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Jan 29, 2016

Analysis of Death Rates for Middle-Aged Whites Finds Substance Abuse and Suicide Only Partly to Blame for Higher-Than-Expected Mortality; Progress Has Halted or Reversed for Most Diseases

Alabama, Arkansas, Kentucky, Mississippi, Oklahoma, Tennessee, and West Virginia Saw Worst Death Trends Among 45-to-54-Year-Old Whites

New York, NY, January 29, 2016—A lack of progress since 1999 against common illnesses such as heart disease, diabetes, and respiratory disease was largely responsible for higher-than-expected death rates for middle-aged (45–54) white adults in 2014, according to a new Commonwealth Fund study. While substance abuse and suicide rates increased during the same period, they did not increase enough to explain why death rates for this group have deviated from their historical decline. 

The study, Mortality Trends Among Working-Age Whites: The Untold Story, also looked at whites’ higher-than-expected death rates state by state. The worst trends were seen in the South, particularly Alabama, Arkansas, Kentucky, Mississippi, Oklahoma, Tennessee, and West Virginia. In West Virginia, whites 45 to 54 are dying at the highest rates seen since 1980.  

We are accustomed to making progress against diseases. We learn how to prevent them and how to treat them and, as we do that, fewer people die from them,” said Commonwealth Fund President David Blumenthal, M.D., a coauthor of the study. “For middle-aged whites, that progress has stalled and even reversed for some conditions. We need to find out why this is happening. However, maintaining and improving access to health care remains important, especially for lower-income people in states that have not expanded Medicaid.” 

The Death Gap: What Should Have Happened vs. What Actually Happened

The authors looked at actual and expected death rates, as well as causes of death, for working-age adults between 1968 and 2014. They note that if whites’ death rates between 1999 and 2014 had followed past trends, they would have declined about 1.8 percent per year, resulting in fewer deaths. However, the opposite occurred, and death rates rose instead.

According to the study, it is important to look at the gap between expected and actual deaths in order to get the full picture of what is happening among middle-aged whites. While deaths from suicide and substance abuse increased for 45-to-54-year-old whites between 1999 and 2014, these two causes were responsible for roughly 40 percent of the gap between expected and actual death rates. The larger part of the gap, 60 percent, was attributable to death rates failing to improve as expected for nearly all of the leading causes of death (e.g., heart disease, diabetes, and respiratory disease) for middle-aged whites.

Death Gap by State

The study finds that in all states there was a gap between observed and expected death rates for middle-aged whites. The death gap was most pronounced in Alabama, Arkansas, Kentucky, Tennessee, Oklahoma, Mississippi, and West Virginia, where actual 2014 mortality rates were between 60 and 76 percent higher than expected. The gap was smallest in New York, New Jersey, California, Connecticut, Minnesota, Massachusetts, and Illinois, where mortality rates fell slightly between 1999 and 2014.

Additional Study Findings

  • There was a gap between actual and expected death rates for working-age white adults between 19 and 65 years of age. However, it was most pronounced among middle-aged whites.
  • In contrast to middle-aged adults, the gap between expected and actual deaths among younger whites is entirely explained by substance abuse and suicide.
  • Cancer was somewhat of an exception for middle-aged whites, as deaths from the disease declined by 14 percent between 1999 and 2014. But that was still less of a decline than what occurred between 1983 and 1998, when cancer deaths dropped by 25 percent for this group.

Moving Forward

The breadth of the problem suggests that its causes lie outside the health care system. The study’s authors hypothesize that “…the excess deaths among middle-aged whites could be due in large part to the erosion in their socioeconomic standing. On a range of social and economic indicators, middle-aged whites have been falling behind in the 21st century.”

Reversing this trend, along with reducing other health disparities associated with race and income in the United States, should be an urgent priority, the authors conclude.


Publication Details


Jan 29, 2016


Mary Mahon, Former Vice President, Public Information, The Commonwealth Fund

[email protected]