Research Article: The Reversal of Fortunes: Trends in County Mortality and Cross-County Mortality Disparities in the United States

Date Published: April 22, 2008

Publisher: Public Library of Science

Author(s): Majid Ezzati, Ari B Friedman, Sandeep C Kulkarni, Christopher J. L Murray, Thomas Novotny

Abstract: BackgroundCounties are the smallest unit for which mortality data are routinely available, allowing consistent and comparable long-term analysis of trends in health disparities. Average life expectancy has steadily increased in the United States but there is limited information on long-term mortality trends in the US counties This study aimed to investigate trends in county mortality and cross-county mortality disparities, including the contributions of specific diseases to county level mortality trends.Methods and FindingsWe used mortality statistics (from the National Center for Health Statistics [NCHS]) and population (from the US Census) to estimate sex-specific life expectancy for US counties for every year between 1961 and 1999. Data for analyses in subsequent years were not provided to us by the NCHS. We calculated different metrics of cross-county mortality disparity, and also grouped counties on the basis of whether their mortality changed favorably or unfavorably relative to the national average. We estimated the probability of death from specific diseases for counties with above- or below-average mortality performance. We simulated the effect of cross-county migration on each county’s life expectancy using a time-based simulation model. Between 1961 and 1999, the standard deviation (SD) of life expectancy across US counties was at its lowest in 1983, at 1.9 and 1.4 y for men and women, respectively. Cross-county life expectancy SD increased to 2.3 and 1.7 y in 1999. Between 1961 and 1983 no counties had a statistically significant increase in mortality; the major cause of mortality decline for both sexes was reduction in cardiovascular mortality. From 1983 to 1999, life expectancy declined significantly in 11 counties for men (by 1.3 y) and in 180 counties for women (by 1.3 y); another 48 (men) and 783 (women) counties had nonsignificant life expectancy decline. Life expectancy decline in both sexes was caused by increased mortality from lung cancer, chronic obstructive pulmonary disease (COPD), diabetes, and a range of other noncommunicable diseases, which were no longer compensated for by the decline in cardiovascular mortality. Higher HIV/AIDS and homicide deaths also contributed substantially to life expectancy decline for men, but not for women. Alternative specifications of the effects of migration showed that the rise in cross-county life expectancy SD was unlikely to be caused by migration.ConclusionsThere was a steady increase in mortality inequality across the US counties between 1983 and 1999, resulting from stagnation or increase in mortality among the worst-off segment of the population. Female mortality increased in a large number of counties, primarily because of chronic diseases related to smoking, overweight and obesity, and high blood pressure.

Partial Text: Average life expectancy in the United States has increased steadily in the past few decades, rising by more than 7 y for men and more than 6 y for women between 1960 and 2000. Parallel to this aggregate improvement, there are large disparities in health and mortality across population subgroups defined by race, income, geography, social class, education, and community deprivation indices [1–18]. Furthermore, there is evidence that health and mortality disparities have persisted or even increased over time in both relative and absolute terms [2,10,11,15,19,20], indicating that the observed aggregate health gains may not have been distributed evenly.

We arranged the 3,141 US counties into 2,068 units, each consisting of one or multiple individual counties. There were two reasons for forming merged county units: (1) to avoid unstable death rates, smaller counties were merged with adjacent counties to form units with a total population of at least 10,000 males and 10,000 females in 1990 [14]; and (2) to account for changes in county definitions and lines, such as formation of new counties and reversion to non-county status. This grouping of counties created a consistent set of 2,068 individual or merged county units that represent the same physical land areas from 1959 through the present. Because borough-specific death statistics were not available prior to 1982 in New York City, its five separate counties were merged into a single unit. For each county unit, we calculated annual sex-specific life expectancies. Table 1 provides summary information on the sociodemographic characteristics of counties. We also calculated probabilities of death from all causes as well as from specific diseases and disease clusters in the following age groups: 0–4, 5–14, 15–44, 45–64, 65–74, and 75–84 y.

Between 1961 and 1999, average life expectancy in the United States increased from 66.9 to 74.1 y for men and from 73.5 to 79.6 y for women. The spread of male life expectancy across US counties, as measured by SD, rose slowly in the 1960s, then declined steeply until 1983 (1.9 y), when it began to rise again to 2.3 in 1999; the rate of increase declined in the 1990s (Figure 1). For women, cross-county life expectancy SD declined between 1961 and 1983 (from 2.0 y to 1.4 y), but rose steadily to 1.7 y in 1999. Cross-county life expectancy SD was always larger for men than for women.

Our analysis of county-level mortality demonstrates that the 1980s and 1990s marked an era of increased inequalities in mortality in the United States, measured both as the distribution of life expectancy in the US counties, and as the difference between the best-off and worst-off counties. Our finding on the decline and subsequent rise of mortality disparities across US counties would be the same using other metrics of mortality disparity, such as the interquartile range. Equally important is the finding that the higher disparity partly resulted from stagnation or increase in mortality among the worst-off segment of the population, with life expectancy for approximately 4% of the male population and 19% of the female population having had either statistically significant decline or stagnation. This stagnation and reversal of mortality decline, although affecting a minority of the nation’s population, is particularly troubling because an oft-stated aim of the US health system is the improvement of the health of “all people, and especially those at greater risk of health disparities” (see for example