In a discussion with INET’s Lynn Parramore, researcher Steven H. Woolf explains how the peculiar features of life, policy, and economics in America are killing us sooner, and what we can do to change it. *This is Part 1 of a two-part interview.
For all the talk about American exceptionalism, here’s a shocking truth: when it comes to health and longevity, the U.S. has been losing ground for decades. Not just behind wealthy nations, but behind less affluent countries. Even poor ones.
The gap isn’t shrinking; it’s widening.
That’s what public health researcher Steven H. Woolf, professor of family medicine at Virginia Commonwealth University in Richmond, has documented. By 2019, just before COVID‑19 hit, U.S. life expectancy ranked 40th among the world’s most populous countries, trailing places like Albania and Lebanon. The pandemic only made things worse: by 2020, the U.S. had fallen to 46th, as six more nations overtook it.
Woolf hasn’t just compared the U.S. to wealthy countries like Canada, Germany, or the U.K. He looked at life expectancy across dozens of nations with very different histories and economies, and the results are startling. The U.S. began falling behind as early as the 1950s, with countries in Europe, Asia, and the Middle East steadily overtaking it.
If you were born in Albania today, you’d have a longer life expectancy than if you were born in the United States — and that’s been true for several years. Let that sink in.
Woolf argues that America’s exceptionalism is not about health but rather how it’s approached. Policy choices, social conditions, and deep inequalities are driving a health disadvantage that hits hardest in the Midwest and South, where life expectancy has stalled or even declined while other nations, and some U.S. states, keep moving
The Institute for New Economic Thinking spoke with Woolf about why Americans are living shorter lives, why life expectancy varies so dramatically from state to state, and what it would take to reverse a decades-long slide that has quietly — but profoundly — reshaped American life.
Lynn Parramore: Your research shows that the U.S. began losing ground on life expectancy well before obesity rates surged, before the opioid epidemic, and long before COVID. What changed in the 1950s, and in the decades that followed, that other countries got right but the United States didn’t?
Steven Woolf: It’s complicated, but systemic factors in the U.S. appear to drive this pattern.
When we look at trends in life expectancy, we can examine specific causes of death, like heart disease, drug overdoses, gun-related violence, and begin to unpack the drivers. That leads to things like the American food environment or high rates of gun ownership.
But when you step back and consider how many health conditions the U.S. fares worse in than other countries, it really points to broader factors at play — features of life or structural conditions that put Americans at risk for poor health across multiple categories of disease and injury.
An easy example is the health care system. Many countries that outperform us have universal health care systems. Post-World War II, countries like the U.K. and others really made a shift toward offering a national health program for their populations. We did not. So that’s a potential contributor.
There are others. The U.S. regulatory environment has tended to be more lax, prioritizing industrial growth and economic development over robust regulation of products that pose health and safety risks. This was evident early on with the tobacco industry and has since played out with pharmaceuticals, food, firearms, and more. Overall, there’s been a greater tolerance in the United States for a regulatory approach that many European countries and others wouldn’t accept.
LP: You talk about five key factors that help explain why Americans are less healthy than people in many other countries. Can you walk us through them?
SW: Yes. One factor is the health system itself, including public health. The U.S. model is very different — not just because we lack universal health care, but also because access to primary care is more limited. The system is highly fragmented, with real weaknesses in primary care, behavioral health, mental health services, and related areas, all of which contribute to poorer outcomes.
Because the U.S. relies on an insurance-based system, often employer-based, major disruptions in the labor market can profoundly affect access to care. For example, in the 1980s and 1990s, as the manufacturing and mining sectors collapsed, workers and communities that had depended on stable employer support lost jobs, so they lost health insurance and access to care. We know that probably had a big effect on disease outcomes.
So that’s number one. The second factor is health behaviors — Americans simply act differently than people in other countries.
LP: How so?
SW: Americans consume more calories per capita than almost anyone else. We’ve made progress on smoking, which is good, but other behaviors also take a toll. Motor vehicle safety is weaker than in many countries, civilian firearm ownership is much higher, and drug use is another behavior that sets Americans apart.
The third category is adverse socioeconomic conditions. Here, we’re talking about things like poverty, income inequality, inadequate educational attainment.
Looking at OECD data, the U.S. has a very high child poverty rate and among the highest Gini coefficients, a standard measure of income inequality. American families face more socioeconomic adversity than in many countries with stronger social welfare systems.
People everywhere face job loss or tough times, but other countries have systems in place so that people going through tough times do not have to sacrifice their health.
The fourth is the environment — the physical environment and social environment. There are features of the physical environment in American cities that differ, for example, from European or Japanese cities.
LP: You mean like walkability, food deserts and so on?
SW: Yes. The social environment in U.S. cities is also very different in terms of social isolation, low social cohesion, racism, segregation, and, especially in recent years, social division and friction. All of these are harmful to health.
Finally, probably the biggest one is public policy. The way other countries go about approaching policy is different than we do. We also have political and cultural values that differ in important ways from other countries.
