Summary
Woolf and Schoomaker analyze U.S. life expectancy and all-cause and cause-specific mortality trends from 1959 through 2017 using joinpoint regression. They document that life expectancy (LE) rose nearly continuously through 2014 but then declined for three consecutive years (2015–2017) — the first sustained decline since the 1918 influenza pandemic. The reversal was driven by rising midlife (ages 25–64) mortality beginning around 2010, caused by drug overdoses, alcohol, and suicides, plus a larger-than-recognized burden of organ system diseases. By 2014, all major racial and ethnic groups were in retrogression, and excess deaths were concentrated geographically in the Ohio Valley and upper New England.
Key Claims
- U.S. LE peaked at 78.9 years in 2014, then fell to 78.6 in 2017 — three consecutive years of decline not seen since World War I (WWI)/1918 flu. LE growth by joinpoint segment: annual percent change (APC) +0.06 (1959–1969), +0.48 (1969–1979), +0.19 (1979–2003), +0.27 (2003–2011), ≈0.00 (2011–2016 plateau), then decline.
- All-cause midlife mortality (ages 25–64) rose from 328.5 to 348.2/100,000 (+6.0%) 2010–2017. The 25–34 age group saw the worst relative increase: 102.9 → 132.8/100,000 (+29.0%).
- Cause-specific increases began as early as the 1990s for some states but were masked until ~2010 by concurrent declines in ischemic heart disease, cancer, and HIV.
- Drug overdose mortality among adults 25–64 rose +386.5% from 1999 to 2017 (6.7 → 32.5/100,000). Three waves: (1) prescription opioid overprescription beginning with OxyContin in 1996; (2) transition to heroin among opioid-addicted patients; (3) fentanyl analogues post-2013 driving a large secondary surge.
- Organ system diseases account for substantial excess deaths beyond the drugs/alcohol/suicide cluster: hypertension mortality +78.9%, obesity/metabolic mortality +114.0%. Drug overdoses account for only ~15% of the U.S.–peer-country LE gap.
- By 2014, all major racial groups were in retrogression: White Non-Hispanic (WNH) ~2010, Hispanic ~2011, Black Non-Hispanic (BNH) ~2014, American Indian/Alaska Native (AI/AN) continuously increasing. BNH overdose mortality rose +171.6% 2010–2017 — the largest relative increase of any racial group, driven by fentanyl exposure after 2011.
- Women experienced larger relative increases in most specific causes: overdoses +485.8% (women) vs. +350.6% (men); alcoholic liver disease 3.4× larger relative increase; suicide 1.5× larger. Absolute rates remain higher for men.
- 33,307 estimated excess U.S. midlife deaths 2010–2017. Ohio, Pennsylvania, Indiana, and Kentucky (10.8% of population) accounted for 32.8% of all excess deaths. New England showed the largest relative increases: New Hampshire +23.3%, Maine +20.7%.
- State LE gaps widened to 7.0 years by 2017 (Hawaii highest, Mississippi lowest); divergence began in the 1980s with substantial jumps in the 1990s coinciding with neoliberal devolution of federal social policy to states.
- Adjacent state pairs diverged sharply: Colorado/Kansas gap grew from 0.3 to 1.5 years; Alabama/Georgia from 0.1 to 2.3 years. State policy choices (minimum wage, Earned Income Tax Credit (EITC), Medicaid expansion, gun laws) are candidate explanations.
Concepts Introduced or Extended
- Deaths of Despair — extends Case-Deaton findings to all racial groups; adds three-wave opioid quantification and organ system disease burden
- Period Mortality — provides the 60-year LE joinpoint picture; documents the 2011 plateau and 2014–2017 three-year decline; state LE divergence to 7.0 years
- Income-Mortality Gradient — geographic concentration of excess deaths in Ohio Valley; state policy divergence hypothesis
Entities Mentioned
- Steven H. Woolf — lead author; Virginia Commonwealth University (VCU) Center on Society and Health
- Heidi Schoomaker — co-author; VCU / Eastern Virginia Medical School
- Anne Case — cited for deaths of despair framework
- Angus Deaton — cited for deaths of despair framework
Quotes
"US life expectancy increased for most of the past 60 years, but the rate of increase slowed over time and life expectancy decreased after 2014."
"The largest relative increases in midlife mortality occurred among adults with less education and in rural areas or other settings with evidence of economic distress or diminished social capital."
"Two recent studies estimated that drug overdoses accounted for 15% or less of the gap in life expectancy between the United States and other high-income countries in 2013 and 2014, respectively."
My Take
Woolf and Schoomaker's most important contributions are (1) the 60-year LE joinpoint picture, which makes the long-run divergence from peer countries visible in a single dataset, and (2) the racial universalization finding — by 2014, all groups were in retrogression, contradicting any reading of deaths of despair as exclusively a WNH phenomenon. The organ system disease finding (hypertension, diabetes, chronic lower respiratory diseases (CLRD)) is underappreciated: it shows the crisis is broader than opioids and has roots in long-run lifestyle and healthcare access factors. The state policy divergence hypothesis is suggestive but not causal; adjacent-state comparisons control for regional factors but not for historical migration patterns, industrial composition, or pre-existing health stocks. The paper is primarily descriptive — it maps the crisis in unprecedented geographic detail without adjudicating between competing explanations.