Getty ENHANCED INTERROGATION Why Are So Many White Americans Dying? Economist Anne Case explains the health mystery that’s upending American politics.

Katelyn Fossett is associate editor at POLITICO Magazine.

It’s a mystery with profound implications for American politics, not to mention public health: Why are so many white people dying?

When economists Anne Case and Angus Deaton released their first bombshell study in 2015, showing that mortality rates were rising for middle-aged white Americans after years of decline, the finding stunned the research world. This wasn’t a global trend—it was a distinctly American phenomenon, Case and Deaton had discovered. Among other races and age groups in Europe, mortality rates had continued to fall. But in the U.S. white people aged 45 to 54 without a college degree were dying sooner, and not from the usual suspects like heart disease and diabetes. For an advanced country where the notion of continuous progress is practically a national creed, the revelation was shocking.


A year later, when Donald Trump won an upset victory in the presidential victory with a message that resonated with those same voters, many turned to Case and Deaton’s research as one possible explanation for his ascendance.

Now Deaton, who won the Nobel Prize in 2015, and Case, his wife and coauthor, are back with a new paper that aims to refine their original findings, digging into the group that’s seeing the largest increases in mortality rates: white people without college degrees, accelerated by what they call deaths of despair, or suicide, alcohol- and drug-related deaths. “Ultimately,” they write, “we see our story as about the collapse of the white, high school educated, working class after its heyday in the early 1970s, and the pathologies that accompany that decline.”

The discussion over Case and Deaton’s research has come along with a spate of media coverage on the economic anxieties, poor marriage prospects and the surge in substance-abuse-related deaths in the distressed white communities that powered Trump’s victory. But because Case and Deaton’s topic is so central to one of the biggest storylines of the past election, it’s also been a magnet for criticism. In particular, journalists and scholars have voiced concern about the spotlight on white people’s economic problems, which are still, relatively speaking, far smaller than those of, say, African-Americans.

“It shouldn’t matter more now that it’s white people who feel pain,” Sam Fulwood III, a senior fellow at the Center for American Progress, wrote in one post. Washington Post writer Jeff Guo pointed out that throughout American history, problems faced by blacks often didn’t generate such nuanced, rigorous study. “The argument would have been well heeded during Johnson’s War on Poverty, when the breakup of black families was blamed on broken values instead of a broken economic system for black Americans,” he wrote.

Case doesn’t see a conflict. “I don’t see why this would detract from the fact that all of these people are dying in middle age who have no business dying—black and white,” she said in a recent interview. More than anything, she continued, we’re seeing the convergence of health outcomes for black people without college degrees and white people without college degrees, which suggests that class gaps could be supplanting racial gaps, in some health outcomes at least.

Some statisticians and researchers have also raised questions about a methodology issue called “lagged selection bias,” a complication that arises when someone aims to study a cohort of the same group of people over an extended period of time—but, during that same period, the composition of that group of people changes in a material way. In this case, widening access to education could mean that those without college degrees were a smaller, unhealthier pool of people than they were years ago. Case says that’s not what’s happening here, though. The increase in those getting college educations wasn’t that large for one of the main groups studied, the white non-Hispanic age group of 45-54 year-olds. “It went from 32 percent in 1999 to 37 percent in 2015, which isn’t the sort of dramatic change that would drive the changes we document over that period,” she wrote in an email.

These methodological questions aside, nobody is disputing that the United States has a real problem as it struggles to understand the despair in communities left behind by globalization and automation. And, Case argues, the reversal of decades of progress on health among the least educated should be setting a fire under political leaders and policy wonks in both parties as they try to craft real solutions:

This conversation has been edited and condensed for clarity.

Politico Magazine: I just wanted to start by asking a general question about how this new research builds on or complements your earlier 2015 study.