LP: You included communist and former communist countries in your comparison, and many have made faster gains than us, and now have a higher life expectancy — even Albania, one of Europe’s poorest nations. Several Eastern and Central European countries surpassed the U.S. despite being far less wealthy. I remember living in the Czech Republic in the ’90s: when I caught the flu, my employer and doctor told me to stay home for two weeks. Back in the U.S., I likely would have been pushed to return quickly. There, it felt like a social duty to rest, recover, and protect others – an example of different values and practices around health.
SW: You hear this time and time again. I’ve had my own experiences like this when I traveled. What you just described is a combination of factors. Some of it is structural in terms of how their system is set up, but the other aspect that you talked about is the value system, and it differs in these other countries.
It’s fascinating that our health outcomes now are slipping below so many other countries we wouldn’t have considered competitors. In much of the past research on the U.S. health disadvantage, the focus has been on comparisons with other high-income countries. The assumption was that it wouldn’t be fair to compare the U.S. with less wealthy nations. Of course we’d do better, right? I pushed myself to question that assumption: are we really doing better?
That’s when I dug into the data and thought, wait a minute. That was the moment that really got me.
LP: Do you think this reflects political and economic choices even more than medical ones?
SW: I think so. Social epidemiology and medical research show that only about 10–20% of our health outcomes are shaped by health care. Health care matters, but it’s only part of the story. One of the interesting things about the U.S. and our 50-state laboratory of democracy is that we get to see some experiments in action.
You can look at different states’ health trajectories and see some dramatic differences, and it’s hard to say it’s all about health care. Some of it is, but much of it comes from other social and economic policies that shape health outcomes. We saw this for many years leading up to the COVID-19 pandemic.
An example I often used before COVID-19 was the polarization of states. After the 1990s, and especially after 2010, we saw increasing political divides, tied to Reagan-era policies and Gingrich’s Contract with America, which pushed for devolution and more state power. The states then went in very different directions.
A striking example: in 1990, New York and Oklahoma had the same life expectancy. Since then, New York’s has climbed dramatically. It’s now the third highest in the country. Oklahoma’s has fallen to around 47th. You can point to demographic or economic reasons for New York’s change, but much of it comes down to policy decisions that New York and New York City made, and that Oklahoma did not.
LP: Can you give an example?
SW: The ones people think of right away are things like Medicaid expansion and tobacco taxes. In New York City, there was a very aggressive tobacco-control campaign that had a dramatic impact on life expectancy. And because of New York’s population dynamics, what happens in the city heavily influences the state’s overall statistics.
But we also have to consider economic policies: tax policy, minimum wage, the earned income tax credit. These are all policies we know strongly affect health outcomes. New York and Oklahoma take very different approaches on these issues.
In terms of national versus state failure, much of the decline is driven by the Midwest and the South. And again, many states now rank behind countries like Albania — I don’t mean to pick on Albania, since they should be proud of their longer life expectancy — but should we see this as a national health failure, or the cumulative result of state-level policy decisions, or both? It’s got to be both. Even our best-performing states, like New York and Hawaii, are still outperformed by other countries.
There are consequences of not having a national health system—not just for routine care, but also what was dramatically shown during the pandemic, when other countries, like South Korea or New Zealand, were able to implement a single national strategy to respond. In the U.S., by contrast, the way the Constitution was designed meant we ended up with 50 separate response plans.
LP: How does our Constitution figure in?
SW: Aspects of it set some of these problems in motion for us in terms of health care. The Tenth Amendment — the police powers amendment — basically places police powers in the hands of the states, and public health falls under those powers.
So under the Constitution, decisions about health rest with the states. By design, that’s why we have 50 different health systems. The Second Amendment is another example: the Constitution protects the right to bear arms, which is rare in other countries. As a result, the U.S. has a huge epidemic of gun ownership, and firearm-related mortality here is massive compared to other countries and contributes to our shorter life expectancy.
Part of this also reflects our history: we were founded by people who wanted to limit government control. It’s part of our culture not to want heavy taxes or big government — our idea of liberty, however you define it, often includes freedom to take risks, even if that means freedom to die.
Social values make a difference. In many other countries, there’s a stronger ethic of a social compact where “we’re all in this together.” When I studied in Europe and rode the trains talking to people, they complained about high taxes and the health system like everyone does. But if you ask them whether they’d rather have the U.S. model, they say, “Oh God, no.” Even if the National Health Service has problems, they believe society has an obligation to care for those struggling. That ethic is far stronger elsewhere than it is in the U.S.
When the pandemic hit, I think the White House could have done more to organize a national response plan than it did. The Trump administration in 2020 really stepped back and deferred to the states to let them figure out how they want to address this. I think more could have been done even within our American model. But we’re not organized that way.
LP: During the pandemic, how did differences in, say, vaccination rates across states affect longevity and other health outcomes?
SW: It had a huge impact. If you compare 2020 and 2021, you’re essentially comparing the pandemic before vaccines and then the pandemic with vaccines. That was true worldwide.
In 2020, every country experienced devastating losses in life expectancy because of the pandemic. Within the U.S., however, we saw differences across states in the magnitude of those losses. We were doing research in real time using a method called excess deaths, which compares how many additional deaths occurred relative to what was expected.
