U.S. Life Expectancy Falls Again in ‘Historic’ Setback
The decline during the pandemic is the sharpest in nearly 100 years, hitting American Indian and Native Alaskan communities particularly hard.
by Ronni Caryn Rabin - NYT - August 31, 2022
The average life expectancy of Americans fell precipitously in 2020 and 2021, the sharpest two-year decline in nearly 100 years and a stark reminder of the toll exacted on the nation by the continuing coronavirus pandemic.
In 2021, the average American could expect to live until the age of 76, federal health researchers reported on Wednesday. The figure represents a loss of almost three years since 2019, when Americans could expect to live, on average, nearly 79 years.
The reduction has been particularly steep among Native Americans and Alaska Natives, the National Center for Health Statistics reported. Average life expectancy in those groups was shortened by four years in 2020 alone.
The cumulative decline since the pandemic started, more than six and a half years on average, has brought life expectancy to 65 among Native Americans and Alaska Natives — on par with the figure for all Americans in 1944.
In 2021, the shortening of life span was more pronounced among white Americans than among Black Americans, who saw greater reductions in the first year of the pandemic.
While the pandemic has driven most of the decline in life expectancy, a rise in accidental deaths and drug overdoses also contributed, as did deaths from heart disease, chronic liver disease and cirrhosis, the new report found.
Until now, experts have been accustomed to measuring life expectancy changes in increments of months, not years.
“Even small declines in life expectancy of a tenth or two-tenths of a year mean that on a population level, a lot more people are dying prematurely than they really should be,” said Robert Anderson, chief of mortality statistics at the N.C.H.S.
“This signals a huge impact on the population in terms of increased mortality,” he added.
Dr. Steven Woolf, director emeritus of the Center on Society and Health at Virginia Commonwealth University, characterized the diminution of life expectancy in the United States as “historic.”
While other high-income countries were also hard hit in 2020, the first year of the pandemic, most had begun to recover by last year, he said.
“None of them experienced a continuing fall in life expectancy like the U.S. did, and a good number of them saw life expectancy start inching back to normal,” Dr. Woolf said.
Those countries had more successful vaccination campaigns and populations that were more willing to take behavioral measures to prevent infections, such as wearing masks, he said, adding: “The U.S. is clearly an outlier.”
But the coronavirus was not solely to blame. Longstanding health problems — rooted in poverty, discrimination and poor access to health care — left Native Americans and Alaska Natives particularly vulnerable to the virus, said Dr. Ann Bullock, former director of diabetes treatment and prevention at the federal Indian Health Service agency and a member of the Minnesota Chippewa Tribe.
One in seven Native Americans and Alaska Natives has diabetes, the highest rate among racial or ethnic groups in the United States, and many struggle with obesity or excess weight. Both conditions make people more susceptible to severe Covid-19, and crowded multigenerational housing adds to the risk.
“There is no doubt Covid was a contributor to the increase in mortality during the last couple of years, but it didn’t start these problems — it made everything that much worse,” Dr. Bullock said.
Average life expectancy in these populations is now “lower than that of every country in the Americas except Haiti, which is astounding,” said Noreen Goldman, professor of demography and public affairs at the Princeton School of Public and International Affairs.
The continued plunge was all the more upsetting because it occurred after a successful vaccination campaign, she said, adding: “The Native American population did quite well in the vaccination efforts, and that made us feel that 2021 would not be as devastating as 2020.”
“That was wrong, and it’s pretty hard to swallow,” she added.
White Americans saw the second-largest decline in average life expectancy in 2021, a drop of one year, to 76.4 in 2021 from 77.4 in 2020. The decline was steeper than that among Black Americans, at seven-tenths of a year. That was followed by Hispanic Americans, whose life expectancy dropped only two-tenths of a year in 2021.
But both Black and Hispanic Americans were hit hard in 2020, the first year of the pandemic. Average life expectancy for Hispanic Americans fell by four years, to 77.9 from 81.9 in 2019. The figure for Black Americans declined almost as much, by more than three years to 71.5 years in 2020.
White Americans experienced the smallest decline during the first year of the pandemic, a drop of 1.4 years to 77.4 from 78.8. For white and Black Americans, life expectancy is now the lowest it has been since 1995, federal researchers said.
