Mortality Disadvantage by Age
International Differences in Life Expectancy Decomposed by Age
U.S. Mortality Relative to International Peers by Age
International Trends in Working-Age Mortality
U.S. Mortality by Cause of Death in International Perspective
ANNEX 2-1 International Trends Methodology
Source of International Trend Comparison Data
Data for the Sixteen Peer Countries
Arriaga Age Decomposition of Differences in Life Expectancy
Ratio of Age-Specific Mortality in the United States to That in the Peer Countries
The Probability of Death Between Ages 25 and 64
3 U.S. Trends in All-Cause Mortality Among Working-Age Adults
Trends in All-Cause Mortality by Sex and Age
Trends in All-Cause Mortality by Sex, Age, and Race and Ethnicity
Trends in Mortality by Socioeconomic Status
Geographic Differences in Mortality Trends
Trends in All-Cause Mortality by Metropolitan Area Type
Trends in All-Cause Mortality Across U.S. Regions and States
Trends in All-Cause Mortality Across U.S. Counties
Summary of Geographic Trends in Mortality
ANNEX 3-1 Mortality Trends Among U.S. Asians/Pacific Islanders and American Indians/Alaska Natives
Mortality Trends Among U.S. Asians and Pacific Islanders
Mortality Trends Among American Indians/Alaska Natives
Changes in High/Low Mortality Counties by Metropolitan Status
4 U.S. Trends in Cause-Specific Mortality Among Working-Age Adults
Trends in U.S. Working-Age Mortality by Cause of Death
Working-Age Non-Hispanic Black Adults
Disparities in Cause-Specific Mortality by Socioeconomic Status
Cause-Specific Mortality Trends by Metropolitan Status
Temporal Patterns in Cause-Specific Mortality Trends
ANNEX 4-1 Trends in Cause-Specific Mortality Among American Indians and Alaska Natives
5 U.S. Mortality Data: Data Quality, Methodology, and Recommendations
The U.S. National Vital Statistics System (NVSS) and the Construction of Mortality Rates
Limitations and Quality of Mortality Data
Limitations of Death Certificate Data and Use of Linked Mortality Data
Estimation of Mortality Rates in This Report
6 A Framework for Developing Explanations of Working-Age Mortality Trends
A Conceptual Framework for U.S. Working-Age Mortality
Macro-Level Upstream Factors in Working-Age Mortality
Considerations in Developing Explanations for Trends in Working-Age Mortality
Single Versus Multiple Explanations
Interactions or Synergies and Dynamic Relations Among Factors
Socioeconomic Inequality at All Levels
Differences Across Social Groups
Attention to Period and Cohort Effects
ANNEX 6-1 Period- and Cohort-Based Examination of Trends in U.S. Working-Age Mortality
Drug-Related Death Rates Among U.S. Black and White Men
Death Rates from Cardiometabolic Diseases Among U.S. White Men and Women
Death Rates from Alcohol Use Among U.S. Black and White Men and Women
7 Opioids, Other Drugs, and Alcohol
Trends in Mortality Due to Drug Poisoning and Alcohol
Summary of Trends in Mortality from Drugs and Alcohol
Explanations for the Rise in Working-Age Mortality from Drug Poisoning and Alcohol-Induced Causes
Implications for Research and Policy
Explanations for the Rise in Suicide Mortality
Implications for Research and Policy
Trends in Cardiometabolic Mortality
Endocrine, Nutritional, and Metabolic Diseases
Ischemic Heart Disease and Other Circulatory System Diseases
Explanations for the Trends in Cardiometabolic Mortality
Diminishing Returns of Medical Advances
Social, Economic, and Cultural Change
Implications for Research and Policy
10 The Relationship Between Economic Factors and Mortality
Association Between Economic Deprivation and Worse, and Rising, Mortality
Job Loss and Deaths of Despair
Trade/Import Competition and Mortality
Lack of a Strong Association Between Economic Fluctuations and Increased Mortality
11 Implications for Policy and Research
A Framework for the Categorization of Policy and Research Implications
Medical Science and Health Care Access and Delivery
Implications for Policy and Research
Implications for Policy and Research
Implications for Research and Policy
Lessons from the COVID-19 Pandemic
A Mortality Data Analyses: Review Process and Detailed Mortality Rate Tables
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Boxes, Figures, and Tables
BOXES
3-1 Trends in Mortality Among Asians and Pacific Islanders
3-2 Trends in Mortality Among American Indians and Alaska Natives
4-1 Trends in Cause-Specific Mortality Among Asians and Pacific Islanders (APIs)
4-2 Trends in Cause-Specific Mortality Among American Indians and Alaska Natives (AI/ANs)
FIGURES
2-1 Female and male life expectancy at birth in the United States and peer countries, 1950–2016
3-1 All-cause mortality rates by sex and 10-year age group, 1990–2017
4-4 Summary of Findings: Cause-Specific Mortality Among Working-Age Adults, 1990–2017
5-1 Assignment to 20 Cause-of-Death Categories
A6-1 Simulated Data Used in Annex Figures 6-1 to 6-6
11-1 Recommendations and Policy Conclusions
A-1 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic White Males Ages 25–44
A-2 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic Black Males Ages 25–44
A-3 Cause-Specific Mortality Rates (deaths/100,000): Hispanic Males Ages 25–44
A-4 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic White Females Ages 25–44
A-5 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic Black Females Ages 25–44
A-6 Cause-Specific Mortality Rates (deaths/100,000): Hispanic Females Ages 25–44
A-7 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic White Males Ages 45–54
A-8 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic Black Males Ages 45–54
A-9 Cause-Specific Mortality Rates (deaths/100,000): Hispanic Males Ages 45–54
A-10 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic White Females Ages 45–54
A-11 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic Black Females Ages 45–54
A-12 Cause-Specific Mortality Rates (deaths/100,000): Hispanic Females Ages 45–54
A-13 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic White Males Ages 55–64
A-14 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic Black Males Ages 55–64
A-15 Cause-Specific Mortality Rates (deaths/100,000): Hispanic Males Ages 55–64
A-16 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic White Females Ages 55–64
A-17 Cause-Specific Mortality Rates (deaths/100,000): Non-Hispanic Black Females Ages 55–64
A-18 Cause-Specific Mortality Rates (deaths/100,000): Hispanic Females Ages 55–64