What is an economy in service to life?
About a year ago, the husband-and-wife team of Anne Case and Angus Deaton published some alarming numbers: Unlike citizens of just about every other wealthy, advanced country, and most other American subgroups, middle-aged white Americans have not seen reductions in their mortality between 1999 and 2013, and had by many metrics been getting sicker and sicker.
It was a shocking finding that garnered numerous headlines, the sort of thing that just isn’t supposed to happen in a rich, developed country, let alone the richest developed country. And it lent credence to what some public-health researchers and other societal observers had been saying for a while: The United States likes to view itself as a singular force of prosperity and opportunity, but by many public-health metrics — including infant mortality and preventable deaths and a variety of others — it doesn’t look like a top-tier world power.
Yesterday, the National Center for Health Statistics released a report that should further puncture the myth of American superiority when it comes to health outcomes — and which should set alarm bells loudly clanging for anyone worried about how the country treats its most vulnerable residents. The report found that life expectancy in the United States dropped from 78.9 in 2014 to 78.8 in 2015, the first drop in life expectancy since 1993. (For men, the decline was from 76.5 to 76.3; for women, from 81.3 to 81.2.)
Whatever’s going on, a lot of it has to do with opioid abuse — the government believes that those who illicitly take prescription opioids are far more likely than other people to try injecting heroin — and the opioid crisis has hit whites harder than blacks, partly because doctors appear to be less likely to recognize and treat pain in black patients. These new stats reflect the massive amounts of despair strongly hinted at by Case and Deaton’s work — after all, two of the areas that saw mortality increases between 2014 and 2015 were suicide and “unintentional injuries,” a category that includes overdoses.
So when those two findings are combined, it’s hard to deny that something truly dire has ensnared a large chunk of the country. In a country as big, complicated, and diverse as the United States, that “something” is actually a great many things, but I would argue they can be broadly summed up by one idea: what I call the “one-bad-break test.”
Counter a majorly bad break. That bad break can be anything — an injury, the sudden need to take in and care for an ailing relative, an unexpected layoff — and the effects of a single bad break vary tremendously depending on who you are, where you live, and what resources you have access to. (Rich people hit bad breaks too, of course, but they generally have far more capacity to handle them than everyone else, so I’m restricting this discussion to those who lack those resources.)
In societies that function well, there are various safety nets in place to prevent a bad break from leading to a tailspin for particularly vulnerable victims. Compared to many other rich nations, the U.S. is not such a society — all too often, when vulnerable Americans encounter a bad break, there’s nothing underneath them to stop their slide. Instead, devastation follows, sometimes in the form of bankruptcy and addiction and death.
For a particularly painful example of the one-bad-break test in action, take Inara Verzemnieks’s wrenching New York Times story about “Life in Obamacare’s Dead Zone” — that is, the Republican-controlled states that turned down the Obamacare-trigger Medicaid expansion after the Supreme Court ruled they had the right to do so in 2012 (19 states did so in total, and the illness and death toll of this missed opportunity to cover vulnerable populations is staggering to think about).
Verzemnieks focuses on Kansas, which was denied expanded Medicaid by its hard-right governor, Sam Brownback, who has also sought to cut back social safety-net programs in various ways. Here’s what happened to one of her subjects, Janet Foy:
At 56, Foy was broke, jobless and living with her older sister in public housing in Kansas City, Mo. … Recently, she had been told by a manager at a Victoria’s Secret that there was no need to leave her résumé. But not too long ago, she wanted me to know, she was pulling in $1,000 a week at a Merle Norman makeup store, helping other people look and feel their best. But then she took in her brother to try to help him overcome an addiction, and soon she was pulled under financially as he spiraled out of control. She would show up to work too overwhelmed and exhausted to make any sales, and had to dip into her savings until that was gone. She begged to borrow against her next paycheck but eventually lost her apartment and moved into a friend’s spare room…
“I tried to get Obamacare,” Foy recalls. “I called the number, and when the woman told me what it would cost me, I just about dropped the phone. She told me I’d needed to make at least $12,000 a year for there to be any help to make it something I might be able to afford. Which still doesn’t make a lot of sense to me, even now, that having no money meant I got no help when I really needed it.”
Foy’s bad break was the direct result of her brother’s bad break: addiction. This story would have turned out differently if her brother had had options for treating his addiction other than moving in with a sister who was in no position to offer him the help he needed. He lacked any such options, so he moved in with Janet instead, and shortly thereafter her life, too, was spiraling out of control. Sometimes, if you have a bad break and there isn’t a net to catch you, you slide into a compassionate loved one, triggering a bad break of their own.
This is happening over and over and over throughout the country. Of course, it wouldn’t be right to say things are getting worse everywhere, that every part of the U.S. fails the bad-break test as badly as Kansas does on health issues. Obamacare wasn’t perfect, for example, but it did bring insurance to 20 million low-income people who lacked it previously — it saved some lives where it was allowed to. There are a lot of places where people are better able to weather medical bad breaks now than they were before the law passed.
So if we have an inflection point signaling that things really are getting worse, rather than at least chugging along stably, part of the mystery is why. A partial answer is that while Obamacare passed in 2009, the Great Recession hit in December of 2007. But layered atop both events is the nation’s grim long-term economic reality for working people, which is that for a huge chunk of the country wages have been stagnant and economic opportunity constricting for a very long time. There are intimate connections between economic opportunity and psychological well-being, and between psychological well-being and potentially disastrous outcomes like addiction and suicide. Another finding just released yesterday? As The Wall Street Journal puts it, “Barely half of 30-year-olds earn more than their parents did at a similar age, a research team found, an enormous decline from the early 1970s when the incomes of nearly all offspring outpaced their parents. Even rapid economic growth won’t do much to reverse the trend.” And inequality is growing, so the indicator is making many others worse right now. For example, The Spirit Level: Why More Equal Societies Almost Always Do Better, highlights the “pernicious effects that inequality has on societies: eroding trust, increasing anxiety and illness, (and) encouraging excessive consumption”. It shows that for each of eleven different health and social problems: physical health, mental health, drug abuse, education, imprisonment, obesity, social mobility, trust and community life, violence, teenage pregnancies, and child well-being, outcomes are significantly worse in more unequal rich countries. A collection of Powerpoint slides regarding The Spirit Level can be downloaded here.
We don’t know how bad the United States’ burgeoning mortality crisis is going to get. Russia provides a disturbing worst-case scenario. “Sometime in 1993, after several trips to Russia, I noticed something bizarre and disturbing: people kept dying,” wrote Masha Gessen in New York Review of Books in 2014. “I was used to losing friends to AIDS in the United States, but this was different. People in Russia were dying suddenly and violently, and their own friends and colleagues did not find these deaths shocking.” She went on to explain that “In the seventeen years between 1992 and 2009, the Russian population declined by almost seven million people, or nearly 5 percent — a rate of loss unheard of in Europe since World War II. Moreover, much of this appears to be caused by rising mortality,” with alcohol a prime culprit. This is what happens when the insides of a developed country begin to rot.
The United States isn’t Russia. Probably. But wherever this trend goes, what we’re seeing is the end result of decades of slow-burn economic decline and decay, with no end in sight. You can only make it hard for people to work and pay rent and buy necessities and live so long, you can only have them living right on the brink of bad-break ruin for so long, before there will be serious consequences. And we’re seeing those serious consequences in every new set of shocking mortality statistics.