Rising geographic inequality in mortality in the United States

Objectives: To examine trends in inequality in life expectancy and age-specific death rates across 40 US spatial units from 1990 to 2016. Methods: We use multiple cause-of-death data from vital statistics to estimate measures of inequality in mortality across metropolitan status and geographic region. We consider trends for 5-year age intervals and examine inequality in cause-specific mortality. Results: For both sexes, spatial inequality in life expectancy and all-cause mortality above age 25 rose between 2002-04 and 2014-16. During this period, the standard deviation in life expectancy at birth increased by 19% for males and by 44% for females. Areas that had higher life expectancy at the beginning of the period enjoyed larger gains in life expectancy. Especially noteworthy are divergent trends between large central metropolitan areas on the coasts and non-metropolitan areas in Appalachia and the South. Spatial inequality in mortality from lung cancer/respiratory diseases rose substantially, particularly for older women. Spatial inequality in mortality from the combination of drug overdose, alcohol use, and suicide increased at ages 30-34, but declined at ages 50-54 and 70-74. Inequality in mortality from circulatory diseases, the largest cause of death, grew for some groups, particularly 30-34 year-old women. Mortality from screenable cancers, an indicator of the performance of medical systems, showed relatively little spatial disparity during the period. Conclusions: Spatial inequality in life expectancy at birth and adult mortality has increased in recent decades.