Crimmins and Beltrán-Sánchez 2010 — Mortality and Morbidity Trends Is There Compression of Morbidity

Summary

Using National Health Interview Survey (NHIS) data for 1998 and 2006, Crimmins and Beltrán-Sánchez test whether morbidity has compressed alongside declining mortality in the US. Their answer depends critically on what "morbidity" means. If defined as activities of daily living (ADL) disability, prior studies show compression — but ADL disability is partly determined by the environment (wheelchairs, home modifications), not solely by innate biological functioning. When morbidity is defined as (1) prevalence of major chronic diseases (heart disease, stroke, cancer, diabetes) or (2) mobility functioning loss — a more innately physiological measure — the data show expansion, not compression. Both years lived with disease and years lived with mobility disability increased between 1998 and 2006, even as total life expectancy modestly rose. The paper directly confirms Gruenberg's (1977) "failure of success" — declining mortality from chronic disease keeps more sick people alive, raising disease prevalence — and challenges the optimistic compression narrative grounded in disability-focused metrics.

Key Claims

1. Disease prevalence increased 1998–2006 (Tables 1–2): Across nearly all age groups and both sexes, self-reported prevalence of coronary heart disease, myocardial infarction, stroke, cancer, and diabetes increased. Representative figures: coronary heart disease in men 80+ rose from $18.9\%$ to $26.2\%$; cancer in men 80+ from $15.6\%$ to $28.2\%$; diabetes in men 60–69 from $13.1\%$ to $19.2\%$. There is "no hint of a declining prevalence of disease."
2. Mobility functioning deteriorated (Table 3): The percentage unable to perform at least one of four mobility tasks (walk ¼ mile, walk up 10 steps, stand/sit 2 hours, stand/bend/kneel) increased markedly across all adult age groups: men 60–69 from $10.7\%$ to $14.6\%$; women 60–69 from $14.9\%$ to $21.5\%$; men 80+ from $27.7\%$ to $41.7\%$; women 80+ from $42.8\%$ to $51.3\%$. These increases in mobility difficulty have not been widely reported for the full adult age range.
3. Years lived with disease and disability increased (Table 4, Sullivan method): Linking NHIS prevalence data to official US life tables for 1998 and 2006, the Sullivan approach shows: at age 20, men gained $1.1$ years of total life expectancy but lost $1.2$ disease-free years (disease years rose from $10.0$ to $12.3$); women gained $0.7$ life expectancy (LE) years but lost $1.2$ disease-free years. At age 65, men's mobility-disabled years rose from $2.9$ to $4.5$ while able-to-function years fell from $13.1$ to $12.5$. The survival curve for disease-free life shifted inward (leftward), while total survival shifted outward — expansion of morbidity in the life-table sense.
4. Physiological status not improving: Beyond self-reported disease, measured biomarkers show no improving trend. Obesity increased markedly. C-reactive protein (CRP; inflammation) and glycated hemoglobin (glucose control) stayed roughly constant. Hypertension and high cholesterol declined only because of increased pharmaceutical treatment — diagnosis rates did not fall, only medical management of already-diagnosed conditions improved. The population is not becoming physiologically healthier; it is being better medicated.
5. Gruenberg confirmed — failure of success: The mechanism: treatment improvements reduce case fatality, so more people survive with active chronic disease → disease prevalence rises. For cardiovascular disease (CVD), incidence of first heart attack remained relatively stable 1960s–1990s while survival after an attack increased substantially. More survivors with CVD → higher CVD prevalence. This is precisely Gruenberg's (1977) prediction.
6. Reconciliation with Cutler et al. (2013): The compression finding from Medicare Current Beneficiary Survey (MCBS)-based studies (Cutler et al. 2013; Chernew et al. 2016; Stallard 2011) uses ADL / instrumental activities of daily living (IADL) disability measures, which are partly determined by the environment — electric wheelchairs, modified housing, assistive devices, changes in living arrangements. Crimmins and Beltrán-Sánchez deliberately chose mobility functioning (ability to walk, stand, etc.) as a measure more reflective of innate physical capacity than of environmental accommodation. Disability-free life expectancy (DFLE) based on ADLs can improve even as underlying physiological morbidity expands, if environmental adaptations increase. This is not a contradiction — it is a distinction between two different measures of two different things.
7. US women falling behind internationally: Mortality decline has slowed in recent years, especially for women. US life expectancy at birth is $78$ years (2006), falling behind many peer countries; women in particular are gaining less LE than men ($+0.7$ vs. $+1.1$ years at age 20, 1998–2006).
8. Three-hypothesis verdict: At the disease/mobility level, the evidence supports Gruenberg's expansion hypothesis. At the ADL disability level, the evidence is more consistent with Manton's dynamic equilibrium — diseases are progressing more slowly but are not being prevented, keeping the disability burden roughly stable even as disease burden grows.

Concepts Introduced or Extended

• Compression of Morbidity — primary challenge: disease and mobility functioning data show expansion, not compression; reconciles with Cutler et al. via the ADL vs. innate functioning distinction
• Morbidity-Mortality Distinction — provides the clearest empirical case for why declining mortality ≠ declining morbidity; Gruenberg mechanism confirmed

Entities Mentioned

• Eileen M. Crimmins
• Hiram Beltrán-Sánchez

Quotes

"Empirical findings do not support recent compression of morbidity when morbidity is defined as major disease and mobility functioning loss."

"There is no hint of a declining prevalence of disease over these eight years."

"When mortality declines because people survive longer with a disease rather than because people were less likely to get a disease, there will be an expansion of disease morbidity."

"Compression of morbidity may be as illusory as immortality."

My Take

This paper performs a valuable service: it shows that the compression story depends entirely on what you measure. If compression means "fewer years in an assisted-living facility or needing ADL help," the evidence supports it — but that improvement is at least partly environmental (better wheelchairs, better housing). If compression means "fewer years with active chronic disease in your body," the evidence clearly runs the other way. For policy purposes, the distinction matters enormously: a population with expanding disease but compressed ADL disability still needs more medical care (treatment, pharmaceuticals, specialist visits) even if it needs somewhat less personal care assistance. The Medicare cost implications are the opposite of what the optimistic compression narrative implies. The paper is also an unusually clear confirmation of the Gruenberg mechanism: the same medical progress that lets us celebrate declining mortality from heart disease populates the world with more heart disease survivors, raising overall disease prevalence.