In January of this year, Senior White House Advisor Kellyanne Conway raved over what she saw as one of the finest achievements of the Trump administration, saying, “This has not happened through coincidence, it’s happened through causation. It’s owing in large part to a whole-of-government approach … led by President Trump, first lady Melania Trump, and really the entire administration.” Her laudatory statement wasn’t aimed at record-low unemployment or a new trade deal with China — it was celebrating a rise in the U.S. life expectancy by 0.1 years from 2017 to 2018.
While Conway triumphantly touted America’s good health, her effort reflects the scarcity of such increases in recent years. After steadily climbing for decades, America’s life expectancy began to drop in 2014. The three-year skid that followed presented an enigma for a wealthy country. A 2019 paper in the Journal of the American Medical Association explained this drop as the culmination of a rise in deaths among adults ages 25 to 64 from specific causes — namely drug overdoses, alcohol abuse, and suicides — that began in the 1990s. In other words, these preventable deaths were dragging down the collective well-being of the nation.
These tragedies especially devastated one demographic. Princeton economists Anne Case and Sir Angus Deaton found that between 1999 and 2013, the largest surge in suicides and drug and alcohol overdoses was seen in White, non-Hispanic Americans between the ages of 45 and 54. Within this cohort, cause-specific mortality rates were highest for those with the least education. Case and Deaton labeled the deaths that they analyzed “deaths of despair.” Prior to the pandemic, the phrase had already entered the mainstream lexicon as a catch-all term for deaths by suicide and drug overdoses; now, its importance takes on a new urgency.
The pandemic created a perfect storm of economic malaise and social isolation, leading many to predict a spike in deaths of despair. A report from the Well Being Trust, a foundation focused on mental health, projected that COVID-19 could cause up to 150,000 additional deaths of despair this decade. Benjamin F. Miller, an author of the report, believes that another major factor to watch is pandemic-induced uncertainty. “When all of us are terrified thinking if COVID will get better or worse, if our kids will go back to school or if we can go back to our jobs,” he told the HPR, “it adds a layer of complexity that you have to bake in.” This uncertainty, along with the tangible economic and social ramifications of COVID-19, indicates that deaths of despair must be closely watched as the pandemic progresses.
However, COVID-19’s exacerbation of deaths of despair should not obscure the gravity of the preexisting problem, which exposes a number of ugly realities in American society: the hollowing out of the working class, the inadequacy of our health care system, and the penalization of those without college degrees. By worsening the nation’s collective despair, the pandemic could lead to thousands of additional deaths in the years to come. Within this unconscionable tragedy, however, lies a crucial opportunity to address the underlying factors behind such deaths.
The Origins of Despair
Identifying the root of America’s preventable mortality crisis is a difficult task, but one that begins with economics. Case and Deaton suggest that the weakening of America’s White working class, through a decline in labor opportunities over time, is likely to blame for this group’s decline into despair. This account dovetails with other research conducted on loss of opportunity in the American working class. In 2017, economist Raj Chetty and others estimated that 90% of Americans born in 1940 were better off at 30 than their parents had been at the same age. For the cohort born in 1960, this number was only 60%, lending credence to Case and Deaton’s theory of how the White working class was left behind. In this theory, globalization and automation erased the manufacturing jobs and unions that once yielded middle class prosperity and social cohesion, leaving those without a college degree unwanted in the new economy.
This theory falls short when other wealthy countries, which have experienced globalization and automation but have not seen such drastic increases in deaths of despair, are taken into account. America’s bare-bones social safety net deserves scrutiny, but the U.S. health care system is also at fault. Under this system, 49% of Americans have health insurance through their employer, but companies face financial incentives to not provide insurance for low-skilled workers. Workers like janitors, food service workers, and drivers likely offer companies about $20,000 to $30,000 in value each year, but the price for a company to cover the average family health insurance policy was $21,000 in 2019. In an interview with Vox, Deaton pointed to this costly dilemma as the reason why many corporations have cut or contracted out these types of jobs — jobs that are now, ironically, considered essential.
Even for those with health insurance, a potential lifeline for struggling workers may still be out of reach: mental health care. The Mental Health Parity and Addiction Equity Act of 2008 stipulated that mental health and addiction treatment should be treated the same as physical treatment, while the Affordable Care Act requires most individual and small employer health insurance plans to cover behavioral health care. However, enforcement at the state level has been abysmal; Parity Track, an advocacy group, gave 32 states a failing grade on mental health parity in 2018. Unsurprisingly, a mental health office visit is still five times as likely to not be covered by health insurance than a physical health office visit, and only 10% of those with a known substance use disorder receive care. The seeds of a mental health crisis were already planted, portending to worsen deaths of despair, before the coronavirus upended the nation’s psyche.
When the Virus Hit
The first sign that the pandemic could worsen America’s collective despair came when crisis hotlines were inundated with calls. During the month of March, the Substance Abuse and Mental Health Services Administration recorded a fivefold increase in calls to its National Hotline. The severity of each crisis has been increasing as well. Laura Mayer, the director of the PRS CrisisLink call center in Oakton, Virginia, told the HPR that in June, half of all COVID-related calls were from people with active suicide plans. Crisis center workers have been forced to take calls from home while dealing with their own pandemic problems. As Mayer noted, “This is an unprecedented time when not only are the people we’re serving in crisis, but crisis workers are as well.” She spoke of having to comfort hotline workers over Zoom after callers took their own lives while on the phone.
