America has a life expectancy crisis. But it’s not a political priority.
December 28, 2023 at 6:00 a.m. EST
"The commissioner of the Food and Drug Administration had an urgent message last winter for his colleagues, brandishing data that life expectancy in the United States had fallen again — the biggest two-year decline in a century.
Robert Califf’s warning, summarized by three people with knowledge of the conversations, boiled down to this:
Americans’ life expectancy is going the wrong way. We’re the top health officials in the country. If we don’t fix this, who will?
A year after Califf’s dire warnings, Americans’ life expectancy decline remains a pressing public health problem — but not a political priority.
President Biden has not mentioned it in his remarks, according to a review of public statements; his Republican challengers have scarcely invoked it, either. In a survey of all 100 sitting senators, fewer than half acknowledged it was a public health problem. While recent federal data suggests that life expectancy ticked up in 2022, a partial rebound from the ravages of the coronavirus pandemic, no national strategy exists to reverse a years-long slide that has left the United States trailing peers, such as Canada and Germany, and rivals, such as China.
“I wish that life expectancy or health span were a fundamental political issue in the 2024 presidential campaign,” said Dave A. Chokshi, a physician and public health professor who formerly served as health commissioner of New York. “We’re not living the healthiest lives that we possibly could.”
The Washington Post spoke with more than 100 public health experts, lawmakers and senior health officials, including 29 across the past three presidential administrations, who described the challenges of attempting to turn around the nation’s declining life expectancy. Those challenges include siloed operations that make it hard for public and private-sector officials to coordinate their efforts, a health-care payment system that does not reward preventive care and White House turnover that can interrupt national strategies.
Many suggested the nation needed an effort that would transcend political administrations and inspire decades of commitment, with some comparing the goal of improving life expectancy to the United States’ original moonshot.
“We’re no longer an America that talks about building a national highway system or sending a man to the moon, and yet it’s that kind of reach and ambition that we need to have to tackle the declining longevity problem,” said Sen. Elizabeth Warren (D-Mass.).
Experts, officials and lawmakers acknowledged that a political pledge to reverse the nation’s life expectancy slide could quickly backfire, given the need to focus on long-term goals that might not be reflected in short-term progress reports. A politician attempting to improve life expectancy could be out of office by the time improvements were detected.
“Politicians, in general, haven’t wanted to engage on this because it feels kind of squishy and the solutions don’t seem clear,” said Ashish Jha, the dean of Brown University’s public health school who this year stepped down as the White House’s coordinator of the national covid response.
In an interview, Califf confirmed he’d urged colleagues in “so many” meetings to take action on America’s eroding life expectancy.
The trend is “quite alarming,” the FDA commissioner said, sitting in his office in White Oak, Md., where he oversees the nearly $7 billion agency that regulates drugs, food and other common products used by Americans. “All of the leaders within the [Department of Health and Human Services] I’ve talked with about this.”
White House officials said the president and his team were focused on combating the “drivers” of life expectancy declines, pointing to efforts to reduce drug overdoses, create an office to prevent gun violence and other initiatives. A senior health official in the Biden administration said pledging to improve life expectancy itself “would have to be viewed as something for a legacy.”
“Maybe a second-term priority for Biden,” said the official, who spoke on the condition of anonymity to speak frankly about internal White House operations.
No single reason explains why America’s life expectancy has declined, with chronic disease, poor nutrition, insufficient access to care and political decisions all linked to premature deaths. There also is no single strategy to turn it around — and no agreement on how to do it. Some public health leaders and policymakers have called for sweeping reforms to how the health-care system operates, while others home in on discrete factors such as lethal drug overdoses, which have spiked in recent years and received considerable attention but are not solely responsible for the decline in life expectancy.
The paralysis over how to address the nation’s declining life expectancy extends to Congress, where a handful of lawmakers — mostly Democrats — have repeatedly portrayed the slide as a crisis, but most other lawmakers have said little or nothing.
