High and Rising Mortality Rates Among Working-Age Adults (2021) / Chapter Skim
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11 Implications for Policy and Research
11 Implications for Policy and Research
Pages 377-418
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From page 377... ...
As a result, causal evidence in this area is limited, and controlled experiments are difficult, if not infeasible. Moreover, as also discussed throughout the report, the key hypothesized influences on working-age mortality patterns and trends are numerous and operate concomitantly at multiple levels.
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From page 378... ...
The chapter concludes with a brief discussion of lessons learned from the COVID-19 pandemic. For ease of reference, Table 11-1 at the end of the chapter lists all of the recommendations and policy conclusions presented in the report, grouped thematically in the categories of opioids, other drugs, and alcohol; suicide; cardiometabolic diseases; cross-cutting themes; and data needs.
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From page 379... ...
Public health strategies to promote healthy behaviors include communication and education campaigns, strat egies that create healthier environments (e.g., building walkable neighborhoods, subsidizing access to healthy foods, limiting por tion sizes, restricting advertising of unhealthy products) , and laws and regulations (e.g., limits on the density of tobacco outlets, taxa tion of unhealthy products, restrictions on sales to minors, required use of seatbelts, limits on access to guns)
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From page 380... ...
Social and economic policies tend to operate on broad scales (e.g., national, state) and to have their greatest influence on upstream influences on health, including the distal drivers of working-age mortality and disparities therein (House, 2015; Schoeni et al., 2008)
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From page 381... ...
. Among the greatest successes in recent decades was the introduction of protease inhibitors and highly active anti-retroviral treatment for treatment of HIV infection, which led to pronounced reductions in working-age mortality due to HIV/AIDS starting in the mid-1990s, as documented in Chapter 3.
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From page 382... ...
Among its provisions, the Affordable Care Act of 2010 requires all health plans to provide first-dollar coverage of all services recommended by the U.S. Preventive Services Task Force.
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From page 383... ...
Based on its findings regarding the leading causes of death responsible for increasing working-age mortality, the committee developed policy and research recommendations relevant to providing access to care and treatment for persons at risk of dying from drug poisoning, alcohol-related causes, and suicide; to providing care and treatment to reduce obesity; to addressing other metabolic and cardiovascular conditions; and to instituting regulatory policy to avoid future catastrophes like the opioid epidemic. As discussed above, there is growing evidence that Medicaid expansion under the Affordable Care Act has led to lower mortality among working-age adults living in expansion states.
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From page 384... ...
. However, more research is needed on the effectiveness of behavioral health interventions in reducing mental illness and its consequences, on improved methods for delivering mental health and substance use treatment, on harm reduction, and on the extent to which inadequate access to these services has contributed to rising working-age mortality from substance use and suicide (see Chapter 7, Recommendation 7-2)
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From page 385... ...
Given the limitations of reliance on individual-level change, public health policy initiatives at the national, state, and local levels have been crucial to support behavior change. The case of tobacco control policy, perhaps the greatest public health success of the 20th century, is instructive.
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From page 386... ...
Phillip Morris, a federal court held several tobacco companies liable for racketeering; in 2009, a law gave authority to the Food and Drug Administration (FDA) to regulate the tobacco industry.1 This history would find parallels in recent discoveries about prior knowledge of the addictive properties of prescription opioids in the pharmaceutical industry and new lawsuits by states seeking remedies for losses due to the opioid epidemic.
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From page 387... ...
These include conducting educational campaigns (in mass media and at work) , implementing menu labeling and providing dietary guidelines, increasing access to healthy foods and limiting access to unhealthy foods (through subsidies and taxes)
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From page 388... ...
, although promising, have not been implemented on a broad or national scale. The example of tobacco control is a clear success: the combination of tax policy, smoking restrictions, and public health campaigns clearly altered behavior, improved health, and reduced mortality due to cigarette smoking among working-age adults.
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From page 389... ...
Based on the findings presented in this report, the committee developed several policy recommendations focused on curbing the availability of addictive drugs and reducing rates of obesity and smoking. The committee also identified several gaps for which additional public health research could help pave the way for future policy recommendations that could help reduce working-age mortality.
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From page 390... ...
To further support the committee's policy recommendation for better regulatory control of narcotic prescription drugs, further public health research is needed on the mechanisms that underlie physicians' and patients' unintended responses to tighter regulation of drugs posing a high risk of misuse and addiction. Evidence shows, for example, that some individuals who were dependent on prescription opioids were pushed by their inability to obtain those drugs to markets for heroin and fentanyl.
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From page 391... ...
Specifically, the committee recommends public health research to explore how the various mechanisms that explain sociodemographic and geographic differences and temporal changes in mortality due to drug poisoning compare with those that explain sociodemographic and geographic differences and temporal changes in mortality due to alcohol and suicide (see Chapter 7, Recommendation 7-3)
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From page 392... ...