Asian Americans held the highest life expectancy among racial and ethnic groups included in the new analysis: 83.5 years, on average. The figure fell only slightly last year, from 83.6 in 2020.
It was the largest reduction in life expectancy in the United States over the course of a two-year period since the early 1920s, when life expectancy fell to 57.2 in 1923. That drop-off may have been related to high unemployment and suicide rates during an earlier recession, as well as a steep increase in mortality among nonwhite men and women.
Although the U.S. health care system is among the best in the world, Americans suffer from what experts have called “the U.S. health disadvantage,” an amalgam of influences that erode well-being, Dr. Woolf said.
These include a fragmented, profit-driven health care system; poor diet and a lack of physical activity; and pervasive risk factors such as smoking, widespread access to guns, poverty and pollution. The problems are compounded for marginalized groups by racism and segregation, he added.
The result is a high disease burden among Americans, and shorter life expectancy compared with that in comparable high-income nations over the last two decades, Dr. Woolf said.
Over a million Americans have died of Covid-19, and more died in 2021 than in 2020 despite the availability of vaccines. To date, only two-thirds of Americans are fully vaccinated, and only one-third have had a booster shot.
“The white population did worse in 2021 than communities of color, besides Native American and Alaska Natives,” Dr. Woolf said. “I think that’s very telling: It reflects the greater efforts by Black and Hispanics to get vaccinated, to wear masks and take other measures to protect themselves, and the greater tendency in white populations to push back on those behaviors.”
The longevity gap between men and women also grew by a couple of months in 2021. American women can now expect to live 79.1 years, almost six years longer than men, whose average life expectancy was 73.2 last year, according to the new data.
The longevity gap between the sexes has been increasing for more than a decade, after narrowing between 2000 and 2010 to about five years.
https://www.nytimes.com/2022/08/31/health/life-expectancy-covid-pandemic.html
Editor's Note -
The following three clippings are letters to the editor about Joe Lawlor's series of articles about medical billing in Maine, that I posted in my August 21 blog.
- SPC
Letter to the editor: Billing coverage makes case for publicly financed Maine care system
The Aug. 21 article by Staff Writer Joe Lawlor (“Hidden charges, denied claims,” Page A1) shines a light on how confusing and frustrating medical billing is in this country, and how it affects Maine people.
From surprise charges such as “facility fees” and denial of claims, to insurance companies not covering medications or procedures that physicians prescribe, the poignant stories of Maine people highlight just how broken our system is.
Many of the fixes enacted so far – from the Affordable Care Act to pricing transparency laws – have made limited improvements. But all leave in place an inherent flaw: the idea that a market-based approach, which allows a few to profit from people needing health care, will work.
In our current, overly complex system, multiple for-profit players seek to maximize their earnings, and one of the ways they do this is by limiting the amount they pay out for care as much as possible. Meanwhile, patients and providers are trapped in a maze of networks, plans, claim denials and billing practices that are murky at best.
We’ve been trying the market-based approach for decades – how’s it working? We pay more for health care than any other developed nation, with worse outcomes. People are spending precious time and energy dealing with the insanity of medical billing; physicians are burning out, and patients and providers alike are losing confidence in a system we all rely on.
lt’s time to take the profit out of health care and choose a simplified, publicly financed system that covers everyone and saves money.
Karen Foster
chair, board of directors, Maine AllCare
Portland
Letter to the editor: Free market health care dysfunction at root of medical billing problems
by George McNeil - Portland Press Herald - August 28, 2022
Staff Writer Joe Lawlor did a wonderful job depicting the pain and dysfunction of our American system of health care (“Hidden charges, denied claims,” Aug. 21, Page A1). The stories he tells are compelling and leave little question but that the system is badly broken. But while Lawlor hints at the roots of the problem (citing, for example, powerful vested interests that oppose reform), I think he missed an opportunity to make a more definitive diagnosis.
What separates the American medical landscape from the rest of the developed world, aside from the staggering gulf in money spent, is the powerful dominance of the corporate model, and the increasingly absurd argument that the free market will fix things.
