CHARLOTTE, North Carolina—John LaRue is having a tough time of it these days. He used to move things for people, advertising his services on Craigslist. But work slowed up, and he became homeless and started sleeping in his truck, until, that is, someone stole it.
Now, he told me, he’s fighting alcoholism and his health is deteriorating from living on the streets. I met LaRue at a Social Security office outside of Charlotte, where he was hiding his belongings in the bushes because he didn’t have anywhere to keep them and wasn’t allowed to bring them inside. “I feel like there’s a cloud over my head,” he told me. “It’s just been one thing after another.”
LaRue is one among many. In 1957, 97 percent of men in America ages 25 to 54 were either working or looking for work. Today, only 89 percent are. Italy is the only OECD country with a lower labor-force participation rate for men in their prime years. Just why there are so many men who aren’t working is a matter of debate. In a 2016 report, President Obama’s Council of Economic Advisers examined the declining labor-force participation rate and suggested that a drop-off in good jobs for low-skilled men was part of the explanation. Wages, the report theorized, are so low for many jobs that don’t require a college education that men don’t find it worth it to seek out bad jobs. A lack of job training and job-search assistance—when compared to other OECD countries—makes it more difficult for men to move into more lucrative fields. And a surge in incarceration has made it more difficult for men to find work when they leave prison, according to the report.
Conservative scholars have a different view. In his 2016 book, Men Without Work, Nicholas Eberstadt of the American Enterprise Institute put forward two arguments: First, that as social welfare programs have gotten more generous, they’ve lured men away from trying to find a job, and, second, that a large share of the men who are not working are ones with criminal records who have not been able to find a job, and have thus given up. To some degree, Eberstadt puts the blame on American men themselves. “It is impossible to imagine any earlier generation in which such a huge swath of prime-age men would voluntarily absent themselves from the workforce, living instead on the largesse of women they knew and taxpayers they did not,” he writes.
In all likelihood, men’s labor-force participation is declining because of a combination of the reasons mentioned above. But there’s another theory that deserves mentioning, especially because it fits with recent research about the declining health outcomes among American men. That theory suggests that American men are dropping out of the workforce because they are suffering from serious health conditions that make it difficult for them to work. As their health deteriorates, they’re getting on pain medications, which then make it even more difficult to re-enter the workforce.
Princeton economist Alan Krueger argued this theory late last year at a conference at the Federal Reserve Bank of Boston, and in an October 2016 paper circulated by the National Bureau of Economic Research. In his research, he found that almost half of working-age men who were not in the labor force were taking pain medication on a daily basis, and that two-thirds of those men were taking prescription medication. These men also reported more functional disabilities: Krueger found that 43 percent of prime-aged men who are out of the labor force report their health as fair or poor, compared with 12 percent of employed men and 16 percent of unemployed men. Health-related problems “are a substantial barrier to work that would have to be addressed to significantly reverse their downward trend in participation,” Krueger writes.
Krueger’s work looks specifically at pain medication, but the health problems keeping Americans out of the workforce may be broader than that. Millions of Americans are increasingly struggling with obesity and with diabetes, as well as with alcoholism. A 2015 paper by husband-and-wife team Anne Case and Angus Deaton in the Proceedings of the National Academy of Sciences found that while the mortality rates for people aged 45 to 52 in most rich countries declined by 2 percent per year, mortality rates for U.S. whites rose by half a percent each year starting in 1998. “Deaths of despair” such as suicide, alcohol and drug poisoning, and alcohol-related liver disease killed many of these men, the paper found.
As my colleague Olga Khazan has written, a subsequent analysis by the Commonwealth Fund found that things like heart disease, diabetes, and respiratory disease were contributing to some of the increased mortality among middle-aged Americans. There are now 30 million Americans living with diabetes, more than three times the number living with the disease in the early 1990s. And a recent study has suggested that diabetes might be more of a factor in American mortality than was previously thought—perhaps the third leading cause of death in America, after cancer and heart disease. (Diabetes is prone to under-counting because the official cause of death is often something else.) Obesity and diabetes have been shown to disproportionately affect people with a high-school education or less—the same group who are disappearing from the labor force.
