This essay, on lessons from America about the relationship between inequality and mortality rates, was my Observer column this week. It was published in the Observer, 19 September 2021, under the headline “America’s mortality gap should sound a blaring alarm across the Atlantic”.
Americans die younger than Europeans. That is true whether they are rich or poor, black or white, toddlers or OAPs. The latest confirmation of the mortality gap across the Atlantic comes from a newly published study that tracked death rates in the United States and Europe over the past 30 years. The paper sets out to compare the changing gap in mortality rates of black and white Americans over time, using Europe as an external benchmark. (The paper combines data from six countries – England, France, Germany, the Netherlands, Norway and Spain.) In so doing, it provides lessons, not just for America but for European nations too, not least Britain.
In 1990, the gap between the life expectancies of black and white Americans was huge, while rich white Americans died at around the same rate as Europeans. Today, the mortality gap between the average American and the average European is greater than that found between black and white Americans. The racial gap in America has narrowed even as that with Europe has widened. In 2017, the average American lived for 78.6 years, the average French citizen four years longer, the average Briton almost three years more.
The social and economic differences between the US and Europe are myriad and there can be no single explanation for these changes. A number of issues, however, stand out. The first is the role of inequality.
Social inequality is a key political issue in Europe and is at the heart of the “levelling- up” debate in Britain. The pandemic has exposed much of the underlying social and health inequalities. Last week, Public Health England revealed that not only has life expectancy fallen to its lowest level since 2011 but that inequality in life expectancy between the most and least deprived areas of England is at its highest.
In comparison with America, however, European nations can appear highly egalitarian. The US has among the worst levels of poverty and inequality within the OECD. And that inequality has a major impact on life expectancy.
It should not surprise us that, from infancy to old age, Americans are more likely to die in the poorest areas than in richer ones. More telling, though, is that inequality has a greater impact in the US than it does in Europe. If you plot mortality against poverty, the slope of the curve is much steeper in America.
Rich Americans outlive poor Americans but, strikingly, rich Europeans outlive rich Americans. Inequality is a particular burden on the poor and it is those at the bottom of the ladder whose fate should concern us. However, the fact that, when it comes to life expectancy, the rich in America don’t always benefit from greater inequality should also give us pause for thought. The reasons for this are manifold. It suggests, however, that deep inequality is a curse on the poor but not necessarily a blessing for the rich.
If the relationship between inequality and life expectancy is relatively clear, the relationship between race, class and mortality is not so straightforward. Black Americans have a higher mortality rate than whites and have always done so. There are major racial disparities both in access to healthcare and in healthcare outcomes.
At the same time, the mortality gap between black and white Americans has narrowed considerably, decreasing by almost half over the past 30 years, from seven to 3.6 years. This is partly for reasons of policy, such as US Medicare expansion, and partly because of better medical intervention, including improvements in treating cardiovascular disease and cancer.
The racial gap has also narrowed, however, for a bleaker reason – the reduction in the lifespan of poor whites, especially those without higher education. The economists Anne Case and Angus Deaton have shown that, when it comes to mortality statistics, black people with a university degree have almost caught up with university-educated whites, while white people without a degree have fallen almost to the level of blacks who lack university education. “Education,” they observe, “is now a sharper differentiator of expected years of life between 25 and 75 than is race, a reversal of the situation in 1990”. That education divide is a major issue on this side of the Atlantic, too.
Case and Deaton have tracked the surge in recent years of what they call “deaths of despair” – deaths from alcoholism, drug addiction and suicides – among working-class whites. The latest data suggest that the biggest single contributor to the closing of the racial gap in mortality is the disproportionate rise in deaths of despair among poor white people.
What, then, are the lessons in all this for Europe? The first is the devastating impact of inequality, not just on the poorest but on society as a whole. European nations may be less unequal than the US but the American experience is still a warning. Income inequality is worse in the UK than in most European countries. A government that talks of “levelling up” while willing to cut the universal credit £20 uplift is not serious about the issue.
The second lesson is that what matters for health outcomes is not simply the amount of money spent, though that is important, but also what a health service is designed to do. One of the most extraordinary features of the US system is that no country spends more of its national income on health – 16.8% of GDP in 2018 compared with 11.1% for France and 10.2% for the UK – and yet has such poor outcomes. The money delivers not better healthcare but bulging bank balances for profit-seeking corporations. This, again, should be a warning at a time when there is greater pressure and, in some quarters, a strong desire, to increase the role of private corporations within the NHS.
The US also reveals the complex inter-relationship between race and class in shaping health outcomes. Questions of race and class play out differently in Britain than they do in America, and there are no direct comparisons. However, there is often a common blindness, ignoring the complexity of race and class and using the one to deny the reality of the other.
The US experience does not translate directly to Britain. Nevertheless, the issues at the heart of the debacle that is American healthcare – social inequality, the scourge of the profit motive in the health industry, the disparities of race and class – are central to debates in Britain, too. We have been warned.