Anne Case: So the first study really just pointed out a set of facts about what was happening in the U.S. relative to other parts of the rich world. In almost every other rich country, mortality rates have been falling at about 2 percent a year for decades. In the U.S., there was this remarkable century of mortality decline among people in middle age, but then around the turn of the century, white non-Hispanics decided to leave the herd, and their mortality rates slowed, and then they started to increase, whereas previously their rates were falling at the same rates that characterized other parts of the rich world. Also in comparison, black non-Hispanic mortality was falling at an even faster rate than what was seen in Europe—although it was at a much higher level, which is just totally unacceptable—but black non-Hispanics were making progress. And Hispanics, who are even poorer than whites and have less education on average than whites, their mortality rate was falling at the same rate that is seen in Europe and their mortality rates are much better than they are for white non-Hispanics. So those were the facts from the first paper.

This new paper really drills down into those results to try to see if we can isolate where this is happening, why this is happening. The first paper pointed out that the increases in drug overdose and alcohol-related liver deaths and suicide were the three big drivers that were actually turning mortality rates up for whites and middle-aged people in America. What we’ve discovered is, yes, that is happening, but that would never have come to anyone’s attention, I think, if it weren’t for the fact that white non-Hispanics stopped making progress on heart disease, which is a big killer in middle age. First progress slowed, then it flatlined, and now it looks like it’s turned in the opposite direction.

Interestingly, and sadly, we’re starting to see a slowdown in heart disease progress among black non-Hispanics as well now. So that progress continued for a lot longer than it did for whites, but since about 2010, that progress has flatlined as well for heart disease.

So we thought we should try to isolate where this is happening. If you break people into broad education categories—people with a high school degree or less; people with some college but less than a B.A.; and people with a B.A. or more—all of this is happening for people with less than a four-year college degree. So people age 45 to 54, from the early 1990s through 2015, the fraction of the population in each of those broad categories stayed relatively constant. Which is important, because earlier work has focused on less than a high school degree, who are becoming a smaller and smaller part of the population, and becoming a much less healthy part of the population, so you don’t necessarily want to focus on a part of the group that’s becoming more negatively selected over time.

So a [high school] degree seems to be a marker for a lot of dysfunction that we’re seeing. But this new paper shows that the body count is only the tip of the iceberg. People with less than a college degree are reporting a lot more pain, much poorer health, poorer mental health. They’re less likely to be married, they’re less likely to be attached to the labor market, their wages don’t increase with age as quickly as they had in previous generations. So part two is being able to document that these things are happening in sync with each other.

And the third part is the fact that things appear to be getting worse and worse with every successive birth cohort, so that the cohort born in 1980 is having a much harder time on all those dimensions than the cohort born in 1970, who is in turn having a much harder time than the cohort born in 1960. And you can go back to the cohort born in 1945, which would have entered the labor market in the early 1970s, and things seemed to be getting progressively worse since then for people who are leaving high school and entering the labor market.

Politico: How do you expect this to change as more and more people get college degrees? In twenty or thirty years, will this be a much smaller group?

Case: It used to be the case that with a high school degree, you could get a good job, with potential for on-the-job training and you could expect to have a middle-class life. You could get married, you could have a family. And the kinds of jobs a person can get now with a high school degree are not jobs where there is any up to move to. So what we call ‘returns to experience’, how much more you’d expect to earn at any given age, are lower and lower. We think the data is consistent with the story where: people enter the labor market, they can’t get a good job, their girlfriend or boyfriend doesn’t want to marry them, because if you leave your options open, you might find someone with a better job. People cohabitate, but those cohabitations are extremely fragile, because unlike Europe, where cohabitation is quite a stable form of living together, in the U.S. it’s much less stable. So there’s just not the kind of stability for people without high school degrees like there has been in the past.

So what’s going to happen? Not everybody wants to go to college. Not everybody has the wherewithal to go to college. What I personally think would be a much better idea is to revamp the kind of education that we offer people so that they have the kind of skills that would be rewarded in the 21st century job market. So that would be probably, more vocational training at a high level that would allow people to participate without having a four-year college degree, and still be able to support a family and support a middle class life.

Politico: So are you talking right now just about working-class whites from 45-54?

Case: Well actually, if you look at every five-year age group, from ages 25-29 up through 60-64, what you see is that for people with less than a college degree, the mortality rates have increased. So it’s not just people in that window; we originally focused on people in that window so that we had something precise to focus on. But when you open it up, it’s happening for a very broad swath of people who you might think of as middle-aged. And I think middle-aged is really in the eye of the beholder.

