Ten Americas: a systematic analysis of life expectancy disparities in the USA.
Nearly two decades ago, the Eight Americas study offered a novel lens for examining health inequities in the USA by partitioning the US population into eight groups based on geography, race, urbanicity, income per capita, and homicide rate. That study found gaps of 12·8 years for females and 15·4 years for males in life expectancy in 2001 across these eight groups. In this study, we aimed to update and expand the original Eight Americas study, examining trends in life expectancy from 2000 to 2021 for ten Americas (analogues to the original eight, plus two additional groups comprising the US Latino population), by year, sex, and age group.
In this systematic analysis, we defined ten mutually exclusive and collectively exhaustive Americas comprising the entire US population, starting with all combinations of county and race and ethnicity, and assigning each to one of the ten Americas based on race and ethnicity and a variable combination of geographical location, metropolitan status, income, and Black-White residential segregation. We adjusted deaths from the National Vital Statistics System to account for misreporting of race and ethnicity on death certificates. We then tabulated deaths from the National Vital Statistics System and population estimates from the US Census Bureau and the National Center for Health Statistics from Jan 1, 2000, to Dec 31, 2021, by America, year, sex, and age, and calculated age-specific mortality rates in each of these strata. Finally, we constructed abridged life tables for each America, year, and sex, and extracted life expectancy at birth, partial life expectancy within five age groups (0-4, 5-24, 25-44, 45-64, and 65-84 years), and remaining life expectancy at age 85 years.
We defined the ten Americas as: America 1-Asian individuals; America 2-Latino individuals in other counties; America 3-White (majority), Asian, and American Indian or Alaska Native (AIAN) individuals in other counties; America 4-White individuals in non-metropolitan and low-income Northlands; America 5-Latino individuals in the Southwest; America 6-Black individuals in other counties; America 7-Black individuals in highly segregated metropolitan areas; America 8-White individuals in low-income Appalachia and Lower Mississippi Valley; America 9-Black individuals in the non-metropolitan and low-income South; and America 10-AIAN individuals in the West. Large disparities in life expectancy between the Americas were apparent throughout the study period but grew more substantial over time, particularly during the first 2 years of the COVID-19 pandemic. In 2000, life expectancy ranged 12·6 years (95% uncertainty interval 12·2-13·1), from 70·5 years (70·3-70·7) for America 9 to 83·1 years (82·7-83·5) for America 1. The gap between Americas with the lowest and highest life expectancies increased to 13·9 years (12·6-15·2) in 2010, 15·8 years (14·4-17·1) in 2019, 18·9 years (17·7-20·2) in 2020, and 20·4 years (19·0-21·8) in 2021. The trends over time in life expectancy varied by America, leading to changes in the ordering of the Americas over this time period. America 10 was the only America to experience substantial declines in life expectancy from 2000 to 2019, and experienced the largest declines from 2019 to 2021. The three Black Americas (Americas 6, 7, and 9) all experienced relatively large increases in life expectancy before 2020, and thus all three had higher life expectancy than America 10 by 2006, despite starting at a lower level in 2000. By 2010, the increase in America 6 was sufficient to also overtake America 8, which had a relatively flat trend from 2000 to 2019. America 5 had relatively similar life expectancy to Americas 3 and 4 in 2000, but a faster rate of increase in life expectancy from 2000 to 2019, and thus higher life expectancy in 2019; however, America 5 experienced a much larger decline in 2020, reversing this advantage. In some cases, these trends varied substantially by sex and age group. There were also large differences in income and educational attainment among the ten Americas, but the patterns in these variables differed from each other and from the patterns in life expectancy in some notable ways. For example, America 3 had the highest income in most years, and the highest proportion of high-school graduates in all years, but was ranked fourth or fifth in life expectancy before 2020.
Our analysis confirms the continued existence of different Americas within the USA. One's life expectancy varies dramatically depending on where one lives, the economic conditions in that location, and one's racial and ethnic identity. This gulf was large at the beginning of the century, only grew larger over the first two decades, and was dramatically exacerbated by the COVID-19 pandemic. These results underscore the vital need to reduce the massive inequity in longevity in the USA, as well as the benefits of detailed analyses of the interacting drivers of health disparities to fully understand the nature of the problem. Such analyses make targeted action possible-local planning and national prioritisation and resource allocation-to address the root causes of poor health for those most disadvantaged so that all Americans can live long, healthy lives, regardless of where they live and their race, ethnicity, or income.
State of Washington, Bloomberg Philanthropies, Bill & Melinda Gates Foundation.
