Missing Life Expectancy

Mike Koetting October 13, 2036

I recently ran across an article that argued that the United States had far too many premature deaths. The article called it a crisis. This echoed an article from a couple years ago by Matt Yglesias that America’s shorter life expectancy should be a priority because, as he put it, “Dying is bad.”

Whether it’s a crisis or not, it is clear that life expectancies in the U.S. lag behind those of other developed countries and, over time, seem to be falling further behind. In 1980, the U.S. had the 14th highest average life span of countries with populations above 1 million. It has slipped steadily since then, now ranking 38th among countries with more than 1 million people.

For the most part, life expectancy in the U.S. has continued to increase over this period, just not as fast as the rest of the developed world. The aggregate differences are not large—U.S. average life expectancy was about 79 whereas, say, European countries were typically two to four years higher. The differences between an average life expectancy of 79 and 82 may not seem like a critical difference in the course of long lives. But these numbers disguise what’s going on. In fact, longevity at older ages has generally improved in relation to other countries. The difference in the overall rates arises from higher mortality among young and middle-age people–people who could be expected to live longer and whose shorter lives make a difference.

The following chart compares projected mortality rates before the age of 40 in the US versus an average of high-income countries.

So what’s going on? Why should a country that prides itself on its technology leadership and leads the world in per-capita health expenditures by a ridiculous margin have mediocre longevity?

We can get better understanding by looking at specific age groups.

Infant Mortality

One of the starker differences is at the beginning of life. Infant mortality in the U.S. is just under 5 per 1000. In other words, about five out of every 1000 babies born in the U.S. die before age one. There have been efforts in this area and the mortality rate has continued to fall over time. But in the high-income countries in Europe, infant mortality rates cluster between 2.5 and 3.5. Thus, there are about 2 more U.S. infant deaths per year in every thousand babies than if we had the same rate as these countries.

Youth (1-24)

Motor vehicle deaths were cut almost in half between 1999 and 2014 and have remained relatively stable since then. But from 2014 to 2023, all-cause mortality rates for youths increased sharply, primarily as a result of a dramatic increase in drug overdoses, along with a more than 33% increase in the suicide rate. Note, in the chart below, mortality from childhood cancer continues to fall. This is typical of what is happening among traditional pediatric killers.

Young Adults (25-44)

The biggest increases in mortality were among young adults; between 1999 and 2023, aggregate rates of mortality in this group increased by more than 40%. They were driven by a seven-fold increase in drug overdoses, which became by far the most common cause of death in this age range. Suicides and homicides are other large causes. Motor vehicle deaths, which declined precipitously between 2000 and 2014, trended up again. It seems possible this increase in motor-related deaths is related to the same factors driving increase in suicide, drug and alcohol rated deaths. Cardiometabolic conditions—which can include obesity, heart disease, and diabetes—also contribute but are not as large as above causes.

Middle Age (45-65)

Mortality in this age range was a mixed bag. The rate of cancer deaths has dropped by more than one-third. If nothing else were going on, this would have bent the life expectancy curve upward. But there was a lot going on. Heart-related mortality was dropping until about 2012, at which point an increase in hypertensive diseases overwhelmed decreases in ischemic heart diseases. Drug overdose deaths in this period jumped by 900% and by 2023 were the third largest cause of deaths in this age group. Death from metabolic and endocrine diseases (frequently related to obesity) experienced a 50% jump. Alcohol related deaths, though less frequent, increased by 60%.

What to Do: Amelioration Obvious; Solutions Less So

The most immediate response to the lower life expectancy in the U.S. is that we don’t have universal health care—like all the other countries with better life expectancy.

That is certainly a big part of the problem. Numerous studies have shown that with better Medicaid, with ACA coverage, health status and mortality improve. Conversely, we know that states with the most stingy coverage have higher mortality rates, although the correlation is not perfect.

Over my career, I have spent a lot of time thinking about the connection between coverage and outcome. The coverage that seems to make the most difference is not the explicit coverage for specific health issues. If people experience serious health problems and they show up in hospitals, they typically get treated. I think—which is not the same as having data; someone should think of a clever way to study this—the problem arises because people whose health care is dependent on the vagaries of government don’t think of health care as an ongoing process, but as an episodic event when unavoidable needs arise. This is not conducive to good health.

