COVID-19 pandemic may be winding down but Americans are still sick and dying

It’s no accident that the United States experienced more COVID-19 deaths in 2020 than any other country and one of the world’s highest per capita death rates. We can — and should — blame the nation’s bungled response, but a “U.S. health disadvantage” predates and extends far beyond COVID-19. Unless we understand and address the root causes of what’s ailing us, Americans will continue to experience greater illness and early deaths for years to come.

In 2013, we led a cross-national study for the National Research Council and Institute of Medicine. Our report, “U.S. Health in International Perspective: Shorter Lives, Poorer Health,” documented how Americans — even the most advantaged ones — are less healthy and dying earlier compared to people in other rich nations. 

Evidence of a large and growing U.S. health disadvantage extends back to the 1980s and persists to this day. U.S. life expectancy dropped below the OECD average in 1998 and has since fallen further behind. By 2010, the life expectancy of Americans stopped improving altogether, plateauing until 2014 and then decreasing for three consecutive years — while it continued to climb in peer nations. By 2018, the U.S.  ranked 46th in life expectancy worldwide, according to the World Bank.

With the arrival of COVID-19 in late 2019, its global spread in 2020, and its devastating effects on human mortality, life expectancy was bound to fall in many nations. But the extent of the decline in the U.S. has been shocking. Our recently published study (co-authored with Ryan Masters) shows that in 2020, U.S. life expectancy plunged 1.9 years — a drop not seen since World War II. This decline was 8.5 times greater than the average experienced by 16 other high-income nations, further widening our cross-national life expectancy gap.

In American communities of color, the drop was even more alarming. Compared to a decrease of 1.4 years among white Americans, life expectancy among Black and Hispanic Americans fell 3.3 years and 3.9 years, respectively. Years of progress in narrowing the Black-white mortality gap were erased, and the Hispanic population — which has historically enjoyed longer life expectancy than whites — saw that advantage almost entirely erased. Unfortunately, data limitations prevented us from estimating changes for other important groups, including Native Americans, whose health and survival rates are among the worst in the nation.

So how can our country prevent these excess deaths? Certainly not by spending more on health care, given that we already outspend every other country (by far) and still die prematurely. Health care, while essential, accounts for no more than 20 percent of health outcomes. The solutions extend beyond medicine. Epidemiologists, public health experts and social scientists have long understood that our living conditions — the so-called social determinants of health — determine whether we live long, healthy, productive lives. Our risks for disease and injury are strongly influenced by our education, income, housing, neighborhoods and workplaces.

Living conditions that preserve health and promote wellbeing are simply lacking for too many Americans. Against a backdrop of growing income and wealth inequality, many families go without essential resources and basic protections, including education and training, good jobs, steady income, safe and affordable housing, and community services to help families raise children and support youth, older adults, and people with disabilities.  

A new National Academies report found that death rates are increasing among Americans in the prime of life — at ages 25 to 64 when many are working, raising children and caring for dependents. This means that, in addition to the many other challenges they face, American children and youth are now more likely to lose a parent and need bereavement care.

The implications of these trends for families, communities, employers and the nation’s economy and national security are enormous — but the solutions are no mystery. Curbing the decline in the health of Americans requires adequate and equitable investments in childcare, education, jobs that pay a living wage and affordable housing. We must invest not only in people but also in communities. Health depends on conditions outside our door, such as clean air, green space, strong social networks and services for individuals and families with social, economic, and health needs. What distinguishes other countries with better health outcomes are sensible and equitable investments in people and places.

Historically, such investments have been resisted by powerful interest groups and privileged classes seeking to protect private capital, profits and power. Our nation lives with the results. We spend more on mass incarceration than childcare. Unlike other countries, we allow unhealthy foods, cigarettes, guns and opioids to be marketed with limited regulatory constraints. Americans have made a deadly bargain to accept shorter lives, for themselves and their children, to protect these arrangements. 

And racial inequities have haunted this nation for generations. Let’s be clear: It’s racism — not race — that drives racial health disparities, such as higher death rates from COVID-19 and dozens of other diseases. The steep declines in the survival of Black and brown Americans that our study reports are not explained by skin color but instead reflect the systemic racism that permeates almost every aspect of life in this country, including health. People discomfited by the notion of systemic racism often blame its victims for lacking “personal responsibility,” but racial disparities are less about the choices people make than the choices society gives them.

The end of the pandemic will bring relief to many Americans, but it will not end America’s health and survival crisis. The good news is that solving the U.S. health disadvantage does not require a new slate of policy proposals but a greater focus on those currently under debate. Policies to create jobs, expand infrastructure, invest in human capital and address systemic racism will do more to address the U.S. health disadvantage than anything doctors or hospitals might do. The reverse is also true: failure to act — not building an economy for the 21st century centered on people and justice — will condemn our children to shorter lives and poorer health and diminish the future of our entire country.

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. 

Laudan Y. Aron is a senior fellow in the Urban Institute’s Health Policy Center where she co-directs Urban’s cross-center initiative on the social determinants of health and the national coordinating center of the Robert Wood Johnson Foundation’s Policies for Action (P4A) research program. Follow Aron on Twitter: @laudyaron.

Woolf and Aron are the editors of “U.S. Health in International Perspective: Shorter Lives, Poorer Health.”