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Objectives. To estimate total life expectancy (TLE), disability-free life expectancy (DFLE), and disabled life expectancy (DLE) by US state for women and men aged 25 to 89 years and examine the cross-state patterns. Methods. We used data from the 2013-2017 American Community Survey and the 2017 US Mortality Database to calculate state-specific TLE, DFLE, and DLE by gender for US adults and hypothetical worst- and best-case scenarios. Results. For men and women, DFLEs and DLEs varied widely by state. Among women, DFLE ranged from 45.8 years in West Virginia to 52.5 years in Hawaii, a 6.7-year gap. Men had a similar range. The gap in DLEs across states was 2.4 years for women and 1.6 years for men. The correlation among DFLE, DLE, and TLE was particularly strong in southern states. The South is doubly disadvantaged: residents have shorter lives and spend a greater proportion of those lives with disability. Conclusions. The stark variation in DFLE and DLE across states highlights the large health inequalities present today across the United States, which have significant implications for individuals' well-being and US states' financial costs and medical care burden.

Policy Points Explanations for the troubling trend in US life expectancy since the 1980s should be grounded in the dynamic changes in policies and political landscapes. Efforts to reverse this trend and put US life expectancy on par with other high-income countries must address those factors. Of prime importance are the shifts in the balance of policymaking power in the United States, the polarization of state policy contexts, and the forces behind those changes., (© 2020 Milbank Memorial Fund.)

Policy Points Changes in US state policies since the 1970s, particularly after 2010, have played an important role in the stagnation and recent decline in US life expectancy. Some US state policies appear to be key levers for improving life expectancy, such as policies on tobacco, labor, immigration, civil rights, and the environment. US life expectancy is estimated to be 2.8 years longer among women and 2.1 years longer among men if all US states enjoyed the health advantages of states with more liberal policies, which would put US life expectancy on par with other high-income countries., Context: Life expectancy in the United States has increased little in previous decades, declined in recent years, and become more unequal across US states. Those trends were accompanied by substantial changes in the US policy environment, particularly at the state level. State policies affect nearly every aspect of people's lives, including economic well-being, social relationships, education, housing, lifestyles, and access to medical care. This study examines the extent to which the state policy environment may have contributed to the troubling trends in US life expectancy., Methods: We merged annual data on life expectancy for US states from 1970 to 2014 with annual data on 18 state-level policy domains such as tobacco, environment, tax, and labor. Using the 45 years of data and controlling for differences in the characteristics of states and their populations, we modeled the association between state policies and life expectancy, and assessed how changes in those policies may have contributed to trends in US life expectancy from 1970 through 2014., Findings: Results show that changes in life expectancy during 1970-2014 were associated with changes in state policies on a conservative-liberal continuum, where more liberal policies expand economic regulations and protect marginalized groups. States that implemented more conservative policies were more likely to experience a reduction in life expectancy. We estimated that the shallow upward trend in US life expectancy from 2010 to 2014 would have been 25% steeper for women and 13% steeper for men had state policies not changed as they did. We also estimated that US life expectancy would be 2.8 years longer among women and 2.1 years longer among men if all states enjoyed the health advantages of states with more liberal policies., Conclusions: Understanding and reversing the troubling trends and growing inequalities in US life expectancy requires attention to US state policy contexts, their dynamic changes in recent decades, and the forces behind those changes. Changes in US political and policy contexts since the 1970s may undergird the deterioration of Americans' health and longevity., (© 2020 The Authors. The Milbank Quarterly published by Wiley Periodicals LLC on behalf of The Millbank Memorial Fund.)

Studies of the early-life origins of adult physical functioning and mortality have found that childhood health and socioeconomic context are important predictors, often irrespective of adult experiences. However, these studies have generally assessed functioning and mortality as distinct processes and used cross-sectional prevalence estimates that neglect the interplay of disability incidence, recovery, and mortality. Here, we examine whether early-life disadvantages both shorten lives and increase the number and fraction of years lived with functional impairment. We also examine the degree to which educational attainment mediates and moderates the health consequences of early-life disadvantages. Using the 1998-2008 Health and Retirement Study, we examine these questions for non-Hispanic whites and blacks aged 50-100 years using multistate life tables. Within levels of educational attainment, adults from disadvantaged childhoods lived fewer total and active years, and spent a greater portion of life impaired compared with adults from advantaged childhoods. Higher levels of education did not ameliorate the health consequences of disadvantaged childhoods. However, because education had a larger impact on health than did childhood socioeconomic context, adults from disadvantaged childhoods who achieved high education levels often had total and active life expectancies that were similar to or better than those of adults from advantaged childhoods who achieved low education levels.