Elinore McCance-Katz, an assistant secretary at the Department of Health and Human Services and the director of SAMHSA, thinks the effects of prolonged social isolation have likely fueled this rise. “When you think about suicidality, it’s really defined by isolation,” she told the HPR. While suicide data for the spring is not yet available, another measure of despair, suspected drug overdoses, shot up 42% in May compared to 2019, in part because the pandemic has disrupted supply lines for current users and isolated recovering addicts. Nicholas Kristof, a New York Times columnist and author of a recent book about the experience of the working poor across all 50 states, wrote a column in March about Keylan Knapp, who rode Kristof’s childhood school bus and died of a heroin overdose in March. Kristof told the HPR, “It’s hard to know whether there was a connection [to the pandemic] but he had lost his job and was certainly isolated.”
Manzo, in addition to facing isolation, had also lost his job — a harbinger of mental health distress during this recession. With 17.8 million Americans out of work, economic distress is frequently on the mind of Joe Parks, who practices psychiatry at the Family Health Center in Columbia, Missouri. “A lot of people are burdened by the economic uncertainty,” Parks told the HPR.” It makes them feel anxious. It makes them feel depressed, distracted, and desperate.” While Case and Deaton assert that deaths of despair unfold after years of deteriorating economic conditions, the scale and abruptness of the current recession are unprecedented, and it is worth noting that Hispanic and Black Americans are bearing the brunt of the economic pain.
These demographics will likely feel the after-effects of the recession for years to come, along with a group that fared just as poorly: those with only a high school diploma or less. This is especially disconcerting because some small colleges have shuttered due to tuition shortfalls and unexpected costs due to the pandemic, with more sure to follow. State budgets have been decimated by the pandemic and public colleges have quickly lost funding in response. At the same time, high school students’ college plans have been thrown into disarray by their families’ declining economic situation, indicating that a college degree could be out of reach for many just as the economy punishes those without one the most. The uncertainty of coronavirus’ impact on educational divides, the economy, and long-term mental health makes forecasting and preventing deaths of despair truly Herculean tasks — but vital ones at the same time.
A Path Forward
The multifaceted factors that drive deaths of despair mean that solutions, during and after the pandemic, must be multifaceted as well. Upstream initiatives that limit access to lethal means of suicide and address substance use disorders should certainly play a role. For example, the Kentucky-based Sobriety Treatment and Recovery Teams has tremendously helped families with issues of substance abuse and child neglect. Crisis hotlines, the ultimate upstream programs, look set to score a major victory as the FCC changes the national suicide hotline number to 988, putting mental health emergencies on par with emergencies requiring a 911 call. What is still missing for Mayer’s PRS and other hotlines is federal funding. “$16.50 an hour for a crisis worker making life and death decisions is not a reasonable rate,” she said.
The battle for funding is a familiar fight for anyone who works in behavioral health. Although HHS has doled out over $9 billion to advance addiction treatment, the Trump administration’s various changes to Medicaid have undermined a program that accounts for 25% of all mental health spending and 21% of all addiction spending. When it came time to provide stopgap mental health funding in the $2.2 trillion stimulus bill, SAMHSA received $425 million, less than one-tenth of 1% of total spending. When asked about this sum, Miller said it was just a “paltry” amount — “almost an embarrassment,” he said. “If it doesn’t personify the ongoing marginalization of mental health, I don’t know what does.”
Rallying political support for mental health care funding might seem unlikely at the moment, given how much stimulus funding Congress has already passed, but there are already promising options. The HEROES Act, another stimulus bill that the House passed in May, would allocate $3 billion to various SAMHSA programs including Certified Community Behavioral Health Clinics, which provide mental health and addiction services and receive Medicaid reimbursement to cover the costs. McCance-Katz called this program “a model for the nation,” whereas Parks was more skeptical of the clinics. “You know exactly what you are getting,” he said. McCance-Katz also lauded the potential of telehealth, which has made great strides during the pandemic but is still not covered by all insurance plans. The fact that neither the HEROES Act nor the Health Care at Home Act look likely to pass the Senate is a tough pill to swallow for mental health advocates.
Even if both bills were passed, they would represent a flimsy bandage on the bleeding wound that leads to deaths of despair. This wound is one that demands change to a health care system that takes but does not give back, and an American economic system that Case and Deaton write looks “more like a racket for redistributing upward than an engine of general prosperity.” How can America’s middle class regain its lost vigor? Some economists recommend raising the minimum wage and making the tax code more progressive. Kristof honed in on corporate governance, arguing, “The US has seen the rise of an ethic in which corporations should look after only shareholders, not other stakeholders.” Richard Wilkinson, a British epidemiologist and author, echoed this sentiment, pointing to the fact that roughly half of European Union member countries allow for employee representation on company boards. This model, he said, “embeds greater equality more fundamentally into our society.”
A proposal like this one might seem more at home in a Bernie Sanders policy brief than in a book by two Princeton economists, but the nature of our working class predicament favors boldness. A silver lining of the coronavirus and its complete destruction of normalcy is that seismic change — the kind that confronts systemic racism or climate change — does not seem fantastical but almost practical in a world that lacks predictability. Therefore, this moment is the perfect one to confront the scourge of deaths of despair. The virus has made us appreciate the importance of human connection, stability, and hope. Each of these tenets will be essential as we muddle into a post-pandemic world, one in which rising life expectancy will hopefully be the norm, not the exception.
Image Credit: Photo by Ian Espinosa is used under the Unsplash License