Late last year, a study in the Proceedings of the National Academy of Sciences found that middle-aged, white Americans have been getting sicker and dying in greater numbers, even as the rest of the world is living longer and healthier.

The authors of that study attributed the trend to what we called “despair deaths:” mainly suicides, drug overdoses, and alcohol-related liver disease.

Now, a new analysis from the Commonwealth Fund suggests there’s more to the story. The report, by David Squires and David Blumenthal, notes that between 1999 and 2014, mortality rates in the U.S. rose for white Americans aged 22 and 56. Before that, death rates had been falling by nearly 2 percent each year since 1968. Squires and Blumenthal call the difference between the those two mortality trend lines—the expected, declining one and the actual, rising one—the “mortality gap.”

The Mortality Gap for White Americans, By Age

Change in deaths per 100,000 people between 1999 and 2014. (CDC Wonder Database / Commonwealth Fund)

In 2014, they write, the mortality gap was so big that it accounted for an extra 100 dead, middle-aged white people for every 100,000.

By digging through CDC data, they saw that the reason death rates failed to decline as expected was not entirely due to suicide and substance abuse. Although those factors explained about 40 percent of the gap, the rest was attributable to the leading causes of death—things like heart disease, diabetes, and respiratory disease. Though there are still fewer people dying from those diseases than there were in the 1960s, according to this analysis, the rate of decline has slowed.

Death Rate From the 10 Leading Causes of Death

Data between 1968 and 1998 for all whites; data between 1999 and 2014 for non-­Hispanic whites. Mortality rate is deaths per 100,000 people. (CDC Wonder Database / Commonwealth Fund.)

That means not only are middle-aged white people drinking more, using more opioids, and killing themselves at higher rates, more of them are getting sick with the diseases that usually kill older people. And when they do get sick, they don’t get better.

This trend was especially concentrated in the South, they found. “In seven southern states—West Virginia, Mississippi, Oklahoma, Tennessee, Kentucky, Alabama, and Arkansas—the gap between actual and expected mortality in 2014 exceeded 200 deaths per 100,000 people. In West Virginia, mortality rates were higher than at any time since 1980,” they write. The report was not published in a peer-reviewed journal, and its raw data was not made available.

Mortality Gap for Middle-Aged Whites, by State

‘Gap’ is the actual mortality rate for middle-aged whites in 2013-2014 to what it would have been if it had continued declining by about 2 percent per year. (CDC Wonder database / Commonwealth Fund.)

It’s worth noting that, because of historic racial injustice, health outcomes for African Americans still lag behind those of white Americans in many areas. African Americans die an average of four years younger than white Americans do, for example. However, the mortality rate for African Americans is declining, and that of white Americans is increasing—a historically anomalous trend.

Squires and Blumenthal think the worsening economic standing of uneducated, middle-aged whites might have played a role.

“On a range of social and economic indicators, middle-aged whites have been falling behind in the 21st century,” they write. “They have lower incomes, fewer are employed, and fewer are married.”

This does not mean whites are worse off than minorities, they note. But it could mean that they are the canaries of a coal mine of broader societal problems that have deleterious health effects, such as “less-educated workers’ increasing disengagement from the mainstream economy; declining levels of social connectedness; weakened communal institutions; and the splintering of society along class, geographic, and cultural lines,” they write.

The findings are also concerning because four of the seven worst-off states the researchers highlighted have opted not to expand Medicaid as part of Obamacare. And although health insurance alone likely won’t be enough to turn the tide of premature deaths, it’s certainly one of the few immediate interventions that could help.