Economic influences on population health in the United States: Toward policymaking driven by data and evidence
Authors: Atheendar S. Venkataramani, Rourke O’Brien, Gregory L. Whitehorn, et al.
Introduction: Over the last 40 years, the secular increase in longevity in the US has slowed relative to peer countries, a phenomenon capped in more recent years by an unprecedented decline in US life expectancy [1]. These broad trends mask widening disparities in health outcomes by socioeconomic status. Stagnant—and more recently, rising—mortality among working-age adults in lower income brackets who have less formal education, primarily driven by rising drug overdose and suicide death rates, appear to entirely account for the growing gap in health outcomes between the US and other high-income countries [1–4].
During this time, economic outcomes in the same population subgroups have worsened as well. Since the late 1970s, growth in wages and incomes stagnated for most US residents [5]. The ability of individuals from poor families to achieve upward socioeconomic mobility has fallen considerably [6–8], whereas insecurity in many aspects of life—such as earnings, work, and housing—has risen [8,9]. Consequently, income inequality has increased dramatically over this period, reaching levels not seen since the eve of the 1929–1939 Great Depression [10].
We argue that worsening economic outcomes among low-income and less-educated working-age adults may be a key driver of adverse population health trends in the US.
We begin by describing trends in economic outcomes since the late 1970s and their underlying drivers. We then discuss the myriad ways in which these trends have affected population health, focusing primarily on working-age adults. We review existing and new interventions that may jointly improve economic outcomes and population health (or mitigate the adverse health consequences of negative economic shocks). We also highlight the importance of new and more accessible data to better inform policy and the role of political processes in realizing the full potential of evidence-based policymaking.
Fig 1. Drivers of economic outcomes and consequences for population health.
Figure summarizes the key relationships between economic outcomes—and their underlying drivers—and health. To ensure better clarity, the figure only focuses on drivers and pathways discussed in this review. In doing so, we do not directly specify some relationships that are likely important for population health, e.g., direct effects of public policy (e.g., Medicaid expansions) and structural racism on health outcomes.
Key Takeaways
The United States is in the midst of a 40-year-long population health crisis. Life expectancy has declined since 2014, an unprecedented event that has followed on the heels of a decades-long slowing in secular gains in longevity in the US relative to peer countries. These adverse population health trends appear to be primarily driven by worsening health among working-age individuals of lower socioeconomic status.
A growing body of research suggests that worsening economic outcomes—e.g., fading employment opportunities and increasing economic insecurity—may be a primary causal driver of adverse health trends among low-income and less-educated working-age US residents.
Evidence-based public policies to address widening gaps in economic and health outcomes include expanding early childhood health and educational investments, increasing the scope of programs that assist displaced workers in developing new skills and finding new jobs, reinforcing the social safety net, and improving the reach of public health efforts to help moderate the health consequences of adverse economic shocks.
Policymakers will also need to consider and rigorously evaluate new approaches, such as basic income grants, investments to direct automation toward complementing rather than replacing the work force, or job guarantee programs.
The size and scope of the population health challenges that have arisen with the changing economy highlight the importance of new data sources and evidence-based engagement by policymakers.