Abstract
Adult mortality varies greatly by educational attainment. Explanations have focused on actions and choices made by individuals, neglecting contextual factors such as economic and policy environments. This study takes an important step toward explaining educational disparities in U.S. adult mortality and their growth since the mid-1980s by examining them across U.S. states. We analyzed data on adults aged 45–89 in the 1985–2011 National Health Interview Survey Linked Mortality File (721,448 adults; 225,592 deaths). We compared educational disparities in mortality in the early twenty-first century (1999–2011) with those of the late twentieth century (1985–1998) for 36 large-sample states, accounting for demographic covariates and birth state. We found that disparities vary considerably by state: in the early twenty-first century, the greater risk of death associated with lacking a high school credential, compared with having completed at least one year of college, ranged from 40 % in Arizona to 104 % in Maryland. The size of the disparities varies across states primarily because mortality associated with low education varies. Between the two periods, higher-educated adult mortality declined to similar levels across most states, but lower-educated adult mortality decreased, increased, or changed little, depending on the state. Consequently, educational disparities in mortality grew over time in many, but not all, states, with growth most common in the South and Midwest. The findings provide new insights into the troubling trends and disparities in U.S. adult mortality.
Similar content being viewed by others
Notes
In 2016, the pairwise correlation between state tobacco taxes and minimum wage was .62 (p < .001); it was .49 (p < .001) for tobacco taxes and the number of years EITC has been offered, and .26 (p < .10) for minimum wage and the number of years EITC has been offered (authors’ calculations).
Table A3 in the online appendix provides 95 % confidence intervals for the RRs in each period.
The Pearson correlation coefficient between the change in the gradient between the two periods and the change in the proportion of low-educated adults aged 45–89 is just .04 (N = 36 states).
References
Arcaya, M., Brewster, M., Zigler, C. M., & Subramanian, S. V. (2012). Area variations in health: A spatial multilevel modeling approach. Health & Place, 18, 824–831.
Baker, D. P., Smith, W. C., Muñoz, I. G., Jeon, H., Fu, T., Leon, J., . . . Horvatek, R. (2017). The Population Education Transition Curve: Education gradients across population exposure to new health risks. Demography, 54, 1873–1895.
Bambra, C., Netuveli, G., & Eikemo, T. A. (2010). Welfare state regime life courses: The development of Western European welfare state regimes and age-related patterns of educational inequalities in self-reported health. International Journal of Health Services, 40, 399–420.
Beckfield, J., Bambra, C., Eikemo, T. A., Huijts, T., McNamara, C., & Wendt, C. (2015). An institutional theory of welfare state effects on the distribution of population health. Social Theory & Health, 13, 227–244.
Beckfield, J., & Krieger, N. (2009). Epi + demos + cracy: Linking political systems and priorities to the magnitude of health inequities—Evidence, gaps, and a research agenda. Epidemiologic Reviews, 31, 152–177.
Bird, C. E., & Rieker, P. P. (2008). Gender and health: The effects of constrained choices and social policies. New York, NY: Cambridge University Press.
Bound, J., Geronimus, A. T., Rodriguez, J. M., & Waldman, T. A. (2015). Measuring recent apparent declines in longevity: The role of increasing educational attainment. Health Affairs, 34, 2167–2173.
Brennenstuhl, S., Quesnel-Vallée, A., & McDonough, P. (2012). Welfare regimes, population health and health inequalities: A research synthesis. Journal of Epidemiology and Community Health, 66, 397–409.
Brown, D. C., Hayward, M. D., Montez, J. K., Hummer, R. A., Chiu, C.-T., & Hidajat, M. M. (2012). The significance of education for mortality compression in the United States. Demography, 49, 819–840.
Bullinger, L. R. (2017). The effect of minimum wages on adolescent fertility: A nationwide analysis. American Journal of Public Health, 107, 447–452.
Cambois, E., Solé-Auró, A., Brønnum-Hansen, H., Egidi, V., Jagger, C., Jeune, B., . . . Robine, J.-M. (2016). Educational differentials in disability vary across and within welfare regimes: A comparison of 26 European countries in 2009. Journal of Epidemiology and Community Health, 70, 331–338.
Case, A., & Deaton, A. (2015). Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proceedings of the National Academy of Sciences, 112, 15078–15083.
Chetty, R., Stepner, M., Abraham, S., Lin, S., Scuderi, B., Turner, N., . . . Cutler, D. (2016). The association between income and life expectancy in the United States, 2001–2014. JAMA, 315, 1750–1766.
