An American Disgrace

In 2015 Princeton economist Anne Case and her husband, Nobel laureate Angus Deaton, published an analysis of the unexpected rise in mortality among White Americans in midlife, attributing it to so-called deaths of despair: drug overdoses, suicide, and alcohol-related deaths such as from cirrhosis. Their 2020 book Deaths of Despair and the Future of Capitalism delves further into this striking anomaly.

Case and Deaton connect the rise of deaths of despair to the decline of the US working class. Middle-aged White Americans without a high school diploma are more than three times as likely as those with bachelor’s degrees to die a death of despair. This epidemic is not randomly distributed geographically: Its center is what might be termed greater Appalachia, which stretches from the Ohio River Valley and West Virginia across southern Illinois and the Ozarks into Oklahoma. But deaths of despair also afflict the Deep South and significant stretches of the Mountain West, including many of the nation’s Native American reservations. These areas all have in common a more than fifty-year record of economic stagnation.

To a sociologist, the authors’ maps and graphs raise some interesting questions. Why are rural areas and small towns in the heartland afflicted, but not upstate New York or the Great Lakes Rust Belt, the core of America’s deindustrialization? And why hasn’t the same epidemic of deaths of despair struck industrial Northern England or Germany’s Ruhr Valley, which also suffered long-term deindustrialization?

It is also puzzling why health status and life expectancy among midlife Black and Hispanic people, who have been afflicted by systemic racial bias in addition to the decline of the working class, improved during this fifteen-year period while those of midlife Whites declined. And if the working class is being systematically denied opportunities, what then explains the growing shortages in the skilled trades that do not require a bachelor’s degree—such as electricians, welders, and plumbers—despite their near-six-figure earning opportunities?

As Case and Deaton explore the causes of the decline of the US working class they find a target-rich environment: feckless trade policy, shortsighted corporate management that prioritized growth and stock buybacks over investment, “rent-seeking” corporate interests, outsourcing, the decline of labor unions, and a collapse of antitrust enforcement, to name only a few. However, the authors’ main villain is not any of these things but, rather, the US health system, which they characterize as a metastatic cancer on American society. In their view, this is not only due to its role in catalyzing the opioid crisis but also a result of the fact that rising health benefits costs have squeezed out wage gains, which the authors liken to extortion or to a tribute paid to a foreign power.

Some macroeconomists might wonder about this argument, which implies that health care is somehow not actually a part of the US economy. Money spent on health care does not leave the US, as does much of the money spent at Walmart or Best Buy, but stays in communities where—for better or worse—in many places the local hospital has become the largest employer. Growth in health spending during the past two decades has created many hundreds of thousands of working-class jobs and, through the multiplier effect, perhaps double that many jobs in education and other public services, as well as retail and the skilled trades.

It is also tiresome to hear the difference between US health spending and that of other much smaller and less diverse countries characterized as “waste.” If countries like Switzerland, Taiwan, or Sweden had beleaguered urban centers like the South Bronx in New York; Baltimore, Maryland; St. Louis, Missouri; or Detroit, Michigan, as well as a half-million homeless folks and an estimated 393 million guns in circulation, their per capita health spending might look a lot more like that of the US. Problems like these cannot legitimately be attributed to the health system.

The least satisfying part of the book is the final chapter, titled “What to Do.” Progressive policy advocates will be disappointed by the authors’ lack of interest in a radical redistribution of wealth, a universal basic income, or Medicare for All (which they characterize as “extremely expensive”), although they do call for universal health coverage in some form. Surprisingly, although they acknowledge that a decline in social capital has put lives at risk, they also give short shrift to measures that might strengthen the social safety net (which they characterize as “something of a Band-Aid”).

The epidemic of deaths of despair is, in the first instance, a public health crisis. Yet the authors do not advocate an increase in our woefully low level of investment in public health or in social and human services such as child care, mental health care, and substance abuse treatment, which directly address the disintegration of families, addiction, and other issues. Restoration of an American working class would also be materially aided by increased investment in public works, vocational education, or job training, which the authors also do not advocate.

As the authors note, the rise in deaths of despair is part of a larger sad story: the continuing decline in overall US life expectancy, resulting not only from deaths of despair but also from the end of a fifty-year decline in mortality from heart disease and stroke. As a result of the isolation and economic stress brought about by coronavirus disease 2019 (COVID-19), deaths of despair appear to be soaring—and not merely among Whites without college degrees. Add in the explosion of COVID-19 deaths, and by the end of 2020 the US will probably have had a five-year stretch of declining life expectancy and suffered many hundreds of millions of avoidable lost years of life.

For a wealthy country with a $21 trillion economy, this sustained decline in life expectancy is a disgrace and a catastrophic civic embarrassment. It is also a leading indicator of escalating political instability, polarization, and civil disorder. Rebuilding the American working class is an essential precondition to a more equitable and sustainable society that benefits Americans of all races and ethnic backgrounds. Case and Deaton have made a major contribution by drawing attention to deaths of despair in their well-written (and mercifully jargon-free) volume, if they have not given us a compelling plan of action to address it.

Originally published on Health Affairs.