Almost all obesity scholars point to the important role of obesogenic factors in the physical and food environments, including the interplay between individual health behaviors involving diet and physical exercise and societal-level changes in food production, transportation systems, green space, and sedentary work environments. For example, there is evidence that technological changes in the way food is produced, distributed, and consumed have contributed to the increase in obesity, and that there is a role for public health policy in improving the production of healthy foods and reducing the distribution and consumption of unhealthy foods, especially among children and adolescents.
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From page 393... ...
As a first step toward identifying some of the key drivers, the committee recommends research using experimental designs and taking advantage of existing neighborhood experimental projects (e.g., Moving to Opportunity) to examine the causal role of obesogenic factors in the environment and determine which are most responsible for the rise in obesity prevalence and body mass index levels (see Chapter 9, Recommendation 9-2)
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From page 394... ...
public health success, reductions in smoking behavior have been much greater among the highly educated than among the less educated, leaving large disparities in tobacco use that in turn contribute to disparate rates of mortality from cardiometabolic diseases and cancer. The committee recommends further public health research to address the barriers to smoking cessation and prevention of initiation faced by populations that continue to smoke at high rates, especially those with less education or income, and to evaluate programs that have been successful in promoting smoking cessation or preventing initiation (see Chapter 9, Recommendation 9-4)
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From page 395... ...
The significant potential for confounding further makes it difficult to infer causality from associational studies of policy contexts and mortality trends and disparities. For example, trends in death rates due to drug poisoning differed between the United States and European countries over the past 25 years even though recessions and economic disruptions due to globalization that were experienced by the United States also affected European countries.
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From page 396... ...
As noted earlier, as a result of the U.S. history of structural racism and related discriminatory practices that persist today, non-Whites -- and particularly Blacks and American Indians -- have faced greater barriers to education, good jobs, high incomes, and stable housing relative to Whites and have had fewer opportunities than Whites to transfer wealth to subsequent generations.
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From page 397... ...
There is also reasonable evidence that some targeted social and economic policies, such as higher minimum wages and the EITC, can reduce mortality rates in these vulnerable populations (Dow et al., 2019; Kaufman et al., 2020)
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From page 398... ...
The different governmental and policy responses to these epidemics are telling, however, revealing a deeper societal explanation not only for these discrepant policies but also for the persistent Black–White mortality gap: the drug crisis among Blacks of low socioeconomic status was treated primarily as a criminal justice problem, while the crisis among their White counterparts was largely recognized as a public health problem, although the criminalization of addiction remains strong today. A second theme -- which helps explain the pace and timing of rising 21st-century working-age mortality and long-standing racial/ethnic disparities in mortality that have persisted throughout U.S.
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From page 399... ...
As a consequence of the long history of structural racism in the United States (more on this below) , Blacks and American Indians, in particular, have experienced long-standing and persistent inequalities in opportunities for educational attainment in high-quality schools, stable jobs with good incomes, wealth accumulation, and the kind of intergenerational mobility that would place them on socioeconomic parity with Whites.
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From page 400... ...
Declining economic conditions, socioeconomic inequality, and vulnerability are themes that help in understanding how the different and changing social, economic, and geographic contexts of population subgroups may explain recent trends and disparities in working-age mortality. Macro-level shifts in economic conditions and inequalities that operate at all levels of society have made various subgroups vulnerable in different places and times.
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From page 401... ...
While drug mortality rates increased for White males and females of all working ages during 1990–2017, with especially pronounced increases after 2010, Black males ages 55–64 had higher drug mortality rates than Whites throughout the study period. The steepest increases in suicide mortality occurred among Whites of all working ages, especially White males (although Black and Hispanic suicide rates began to increase after 2010)
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From page 402... ...
While data limitations prevented an in-depth examination of cause-specific trends in AI/AN working-age mortality, previous research suggests similarly heightened mortality due to cardiometabolic diseases for this group as well. Structural racism remains a central explanation for the persistent disparity in mortality rates between Blacks and Whites.
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From page 403... ...
The committee recognizes that structural racism is too complex to be amenable to easy fixes; isolated interventions are therefore unlikely to achieve meaningful impact. As in other countries, such as South Africa decades ago, success in dismantling structural racism in the United States will invariably require a suite of solutions that confront the problem at multiple levels of society and across sectors.
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From page 404... ...
POLICY CONCLUSION 11-1: To reduce and ultimately eliminate racial/ethnic and other socioeconomic inequalities that continue to drive racial/ethnic disparities in U.S. working-age mortality, policy makers and decision makers at all levels of society will need to dis mantle structural racism and discriminatory policies of exclusion (in such areas as education, employment and pay, housing, lending, civic participation, criminal justice, and health care)
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From page 405... ...
RECOMMENDATION 11-6: Federal agencies, in partnership with private foundations and other funding entities, should support quanti tative and qualitative interdisciplinary research on how factors defined at multiple levels (e.g., nation, state, community, family, individual) relate to working-age mortality, especially to deaths involving drug and alcohol use, suicide, and cardiometabolic disease.
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From page 406... ...