To be sure, the problem cannot be solved by universal health care alone. People with less income tend to have more chaotic lives and, accordingly, higher mortality. This is true in countries with universal health care as well as the U.S. The difference is the resulting U.S. mortality for poor people, especially Blacks, is markedly higher than for poor people in countries with universal health care.

Of course, mortality seems only partially related to availability of health care per se. For instance, other high income countries spend about $1.70 in social services for every dollar spent on health care. The comparable U.S. number is $.56.

Looking over recent changes is U.S. mortality, it is clear that increasing deaths from drug overdoses are a major contributor to lower life expectancy. They are shockingly greater in the US than in other counties.

To the extent universal health care would lead to earlier intervention or more comprehensive drug treatment, it could be a factor. But it is probable other factors are at work. Same may be true for suicides—where the U.S. has about 20% more than the other advanced economies. Homicides are mostly outside what conventional health care can do, but they are a big cause of life expectancy differences. The American homicide rate is four or five times as high as the European societies.

Beyond these, it’s a bit hard to see what’s going on. Cancer death rates in the U.S. compare favorably with other countries. And while obesity rates and hypertension mortality rates in the U.S. have been growing, they are not that different from those in other rich countries. Still, the mortality rate in the U.S. remains higher than these other countries

No easy answers. Note also, mortality rates in high income groups in the U.S. are higher than mortality rates among higher income groups in Europe. This is not likely due to differences in universal coverage.

In Short

As can be seen in this sometimes dizzyingly tour through statistics, there is no clear answer to resolving the American life expectancy shortfall. It stems from a number of loosely related issues, some of which have obvious answers and some of which don’t.

It is clear one of the biggest things America could do to address differences in life expectancy is get its drug problem under control. While America has had steep declines in overdose related mortality in the last several years, it is still a significant differentiator between the U.S. and other advanced economies. Unfortunately, identifying this as the biggest issue doesn’t offer much direction on how to accomplish that.

Adopting universal health care is a no-brainer if a country is really interested in the health of its population. The resistance of the U.S. to this is an impressive testimony to the power of established interests to overcome overwhelming rational arguments in favor—better health, lower costs, and reduced human suffering.

Two things the U.S. should not do is cut back on health research and on public health measures, both of which the Trump administration keeps trying to do.

The bright spots in national life span, such as the major decrease in age-adjusted cancer deaths, have been from the successful application of research. Additionally, there have been major improvements in quality of life stemming from recent scientific advances. But, last year, OMB proposed a 40% reduction in funding for the NIH, which received pushback even from Republicans. On top of that, there has been repeated and significant meddling in the process of making grants, resulting in impairment in the ability to do research. One of the particular focal points for the administration is any research that might have “policy implications.” This is nuts. Many of the greatest health achievements of the past century—including reductions in smoking, improvements in motor vehicle safety, cleaner air and water, and control of infectious diseases—depended on research concerning the design, implementation, and effects of laws, regulations, and other policy interventions.

Cutting back on direct public health expenditures is likely to further increase the mortality gap between America and other advanced economies. The absurd assault on vaccinations is the poster child, with growing outbreaks of infectious diseases all around the country. Withdrawing support from the promotion of flu vaccinations will cause more preventable deaths—and a bunch more unpleasantness that might have been avoided. What other outcome could be expected is a mystery.

On balance, what would reduce the mortality gap between the U.S. and other countries is clear, but we are unable or unwilling to pursue it. Why won’t this country protect its citizens as well as other advanced countries do?

Midterm Thoughts

By Mike Koetting September 29, 2025

Today is five weeks from the election day…although, in fact, the election is well under way in many states. Increasingly, “election day” could be better characterized as “disclosure day”—an announcement of the results that have been building for weeks.

I have been reading polls, poll analytics and poll pundits. From all this reading, I see the experts converging on one idea: “Well, we’ll just have to see.”

There is, of course, much more thought behind this and all concede that there is plenty of reason for Democratic optimism and Republican concern. But the overall composition of the next Congress will come down to a whole lot of individual races that are hard to predict. The hardening of the country into Red and Blue (most of it reinforced by gerrymandering to make small majorities larger majorities) structurally dampens the likelihood of change.)

Polling Less About Polling

I recently saw an article that crystalized something I have been sensing for a while. Over time, it has become increasingly difficult, and correspondingly more expensive, to obtain actual respondents. Response rates to polling inquiries are now somewhere in the 2% range. At the same time, the number of factors that a pollster might want to take into account has increased. If that were to be achieved by polling alone, accuracy would require even larger numbers of respondents. Instead, what is called polling seemingly has as much to do with the underlying statistical adjustments made to what responses have been obtained.