Clouston, S. A. P., Rubin, M. S., Phelan, J. C., & Link, B. G. (2016). A social history of disease: Contextualizing the rise and fall of social inequalities in cause-specific mortality. Demography, 53, 1631–1656.
Cutler, D. M., Lange, F., Meara, E., Richards-Shubik, S., & Ruhm, C. J. (2011). Rising educational gradients in mortality: The role of behavioral risk factors. Journal of Health Economics, 30, 1174–1187.
Cutler, D. M., & Lleras-Muney, A. (2010). Understanding differences in health behaviors by education. Journal of Health Economics, 29, 1–28.
DiPrete, T. A., & Buchmann, C. (2006). Gender-specific trends in the value of education and the emerging gender gap in college completion. Demography, 43, 1–24.
Dowd, J. B., & Hamoudi, A. (2014). Is life expectancy really falling for groups of low socio-economic status? Lagged selection bias and artefactual trends in mortality. International Journal of Epidemiology, 43, 983–988.
Dziak, J. J., Coffman, D. L., Lanza, S. T., & Li, R. (2012). Sensitivity and specificity of information criteria (Technical Report Series No. 12-119). State College: The Methodology Center, The Pennsylvania State University.
Ezzati, M., Friedman, A. B., Kulkarni, S. C., & Murray, C. J. L. (2008). The reversal of fortunes: Trends in county mortality and cross-county mortality disparities in the United States. PLoS Medicine, 5(4), e66. https://doi.org/10.1371/journal.pmed.0050066
Fenelon, A. (2013). Geographic divergence in mortality in the United States. Population and Development Review, 39, 611–634.
Frohlich, K. L., Ross, N., & Richmond, C. (2006). Health disparities in Canada today: Some evidence and a theoretical framwork. Health Policy, 79, 132–143.
Galea, S., Tracy, M., Hoggatt, K. J., DiMaggio, C., & Karpati, A. (2011). Estimated deaths attributable to social factors in the United States. American Journal of Public Health, 101, 1456–1465.
Golden, S. D., Ribisl, K. M., & Perreira, K. M. (2013). Economic and political Influence on tobacco tax rates: A nationwide analysis of 31 years of state data. American Journal of Public Health, 104, 350–357.
Grusky, D. B., Mattingly, M. J., & Varner, C. (2015). State of the states: The poverty and inequality report. Pathways: A Magazine on Poverty, Inequality, and Social Policy, 2015(Special Issue), 3–9.
Hayward, M. D., Hummer, R. A., & Sasson, I. (2015). Trends and group differences in the association between educational attainment and U.S. adult mortality: Implications for understanding education’s causal influence. Social Science & Medicine, 127, 8–18.
Hayward, M. D., Pienta, A. M., & McLaughlin, D. K. (1997). Inequality in men’s mortality: The socioeconomic status gradient and geographic context. Journal of Health and Social Behavior, 38, 313–330.
Hendi, A. S. (2015). Trends in U.S. life expectancy gradients: The role of changing educational composition. International Journal of Epidemiology, 44, 946–955.
Hendi, A. S. (2017). Trends in education-specific life expectancy, data quality, and shifting education distributions: A note on recent research. Demography, 54, 1203–1213.
Hummer, R. A., & Lariscy, J. T. (2011). Educational attainment and adult mortality. In R. G. Rogers & E. M. Crimmins (Eds.), International handbook of adult mortality (pp. 241–261). Dordrecht, the Netherlands: Springer.
Hurd, M. D., Smith, J. P., & Zissimopoulos, J. M. (2004). The effects of subjective survival on retirement and social security claiming. Journal of Applied Econometrics, 19, 761–775.
Ingram, D. D., Lochner, K. A., & Cox, C. S. (2008). Mortality experience of the 1986–2000 National Health Interview Survey linked mortality files participants (Vital Health Statistics Series 2, No. 147). Hyattsville, MD: National Center for Health Statistics.
Jemal, A., Ward, E., Anderson, R. N., Murray, T., & Thun, M. J. (2008). Widening of socioeconomic inequalities in U.S. death rates, 1993–2001. PLos ONE, 3(5), e2181. https://doi.org/10.1371/journal.pone.0002181
Kawachi, I., Kennedy, B. P., Lochner, K., & Prothro-Stith, D. (1997). Social capital, income inequality, and mortality. American Journal of Public Health, 87, 1491–1498.
