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<i>Steven H. Woolf is a professor of family medicine and population health at Virginia Commonwealth University. Laudan Aron is a senior fellow in the Health Policy Center at the Urban Institute in D.C.</i>

Last fall, when federal statistics <a href="https://www.cdc.gov/nchs/products/databriefs/db456.htm" target=_blank>showed life expectancy had fallen</a> for Americans in 2021 for a second year in a row, it was clear that the devastating covid-19 pandemic was the immediate cause. The <a href="https://www.washingtonpost.com/coronavirus/" target="_blank" class="contextual_link">coronavirus</a> took the lives of more than 1 million Americans. Life expectancy fell by more than two years — and by twice as much among Hispanic, Black and Native Americans — setting the country back by two decades and producing the most abrupt decline in life expectancy <a href="https://www.bmj.com/content/373/bmj.n1343" target=_blank>since World War II.</a>

But plotting life expectancy in the United States against that of other wealthy countries reveals three dark insights: Our life spans lag behind those of our peers; our life expectancy was already more or less flat, not growing; and most<b> </b>other countries bounced back from covid-19 in the second year of the pandemic, while we went into further decline.

Ten years ago, long before the world was hit by covid-19, we served as the chair and study director for a <a href="https://nap.nationalacademies.org/catalog/13497/us-health-in-international-perspective-shorter-lives-poorer-health" target=_blank>landmark report</a> that warned about the “U.S. health disadvantage,” a gap in the health and survival of Americans relative to residents of other high-income countries. Released by a committee convened by the National Research Council and Institute of Medicine, the report showed the United States had the lowest life expectancy among peer countries, and higher morbidity and mortality rates for dozens of causes. The disparity had been growing since the 1950s, by some measures, and was pervasive — affecting both sexes, young and old, rich and poor, and Americans of all races and ethnicities.

The committee examined five areas of relative deficiency that are likely contributing to the U.S. health disadvantage: (1) unhealthy behaviors, such as our diets and use of firearms;<b> </b>(2) inadequate health care and public health systems; (3) poor socioeconomic conditions; (4) unhealthy and unsafe environments; and (5) deficient public policies. The last category especially exerts a powerful influence on the other domains — and helps explain why other advanced democracies are outperforming the United States on almost every measure of health and well-being.

In the years before the covid-19 pandemic, as life expectancy continued to increase in other countries, <a href="https://jamanetwork.com/journals/jama/article-abstract/2756187" target="_blank">U.S. life expectancy plateaued</a> and then decreased for three consecutive years. Researchers identified a key reason: <a href="https://jamanetwork.com/journals/jama/article-abstract/2756187" target="_blank">U.S. mortality in midlife (ages 25 to 64) was increasing</a>, a phenomenon not occurring in peer countries. This, too, became the subject of a <a href="https://nap.nationalacademies.org/catalog/25976/high-and-rising-mortality-rates-among-working-age-adults" target="_blank">landmark report</a>, which cited drug overdoses, alcohol use, suicides and cardiometabolic diseases (e.g., obesity, diabetes, hypertensive heart disease) as leading causes. Enduring systemic racism and health inequities means that the U.S. health disadvantage is particularly acute among <a href="https://www.nejm.org/doi/10.1056/NEJMms2025396" target="_blank">people of color</a>, especially Native and Black Americans, whose life expectancy is far lower than that of White Americans.

With the arrival of the covid-19 pandemic in 2020, the long-standing U.S. health disadvantage only worsened. In 2020 and 2021, U.S. deaths were the highest of any country and <a href="https://jamanetwork.com/journals/jama/fullarticle/2798990" target="_blank">among the highest per capita</a>. All five domains we identified in the “Shorter Lives, Poorer Health” report contributed to the death toll: Health behaviors (e.g., resistance to masking and vaccinations) facilitated viral transmission and limited vaccine uptake; health-care and public health services were unprepared and rapidly overwhelmed; socioeconomic conditions further deteriorated, especially for poorer Americans, as the economy imploded; aspects of the physical environment heightened viral exposure; and the policy response to the pandemic was deeply flawed and highly politicized. Once again, people of color paid the highest price, with Native, Hispanic/Latino and Black Americans experiencing devastating losses in life expectancy, despite an interesting twist: In 2021, declines were <a href="https://www.cdc.gov/nchs/products/databriefs/db456.htm" target="_blank">higher among White Americans</a> than in most other groups, <a href="https://www.nytimes.com/2022/06/09/briefing/covid-race-deaths-america.html" target="_blank">perhaps because of greater resistance to vaccination</a> and masking in conservative communities.

Many of us long for a return to pre-pandemic conditions, but the reality is that health conditions in our country then were already dire.<b> </b><a href="https://academic.oup.com/pnasnexus/advance-article/doi/10.1093/pnasnexus/pgad173/7185600" target=_blank>One study estimated that</a>, between 1980 and 2019,<b> </b>the U.S. mortality disparity with peer countries resulted in an estimated 11 million excess deaths. A return to “normal” that ignores the U.S. health disadvantage — and its root causes — is certain to claim more lives and further weaken the country.

We know from other countries how to achieve higher life expectancy, since many have enjoyed better results than the United States for decades — and at far lower cost. Better food and nutrition policies, for example, can reduce the prevalence of disease. Common-sense gun-control measures could reduce the injury, death toll and psychological impact of threats from firearms. Better access to health care and behavioral health services would improve our physical and mental condition in the face of rising rates of depression, drug overdoses and suicides. The same goes for access to reproductive, sexual and maternity care. A living wage, a stronger safety net, more progressive taxation and more affordable care for families and children would go far in increasing our economic security — and thus our survival.

Unfortunately, in the United States, these proposals to improve health outcomes are seen by some as radical, if not un-American. A whole host of industries, furthermore, now depends on keeping things as they are: the health-care and insurance industries; manufacturers of drugs, unhealthy foods and beverages, and firearms; and companies responsible for carbon emissions and toxic pollutants.

Unless the country changes course, and soon, the structural conditions responsible for the shorter lives and poorer health of Americans will continue to claim lives and weaken the country. It is not just the old who pay the price. <a href="https://nap.nationalacademies.org/catalog/25976/high-and-rising-mortality-rates-among-working-age-adults" target="_blank">Young and middle-aged Americans</a> are now more likely to die in the prime of their lives, devastating families and communities and taking a hard toll on our economic productivity. Even more disturbing, in a change never recorded in the past century, the probability that <a href="https://jamanetwork.com/journals/jama/article-abstract/2802602" target="_blank">children and adolescents</a> will live to age 20 is now <i>decreasing</i>. If our country failed to hear the warning we sounded a decade ago, we can at least respond to the pandemic by starting to make the changes that could let more of our children see adulthood — and give the rest of us more years on Earth.

Steven H. Woolf

Laudan Aron

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American life expectancy is dropping — and it's not all covid's fault

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Life expectancy in the U.S. compared to other wealthy countries.

Chart showing that life expectancy in the United States declined significantly during the pandemic in comparison to other rich countries

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Opinion American life expectancy is dropping — and it’s not all covid’s fault