“We don’t talk about life expectancy, because it just makes it clear what kind of failed system we currently have,” said Sen. Bernie Sanders (I-Vt.), who has repeatedly warned about the rise in premature deaths, including organizing a July 2021 Senate hearing on the issue. Just 11 of the panel’s 18 senators attended, several only briefly; just five asked questions.
“I talk to other senators about life expectancy data and watch their eyes glaze over,” Warren said.
The Post submitted questions about life expectancy to all 100 sitting senators, sending emails, placing calls and making visits to their offices. Forty-eight senators — including 35 Democrats, 11 Republicans and two Independents — said they agreed that declining life expectancy was a problem. Many of those lawmakers pointed to their own legislation intended to combat opioid misuse and address conditions such as cancer and other factors linked to causes of premature death. All told, the 48 senators cited more than 130 separate bills focused on health-care issues.
Despite the flurry of legislation, the nation’s progress on life expectancy has stalled, with the United States increasingly falling behind other nations well before the pandemic. No senator has crafted a bill specifically intended to improve life expectancy or create goals for health leaders to reach.
Lawmakers have also worked at cross purposes, with Republicans fighting Democrats’ efforts to enact legislation linked to gains in life expectancy, including efforts to expand access to health coverage and curb access to guns. Sen. John Neely Kennedy (R-La.), whose state had the third-worst life expectancy in 2020, about 73 years, recently suggested that life expectancy would even go up for young Americans.
“I mean, the life expectancy of the average American right now is about 77 years old. For people who are in their 20s, their life expectancy will probably be 85 to 90,” Kennedy said on “Fox News Sunday” in March. His office did not respond to requests for comment.
Other Republican senators or their staff suggested they did not have a view on the issue because the senator did not sit on a relevant committee.
Sen. Jerry Moran (R-Kan.) has “no jurisdiction over this issue,” his office wrote in response to questions about whether Moran had views on declining life expectancy. Moran, who sits on the Senate panel that determines funding for health agencies, has cast votes on numerous health-care matters, including repeatedly voting to repeal the Affordable Care Act.
In the absence of national solutions, some officials pointed to local efforts such as a new initiative in New York, which has repeatedly pioneered public health improvements later copied across the country. City leaders in November pledged to raise New Yorkers’ life expectancy to a record 83 years, saying a coordinated approach could prevent premature deaths. Ashwin Vasan, the city’s health commissioner, testified in front of the city council, urging members to pass a law requiring the city’s health commissioner — including his successors — to work toward shared public health goals.
“This is a test for government. And I really am hopeful that New York City can pass that test,” Vasan said after his testimony, standing outside New York’s city hall.
‘Further and further behind’
Life expectancy in the United States was once a source of national pride — a reflection of civic improvements, medical advances and other investments that set the nation apart from other countries.
“The future of human longevity, especially for Americans, seems bright indeed,” then-Sen. Larry Craig (R-Idaho) proclaimed at a 2003 congressional hearing, where expert witnesses listed scientific and technological breakthroughs that they expected would soon push U.S. life expectancy past 80 years.
But even the most optimistic expert at the panel warned that America’s prospects could dim. James Vaupel, director of the Max Planck Institute for Demographic Research, urged federal officials to immediately prioritize a “real mystery”: the emerging international gap in life expectancy.
“The United States is doing so well on so many fronts, but it’s falling further and further behind on this critically important [measure], life itself,” Vaupel warned the Senate panel, imploring officials to “really start worrying about this.”
It would take about a decade before Vaupel’s warning was heeded. Policymakers instead were focused on a more urgent political priority related to life expectancy: the growing cost of having so many older Americans seeking services through programs such as Medicare and Social Security.
So when the Obama administration and congressional Democrats hammered out legislation that would become the Affordable Care Act — the sweeping 2010 law that expanded health coverage to millions of Americans and made other changes to the health system — there was little fear life expectancy would decline.