Komro, K. A., Livingston, M. D., Sara Markowitz, P., & Wagenaar, A. C. (2016). The effect of an increased minimum wage on infant mortality and birth weight. American Journal of Public Health, 106, 1514–1516.
Krieger, N. (2001). Theories for social epidemiology in the 21st century: An ecosocial perspective. International Journal of Epidemiology, 30, 668–677.
Lauderdale, D. S. (2001). Education and survival: birth cohort, period, and age effects. Demography, 38, 551–561.
Link, B. G., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of Health and Social Behavior, 35(Extra Issue), 80–94.
Mackenbach, J. P., Stirbu, I., Roskam, A.-J. R., Schaap, M. M., Menvielle, G., Leinsalu, M., & Kunst, A. E. (2008). Socioeconomic inequalities in health in 22 European countries. New England Journal of Medicine, 358, 2468–2481.
MacLean, N. (2017). Democracy in chains: The deep history of the radical right’s stealth plan for America. New York, NY: Viking.
Masters, R. K., Hummer, R. A., & Powers, D. A. (2012). Educational differences in U.S. adult mortality: A cohort perspective. American Sociological Review, 77, 548–572.
Meara, E. R., Richards, S., & Cutler, D. M. (2008). The gap gets bigger: Changes in mortality and life expectancy, by education, 1981–2000. Health Affairs, 27, 350–360.
Miech, R. A., Pampel, F., Kim, J., & Rogers, R. G. (2011). The enduring association between education and mortality: The role of widening and narrowing disparities. American Sociological Review, 76, 913–934.
Mirowsky, J., & Ross, C. E. (2003). Education, social status, and health. New York, NY: Aldine de Gruyter.
Montez, J. K. (2017). Deregulation, devolution, and state preemption laws’ impact on U.S. mortality trends. American Journal of Public Health, 107, 1749–1750.
Montez, J. K., & Berkman, L. F. (2014). Trends in the educational gradient of mortality: Bringing regional context into the explanation. American Journal of Public Health, 104(1), e82–e90. https://doi.org/10.2105/AJPH.2013.301526.
Montez, J. K., & Hayward, M. D. (2014). Cumulative childhood adversity, educational attainment, and active life expectancy among U.S. adults. Demography, 51, 413–435.
Montez, J. K., Hayward, M. D., & Wolf, D. A. (2017a). Do U.S. states’ socioeconomic and policy contexts shape adult disability? Social Science & Medicine, 178, 115–126.
Montez, J. K., Hummer, R. A., Hayward, M. D., Woo, H., & Rogers, R. G. (2011). Trends in the educational gradient of U.S. adult mortality from 1986 through 2006 by race, gender, and age group. Research on Aging, 33, 145–171.
Montez, J. K., & Zajacova, A. (2013). Explaining the widening education gap in mortality among U.S. white women. Journal of Health and Social Behavior, 54, 165–181.
Montez, J. K., & Zajacova, A. (2014). Why is life expectancy declining among low-educated women in the United States? American Journal of Public Health, 104(10), e5–e7. https://doi.org/10.2105/AJPH.2014.302146.
Montez, J. K., Zajacova, A., & Hayward, M. D. (2016). Explaining inequalities in women’s mortality between U.S. states. SSM - Population Health, 2, 561–571.
Montez, J. K., Zajacova, A., & Hayward, M. D. (2017b). Disparities in disability by educational attainment across U.S. states. American Journal of Public Health, 107, 1101–1108.
Muennig, P. A., Mohit, B., Wu, J., Jia, H., & Rosen, Z. (2016). Cost effectiveness of the earned income tax credit as a health policy investment. American Journal of Preventive Medicine, 51, 874–881.
National Center for Health Statistics (NCHS). (2009). National Health Interview Survey (1986–2004) linked mortality files, mortality follow-up through 2006: Matching methodology. Hyattsville, MD: NCHS.
Navarro, V., & Shi, L. (2001). The political context of social inequalities and health. Social Science & Medicine, 52, 481–491.
Newman, K. S., & O’Brien, R. L. (2011). Taxing the poor: Doing damage to the truly disadvantaged. Berkelely: University of California Press.
Olshansky, S. J., Antonucci, T., Berkman, L., Binstock, R. H., Boersch-Supan, A., Cacioppo, J. T., . . . Zheng, Y. (2012). Differences in life expectancy due to race and educational differences are widening, and may not catch up. Health Affairs, 31, 1803–1813.
