High and Rising Mortality Rates Among Working-Age Adults (2021) / Chapter Skim
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; and (2) a slowing of declines in working-age mortality due to other causes of death (mainly cardiovascular diseases)
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that may affect the health of Americans in multiple ways and through multiple pathways that flow through local community contexts and intersect with individuals' lives. To that end, the National Institute on Aging and the Robert Wood Johnson Foundation asked the National Academies of Sciences, Engineering, and Medicine to conduct a consensus study to identify the key drivers of increasing midlife mortality and concomitant widening social differentials; elucidate modifiable risk factors that could alleviate poor health in midlife, as well as widening health inequalities; identify key knowledge gaps and make recommendations for future research and data collection to fill those gaps; and explore potential policy implications.
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The committee had concerns about the quality of data on educational attainment in vital statistics records and the total absence of data on income in death certificate records. Accordingly, the committee did not examine disparities in working-age mortality by socioeconomic status in its analyses, but instead relied on a thorough review of previous research on mortality differentials by education and income.
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Although the committee of necessity focused its attention on the major drivers of increasing working-age mortality -- drugs, alcohol, suicides, and cardiometabolic diseases -- it encourages the research community to seek explanations for increases in working-age mortality due to other causes of death identified in this report. Of particular importance is identifying factors contributing to the large and persistent racial/ethnic disparities in working-age mortality trends, such as the rise in homicides and transport injuries among Black and Hispanic men or the delayed reductions in mortality from HIV/AIDS among older Blacks.
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in large central metropolitan areas. While the committee's review of the literature showed that there was no difference in drug poisoning mortality by educational attainment among Blacks, increasing mortality due to drug poisoning among lower-educated individuals was responsible for most of the growing mortality gap by educational attainment among working-age Whites.
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However, ongoing population surveys addressing adult mental illness and existing research on temporal trends in the prevalence of adverse childhood experiences provide insufficient evidence regarding their potential contribution to the increase in drug overdoses. "Despair" has been among the more controversial potential explanations for the rise in substance-related deaths.
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Quasi-experimental studies suggest that mortality rates increase in response to specific economic forces -- such as job loss, plant closings, and disruption from foreign trade -- but there is less evidence about broader economic forces, such as technological advances that replace workers and general economic trends related to productivity. Other studies have found that opioid supply availability has a larger effect on drug-related mortality relative to changes in specific economic factors.
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Periods of economic downturn, wage stagnation, weak safety nets, and increasing foreclosure rates are associated with rising suicide mortality in national and state-level studies. In addition, deteriorating economic conditions among those without a college degree may be an important factor explaining rising suicide mortality among Whites, especially White men.
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Within the working-age population, certain subgroups experienced greater relative increases in mortality due to ENM diseases and hypertensive heart disease over the study period and slower declines in mortality from ischemic heart disease and other circulatory diseases starting in 2010. These subgroups include younger adults (ages 25–44)
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Substantial evidence shows that obesity increases the risks of hypertension, stroke, coronary heart disease, and diabetes, driving up death rates due to ENM diseases and hypertensive heart disease and slowing declines in mortality due to ischemic heart disease and other circulatory diseases. Obesity rates began to rise in the early 1980s and remain high today as a period-based phenomenon that has affected children and adults of all ages.
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The loss of manufacturing and mining jobs in the industrial Midwest and Appalachia in the 1970s led to a long-term economic decline, often concentrated among the largely White families and communities in these areas. Declining economic conditions tend to weaken societal institutions, community resources, family bonds, social networks, and access to health care -- all of which could help explain disparities in working-age mortality according to race and ethnicity, socioeconomic status, and geography.
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Such vulnerability plays a prominent role in today's drug overdose crisis, described earlier as a "perfect storm" in which the flooding of the market with highly addictive and deadly drugs occurred as the population was growing more vulnerable to emotional and physical pain, heightening demand for these products. 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 in working-age mortality.
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The committee accordingly offers policy recommendations regarding obesity prevention programs, interventions to target the substance use and overdose crisis at multiple levels on both the supply and demand sides, and the expansion of Medicaid under the Affordable Care Act. The committee also presents broader policy conclusions regarding the need to balance the rights of the food industry, advertisers, grocers, and restaurants to enjoy free market competition against the public health imperative to limit the promotion and consumption of foods and beverages that contribute to obesity; the need to revitalize the communities hit hardest by the overdose crisis by addressing the larger economic and social strains and dislocations that made those communities vulnerable in the first place; and the importance of dismantling structural racism and discriminatory policies of exclusion so as
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14 HIGH AND RISING MORTALITY RATES AMONG WORKING-AGE ADULTS to reduce and ultimately eliminate inequalities that continue to drive racial/ ethnic disparities in health and mortality in the United States. The United States is losing far too many lives far too early.
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