Notes on Falling Behind: The Growing Gap in Life Expectancy Between the United States and Other Countries, 1933–2021

Objectives

• Document the evolution of the US life expectancy disadvantage and regional variation across US states.
• Compare US growth with other countries using 3 data sources (UN Population Division, Human Mortality Database, US Mortality Database).
• Examine growth rates, rank of the US, and state-level trends over an 8-decade span (1933–2021 for US data, up to 2021 for international data).
• Address questions on how many countries surpassed the US, how the US position changed, how US growth diverged from other countries, and how state-life expectancy trends contributed to the national picture.

Data and Sources

• Life expectancy estimates used for analysis period 1950–2021 from the United Nations Population Division (UN PD): 237 countries/areas; derived from official life tables and mortality data. $\text{UN data}$
• Pre-1950 life expectancy estimates from the Human Mortality Database (HMD): US begins 1933; many countries begin earlier (e.g., Sweden 1751, France 1816, etc.). $\text{HMD data (pre-1950)}$
• US state life expectancy estimates 1959–2020 from the US Mortality Database (USMD): 50 states, DC, and Census regions. $\text{USMD data}$
• Population thresholds: focus on populous countries with population > 500,000 to stabilize estimates. P>500{,}000
• World regions and US Census regions/divisions used for grouping: continents and 4 US regions with 9 divisions. $\text{US regions/divisions}$

Methods

• Constructed country-by-country life expectancy comparisons by year, focusing on countries that surpassed the US life expectancy at least once during 1950–2021.
• For each year, identified the population with the highest life expectancy among populous countries (e.g., Norway, Sweden, Netherlands, Japan, Macao, Hong Kong over different periods).
• Calculated year-over-year changes in life expectancy, mean changes per decade, and mean changes for 6 distinct growth phases in US life expectancy (see Phase definitions below).
• Ranked US relative to other populous countries by year; computed gaps between US life expectancy and the top performer each year.
• Compared 1959–2019 state life expectancy from USMD with country life expectancy from UN to estimate how states would rank if treated as independent countries (excluding the US when ranking).
• Examined adjacent populous countries for context: 2 higher and 2 lower life expectancy comparisons.
• Analyzed phase-specific slopes and medians across populous countries; used counts of countries surpassing the US to characterize the global context.

Phase-based Growth in US Life Expectancy (1950–2021)

• US life expectancy grew in 6 phases with distinctly different slopes (annual increases in years per year).
• Phase 1: 1950–1954
  • Growth rate: $g_1 = 0.21\ \text{years/annum}$
• Phase 2: 1955–1973
  • Growth rate: $g_2 = 0.10\ \text{years/annum}$ (slowed by about half from Phase 1)
• Phase 3: 1974–1982
  • Growth rate: $g_3 = 0.34\ \text{years/annum}$ (rebound)
• Phase 4: 1983–2009
  • Growth rate: $g_4 = 0.15\ \text{years/annum}$ (slowed again; >2 decades of slow growth)
• Phase 5: 2010–2019
  • Growth rate: $g_5 = 0.06\ \text{years/annum}$ (plateau)
• Phase 6: 2020–2021
  • Growth rate: $g_6 = -0.97\ \text{years/annum}$ (sharp decline during COVID-19)

Key Results: Global and Temporal Trends

• Across 1950–2021, 56 populous countries on 6 continents surpassed US life expectancy at some point.
  • Geographic breadth: Europe, Asia, the Americas, Africa, and the Middle East contributed.
• Initial US disadvantage: In 1933, the US ranked 8th among 16 populous countries; by 1950, rank fell to 12th with a gap of $3.5$ years to the top performer. $\text{Gap}_{1950} = 3.5\text{ years}$
• Growth-rate comparisons (1950–2021): other countries generally outpaced the US in most years, especially during Phase 4 (1983–2009) where the US lagged behind the median pace of populous countries.
• US rank evolution among populous countries:
  • 1950: 12th among 16; top gap $\approx 3.5\text{ years}$ behind Norway at certain early years.
  • 1968: US rank fell to 29th.
  • 1976: US rank recovered to 13th.
  • 1983–2009: US rank declined from 15th to 32nd; life expectancy gap widened from 2.6 to 4.7 years (top performer).
  • 2010–2019: 7 additional populous countries surpassed the US; US rank around the 40th by 2019.
  • 2020: US life expectancy ranked 46th; gap widened to about 7.8 years.
  • 2021: Gap to top performer (Hong Kong) reached $8.3\ \text{years}$.
• Relative gaps in 1950–2021: top performers varied by year (Norway, Sweden, Netherlands, Japan, Macao, Hong Kong) but repeatedly outpaced the US; by 2021, many non-Western countries had higher life expectancy than the US.
• Phase-specific continent/country patterns: growth slowed in several regions during Phase 4 and Phase 5; East Asia and some Eastern European/Latin American countries showed rapid gains in other periods.

US States: Geographic and Temporal Patterns (1959–2019)

• State contributions to US life expectancy changes (1959–2019): Hawaii consistently had among the highest life expectancy by 2019 (highest among states, ranking ~22nd globally in 2019 if treated as a country); Mississippi had one of the lowest life expectancies (ranking ~79th globally if treated as a country).
• Regional patterns of state growth (Phase 4: 1983–2009; Phase 5: 2010–2019):
  • Generally higher increases in the Northeast (Divisions 1–2) and West (Divisions 8–9).
  • Lower increases in the South Central and Midwest (Divisions 6–7; Regions 3–4).
  • Midwest accounted for more than half of states with a decline in Phase 5 (2010–2019).
• Phase 3 (1974–1982) showed broad state-level gains that helped the US rebound temporarily.
• Across 1959–2019, no state matched the median growth of populous countries in Phases 2, 4, and 5; only Hawaii and Nevada matched the median in Phase 2.
• In Phase 3, almost all states outpaced the median growth of populous countries, except perhaps a few outliers (Oklahoma among others).

