{"id":983,"date":"2016-02-24T18:35:27","date_gmt":"2016-02-24T18:35:27","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=983"},"modified":"2017-08-21T11:09:00","modified_gmt":"2017-08-21T11:09:00","slug":"primary-care-corner-with-geoffrey-modest-md-increasing-disparities-in-life-expectancy","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/02\/24\/primary-care-corner-with-geoffrey-modest-md-increasing-disparities-in-life-expectancy\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Increasing Disparities in Life Expectancy"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>The NY Times just featured an article on the growing longevity disparity associated with income disparity (see\u00a0<a href=\"http:\/\/www.nytimes.com\/2016\/02\/13\/health\/disparity-in-life-spans-of-the-rich-and-the-poor-is-growing.html?emc=edit_th_20160213&amp;nl=todaysheadlines&amp;nlid=67866768\">http:\/\/www.nytimes.com\/2016\/02\/13\/health\/disparity-in-life-spans-of-the-rich-and-the-poor-is-growing.html?emc=edit_th_20160213&amp;nl=todaysheadlines&amp;nlid=67866768<\/a> ), based on a report released by the Brookings Institute.\u00a0See\u00a0<a href=\"http:\/\/www.brookings.edu\/research\/reports2\/2016\/02\/life-expectancy-gaps-promise-social-security#recent\/\">http:\/\/www.brookings.edu\/research\/reports2\/2016\/02\/life-expectancy-gaps-promise-social-security#recent\/<\/a> for a brief review of the report\u00a0and\u00a0<a href=\"http:\/\/www.brookings.edu\/~\/media\/Research\/Files\/Reports\/2016\/01\/life-expectancy-gaps-promise-social-security\/BosworthBurtlessZhang_retirementinequalitylongevity_012815.pdf?la=en\">http:\/\/www.brookings.edu\/~\/media\/Research\/Files\/Reports\/2016\/01\/life-expectancy-gaps-promise-social-security\/BosworthBurtlessZhang_retirementinequalitylongevity_012815.pdf?la=en<\/a> for the full 174 page\u00a0report.<\/p>\n<p>Main points:<\/p>\n<ul>\n<li>In the early 1970s,\u00a0a 60-year old man in the top half of the earnings&#8217; ladder had life expectancy 1.2 years longer than one in the bottom half. In\u00a02001, the gap was 5.8 years.<\/li>\n<li>The Brookings report found that, comparing\u00a0life expectancy between those in the top vs bottom 10% of earners\u00a0(data are based on life expectancy at age 50\u00a0yo):\n<ul>\n<li>For\u00a0men born in 1920, there was a 6-year difference;\u00a0for men born in 1950, there was a 14-year difference.<\/li>\n<li>For women born in 1920, there was a 4.7-year difference;\u00a0for women born in 1950,\u00a0there was a 13-year difference.<\/li>\n<li>In a separate analysis,\u00a0the Brookings report noted that life expectancies in those born in 1920 vs 1940, comparing the bottom to the top 10% of mid-career income\u00a0distribution\u00a0were:\n<ul>\n<li>Those in the bottom 10%:\u00a080.4 years for women (no change); 74.3\u00a0increasing to 76.0\u00a0in men<\/li>\n<li>Those in the top 10%:\u00a084.1 years for women increasing to 90.5!!!; 79.3\u00a0increasing to 88.0!!!\u00a0In men<\/li>\n<\/ul>\n<\/li>\n<li>Why are the differences so great and getting dramatically greater? Hard to pinpoint exactly (and studies looked at different endpoints),\u00a0but some differences:\n<ul>\n<li>Cigarette smoking: decreased more in wealthy, could explain 1\/5 to 1\/3 in the gap between men with college degrees vs those with high school degrees; 1\/4 of the gap in women<\/li>\n<li>Obesity: rates of obesity between rich and poor narrowed from 1990-2010,\u00a0when\u00a037% of poorer and 31% of\u00a0richer adults were obese<\/li>\n<li>\u200bPrescription drug abuse has disproportionately increased mortality in poor communities<\/li>\n<li>Of note, limited access to care was not found to play much of a role (they reference an article by Steven Schroeder:\u00a0N Engl J Med 2007; 357:1221), stating that only 10% of the disparity has to do with medical care [note that this statement was not footnoted, so I cannot check on the reliability of it].<\/li>\n<\/ul>\n<\/li>\n<li>One side\u00a0note is that wealthier people live longer and therefore collect more years of social security payments\u00a0as well as longer\u00a0utilization of Medicare services,\u00a0disproportionate financial\u00a0benefits for the wealthy.<\/li>\n<li>These longevity disparities are not necessarily\u00a0reflected in other countries: in Canada, men in the poorest urban areas had the largest declines in heart disease mortality from 1971-1996, and the overall gaps in longevity <strong>decreased <\/strong>over this time period. Cancer survival rates in low-income residents in Toronto were significantly better than in Detroit, yet there was no difference for middle- and high-income residents (see Am J Public Health. 1997; 87(7): 1156).<\/li>\n<li>The Brookings report also commented on the fact that higher wage earners are retiring later (they attribute this to the fact that their jobs are higher-paying which is especially important since most jobs now do not come with a pension or guaranteed income after retirement, the jobs usually are more rewarding, and social security benefits were pushed up a year to age\u00a066). Lower age workers tend to retire earlier with only 13.8% getting social security at age 66. They do not comment explicitly (so, I will): the increase in age for social security from 65 to 66 is much less significant for an office worker than someone doing\u00a0hard manual labor, where they likely have chronic musculoskeletal pains\/problems, and the possibility of extending the work-life another year may be painful and undoable. But getting\u00a0social security\u00a0early adds to income inequality, since the payout is much less\/yr.