Bob Kocher, a venture capitalist who worked in the Obama White House as a health-care and economic aide, said one reason the crafters of the Affordable Care Act were so intent on “bending the curve” on health spending “was our belief that life expectancy was going to keep going up for the foreseeable future.”
By 2013, public health experts had begun issuing more prominent warnings about life expectancy, pointing to the rising number of opioid overdoses, suicides and other preventable deaths. Senior officials across the Obama, Trump and Biden administrations said they were aware of those concerns but that their focus was on improving discrete factors linked to life expectancy, not on the overall number.
“Every meeting at the VA was about ‘life expectancy,’ but I can’t tell you we put charts on the wall of ‘what’s the life expectancy of a veteran,’” said Robert A. McDonald, secretary of veterans affairs under President Barack Obama.
The nation’s current top health official, Health and Human Services Secretary Xavier Becerra, told The Post he’s acutely aware of the life expectancy decline, calling it the “byproduct of some very serious problems” such as gun violence and drug overdoses. But he downplayed the need for a national strategy, saying there was no reason to declare a public health emergency as he has done with the coronavirus and opioid deaths, adding his agency lacked the power to reverse the trend.
“We are so disjointed as a health system in the country,” Becerra said, suggesting that the responsibility to address life expectancy fell on “many of us,” including state health directors.
While Biden hasn’t directly addressed declining life expectancy, some of his rivals have invoked it on the campaign trail.
“We used to think that life expectancy was just going to keep going up, and that’s just not been the case,” Florida Gov. Ron DeSantis (R) said in a CNBC interview in August, linking the decline to the pandemic, drug overdoses and other causes that began years ago. The DeSantis campaign did not respond to a request for comment about how the Florida governor would reverse the trend if elected president.
“If we had regulatory agencies that were actually interested in looking at data, we would be trying to figure out why the all-cause mortality [for Americans] has increased,” Robert F. Kennedy Jr., running as an independent in the 2024 campaign, said in an interview with The Post this summer. “These aren’t covid deaths.”
Political commentator Matthew Yglesias has repeatedly urged politicians to focus on life expectancy, saying that America’s decline reveals systemic problems that leave the country at risk. “Tackling America’s weirdly short life expectancy should be a priority,” Yglesias wrote in one 2022 post.
Although Yglesias has fans within the Biden administration who have sought his counsel after he has written about traffic safety and crime, his appeals on life expectancy haven’t led to similar invitations.
“I think it winds up being a harder topic for politicians to get their heads around,” he said, noting the array of factors that span agencies and administrations.
Califf said he’s keenly aware of his agency’s limits when confronting life expectancy.
FDA is one of the nation’s most powerful regulatory bodies — its staff often tout that they oversee about 20 cents of every dollar spent by U.S. consumers — and Califf is pursuing initiatives, such as banning menthol cigarettes and improving access to generic drugs, that fall in his agency’s purview. But FDA can’t control how hospitals and doctors get paid. It can’t craft legislation, such as curbing access to firearms.
“The highest cause of death in children is guns. That’s a fact,” Califf said. “That’s not something FDA can do something about.”
In Congress, a handful of members have insisted that lawmakers must focus on life expectancy, saying it’s a core responsibility.
“Sometimes, we may, in the midst of our work, lose sight of the big picture … to create a nation in which the people in the United States can live long, healthy, happy and productive life,” Sanders said at the 2021 Senate hearing he convened on lagging life expectancy.
There is a notable partisan split in how members of Congress view life expectancy and whether they say urgent action is needed. Just 11 of the Senate’s 49 Republicans told The Post they believed that declining life expectancy was a public health problem.
The lawmakers who portray the recent decline as a crisis are often Democrats from states with the highest life expectancy — such as Massachusetts (79 years in 2020, according to federal data) and Vermont (78.8 years). Meanwhile, GOP lawmakers representing some of the states with the lowest life expectancy — Mississippi (71.9 years), West Virginia (72.8 years) and Kentucky (73.5 years) — declined to comment or did not respond to repeated questions about whether the issue represents a public health problem.