Even before vaccines became available in 2021, we were seeing differences in excess death rates across states that seemed to reflect how aggressive states were in implementing pandemic control policies — things like the duration of early lockdowns, mask mandates, and social distancing. Because the response became politicized early on, you could largely predict a state’s COVID policies based on the governor’s party affiliation. We saw a clear partisan divide: red states experienced higher excess death rates.
Things became even more dramatic in 2021. In many countries, life expectancy began to rebound as vaccination coverage increased and mortality rates recovered. In the United States, by contrast, life expectancy continued to decline, and a lot of that was driven by states that did not do a great job with vaccination.
LP: You’ll hear people skeptical of vaccines claiming that excess deaths were actually caused by the vaccination: it’s the vaccines that made people sick. How do you counter that?
SW: Yes, such people would point out, well, in 2021, Biden is in office and he’s rolling out these vaccines — and look what happened to our death rates. So people just look at those facts and that seems to support their claim that it’s the vaccines that were killing us.
But it’s sort of like saying that the barn is on fire and the fire department’s come to put out the fire and you’re not letting them use any water. Then you blame the fire department for the barn burning down. The reason why our death rates kept climbing is because we were not vaccinating the population adequately.
You can see it very clearly in the data that the states that did a better job of vaccinating their population experienced much lower excess death rates than those that were more lax about it. Based on the research, there’s no question that those policy choices cost lives. I worry a lot about the next pandemic — because there will be one – and we may not have learned that lesson.
When the next public health crisis comes along, politicians in certain states may decide not to follow public health advice.
LP: Or politicians at the federal level.
SW: Yes.
LP: Given the state of federal health policy under the current Trump administration, do you see any real guardrails that prevent state-by-state life expectancy from diverging even further? Is longevity now largely a political choice made in state capitals?
SW: Yes, it is. And things are going to get worse. The trends that I’ve been studying all these years — I’ve always said that unless there’s a dramatic change in public policy, it’s going to continue to worsen.
What’s happened over the past year is not only is a failure to embrace the policies that would help address the U.S. health disadvantage, it’s moving in the opposite direction – the exact opposite of what you’d want to do to make America healthy again. I think what we’re going to end up seeing, unfortunately, is an acceleration of this trend.
LP: What about cities? Do they still have meaningful ways to protect public health, or has state preemption — where states block what local governments are allowed to do — reduced cities’ ability to act? Any promising developments at the city level?
SW: I view this as sort of like an upside down pyramid. There was a period where federal policy was making transformational changes in our health conditions, like the establishment of Medicare and Medicaid. Things like that that were historic and game changers. Now it’s flipped. Very little is happening in Washington that’s going to improve health – and a lot is actually going to threaten it.
There’s a real opportunity for states to make a difference, but it’s at the community level that you see some really cool stuff happen and very creative and bold strategies that improve population health. It’s true that if you’re in a state where you have a governor or a legislature that wants to use preemption to override what the local government is trying to do, that puts a brake on things. But it definitely doesn’t shut it down.
New York City is an example, but there are other localities that have used collective impact initiatives and a variety of other strategies to really make multi-sector changes in the community that have improved health outcomes, reduced health inequities.
One of my favorite examples is San Diego. There’s an initiative that’s been going on in San Diego now for about 15 years called Live Well San Diego, which is a collective impact initiative that involves hundreds of different entities within San Diego County across sectors. So we’re talking about government agencies, but also the Chamber of Commerce, the schools, the military bases, the supermarket chains. They all are members of this collective impact initiative. You walk into their offices and they have the same emblem on their wall. They are all sharing the same data dashboard.
They have a set of objectives that they’ve identified, and the data dashboard tracks their progress. Each of those entities, those sectors, whether it’s housing, retail, restaurants, what have you, are implementing their part of the plan to try to reduce obesity, reduce violence, and so forth. Those are exciting developments.
There are other examples along those lines.
LP: Some localities are sharing what’s working with others, like New York’s Abortion Access Hub, which has a hotline and referral system that connects people across the U.S. to providers and telehealth services. It’s an effort to fill in the gaps on restrictive federal policies. And I think it’s worth saying plainly: lack of access to abortion and reproductive care does not bode well for longevity. How concerned are you about women’s health in the current political paradigm?
SW: When it comes to women’s health, the policy rollbacks — not just in reproductive health, but across other areas of women’s health — along with reduced investment in early childhood development, are deeply concerning. It raises real worries about the long-term, cohort-level effects this will have on women’s health over time. People like me, a generation or two from now, will likely be publishing papers looking back at what happened to the cohort that lived through the Trump administration. Because it’s going to unfold.
LP: What might you expect to see in terms of impact on health outcomes and longevity for that cohort?
SW: I think you’re going to see that the cohort coming up now — children who are being born and growing up today — will face more challenges across their lives. From a life-course perspective, they’re unfortunately more likely to experience greater adversity, including poorer adolescent health, higher stress levels, mental health challenges, and disease processes that begin earlier in life.
I think that we’re going to see an increase in chronic disease and substance abuse related morbidity and mortality in this generation if we don’t move in a different direction.
*Stay tuned for Part 2 of INET’s discussion with Steven H. Woolf.