Dwyer-Lindgren L
，Baumann MM
，Li Z
，Kelly YO
，Schmidt C
，Searchinger C
，La Motte-Kerr W
，Bollyky TJ
，Mokdad AH
，Murray CJ
... -
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Disparities in wellbeing in the USA by race and ethnicity, age, sex, and location, 2008-21: an analysis using the Human Development Index.
The Human Development Index (HDI)-a composite metric encompassing a population's life expectancy, education, and income-is used widely for assessing and comparing human development and wellbeing at the country level, but does not account for within-country inequality. In this study of the USA, we aimed to adapt the HDI framework to measure the HDI at an individual level to examine disparities in the distribution of wellbeing by race and ethnicity, sex, age, and geographical location.
We used individual-level data on adults aged 25 years and older from the 2008-21 American Community Survey (ACS) Public Use Microdata Sample. We extracted information on race and ethnicity, age, sex, location (Public Use Microdata Areas), educational attainment, and household income and size. We merged these data with estimated life tables by race and ethnicity, sex, age, location (county), and year, generated using Bayesian small-area estimation models applied to death certificate data from the National Vital Statistics System. For each individual in the ACS, we used these combined data to estimate years of education, household consumption, and expected lifespan; converted each of these three features into an index using a percentile score; and calculated the HDI as the geometric mean of these three indices. Finally, we grouped individuals into yearly HDI deciles.
Years of education, household consumption, and expected lifespan-and thus the HDI-varied considerably among adults in the USA during the 2008-21 period. For most race and ethnicity and sex groups, the mean HDI increased gradually from 2008 to 2019, then declined in 2020 due to declines in expected lifespan, although there were systematic differences in the distribution of the HDI by race and ethnicity and sex. In the lowest HDI decile, there was over-representation (ie, >10% of the total population of a given race and ethnicity and sex group) of American Indian and Alaska Native (AIAN) males (50% [SE 0·2] in decile, mean annual population in decile 0·37 million [SE 0·002]), Black males (40% [<0·1], 4·67 million [0·006]), AIAN females (23% [0·1], 0·19 million [0·001]), Latino males (21% [<0·1], 3·27 million [0·006]), Black females (14% [<0·1], 1·86 million [0·004]), and Latina females (13% [<0·1], 2·07 million [0·006]). Given differences in total population size, however, White males were the largest population group in the lowest decile (27% [<0·1] of the lowest decile, 5·87 million [0·012]), followed by Black males (22% [<0·1]) and Latino males (15% [<0·1]). There were notable differences in these patterns by age group: for example, for the 25-44 years age group, the lowest HDI decile had even greater over-representation of AIAN males (66% [0·2] in decile, 0·22 million [0·001]) and Black males (46% [<0·1], 2·52 million [0·005]) than the 85 years and older age group (22% [1·1], <0·01 million [<0·001]; and 20% [0·3], 0·03 million [<0·001]). By contrast, the lowest decile had an under-representation of Asian females (2% [<0·1], 0·06 million [<0·001]) in the 25-44 years age group, but an over-representation in the 85 years and older age group (25% [0·3], 0·03 million [<0·001]). The lowest HDI decile for the 25-44 years age group was primarily male (76% [<0·1], 6·44 million [0·009]) whereas for age 85 years and older it was predominantly female (71% [0·1], 0·42 million [0·002]). In the highest HDI decile, shifts in the composition of the population by age were particularly large for White males, who made up 5% (0·1; 0·39 million [0·001]) of this decile in the 25-44 years age group, but 49% (0·2; 0·29 million [0·001]) in the 85 years and older age group. From 2012 to 2021, the proportion of the population living in the lowest HDI decile varied substantially by location, and a disproportionately high share of the population living in locations in much of the southern half of the USA, Appalachia, and Rust Belt states were in the lowest HDI decile.
Substantial disparities in wellbeing exist within the USA and are heavily influenced by race and ethnicity (due to racism), sex, age, and geographical location. These disparities are not immutable, but improvement is not a given, and gains can be fleeting in the face of a crisis such as the COVID-19 pandemic. Sustained action to ensure that everyone has meaningful access to a high-quality education, the means to earn a sufficient income, and the opportunity to live a long and healthy life is needed to reduce these disparities and should focus on the populations and locations that are worst off.
State of Washington and National Institute on Minority Health and Health Disparities.
Dwyer-Lindgren L
，Kendrick P
，Baumann MM
，Li Z
，Schmidt C
，Sylte DO
，Daoud F
，La Motte-Kerr W
，Aldridge RW
，Bisignano C
，Hay SI
，Mokdad AH
，Murray CJL
... -
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ResearchGate
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