Two Americas: The Death Gap

Are you better off today than you were 10 years ago? Some version of that is a favorite question of politicians looking to oust the party in power. As of today, if the “you” refers to American adults with a high-school education or less, and if the “better off” refers to the most basic measure you can think of—whether you are alive or dead—the answer is a shameful “no.”

Last month I blogged about a study that underlined how we truly are Two Americas (though the idea never gained traction for John Edwards this primary season). That study found that, sgap in death rates between Americans with less than a high school education and college graduates has soared since 1993, they will report tomorrow in the May 14 issue of PLoS One.

The scientists analyzed death certificates (which indicate the last year of schooling that the person completed, as well as cause of death) for blacks and whites between the ages of 25 and 64. The age cut-off was chosen because, for older generations, education is not as strong a proxy for socioeconomic status—class—as it is for younger ones.

The numbers are shocking. Among white men who did not graduate from high school, there were 837 deaths per 100,000 of them in 1993; that same year, only 285 white men with college degrees died per 100,000 in this age group. But it gets worse. In 2001, those respective rates were 931 and 213—the death rate for less-educated white men had risen, while that for college grads had fallen. Do the math: white men who did not graduate from high school were dying at a rate 2.9 times that of college grads in 1993—and at a rate 4.4 times higher in 2001. For black men, the comparable mortality rates were 2.1 times higher in 1993 and 3.4 times higher in 2001.

For white women who never graduated from high school, the death rate was 422 per 100,000 in 1993, and for white women with a college degree it was 165. In 2001? It rose to 553 per 100,000 in the first group, and dropped to 146 in the highly-educated group. Breaking that down, the death rate from cancer among white women with only 12 years of education rose 1.1 percent per year during the period studied; for heart disease and stroke, it rose 1.8 percent per year among these women. All three of these diseases have become more preventable and more treatable—but, apparently, only for some.

Conclusion: the widening death gap was due to sharp decreases in mortality from all causes—but especially in heart disease, cancer and stroke, all of which have benefited from new forms of prevention and treatment—among the most educated. The less educated have benefited hardly at all from medical progress.

Why are the death rates from the major causes of death falling among the educated but rising among the less educated? Think of lower educational attainment as a marker of social and economic class—which has become a big issue in the presidential campaign, as Clinton grabs the votes of those lower on the socioeconomic ladder and Obama gets the votes of the higher-ups. The have-nots are not only poorer; they also are less likely to have health insurance or stable employment, which means little to no preventive care, and lower health literacy. The last factor means less likelihood of knowing when some small symptom means big trouble, and greater difficulty navigating the medical system. Those with less education are also more likely to smoke, be obese, get little exercise, and suffer from high blood pressure due to the stress of unemployment.

“Risk factors are higher in less well-educated groups, and they have less access to preventive medicine and treatment,” says Ahmedin Jemal of the American Cancer Society, who led the study.

The death gap isn’t going away. In 2005, the most recent year the researchers analyzed, the all-cause mortality rate for those with less than a high-school education was 3.2 times higher than that for people with even some college.

The poor will always be with us, as the saying goes, and so will inequality in education. But other countries have socioeconomic inequality also—with no comparable death gap, says Jemal, because they do not make access to health care (especially non-emergency and preventive care) contingent on having health insurance. Two Americas, indeed.