I’ve been lucky to practice medicine during a golden age, in which scientific and technological gains have been stunning. But at the same time, there has been an insidious growth in corporate influence. It may have begun with for-profit hospitals and insurance plans, but it has metastasized to dominate even the not-for-profit world of academic medical centers and community hospitals – the world that we in Maine are familiar with and that now works poorly for too many of us.
Care has become larded up with executives extracting seven-figure salaries while they deliver no patient care. These salaries are rationalized as being “market-driven,” but it’s noteworthy that they are unparalleled in the rest of the industrialized world. The free market trope falls apart when we examine its appropriateness in the equitable delivery of health care.
George McNeil, M.D.
Steep Falls
Maine Voices: Let’s tell elected officials we value, expect universal medical care
by Debra Dunlap - Portland Press Herald - August 30, 2022
Billions of dollars in medical bills have been paid via crowdsourcing platforms like GoFundMe. It doesn’t have to be like this.
In December 2020, a member of my extended family had a medical event and was hospitalized during the holiday season. During emergency surgery, his doctors discovered more complications, and scheduled a second surgery a few days later that resolved the problem.
Through his employer, he had insurance with a high deductible that would be a financial stretch. Then he learned that the timing of his weeklong hospital stay, which crossed from one calendar year into the next, meant he would have to pay the annual deductible twice for one medical event. There was an outpouring of support as this news was shared. His coworkers set up a GoFundMe account, and family and friends from around the country made donations to help him pay his bill.
Crowdsourcing to pay medical expenses has become common in America. Many of us have donated to fundraisers for people we know, and some we don’t know. GoFundMe has a full page devoted to medical fundraising on its site that reports more than 250,000 medical fundraisers a year. A recent study of GoFundMe found 42 fundraisers for medical conditions in 2010, and more than 119,000 by 2018. Collectively, these campaigns have raised more than $3 billion.
This level of support from friends and strangers on crowdsourcing platforms is not surprising. Most people agree that communities should rally around individuals faced with sickness and injury.
Almost all developed countries have health care that is built around this shared value and provide universal care for everyone. Countries do this in different ways, through a mix of government insurance plans and health services, but the central value is the same: Health care is a basic human right. In contrast, the American health care system is not built on the value of helping anyone who falls sick, but on principles of competition and profit.
Americans started talking about universal health care at the same time as other Western countries. Powerful political organizations including the American Medical Association have run successful campaigns against such a system for over 70 years. In 2021, four of the top ten spenders on lobbying were medical and pharmaceutical organizations. These high-powered campaigns have shaped our health care systems for generations. But American public opinion has been changing as treatment has become less affordable even for people who have insurance.
Compared to other wealthy countries, America consistently spends more on health care and has worse outcomes. A 2021 Gallup poll found that 77 percent of Americans were dissatisfied with the total cost of care, but only 56 percent thought it was the responsibility of the federal government to make sure everyone is covered. This is one place where Americans differ from other nations: We have never sent a unified message to our government that we value and expect universal medical care.
Congratulations to Press Herald reporter Joe Lawlor for the swift political response to his recent investigative reporting on medical billing. Changing America’s health care system so everyone has affordable and accessible care will not be easy, but it is possible. Our elected leaders and medical organizations need to know that we expect our health care systems to reflect the shared value we practice every time we hit the “Donate” button: Everyone deserves to get the help they need.
https://www.pressherald.com/2022/08/30/maine-voices-lets-tell-elected-officials-we-value-expect-universal-medical-care/
When Private Equity Takes Over a Nursing Home
When St. Joseph’s Home for the Aged, a brown-brick nursing home in Richmond, Virginia, was put up for sale, in October, 2019, the waiting list for a room was three years long. “People were literally dying to get in there,” Debbie Davidson, the nursing home’s administrator, said. The owners, the Little Sisters of the Poor, were the reason. For a hundred and forty-seven years, the nuns had lived at St. Joseph’s with their residents, embodying a philosophy that defined their service: treat older people as family, in facilities that feel like a home.
