What is to be done about the US death crisis?

A vital statistic has been flashing bright red for decades

Adam Tooze and Edward Luce have rightly drawn attention to the unattended health crisis in America. Tooze notes that the Chinese can now expect to live longer than Americans; not just because Chinese life expectancy continues to grow, but more alarmingly because US life expectancy has been falling in absolute terms — an “extraordinary and shameful fact.”

Judged by this basic metric, the contemporary United States fails and for a substantial minority of its population, it fails spectacularly. And yet that extraordinary and shameful fact barely registers in political debate, a silence that is both symptom and cause.

Adam Tooze, September 2, 2022.

“Americans live almost five years less than the wealthy country average,” Luce notes. The numbers are so concerning that “even the Pentagon has to sit up.” American elites in general, and its political elites in particular, really do need to pay attention.

Life expectancy contains the strongest signal of the general well-being of a population. It is a vital statistic — akin to an organism’s resting heart rate. Declines in life expectancy outside of wars are glaring signs of a society in deep trouble. Indeed, Emmanuel Todd predicted the imminent fall of the Soviet Union in the early-1970s based precisely on his reading of Russia’s life expectancy. Even the CIA concluded that the Soviets were in trouble from the same vital statistic.

While its advanced economy peers have on average gained 12.9 years in life expectancy since 1960, the United States has gained only 8.9. Back in 1960, Americans could expect to live longer than the French, the Germans and the Japanese. Gains in US life expectancy were, in fact, more rapid in the 1970s than in Europe. But after the neoliberal counterrevolution, the United States has fallen more and more behind.

I want to reemphasize the significance of the signal in life expectancy. The World Bank predicted the Sino-Indian economic divergence precisely on the basis of rapid gains in Chinese general well-being after the shock of the cultural revolution (also visible in the graph). The volatility of the graphs for Russia and China contrast sharply with the smooth upward trajectory of the same for India and Brazil — attesting to the chaotic history of the communist powers.

As for the etiology of the crisis, Luce points to rising obesity, the opioid epidemic and Covid. These are all symptoms of a deeper malaise. The crisis certainly predates Covid. And while the Great Recession marks an inflection point, the United States has been steadily falling behind, say, France, since the Volcker coup.

What has gone wrong? Case and Deaton, who uncovered the rise in deaths due to drug overdose, suicides and alcohol poisoning since 2000, agree that the larger structure of the US socioeconomic system since the neoliberal counterrevolution is to blame (although they reserve special blame for the catastrophe of US healthcare in particular). They have shown that the mortality crisis is identical to the crisis of the working class family.

What has happened is that the transformations induced in the economy by the neoliberal counterrevolution hollowed out the US occupational structure, creating ‘an hourglass economy’. This undermined the reproduction of the working class family. This was, as I wrote last year, “the Lewisian model in monstrous reverse.”

The New Economy that obtained with the capitulation of social democracy had led to the rise of an overbearing class of prestige-schooled meritocrats who began to claim a larger and larger share of the income, esteem and even work. What obtained then was an ‘hourglass’ occupational structure where most of the new jobs created were either for the highly-skilled meritocrats who run everything from the New York Times to Goldman and Google, or for unskilled day laborers at fast-food chains and grocery stores. This dual economy echoed the Lewisian model in monstrous reverse: instead of workers leaving the traditional low-productivity sector for the modern high-productivity sector, working-class breadwinners were pushed out of middle-skilled occupations that vanished from the industrial sector and into either the low-productivity sector or to the margins of employment and a life of dependence and indolence.

Policy Tensor. “The Making of the Mother of All Economic Booms.”

So, the US health crisis is an indictment of the American socioeconomic system at large. Leaning against the symptoms alone is not going to cut it. The death crisis is a signal of a society in deep trouble. It calls for deep reform. I don’t think there can be any disagreement on this. So, what are elites thinking?

American elites have a formula for how to get out of this mess. The formula says: in order to restabilize the working class family, broad-based growth must be restored; and broad-based growth is to be restored through running tight labor markets. This is a compelling formula — since we know that working class fortunes respond well to tight labor markets. But it suffers from three problems.

First, it threatens to destroy the essential premise of the formula itself by resurrecting the Phillips curve and thereby recoupling wages and inflation. So, it’s not clear that it can even work on a sustained basis. And if we’re facing secular inflationary headwinds — as we likely are — inflation will be a binding constraint on how far we can go with this.

Second, it leaves the authority over the management of the economic affairs of the nation in the hands of the technocrats. More balanced authority between politicians and technocrats is called for to deal with the secular crisis of the American working class. Put another way, neither the fiscal primacy of high Keynesianism (1961-1979), nor the monetary primacy of neoliberalism (1979-2021), alone offers the combination of stability and effectiveness that is now required. We need both arms to secure price stability and broad-based growth.

Third, and most importantly, it does not go far enough in its attempt at reforming the American social system. Merely restoring broad-based growth is not going to solve the coupled class-political and health crises. As important is the rebuilding of intermediary institutions between the working class and the hated coastal elites, whose decay has been well-documented by Putnam.

Social dynamism can’t simply be conjured up by elites from New York and Oxford, no matter how large a check Sam Bankman-Fried is prepared to write. Working class participation is not optional. The midcentury New Deal system worked precisely because it gave voice, through these intermediary institutions, to the working classes (and provincial elites) in what is now called “flyover country.” So, these intermediary institutions must be rebuilt so that influence over the nation’s affairs in not monopolized by the professional class, as it has been since the Clinton capitulation. One straightforward way to do this is to pour money into state schools (and away from the Ivory Tower and the coastal zones of affluence).

More generally, American elites have a lot of homework to do. The shameful death crisis is a wake-up call. It demands deep reform of the American socioeconomic-political system. A conscious strategy of vertical and regional depolarization has to be pursued on a sustained basis to revitalize the home front.