“Obesity and diabetes are disabling, and they are one explanation for reduced labor-force participation,” Andrew Stokes, a Boston University professor and one of the authors of the diabetes study, told me.
Indeed, of the half a dozen men (and one woman) in North Carolina I talked to who had dropped out of the labor force, many told me of physical challenges that have made it difficult to work a regular job. Charles Lucas, 52, said that he had worked in fast food for a decade until his body got to a place where he could no longer stand. He’s had a few heart attacks, he told me, wheezing as he stood in line to apply for disability benefits. He’s been rejected for disability before. “I don’t know what I could do anymore” for work, he told me. He lives with his father, who gets Social Security.
John Crain, 43, used to work in construction, until alcoholism, divorce, and a death in his family led him to drop out of the workforce. Crain, who is currently homeless, is trying to get his life back together, but spends most of his days holding a sign by the side of the road asking for money. (He makes about $50 a day, he said.)
What is making men sicker than they used to be? I had thought it might be that the difficult jobs worked by Americans over their lifetimes might have worn them down physically, especially after I talked to Sandra White, 49. She could barely walk, and has had multiple surgeries on her back. She spent most of her life waiting tables and doing cleaning jobs on construction sites. The work has impacted her body, she told me. “It’s strenuous work, and it took a toll on my back,” she said.
But Krueger says that jobs are less physically demanding than they used to be, and so it doesn’t make sense that jobs would now be exacting a worse toll. What’s more, he said, workplaces have gotten safer over time, so Americans should be experiencing fewer work-related ailments.
What’s changed may be how people have reacted to pain, he said. Before, they worked through it. Now, they go to their doctors and get on pain medications. Doctors may be prescribing these pain medications too frequently: Recent studies have shown that doctors who prescribe opioids are more likely to have patients that use the drugs chronically.
“One of the things I conclude from my research is that if we are going to turn this around, we need to address the epidemic of widespread use of pain medication,” Krueger told me.
What has also changed is Americans’ eating habits. Obesity is on the rise in part because Americans now eat more ultra-processed foods that are high in sugar, and drink more sugar-sweetened beverages. One study has suggested that more than half of Americans’ calories now come from these “ultra-processed foods.” Part of this is because unhealthy foods are, by and large, cheaper than healthy ones; they also require little to no preparation, and many people enjoy how they taste. Some scientists argue that government policies have played a role in increasing how much sugar Americans consume—by providing farm subsidies, they say, the U.S. government encourages the production of cheap corn that ends up in high-fructose corn syrup, which is used in many processed foods.
Of course, this may be a mutually reinforcing cycle: Changes in the labor market over the last half-century may also be contributing to the declining health outcomes of Americans. More Americans now work in the service industry and in jobs with unpredictable schedules. Such workers may find it more difficult to exercise and eat a healthy diet. “Your occupation does really make an imprint on your health status,” said Stokes, the Boston University professor. Long-term night-shift work, for example, has been linked to an increased risk of heart disease and obesity. And some jobs are not conducive to healthy living: Around 86 percent of U.S. truck drivers are overweight or obese. Then again, people who aren’t in great shape may go into trucking, because it doesn’t require all that much physical activity. So it’s difficult to tease out what is a cause and what is an effect.
Likewise, the state of the economy may also be pushing people to turn to alcohol and drugs, which makes them less healthy. As jobs disappear, working-age men may drink or do drugs, as entertainment, to self-medicate their unhappiness, or both. They then find it hard to find and hold jobs. They are unhealthier because they don’t have something like a job motivating them to stay engaged and substance-free.
Most policymakers thinking up prescriptions for fixing declining labor-force participation focus on jobs. They suggest investing in public infrastructure to increase demand for workers and subsidizing programs that pay people to work temporarily. But this research suggests that gains could also come from investing in public-health programs that seek to encourage better eating, less smoking, and frequent exercise. In other words, policies may need to respond to the idea that the American man is in a state of despair not just because his labor prospects have dimmed but because his chance at good health has dimmed, too.
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