What a striking new study of death in America misses

From the article:

For the past decade or so, Princeton economists Angus Deaton and Anne Case have been promoting a particular story about death in America. Less-educated Americans, particularly those without college degrees, have seen their life expectancy outcomes diverge from those of more-educated Americans. Much of this divide can be explained through a category that Deaton and Case call “deaths of despair”: deaths from suicide, opioid overdoses, and liver cirrhosis and other alcohol-related causes. The deaths are concentrated in non-Hispanic whites. This phenomenon indicates something is deeply wrong with the way American society treats its most marginalized citizens, including lower-class whites.

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Among both Black and white middle-aged Americans, death rates were falling among the most-educated groups pre-Covid. For those in the middle of the education spectrum, death rates have been falling for Black Americans and stagnant for whites; Black death rates still exceed those for whites but the gap is narrowing. For the least-educated, which roughly means high school dropouts, death rates have been rising starkly for white men and women, and rising slightly for Black women, while staying roughly constant for Black men. (Novosad, Rafkin, and Asher also look at death rates in other age ranges, but note that death is rare enough before you get to your 50s that it doesn’t affect life expectancies in the US as much.)

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But they also found that the gap varies substantially based on geography. While it’s true that rich people in America live significantly longer than poor people, that’s much less true in New York City. It’s not true in California as a whole. Heavily urban areas with high education levels see a modest relationship between income and death rates. More-rural, less-educated areas, by contrast, see a very strong relationship between the two.

Areas with smaller mortality gaps tend to be places, the researchers find, with lower rates of smoking and higher rates of exercise, which makes sense when you consider that the variation in death rates between cities is driven not by factors like car crashes or suicide but conditions like heart disease and cancer, which are themselves driven in part by lifestyle conditions. Local unemployment rates and other indicators of the health of the local labor market did not seem to be associated with longevity, nor did income inequality. These aren’t firmly causal findings, to be clear, but they might be suggestive of potential causes to investigate.

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Researchers Neil Mehta, Leah Abrams, and Mikko Myrskylä argued in a 2020 paper that the dominant reason life expectancy has stalled in the US is not that drug deaths have grown but that a previously large, robust decline in deaths from cardiovascular disease has stalled out. The death rate fell by half between 1970 and 2002, but given that it’s still common enough to cause 695,000 deaths in 2021, a stalled decline could be a very big deal.

Though explanations for this stagnation are still unclear, the authors present a couple of options: rising levels of obesity (especially at younger ages, compounding negative health effects over more time), or, counterintuitively, the US’s early success at discouraging smoking (which could explain why its cardiovascular death rates aren’t falling as fast as those in Europe, which gave up smoking later on). They find that the stagnation from cardiovascular disease is broad-based geographically in the US, unlike the rising death rates among low-income Americans studied by Chetty et al.

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Economists Novosad, Rafkin, and Asher make similar points in their paper on the fate of the least-educated Americans over time. As of their data endpoint in 2018, “deaths of despair” — that is, from drug overdoses, suicides, and alcoholism — “account for a large share of mortality increases for young whites, but a very small share of rising mortality among older whites and very little of the divergent mortality rates of black,” they note. “Further, deaths of despair have increased more uniformly across the education distribution than deaths from other causes.” In other words, while the overall rise in mortality is concentrated among the least-educated, the opioid, suicide, and alcohol-related rise is not.

Here's a blog article where about it:

The "Deaths of Despair" narrative is wrong (Slow Boring)

Over the past few years, Anne Case and Angus Deaton have unleashed upon the world a powerful meme that seems to link together America’s troublingly bad life expectancy outcomes with a number of salient social and political trends like the unexpected rise of Donald Trump.

Their “deaths of despair” narrative linking declining life expectancy to populist-right politics and to profound social and economic decay has proven to be extremely powerful. But their analysis suffers from fundamental statistical flaws that critics have been pointing out for years and that Case and Deaton just keep blustering through as if the objections don’t matter. Beyond that, they are operating within the confines of a construct — “despair” — that has little evidentiary basis. The rise in deaths of despair turns out to overwhelmingly be a rise in opioid overdoses. This increase is not happening in European countries that have not only been buffeted by the same broad economic trends as the United States, but are also seeing the rise of right-populist backlash politics.

The obvious explanation is that the US and Europe have very different laws governing pharmaceutical marketing.

But this links to Washington Post piece that claims state-level differences in public health are important:

How red-state politics are shaving years off American lives

Many of those early deaths can be traced to decisions made years ago by local and state lawmakers over whether to implement cigarette taxes, invest in public health or tighten seat-belt regulations, among other policies, an examination by The Washington Post found. States’ politics — and their resulting policies — are shaving years off American lives.

Ashtabula [Ohio]'s problems stand out compared with two nearby counties — Erie, Pa., and Chautauqua, N.Y. All three communities, which ring picturesque Lake Erie and are a short drive from each other, have struggled economically in recent decades as industrial jobs withered — conditions that contribute toward rising midlife mortality, research shows. None is a success story when it comes to health. But Ashtabula residents are much more likely to die young, especially from smoking, diabetes-related complications or motor vehicle accidents, than people living in its sister counties in Pennsylvania and New York, states that have adopted more stringent public health measures.

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[Ohio] House Republicans in April blocked DeWine’s proposal to allow police officers to pull over cars when they see drivers or their passengers not wearing seat belts. In contrast, New York in 1984 became the first state to enact such a law, followed by 34 others.

State data shows that seat-belt use has fallen in Ohio to its lowest level in 18 years — with fewer than 81 percent of residents regularly buckling up, compared with 92 percent of Americans as a whole — worrying officials who say the decline is preventable, inexplicable and contributes to greater risk. A Post analysis shows that Ashtabula residents are twice as likely to die of motor vehicle accidents as are people in Chautauqua.

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Today, cigarettes in Ohio are notably cheaper than the same packs sold just over the state line: A Post reporter in June purchased Marlboro Gold — formerly called Marlboro Lights, among the most popular cigarettes — for $9.74 in Ashtabula, $10.35 in Erie and $13 in Chautauqua, the only place where the reporter was required to prove she was at least 21 years old.

At the time, cigarette taxes were $1.60 per pack in Ohio, $2.60 in Pennsylvania and $4.35 in New York. In September, New York, which already boasts one of the highest state cigarette taxes in the nation, raised its tax another $1 per pack.

Not surprisingly, experts said, Ohio’s smoking rate exceeds that of nearby states with stricter tobacco measures. Almost 21 percent of adults in Ohio smoked in 2019, compared with 17 percent of Pennsylvanians and nearly 13 percent of New Yorkers, according to the CDC.