Adjacent Countries and Contextual Benchmarks

• For contextual ranking, 4 adjacent populous countries used: two higher, two lower life expectancy for comparison purposes (e.g., Netherlands/Denmark higher; Hungary/Bulgaria higher/lower in some contexts; UK/Poland etc.).
• The analysis showed that some middle-income and Communist countries outperformed the US, illustrating that the US gap is not simply a matter of overall global income level but involves country-specific policies and historical trajectories.

Explanations and Interpretations (Discussion)

• Broad finding: The US health disadvantage is pervasive, not confined to a single disease or issue, and intensified from Phase 4 onward.
• Potential contributing domains (from National Academies and subsequent research): health systems, individual behaviors, socioeconomic factors, environment, policies and social values. Distinctive US characteristics in each domain may contribute to poorer health outcomes compared with peers.
• Specific proximate and upstream factors mentioned as potential contributors:
  • Downstream: obesity, substance use disorders, and cardiometabolic diseases; limitations in the health care system.
  • Upstream: macrostructural factors such as social welfare, income support, and broader policy environments.
• Timing and slope changes: Although prior literature often pointed to the 1980s–1990s as onset, this study documents slowing growth beginning in Phase 2 (1955–1973), with continued slowdowns and reversals that allowed many countries to surpass the US in later decades.
• Phase 5 (2010–2019) plateau: historically sharp plateaus in US life expectancy were accompanied by 7 additional countries surpassing the US; some explanations include obesity trends, opioid crisis, and metabolic/substance-related factors, but the author calls for more research to distinguish mediators from confounders.
• The 2020–2021 COVID-19 period drastically reduced US life expectancy (
• Contextual examples of rapid gains elsewhere: for instance, Hong Kong’s ascent to the world’s highest life expectancy by 2011 illustrates that extraordinary improvements can occur; conversely, the US stagnation persisted despite national wealth and resources.

Policy, Ethics, and Practical Implications

• Public health implications: US health disadvantage has broad consequences beyond mortality, including morbidity, health care costs, workforce productivity, and the economy.
• Policy implications: Investigate what foreign countries do differently—social welfare generosity, public health regulations, and health system design—and consider how such policies might be adapted in the US context.
• Socioeconomic and structural considerations:
  • The US has high income inequality, wealth concentration, and poverty relative to other OECD high-income nations.
  • Since the mid-1990s, US improvements in education and other social indicators lag behind peers in several domains; neoliberal policy shifts since the 1970s may have shaped broader health and social outcomes.
• Geographic and political factors: Conservative policy contexts at the state level correlated with stagnant or decreasing life expectancy after adjustment for confounders; further research is needed to establish causality and disentangle mediators vs. confounding variables.
• Structural racism and social determinants: The author highlights racism, diet, psychosocial stress, trauma, family structure disruptions, economic segregation, political polarization, and other social determinants as important research priorities to explain persistent disparities.
• Practical takeaway: While definitive causal links require further study, the magnitude and persistence of the US life expectancy disadvantage argue for policy exploration and experimentation to identify feasible interventions that could close the gap.

Limitations and Cautions

• Dependence on UN PD and USMD data; while validated, estimates may contain errors that affect rankings and year-to-year changes.
• Inclusion of territories and countries with contested status could influence rankings.
• Phase delineation (Phase 1–6) uses a methodological approach that may be less precise than statistical modeling (e.g., joinpoint regression).
• Smaller-population countries (below 500,000) are excluded from the main comparisons, which could limit some insights.

Connections to Foundational Principles and Real-World Relevance

• The study aligns with broader health science questions about why wealthier nations do not always achieve proportional health gains, challenging simple income-health paradigms.
• It connects macro-level policy environments with population health and shows how regional policy choices (e.g., in the Midwest vs. Northeast) can translate into state-level health differentials.
• The analysis underscores the importance of cross-country benchmarking (peer country comparisons) while expanding the lens to a broader set of nations to capture a more complete global picture.

Key Takeaways (Summary)

• The US life expectancy disadvantage began in the 1950s and has worsened over the ensuing decades, culminating in a widening gap with top-performing peers by 2020–2021.
• Life expectancy growth in the US has slowed in several phases, and many countries surpassed the US during phases 2, 4, and 5.
• By 2019 the US ranked around 40th among populous countries; by 2020 it fell to 46th, with a gap to the top performer widening to about 7–8 years.
• The geographic pattern shows faster gains in the Northeast and West, slower gains in the Midwest and South Central regions, with the Midwest contributing disproportionately to declines in Phase 5.
• A combination of downstream health issues (opioids, suicides, substance use, metabolic diseases) and upstream structural factors (policy choices, social welfare, inequality, structural racism) likely interact to produce the observed trends; more research is needed to identify causal pathways and effective interventions.
• Policy implications point toward examining and potentially adopting successful international policy approaches to reduce health disparities and improve population health outcomes in the United States.

References and Acknowledgments (high-level)

• Woolf SH. Falling behind: the growing gap in life expectancy between the United States and other countries, 1933–2021. Am J Public Health. 2023;113(9):970–980.
• Data and methodological references include UN World Population Prospects 2022, HMD methods, US Mortality Database, and related literature on health disparities and policy impacts.
• Acknowledgments: partial funding from the National Center for Advancing Translational Sciences; mapping assistance.