St. Joseph’s itself was pristine. The grounds were concealed behind a thicket of tall oaks and flowering magnolias; residents strolled in manicured gardens, past wooden archways and leafy vines. Inside the bright, two-story building, the common areas were graceful and warm—a china cabinet here, an upright piano there. An aviary held chirping brown finches; an aquarium housed shimmering fish. The gift shop, created in 2005, to fund-raise for tsunami relief in the aftermath of the Indian Ocean earthquake, sold residents’ handmade aprons and dish towels. People gathered everywhere: in line for the home’s hair salon, over soup in the dining rooms, against handrails in the hallway, where the floors were polished to a shine. “Take a deep breath,” a resident, Ross Girardi, told me, during a visit in May of 2021. He reclined in a plush armchair. “Deeper! What don’t you smell? A nursing home.”
The home fostered unexpected relationships. Girardi, a former U.S. Army combat medic, first discovered St. Joseph’s as a volunteer, in the early nineteen-eighties; thirty years later, he and his wife, Rae, decided to grow old there. Jennifer Schoening, a floor technician, was unhoused before she started at St. Joseph’s. A social worker from the nursing home had approached her on a street corner in Richmond, where Schoening was panhandling, and told her that the Little Sisters had an opening. She began working in the pantry, serving meals and brewing fresh coffee, and found an apartment nearby. Ramon Davila, the home’s maintenance technician at the time, worked in a shop next door to Schoening’s supply room. The two got married on the terrace in front of St. Joseph’s last year. “It got to be that the building wasn’t just my safe spot,” Schoening said. “He was my safe spot.”
The Little Sisters of the Poor was founded by Jeanne Jugan, who, in the winter of 1839, took in an elderly widow off the streets of Brittany. Jugan is said to have carried the woman, who was blind and partially paralyzed, up her home’s narrow spiral staircase—and given up her own bed. (Jugan herself slept in the attic.) From this first act of care, the Little Sisters grew. Jugan took in two more women, then rented a room to house a dozen. A year later, she acquired a former convent to support forty elderly people. Charles Dickens, after visiting one of Jugan’s homes in Paris, described the experience in the English magazine Household Words. “The whole sentiment,” Dickens wrote, “is that of a very large and very amiable family.”
At the organization’s peak, in the nineteen-fifties, the Little Sisters of the Poor owned fifty-two nursing homes in the United States. Today it runs twenty-two. “In general, we like to have ten Little Sisters in each home,” Sister Mary John, a former assistant administrator at St. Joseph’s, said. But, since 1965, the number of Catholic sisters in the U.S. has dropped from roughly a hundred and eighty thousand to some thirty-nine thousand, according to the Center for Applied Research in the Apostolate. As a result, the Little Sisters have withdrawn from many of their nursing homes. Typically, the facilities have been sold to nonprofits. A large Catholic health-care system had expressed interest in buying St. Joseph’s, as had the Catholic Diocese of Richmond. “But the pandemic and the lockdowns of nursing homes made it difficult,” Sister Mary John said, of securing a buyer. In the spring of 2021, an offer materialized from the Portopiccolo Group, a private-equity firm based in Englewood Cliffs, New Jersey, which then had a portfolio of more than a hundred facilities across the East Coast. “They said they like to keep things the way they are,” Sister Mary John told me.
The deal was finalized by June. Portopiccolo’s management company, Accordius Health, was brought in to run the home’s day-to-day operations. Staffers recall that, at an early town hall, Kim Morrow, Accordius Health’s chief operating officer, repeatedly said the company wouldn’t institute significant changes. But many staff members felt a disconnect. Someone asked if the number of residents in each room would change. A staffer remembered Morrow saying, “That might change. We might double it.” (Morrow doesn’t recall saying so.) At another town hall, Celia Soper, Accordius Health’s regional operations director, told St. Joseph’s staff, “We see that you all work hard. But it’s time we start working smart.”
Nearly a quarter of the hundred-person staff had been with the home for more than fifteen years; the activities director was in her forty-fifth year. But the ownership change precipitated a mass exodus. Within two weeks, management laid out plans to significantly cut back nurse staffing. Some mornings, there were only two nursing aides working at the seventy-two-bed facility. A nurse at the home, who spoke on condition of anonymity for fear of retribution, told me, “It takes two people just to take some residents to the bathroom.” (When reached by e-mail, a Portopiccolo spokesperson said, “We never made any staffing cuts during the transition.”)