Educational attainment level has long been a strong predictor of adult health and longevity in the United States. Interestingly, the association between education and these outcomes has strengthened in recent decades. Since the 1980s, higher-educated adults have experienced favorable trends in health and longevity, while lower-educated adults have experienced stagnation or unfavorable trends. Studies have provided important clues about why the association between education and health and longevity has strengthened over time. However, explanations remain incomplete and contested. This article discusses key findings and debates about why the association has become stronger and offers recommendations to advance robust explanations. Two key recommendations call for a fundamental shift in how researchers conceptualize and study the increasingly strong association. These include (a) reconsidering which education groups should be viewed as normative in analyses of the trends and (b) elevating attention on contexts, institutions, and actors that have had an outsized influence on the trends. [ABSTRACT FROM AUTHOR]

Studies of the relationship between income inequality and life expectancy often speculate about the role of policy, but direct empirical research is limited. Drawing on the neo-materialist perspective, we examine whether the longitudinal association between income inequality and life expectancy is mediated and moderated by policy liberalism in U.S. states (2000–2014). More liberal policy contexts are characterized by greater efforts to regulate the economy, redistribute income, and protect vulnerable groups and lesser efforts to penalize deviant social behavior. We find that state-level income inequality is inversely associated with policy liberalism and life expectancy. The association between income inequality and life expectancy was not mediated by policy liberalism but was moderated by it. The association is attenuated in states with more liberal policy contexts, supporting the neo-materialist perspective. This finding illustrates how states like New York and California (with liberal policy contexts) can exhibit high income inequality and high life expectancy. [ABSTRACT FROM AUTHOR]

The United States currently ranks last among high-income countries for life expectancy. Since 2014, U.S. life expectancy has declined. By now, these alarming trends are well known to researchers, the public, and policymakers. Nevertheless, there is no consensus among researchers on the causes of the trends, and there has been no serious and effective bipartisan effort to solve the problem. The dominant narrative has implicated Americans' behaviors, such as smoking, illicit drug use, and suicide; yet, this narrative is misguided and counterproductive. It also exonerates the key structural drivers of behaviors and health, namely the U.S. policy context and the outsized influence of corporations and big donors on those policies. The U.S. policy context has changed dramatically since the 1970s, particularly at the state level. State policies have hyperpolarized along partisan lines. These changes have likely had a profound impact on nearly every aspect of Americans ' lives, cutting short many of them. Consequently, this Essay argues that state policies increasingly affect life and death in the United States. It raises concerns about how the polarization of state policies will further deteriorate the health of many Americans, It points to three significant forces behind the polarization and the growing importance of state policy contexts on Americans ' lives--(1) New Federalism; (2) the new type of state preemption laws; and (3) the emergence of organizations, such as the American Legislative Exchange Council, through which corporations and big donors influence policies. [ABSTRACT FROM AUTHOR]

The article examines whether the longitudinal association between income inequality and life expectancy was mediated and moderated by policy liberalism in U.S. states from 2000 to 2014. It shows that state-level income inequality is inversely associated with policy liberalism and life expectancy. The association between income inequality and life expectancy is attenuated in states with more liberal policy contexts, such as New York and California.

The importance of childhood circumstances, broadly defined, for shaping adult health and longevity is well established. But the significance of one of the most prevalent childhood adversities--exposure to problem drinkers--has been understudied from a sociological perspective and remains poorly understood. We address this gap by drawing on cumulative inequality theory, using data from the 1988-2011 National Health Interview Survey-Linked Mortality Files, and estimating Cox proportional hazards models to examine the relationship between exposure to problem drinkers in childhood and adult mortality risk. Childhood exposure to problem drinkers is common (nearly one in five individuals were exposed) and elevates adult overall and causespecific mortality risk. Compared to individuals who had not lived with a problem drinker during childhood, those who had done so suffered 17 percent higher risk of death (p < .001) over the follow-up period, net of age, sex, and race/ethnicity. We find compelling evidence that the duration, source, and intensity of exposure to problem drinkers in childhood contributes to inequality in adult mortality risk. Favorable socioeconomic status in adulthood does not ameliorate the consequences of childhood exposure to problem drinkers. The primary intervening mechanisms are risky behaviors, including adult drinking and smoking. The findings--which reveal that the influence of problem drinking is far reaching and long term--should inform policies to improve childhood circumstances, reduce detrimental effects of problem drinking, and increase life expectancy. [ABSTRACT FROM AUTHOR]

Female life expectancy is currently shorter in the United States than in most high-income countries. This study examines work-family context as a potential explanation. While work-family context changed similarly across high-income countries during the past half century, the United States has not implemented institutional supports, such as universally available childcare and family leave, to help Americans contend with these changes. We compare the United States to Finland--a country with similar trends in work-family life but generous institutional supports--and test two hypotheses to explain US women's longevity disadvantage: (1) US women may be less likely than Finnish women to combine employment with childrearing; and (2) US women's longevity may benefit less than Finnish women's longevity from combining employment with childrearing. We used data from women aged 30-60 years during 1988-2006 in the US National Health Interview Survey Linked Mortality File and harmonized it with data from Finnish national registers. We found stronger support for hypothesis 1, especially among low-educated women. Contrary to hypothesis 2, combining employment and childrearing was not less beneficial for US women's longevity. In a simulation exercise, more than 75 percent of US women's longevity disadvantage was eliminated by raising their employment levels to Finnish levels and reducing mortality rates of non-married/non-employed US women to Finnish rates. [ABSTRACT FROM AUTHOR]