The Affordable Care Act took a major step toward implementation last Tuesday with the launch of the online insurance exchanges, limping across the finish line despite three years of Republican obstruction that culminated in this week’s 11th hour attempt to dismantle the law by shutting down the federal government.
It’s easy to forget, amid the hyper-partisan controversy, that the main purpose behind President Obama’s signature health-care reform law is not to curtail individual freedom or send senior citizens to death panels, but to give more Americans access to health insurance. Whether you think the Affordable Care Act is the right solution or a dangerous step toward tyranny, it’s hard to dispute that the U.S. health-care system is broken. More than 48 million people lack health insurance, and despite having the world’s highest levels of health-care spending per capita, the U.S. has some of the worst health outcomes among developed nations, lagging behind in key metrics like life expectancy, premature death rates, and death by treatable diseases, according to a July study in the Journal of the American Medicine Association.
For some Americans, the reality is far worse than the national statistics suggest. In particular, growing health disadvantages have disproportionately impacted women over the past three decades, especially those without a high-school diploma or who live in the South or West. In March, a study published by the University of Wisconsin researchers David Kindig and Erika Cheng found that in nearly half of U.S. counties, female mortality rates actually increased between 1992 and 2006, compared to just 3 percent of counties that saw male mortality increase over the same period.
“I was shocked, actually,” Kindig said. “So we went back and did the numbers again, and it came back the same. It’s overwhelming.”
Kindig’s findings were echoed in a July report from University of Washington researcher Chris Murray, which found that inequality in women’s health outcomes steadily increased between 1985 and 2010, with female life expectancy stagnating or declining in 45 percent of U.S. counties. Taken together, the two studies underscore a disturbing trend: While advancements in medicine and technology have prolonged U.S. life expectancy and decreased premature deaths overall, women in parts of the country have been left behind, and in some cases, they are dying younger than they were a generation before. The worst part is no one knows why.
The Kindig study does note strong relationships between county mortality rates and several cultural and socioeconomic indicators. In particular, location appears to have an outsized effect on mortality rates. Counties with rising female mortality rates, marked in red, paint a broad stroke across Appalachia and the Cotton Belt, moving across to the Ozarks and the Great Plains. The Northeast and the Southwest, on the other hand, have been largely untouched.
But it’s not clear how these geographical differences play a role in mortality, or why the effect would be so much greater on women than on men. “Clearly something is going on,” Kindig said. “It could be cultural, political, or environmental, but the truth is we don’t really know the answer.”
Other researchers have pointed out the correlation between education rates and declining female health outcomes. The most shocking study, published in August 2012 by the journal Health Affairs, found that life expectancy for white female high-school dropouts has fallen dramatically over the past 18 years. These women are now expected to die five years earlier than the generation before them—a radical decline that is virtually unheard of in the world of modern medicine. In fact, the only parallel is the spike in Russian male mortality after the fall of the Soviet Union, which has primarily been attributed to rising alcohol consumption and accidental death rates.
“It's unprecedented in American history to see a drop in life expectancy of such magnitude over such a short time period,” said Jay Olshansky, the lead author of the study. “I don't know why it happened so rapidly among this subgroup. Something is different for the lives of poor people today that is worse than it was before.”
Education alone does not explain why female high-school dropouts are so much worse off than they were two decades ago. But researchers have used it as a proxy to determine more significant socioeconomic indicators, like access to health care and income opportunities, as well as health behaviors like smoking and obesity. Smoking in particular appears to have had a significant impact on female mortality rates, as the health consequences of previous decades of tobacco use set in. Olshansky points out that female obesity and drug abuse have risen dramatically over the past two decades, and may also play a role in mortality rates.
Researchers are hopeful that the expansion of health-care coverage under the Affordable Care Act will help ameliorate some of the health risks for poor and uneducated women. But access to health insurance is only part of the puzzle—in fact, Kindig’s study found that medical care factors had no discernible impact on death rates at the county level. “Health care is far from the whole story,” Kindig told me. “More and more people are beginning to realize that the non-health-care factors are at least as important.”
In May, Jennifer Karas Montez, a social demographer who studies health inequalities, co-authored a study that was the first to investigate how quality of life might be playing a role in the early deaths of female high-school dropouts. Montez found that while smoking accounts for half of the decline in life expectancy among these women, whether or not a woman has a job is equally significant. “Women without a high-school degree have not made inroads in the labor force, especially in post-recession America,” Montez said in an interview. In fact, only one-third of women without a high-school diploma are employed, compared to half of their male counterparts, and nearly three-quarters of better-educated women. When they are employed, Montez said, it is usually in low-wage jobs that offer no benefits or flexibility. Smoking and other destructive behaviors, she added, may just be symptoms of the heightened stress and loneliness experienced by women who don’t graduate from high school.
“Life is different for women without a high-school degree than it was a few decades ago, and in most cases it’s a lot worse,” she said. “It’s really just a perfect storm.”