The home was renamed Karolwood Gardens, and the new management filed for a license to admit higher-needs residents, who can be billed at higher rates through Medicare. The aquarium on the second floor disappeared. So, too, did the aviary. Residents’ crafts were removed from the gift shop. No longer did the kitchen serve an eclectic variety of main dishes: turkey tetrazzini, salmon with lobster sauce, or Reuben sandwiches. Now residents were commonly given an option of ground beef. Some days, the kitchen was so short-staffed that the dining hall wasn’t set up, and residents took meals alone in their rooms.
The attentiveness of the nursing staff plummeted. Mary Cummings, a ninety-seven-year-old resident who had lived at St. Joseph’s for six years, went seven days without a bath. Betty Zane Wingo, a ninety-four-year-old resident, went several months without having her hair washed. A resident who suffered from a severe lung disease told me that, one evening, her oxygen tube slipped out, and it took an hour and a half and a call to 911 to get it plugged back in. Several family members told me they called the nursing station to express concerns but that no one picked up. On morning shifts, the home’s nurse aides now changed briefs so saturated with urine they’d turned brown.
Bob Cumber cherished the care that his mother, Bertha, had received under the Little Sisters. One Christmas Eve, a nun had stayed late to file a hangnail on Bertha’s foot. After Portopiccolo acquired the home, Bertha appeared increasingly unkempt. Her hair was dirtier, her teeth coated in plaque. Whenever Cumber visited, she asked him for water. Bertha was a hundred and four years old, but the decline in her care was conspicuous. She had lost weight and developed open bedsores on her hip and buttocks and near her anus. Cumber tried to share his concerns with her nurses. “When I called there, I was put on eternal hold,” he said. Bertha told her son she was ready to pass away. “Mama,” Cumber said, “I don’t want you to leave.”
One evening in September, four months after Portopiccolo purchased the home, Bertha grimaced in pain as a nurse turned her in bed. Cumber, a former pharmacist, and his sister, a nurse, had specified in Bertha’s chart that she was not to be given morphine, expressing preference for a milder painkiller; they asked to be called if a dose of morphine were ever necessary. But the nurse didn’t call. Instead, she released two milligrams of morphine under Bertha’s tongue, according to Cumber. Within an hour, another nurse administered another two-milligram dose. (The spokesperson for Portopiccolo disputed this claim, but noted that he couldn’t provide additional context or comment, owing to privacy regulations under the Health Insurance Portability and Accountability Act, or HIPAA.) Bertha slept for two days. Cumber stayed by her side as her breathing grew labored. He held his mother in his arms, his head against hers. Her breathing slowed, then stopped altogether.
Since the turn of the century, private-equity investment in nursing homes has grown from five billion to a hundred billion dollars. The purpose of such investments—their so-called value proposition—is to increase efficiency. Management and administrative services can be centralized, and excess costs and staffing trimmed. In the autumn of 2019, Atul Gupta, an economist at the University of Pennsylvania, set out with a team of researchers to measure how these changes affected nursing-home residents. They sifted through more than a hundred private-equity deals that took place between 2004 and 2015, and linked each deal to categories of resident outcomes, such as mobility and self-reported pain intensity. The data revealed a troubling trend: when private-equity firms acquired nursing homes, deaths among residents increased by an average of ten per cent. “At first, we didn’t believe it,” Gupta told me. “We thought that there was a mistake.” His team reëxamined its models, testing the assumptions that informed them. “But the result was very robust,” Gupta said.
Cost-cutting is to be expected in any business, but nursing homes are particularly vulnerable. Staffing often represents the largest operating cost on a nursing home’s ledger. So, when firms buy a home, they cut staff. However, this business model has a fatal flaw. “Nurse availability,” Gupta and his colleagues wrote, “is the most important determinant of quality of care.”
At homes with fewer direct-care nurses, residents are bathed less. They fall more, because there are fewer hands to help them to the bathroom or into bed. They suffer more dehydration, malnutrition, and weight loss, and higher self-reported pain levels. They develop more pressure ulcers and a greater number of infections. They make more emergency-room visits, and they’re hospitalized more often.“They get all kinds of problems that could be prevented,” Charlene Harrington, a professor emeritus of sociology and nursing at the University of California, San Francisco, said, of residents at homes with lower nurse-staffing levels. “It’s criminal.”
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