Pomeranz, J. L., & Pertschuk, M. (2017). State preemption: A significant and quiet threat to public health in the United States. American Journal of Public Health, 107, 900–902.
Preston, S. H., & Elo, I. T. (1995). Are educational differentials in adult mortality increasing in the United States? Journal of Aging and Health, 7, 476–496.
Raftery, A. E. (1995). Bayesian model selection in social research. Sociological Methodology, 25, 111–163.
Rostron, B. L., Boies, J. L., & Arias, E. (2010). Education reporting and classification on death certificates in the United States (Vital Health Statistics Series 2, No. 151). Hyattsville, MD: National Center for Health Statistics.
Sasson, I. (2016). Trends in life expectancy and lifespan variation by educational attainment: United States, 1990–2010. Demography, 53, 269–293.
Sasson, I. (2017). Reply to trends in education-specific life expectancy, data quality, and shifting education distributions: A note on recent research. Demography, 54, 1215–1219.
Scott-Sheldon, L. A. J., Carey, M. P., Vanable, P. A., & Senn, T. E. (2010). Subjective life expectancy and health behaviors among STD clinic patients. American Journal of Health Behaviors, 34, 349–361.
Skinner, J., & Staiger, D. (2007). Technology adoption from hybrid corn to beta-blockers. In E. R. Berndt & C. R. Hulten (Eds.), Hard-to-measure goods and services: Essays in honor of Zvi Griliches (pp. 545–570). Chicago, IL: University of Chicago Press.
Strully, K. W., Rehkopf, D. H., & Xuan, Z. (2010). Effects of prenatal poverty on infant health. State earned income tax credits and birth weight. American Sociological Review, 75, 534–562.
Subramanian, S. V., Kawachi, I., & Kennedy, B. P. (2001). Does the state you live in make a difference? Multilevel analysis of self-rated health in the US. Social Science & Medicine, 53, 9–19.
Tauras, J. A. (2004). Public policy and smoking cessation among young adults in the United States. Health Policy, 68, 321–322.
Van Dykea, M. E., Komrob, K. A., Shaha, M. P., Livingstonc, M. D., & Kramera, M. R. (2018). State-level minimum wage and heart disease death rates in the United States, 1980–2015: A novel application of marginal structural modeling. Preventive Medicine, 112, 97–103.
van Raalte, A. A., Kunst, A. E., Deboosere, P., Leinsalu, M., Lundberg, O., Martikainen, P., . . . Mackenbach, J. P. (2011). More variation in lifespan in lower educated groups: Evidence from 10 European countries. International Journal of Epidemiology, 40, 1703–1714.
Wilkinson, R. G. (1996). Unhealthy societies: The afflictions of inequality. London, UK: Routledge.
Wilmoth, J. R., Boe, C., & Barbieri, M. (2011). Geographic differences in life expectancy at age 50 in the United States compared with other high-income countries. In E. M. Crimmins, S. H. Preston, & B. Cohen (Eds.), International differences in mortality at older ages: Dimensions and sources (pp. 333–366). Washington, DC: National Academies Press.
Woolf, S. H., Johnson, R. E., Phillips, R. L., Jr., & Philipsen, M. (2007). Giving everyone the health of the educated: An examination of whether social change would save more lives than medical advances. American Journal of Public Health, 97, 679–683.
Zajacova, A., & Lawrence, E. M. (2018). The relationship between education and health: Reducing disparities through a contextual approach. Annual Review of Public Health, 39, 273–289.
Acknowledgments
This research was supported in part by Grant R01AG055481-01, Educational Attainment, Geography, and U.S. Adult Mortality Risk, awarded by the National Institute on Aging (PI: Montez); the Andrew Carnegie Foundation (PI: Montez); and Grant 5 R24 HD042849 awarded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development to the Population Research Center at the University of Texas at Austin (PI: Hayward). We thank three anonymous reviewers for exceptionally helpful comments on an earlier version of this paper. The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the Research Data Center, the National Center for Health Statistics, or the Centers for Disease Control and Prevention.
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
ESM 1
(PDF 1679 kb)
Rights and permissions
About this article
Cite this article
Montez, J.K., Zajacova, A., Hayward, M.D. et al. Educational Disparities in Adult Mortality Across U.S. States: How Do They Differ, and Have They Changed Since the Mid-1980s?. Demography 56, 621–644 (2019). https://doi.org/10.1007/s13524-018-0750-z
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13524-018-0750-z