But when you think about education—what I think is interesting is where we’re planning to go next with our research—is that in Europe, mortality rates are falling, but they’re falling even more for people on the low end of their education distribution. Their mortality is falling faster than people on the high end of their education distribution. So what are they doing right that we’re not? That’s sort of the question right now. And again, education might just be a marker of something else, but I think it would be wise to look at how the Europeans have actually shouldered the kind of changes in the labor market. You know, they’ve lost a lot of manufacturing jobs to the far East, they’ve weathered the recession, but they haven’t seen the same kind of dysfunction and mortality increases that we’ve seen in the U.S.—so why? What’s that about? We don’t know the answers yet.

Politico: I’ve read some discussion about this study and how it might detract from focusing on African-Americans and Hispanics. How do you respond to that? How do you think these different conversations can happen in tandem?

Anne Case: It’s interesting, because one of the things in the new paper is that mortality rates for black non-Hispanics with a high school degree or less and mortality rates for white non-Hispanics with a high school degree or less are really converging. So there’s been real progress in bringing down mortality rates for blacks, and unfortunately, mortality rates for whites are coming up to meet those. So it seems like we’d be much better off having a conversation about people with less education than we would about people by the color of their skin. I don’t see why this would detract from the fact that all of these people are dying in middle age who have no business dying—black and white. I think there isn’t any reason why we can’t have a conversation about what we do for people in the U.S. who don’t have a college degree, who are facing a labor market that is increasingly hostile—and that’s true regardless of race or ethnicity.

Politico: Do you feel like the conversation around class has changed a lot in the past few years?

Case: It’s interesting, because the U.S. doesn’t like to have conversations about class. We like to say we are a classless society. But from the get-go, class has always been a silent player here, and I think bringing those conversations out into the open is a very good idea.

You’ve heard it before: The only slur that’s still socially acceptable is to call someone a redneck. That doesn’t make any sense to me. Education is not necessarily what’s driving this, but it is highly correlated with all these bad outcomes that are happening to people. And I think part of that is that your high school degree gets you less far than what it used to, and when that happens, a lot of other bad things follow on. And I think we would be having a richer conversation if we talked about it in terms of class than if we talked about it in terms of race.

Politico: Did geography factor into this at all? After the election, we’ve talked a lot about the urban-rural divide, the coasts versus the rest of the country…

Case: Yeah, it’s interesting. When we talk about ‘deaths of despair,’ there’s now not a part of the country that’s not been touched by it. It’s true that there was a lot of attention paid to urban versus rural, but if you actually plot out these deaths of despair—suicide, alcohol, drugs—in every classification of urbanization—so the large central MSAs [Metropolitan Statistical Areas], or small MSAs, or metropolitan areas—in every one of them, those had an increase in deaths of despair, year after year, and they’re pretty much going up in parallel. A small relative increase for people in rural areas, but it’s really not the case that it’s a rural phenomenon. I think for some reporters, it became something like, Oh, let’s go to Appalachia and talk to people in West Virginia. And yes, it’s happening in West Virginia, but it’s also happening in rural Maine and Baltimore City, it’s happening in Florida, it’s happening in Utah.

And we see the prescription opioid epidemic as being an accelerant, as making this worse, but we don’t think it’s a root cause. It was happening before the heavy-duty prescription opioids hit the market. It starts at least as far back as 1990—that death rates from deaths of despair start rising—and then you throw prescription opioids into the mix, and it makes things a heck of a lot worse. But it was happening already.

Politico: So obviously the prospects of white, less-educated people have become this object of fascination since the rise of Trump, when people saw the education levels and race of the people who were voting for him. I was just wondering if you had thoughts on what goes neglected in those conversations about how this issue is affecting our politics.

Case: What we do with the results of this new paper is really a political question. It’s not a normative question—well, I mean, what we should do depends on where you sit. But it is something I worry could really tear us apart. There seem to be two Americas now: one for people who went to college and one for people who didn’t, and that’s going to be truer and truer, regardless of the color of your skin. Whether or not there’s enough political force to bring us back together, I’m really not sure about that.