Geographic Divergence in Mortality in the United States.

Life expectancy at birth in the United States (both sexes combined) rose from 70 years in 1965 to nearly 78 years in 2007. While this is a new milestone for low mortality among Americans, the United States lags significantly behind countries in Western Europe. Especially after age 50, mortality in the US remains substantially higher than in countries with similar levels of economic development, an unfavorable trend that has emerged in the past few decades (Crimmins, Preston, and Cohen 2010).1 Despite spending more per capita on health care than any other peer country, the health performance of the United States is comparatively poor, especially among older adults aged 50 to 80 (Ho and Preston 2010). A recent National Academy of Sciences panel was charged with identifying why US adult mortality is so high relative to its peers (Crimmins, Preston, and Cohen 2010). Although a number of causes were identified, the relatively poor health status of the United States remains a problem that American health policy has not sufficiently addressed. Levels of health and mortality are far from homogeneous across subpopulations in the United States. The experience of the country as a whole does not necessarily reflect the experience of individual subgroups. Health and mortality vary in a number of dimensions including race/ethnicity, socioeconomic status, sex, and geography. Geographic inequalities in adult mortality in the US appear to be greater on average than in Western Europe (Wilmoth, Boe, and Barbieri 2010). Along with varying mortality levels, regions within the US also have vastly different experiences in terms of environmental exposures, disease control, medical treatment and care, and behavioral risk (Geronimus et al. 1996; Hayward, Pienta, and McLaughlin 1997). Since the mid-twentieth century, the sections of the US with particularly high mortality have become increasingly concentrated in space and clustered in the South. The standard South US census region includes all states south of the Mason–Dixon line and westward to Texas and Oklahoma. The most disadvantaged region of the South is the so-called Central South, containing Alabama, Kentucky, Mississippi, and Tennessee. This region is distinctive for experiencing a large health and mortality disadvantage as well as relatively high poverty (Fenelon and Preston 2012). The southern disadvantage in resources is a more longstanding pattern; southern states that are more highly dependent on agriculture have been slower to rebound from economic recessions (Slesnick 1993; Tickamyer and Duncan 1990). As a result, poverty and rural isolation have historically had more profound effects on social and economic opportunities in the South among both whites and blacks (Friedman and Lichter 1998). Although regional differences in poverty have narrowed, some of the enduring disadvantages of southern states may reflect the institutionalization of black inequality (Karnig and McClain 1985). In contrast to economic inequality, the southern disadvantage related to health and mortality is a more recent occurrence. The current southern mortality disadvantage reflects diverging trends between the southern states and states in the Northeast, West, and Midwest over the second half of the twentieth century (Ezzati et al. 2008). In the early to mid-2000s, adult mortality rates in many southern states were 30–40 percent higher than top performers in other regions, particularly the Pacific Coast, Upper Midwest, and New England. This excess mortality translates into 3–4 fewer expected years of life at age 50 for the states that are worst off.2 This article seeks to explain the considerable geographic realignment in adult mortality that occurred in the US since 1965. Identifying the specific consequences of residing in a particular region for a person’s health and life expectancy is analytically difficult. Instead, the analysis examines the aggregate divergence in mortality between the southern states and states with more favorable mortality experience. The article also highlights the contribution of cigarette smoking to the increasing disadvantage of the southern states. Using US vital statistics between 1965 and 2004, the article compares observed mortality trends across states to trends in a counterfactual scenario in which the impact of smoking is removed. If smoking is an important contributor, the latter scenario should reveal substantially less divergence in mortality.