On Dec. 8, the Centers for Disease Control and Prevention released morbidity and mortality data for the United States for 2015. The data showed that Americans’ life expectancy declined for the first time in 22 years.
For the wealthiest large nation on earth, which managed to spend $3.2 trillion on health care that same year, this is both deeply disturbing and inexcusable. Except for cancer, where we saw continued progress, death rates rose for eight of the 10 leading causes of death, most sharply for Alzheimer’s disease. The decline in life expectancy was confined entirely to the under-65 population.
Though the obesity epidemic almost certainly bears some responsibility, other social factors may be at work. In research published in fall 2015, Nobel Memorial Prize laureate Angus Deaton and his wife, Anne Case, found that the death rates for white Americans ages 45-54 had risen 11 percent from 1998 through 2014, with the rise sharply concentrated among those with a high school degree or less. This rise contrasted with steady improvement in death rates for black and Hispanic Americans, as well as in most other countries during the same period.
According to Deaton and Case, the main drivers of the sharp fall in life expectancy among middle-age whites were overdoses of drugs and alcohol, which almost quadrupled; suicides, which increased by 60 percent; and deaths from chronic liver disease and cirrhosis, which rose by a third. If the improvements in health status experienced in the previous 15 years had continued from 1998 to 2014, there would have been nearly half a million fewer deaths in this group. The toll from this unwelcome trend was comparable to that of the HIV epidemic in the U.S.
Deaton and Case commented, “Concurrent declines in self-reported health, mental health and ability to work, increased reports of pain, and deteriorating measures of liver function all point to increasing midlife distress.” In other words, white Americans in midlife are killing themselves, either directly or through destructive personal habits, and in sufficient numbers to affect overall life expectancy in the country.
It is not difficult to trace the despair underlying this trend to deindustrialization and the economic hammering many Americans took in the 2008 recession. About half of American households with members older than 55 have no retirement savings. Millions of older Americans lost the home equity they were counting on as a retirement cushion in the wave of foreclosures and job losses that followed the 2008 crash. A remarkable 86 million American households effectively have no spendable assets, and their asset position has actually declined in the past seven years.
It is going to take more than the “right incentives” and a surge of health care consumerism to alleviate the despair that Deaton and Case uncovered in their work. While the new administration and Congress struggle with health reform issues, hospitals should directly address the “forgotten” in their communities.
What should hospitals do?
Hook them up. A lot of the folks who end up in your emergency department for self-inflicted conditions will survive to fight another day. You may be able to save their lives, but your ED cannot fix the underlying conditions that brought them to you. What you can do is (1) listen to them, (2) gauge their readiness to address their problems, and (3) hook them up — to primary care, to Alcoholics Anonymous/Narcotics Anonymous, to weight loss programs, to rehab and recovery specialists, to mental health professionals, to churches or community agencies. Absent these connections, odds are that they will return to you with their problems unaddressed.
Advocate for continued coverage of mental health and substance abuse treatment. With the possible repeal of the Affordable Care Act on the political horizon, the status of mental health coverage will likely become newly uncertain. The needs are not going away, but coverage might — that is, unless hospitals and their clinicians forcefully advocate for continued or intensified focus on ensuring that mental health services are paid for by private and public insurance.
Explore the psychiatric emergency services center. This fast-growing, innovative form of care is an inexpensive, locked-unit, short-stay special hospital for people with acute psychiatric conditions, including drug problems. It is specifically geared to stabilization and detoxification of people in acute psychiatric distress and is often physically separate from the hospital. Such centers are proliferating and solve a significant problem: freeing up ED personnel to focus on the nonpsychiatric portion of their patient flow. Though it is still early days, some evidence from the field suggests that 80 percent or more of patients treated in PES are discharged to home. And because of the thorough workup they receive, the remaining 20 percent are matched to the right inpatient setting (acute, rehab, etc.) with much improved continuity of care.
Lead your community’s economic development activities. The underlying economic conditions that caused the reversal of life expectancy gains in 2015 may or may not be effectively addressed by the new administration and Congress. But few institutions are more dependent on a viable local economy than the hospital. Communities compete to provide the conditions that bring new industries to town. Each new job employers bring to a community creates 2.5 other jobs through the multiplier effect by supporting local merchants, expanding the tax base and often bringing employer-paid insurance for the worker.
The underlying cause of many of the health problems we have been discussing is a lack of economic opportunity. Do not rest until your hospital is not the largest employer in your community.
Jeff Goldsmith, Ph.D., is national adviser to Navigant Healthcare and associate professor of public health sciences at the University of Virginia, Charlottesville. He is a regular contributor to H&HN Daily and a member of Health Forum's Speakers Express.
The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.