“It’s a hard sell with senators who live in some of the lowest longevity states. And it breaks my heart,” Warren said.
A further complication: Senators concerned about declining life expectancy offer radically different prescriptions for fixing it.
Alabama Sen. Tommy Tuberville — one of the few Republicans whose office said he was “deeply concerned about this trend” — linked America’s decline to drug overdoses, suicides and alcoholism.
“The facts show clearly that this is being driven largely by an increase in deaths of despair, with fentanyl overdoses being the leading cause of death for Americans 18 to 45,” Tuberville spokesman Steven Stafford said in a statement, pointing to legislation to improve mental health funding and secure the Southern border.
In comparison, Sanders has repeatedly called for sweeping reforms, insisting in an interview that “a failed health-care system is tied into a corrupt political system dominated by enormously powerful corporate interests.”
Even Democrats in neighboring states offered significantly different diagnoses. In the eyes of Rhode Island Sen. Sheldon Whitehouse (D), the No. 1 cause of America’s life expectancy problem is clear: broken payment incentives for doctors and hospitals.
But Sen. Chris Murphy (D-Conn.) traced the life expectancy decline to loneliness.
“Americans are just much less physically and spiritually healthy than they have been in a long time,” said Murphy, who has proposed a bill to create a White House office of social connection.
Ten senators singled out the burden of chronic disease, echoing The Post’s own review, which found that among people younger than 65, chronic illness erases more than twice as many years of life as all the overdoses, homicides, suicides and car accidents combined.
In New York, officials are trying to put a framework around those often abstract challenges. Vasan urged the City Council in November to support HealthyNYC, his agency’s initiative backed by Mayor Eric Adams (D) that seeks to avert about 7,300 premature deaths by 2030.
“We want New Yorkers to experience more birthdays, weddings and graduations, more holidays and holy days, more life lived,” Vasan told the lawmakers, citing targets for reducing chronic diseases, cancers and other drivers of premature death. Council members are considering legislation to ensure that future leaders stick to the commitments — a suddenly urgent need with Adams embroiled in a fundraising scandal.
“We wanted this to be something that outlives us, that actually helps people,” said Lynn Schulman, chair of the City Council’s health committee.
Vasan and Schulman said HealthyNYC can be a template for other cities — the latest effort in New York’s long history of trying to tackle life expectancy. Under former mayor Mike Bloomberg, the city raised cigarette taxes, banned smoking in workplaces and attempted to limit sale of large sugary drinks. When Bloomberg left office in 2013, New Yorkers’ projected life expectancy was 81.1 years — more than two years longer than the national average — compared with 77.9 years when he took office in 2001.
“If you want to live longer, you could move to New York — or just vote for me,” Bloomberg said in a speech to Democratic voters during his short-lived 2020 presidential campaign. (Public health experts have cautioned that it may take decades to fully understand the link between Bloomberg’s initiatives and longer life expectancy.)
But Bloomberg’s efforts provoked backlash from food-makers, industry groups and some elected officials. Even as New York took steps a decade ago to limit salt and soda consumption, GOP lawmakers in other states crafted legislation to prevent their own local leaders from taking similar steps.
The Bloomberg legacy “is not a torch anyone has really wanted to carry,” said Yglesias, warning that the former mayor’s public heath agenda would be politically difficult to replicate elsewhere. “Conservatives really don’t like it. … I think it’s fallen out of style on the left as well.”
Sanders, who has spent years pushing for sweeping changes to America’s health system and economy, said Washington’s work to boost life expectancy could begin with a simple framing device.
“The administration, the Congress should have upon their wall, a chart which says … ‘What’s our life expectancy now [and] how do we get up to the rest of the world?’” Sanders said. He pointed to Norway’s life expectancy of more than 83 years. “That should be our goal.”
Dan Keating contributed to this report."