In addition, this area of research should include state- and substate-level examination of the relationship of social policy to health and mortality in the United States, given the suggestion of promising recent work that wide health and mortality disparities in the United States may be driven by differences in social and health policies across state and local areas (Montez et al., 2020)
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From page 407... ...
It has underscored and reinforced the importance of key themes articulated throughout this report by illustrating the ways in which economic conditions and socioeconomic inequalities make certain population groups and geographic areas more vulnerable to COVID-19. First, this report documents increased working-age mortality from drug poisoning (Chapter 7)
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From page 408... ...
Thus, the COVID-19 pandemic has drawn attention to long-standing social and economic inequalities that leave some populations vulnerable when new health threats emerge. It has also highlighted the important role that public policy can play in achieving health equity.
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From page 409... ...
The research implications of this report, also highlighted in this chapter, provide direction to this end. TABLE 11-1 Recommendations and Policy Conclusions Opioids, Other Drugs, and Alcohol POLICY CONCLUSION 7-1 Economic policies are needed to address the larger economic and social strains and dislocations that made communities that experienced economic decline over the past four decades vulnerable to opioids and other drugs.
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From page 410... ...
In general, the most effective interventions target both risk and protective factors at multiple levels, including the individual, family, community, and society. • The Food and Drug Administration, the Drug Enforcement Administration, and other federal and state regulatory agencies should strengthen regulatory control and monitoring of the development, marketing, distribution, and dispensing of prescription drugs.
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From page 411... ...
RECOMMENDATION 7-3 The National Institutes of Health, the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control and Prevention, the Food and Drug Administration, and other relevant federal agencies should support research to address the gaps in knowledge regarding the underlying causes of the rise in drug poisoning, alcohol-related death, and suicide. Specifically, this research should be focused on • the mechanisms underlying physicians' and patients' unintended responses to tighter regulation of drugs with a high risk of misuse and addiction, such as cases in which individuals dependent on prescription opioids were pushed to markets for heroin and fentanyl, and the identification of strategies for preventing those unintended consequences; • whether changes over time in alcohol consumption (including types of alcoholic beverages, frequency of drinking, and volume of consumption)
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From page 412... ...
Cardiometabolic Diseases RECOMMENDATION 9-1 Federal agencies, in partnership with private foundations and other funding entities, should support research that evaluates the effectiveness of programs and policies designed to improve U.S. cardiometabolic health and that considers the impact of changes at multiple levels of analysis: • At the individual level, research should continue to evaluate the effectiveness of programs and policies that promote consumption of healthy foods (e.g., mandatory labeling of food ingredients or components, fruit and vegetable subsidies)
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From page 413... ...
and existing treatments for hypertension, diabetes, and heart disease, federal agencies, in partnership with private foundations and other funding entities, should support research focused on better understanding the barriers to prevention and control of cardiometabolic disease faced by individuals -- especially less-educated and lower-income populations -- and evaluating potential solutions for removing those barriers. Cross-Cutting Themes RECOMMENDATION 11-1 Given recent findings regarding largely better health and lower mortality among working-age adults who live in states that have expanded Medicaid under the Affordable Care Act, the 12 states that have not yet expanded access to Medicaid should do so as soon as possible.
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From page 414... ...
RECOMMENDATION 11-5 Given the potential connection of daily stressors to substance use, suicide, and cardiometabolic disease and mortality, federal agencies, in partnership with private foundations and other funding entities, should support research that documents the sources of increasing stress in the lives of Americans (e.g., student debt, foreclosures, job instability, economic insecurity, family instability) and identifies those groups most affected by increasing stress (e.g., the poor, immigrants, young adults, racial/ethnic minorities, women, those living in rural areas, the long term unemployed, those without a 4-year college degree)
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From page 415... ...
and be intentional in ensuring that new social and economic policies serve to eliminate, and not perpetuate, the social and economic inequalities to which racial/ethnic minority groups have long been exposed. RECOMMENDATION 11-6 Federal agencies, in partnership with private foundations and other funding entities, should support quantitative and qualitative interdisciplinary research on how factors defined at multiple levels (e.g., nation, state, community, family, individual)
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From page 416... ...
. RECOMMENDATION 5-2 The National Center for Health Statistics and the National Institutes of Health should undertake and/or fund studies to evaluate state- and local-level variation in cause of-death coding practices, explore how such variation may contribute to observed mortality trends, and make recommendations for reducing such variation. RECOMMENDATION 5-3 The National Center for Health Statistics should include Asians in its regular reports on life expectancy estimates and trends in the United States and make an item on place of birth available to researchers in the public-use files, even if such information is at first categorical (e.g., foreign-born vs.
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From page 417... ...
Department of Agriculture Economic Research Service rural–urban continuum codes or National Center for Health Statistics urban influence codes. RECOMMENDATION 7-5 The National Institute of Mental Health and other relevant federal agencies should develop a research program to identify innovative and cost-effective methods for conducting periodic or ongoing population surveys of important mental health conditions.
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