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;-<\/p>\n<p>In a (somewhat) related recent\u00a0article (see\u00a0JAMA.<em>\u00a0<\/em>2016;315(6):609), researchers looked at life expectancy from birth (vs from age 50 in above), as a means to evaluate\u00a0mortality in younger people, where both the major causes of death are\u00a0different from those &gt;50yo\u00a0(more from injury\/trauma\/drugs), and the impact is greater (more\u00a0years of expected life are lost). They focused on motor vehicle traffic crashes (MVT), firearm injuries, and drug poisonings (e.g. overdoses). The table below shows the contribution of these injuries\/traumas\u00a0to the life expectancy of men and women, also comparing the US rates to those of\u00a0a variety of other countries. From this data, overall\u00a0death from injury\u00a0accounted for 48% of the longevity gap in men (1.02 years of the 2.15 years of the\u00a0all-cause difference), with firearm-related injuries accounting for 21% of the overall\u00a0gap, drug poisonings 14% and MVT crashes 13%. For women injuries\/traumas\u00a0accounted for 19% of the gap, with 4% from firearms, 9% from drug poisonings, and 6% from MVT crashes. Overall, the impact of these injuries in the US is far greater than in a\u00a0combination of other countries.\u00a0The other table (not shown) details the specifics per country, showing for example that although Portugal is the only country in the list\u00a0with\u00a0an overall death rate higher than the US, their death rate from injuries is much lower than the US, so that Portugal still has a life-expectancy 0.5 years longer than the US (i.e., because there are fewer injuries\/overdoses which disproportionately affect younger people). A caveat here is that they are relying on death coding across different countries.<\/p>\n<p>A few comments:<\/p>\n<ul>\n<li>There are very real reasons why lower wage earners have lower life expectancy, as noted in many prior blogs. Obesity is a major problem but is exacerbated by lack of\u00a0access to good, affordable foods. Doing\u00a0exercise can be an obstacle when people live in unsafe neighborhoods. Manual laborers tend to have more disabilities (I\u2019m not sure I have met any construction workers, masons, plumbers, who do not have\u00a0significant\u00a0musculoskeletal problems by the age of 40). Air quality tends to be worse in poor neighborhoods. General\u00a0stress tends to be higher.<\/li>\n<li>I do have concerns about writing off access to medical care as not much of a factor in the longevity\u00a0discrepancy.\u00a0It is clear that inadequate\u00a0access to care is an issue for the poor only. And there are huge\u00a0discrepancies\u00a0within that group. If you happen to live in Massachusetts, access is generally quite good. If you live in rural Mississippi or Louisiana, access is terrible\/can be effectively nonexistent.<\/li>\n<li>Though I do think that, overall, the predominant issue is that, though we spend lots of $$ in the US on health care, unlike other countries (including many with far fewer resources than in the US), we spend the vast majority on &#8220;medical care&#8221; (where in\u00a0other countries\u00a0a higher % of health care\u00a0money goes to making sure people have good food, housing, jobs, and an array of social services &#8211;see\u00a0<u>The American Health Care Paradox<\/u>, by E Bradley and L Taylor, published in 2013,\u00a0noting that:\n<ul>\n<li>We spend almost twice as much money as the next most expensive health care system;\u00a0yet\u00a0we have\u00a0really\u00a0terrible comparable health outcomes, e.g. ranking 26th in life expectancy.<\/li>\n<li>\u200bCountries with far better health outcomes spend much more money on social services to enhance well-being, such as &#8220;investments in housing, nutrition, education, the environment and unemployment support&#8221; (which dovetails with the\u00a0way the World Health Organization defines health\u00a0as\u00a0&#8220;a state of complete physical, mental and social well-being&#8221;); we spend dramatically less than other countries on these social services.<\/li>\n<li>\u200bAnd, if you add up the strictly medical as well as\u00a0the social costs invested by different countries for health care, the US is somewhere in the middle of the pack in terms of per capita spending.<\/li>\n<\/ul>\n<\/li>\n<li>So, \u00a0I think this is why longevity of wealthier people in the US (who need fewer social services)\u00a0is pretty much as good at those living in the highest ranking countries (Japan, Iceland), but poorer people have the life expectancy of those in Poland and the Czech republic.<\/li>\n<li>There are several reports finding a temporal relationship between divergences in income inequality and longevity inequality over the past 40 years.<\/li>\n<li>And the JAMA study reinforces the overall importance of traumatic or drug-related deaths overall (which is largely missed in the Brookings analysis), and especially in the young\u200b.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Increasing Disparities in Life Expectancy  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/02\/24\/primary-care-corner-with-geoffrey-modest-md-increasing-disparities-in-life-expectancy\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-983","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/983","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=983"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/983\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=983"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=983"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=983"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}