On Friday last week, the Medicare trustees released their latest report on the financial health of the system, and it contained some unexpected good news: Spending is falling short of forecasts and the hospital insurance trust fund will not be depleted as quickly as was predicted. But a key reason for that financial improvement was startling: Covid has killed a significant number of Medicare beneficiaries. And the victims were mostly elderly people already suffering from serious and costly health problems. “As a result, the surviving population spent less than average.”
Now Covid has killed many people around the world so wasn’t that an act of God? Not quite. You see, the United States experienced a greater drop in life expectancy when Covid hit than any other rich country. What’s more, while life expectancy recovered in many countries in 2021, it continued to decline in the United States.
And the dismal numbers of the Covid in the United States are part of a larger story. I don’t know how many Americans realize that over the past four decades, our life expectancy has fallen even further relative to other advanced countries, even countries whose economies have been underperforming by conventional standards. Italy, for example, has experienced a generation of economic stagnation, with virtually no real GDP per capita growth since 2000, while in the United States it has grown by 29%. However, Italians can expect to live about five years longer than Americans.
What explains the American style of death? It seems that a large part of the answer is political. An important note is that the problem of premature death is not evenly distributed across the country. Life expectancy is very unequal in all regions of the United States. Things aren’t much worse in the big coastal cities than in Europe, but they are in the south and inland east. And wasn’t it always like that? No. Geographical disparities in healthcare have increased in recent decades. According to the Mortality Database, Ohio had a slightly higher life expectancy than New York in 1990. Since then, life expectancy in New York has increased rapidly, almost approaching that of other rich countries, while that in Ohio has barely increased and is now four years below New York’s.
Numerous studies have been carried out on the causes of this increase in disparities. A 2021 article published in the Journal of Economic Perspectives discussed several possible reasons, including the increasing concentration of highly educated Americans (whose health status tends to be better than the less educated) in already highly educated states and the Widening disparities in per capita income between states. The authors found that these factors can only explain a small part of the growing mortality gap.
Instead, they argued, the best explanation lies in politics: “The most promising explanation for our results is the effort by high-income states to adopt specific policies and behaviors to improve health since at least the early 1990s.” 1990. Im Over time, these efforts have reduced mortality more rapidly in high-income countries than in low-income countries, widening spatial disparities in health status.”
That seems correct. But have high-income countries taken action to improve health because they were rich and could afford it? Or was it because high-income states in 21st-century America tend to be politically progressive, and it is politics that makes the difference and not the money itself?
In fact, there is a strong correlation between a state’s increase in life expectancy from 1990 to 2019 and its political leanings, as measured by Joe Biden’s lead over Donald Trump in the 2020 election, a slightly stronger correlation by my calculations, than the correlation with income.
There are several reasons to believe that America’s death ride is far more political than economic. One is the comparison with European countries, whose health trends have been much better even when their economies, like Italy, have performed poorly.
Another reason is the fact that some of America’s poorest states, with the lowest life expectancy, continue to refuse to expand Medicaid even though the federal government would pay most of the cost (and that failure to expand is destroying many hospitals). This suggests that they are not improving their health because they don’t want to, not because they can’t afford it.
Finally, since the outbreak of Covid, people in Republican-leaning counties are much less likely to be vaccinated and much more likely to die than people in Democrat-leaning counties, even though the vaccines are free.
All of this seems relevant to explaining our current culture war era, with many Republican politicians extolling rural and Republican values while denigrating those of the coastal elite. Florida Gov. Ron DeSantis, for example, says that although he grew up near Tampa Bay, culturally he is a product of western Pennsylvania and northeastern Ohio. So it’s worth noting that the culture these politicians want to adopt across America seems to have a problem with one of society’s most important functions: keeping people from dying early.
Paul Krugman is a Nobel laureate in economics.
© New York Times, 2023.
Translation of news clips.
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