This does not mean polls are useless. Polls still give some sense of broader currents that is independent of not only the self-serving statements of politicians and others, but also the direct filtering impacts embedded in social media. Without independent polling, when Donald Trump says he is the most popular president of all time, it could be countered only by claims from the other side that he is lying. With polling, while we may not know exactly how unpopular he is, we know that he is plainly wrong.

What this does call for is for pollsters to be more honest about the range of uncertainties contained within their estimates. Likewise, it requires consumers of polls to be realistic about what a poll can be expected to deliver. For openers, we all need to keep in mind that polls are best in mapping broad currents. The narrower the focus—in time and event—the greater the likelihood of error. Elections are one-time events, in the future, and can happen at very granular levels. Thus, while polls give us the best information available, they require several grains of salt.

Understanding the limits of what can be known, let’s take a look at what we have to work with.

Democrats Likely to Win the House

There is a broad consensus that Democrats are likely to win the House. Donald Trump is deeply unpopular. One recent national poll has shown a 10-point lead for Democrats among voters who say they are likely to vote. (This same poll shows remarkably few voters who are undecided. Whichever side they are on, people have made up their mind.)

But it is hard to say how this will translate into specific votes. Races for House seats are not decided on broad trends but on the make-up of the specific districts, the individual candidates, and the issues of particular salience to the district at that time. Voters may be deeply unhappy with the national direction, but that doesn’t mean they will in fact vote against “their” party in a House race.

And, as we all know, districts slice and dice the population to maximize the dominant party’s share. This gerrymandering hit new depths over the past year as Republicans struggle to find more seats. About 10% of the country’s population was impacted by this year’s gerrymandering alone. Some of this may backfire. In order to create more nominally Republican districts, they had to redistribute voters from particularly strong Republican areas to districts that were otherwise closer. In some cases, they may have cut too finely.

In theory, all 435 seats in the House are up for election. The practical reality is that upwards of 90% of them are non-competitive. That is, the odds of someone from the minority party (Republican or Democrat) breaking through are low. According to the Cook Political Report, there are only 37 competitive House seats. Democrats will have to win 22 of the 37 competitive seats to have a bare majority of 218 seats.

This seems doable. Sentiment is running against Republicans. It is also the case that some of the races deemed “non-competitive” will in fact prove competitive. G. Elliott Morris has offered analysis showing many composite predictions of what will be competitive has over the past several election cycles underestimated votes for the out-party (Democratic or Republican) in the mid-term.

Still, the degree to which American politics have become polarized makes it hard to see how Democrats will achieve a commanding majority, which I arbitrarily pick at something like 230 seats. (As the margin of difference grows smaller, it becomes harder for the nominally controlling party to actually control outcomes. The most likely result of such small margins is a do-nothing Congress as we have now.) To get 230 Democratic seats, they would need to win 34 of the 37 competitive seats. Or for a number of seats not expected to become competitive to become competitive. This is not impossible. But it is a climb.

Some observations about campaign financing. Republicans are pouring money into campaigns, including places where they might not have expected to spend money. They are significantly outspending Democrats. But three considerations. First, more money helps, but there are any number of races that show money does not always triumph. Second, it appears Republicans have the money to spend because of donations from various SuperPACs run by and on behalf of the billionaire class. Just 10 billionaires have already invested $730 MILLION into the 2026 midterms. This could present its own problems. Finally, it is likely that the purpose of these expenditures is less to change the minds of anyone but to make sure that Republicans who are discouraged by the Trump clown show in fact turnout to prevent the perfidious Democrats from delivering the country to godless socialism. Not clear who is biting.

Senate Looks Similar

There are 35 seats in play. The Cook report suggests that only 13 of those are competitive as shown below.

Democrats have 34 seats not up for election and 9 seats deemed noncompetitive. Thus, in order to capture control of the Senate, they must win 8 out of the remaining 13 competitive seats. That clearly looks possible. Henry Olsen, a conservative columnist at the Washington Post, thinks Democrats could win as many as 10 of these 13 seats. That would give Democrats a 53-47 margin. But 10 is a tall order. For instance, Texas is in his list. Yes, Talarico is ahead in numerous polls, but do we really believe at the end of the day Texas will vote Democrat? Same in Iowa. In Maine, Susan Collins has a Houdini-like record of escaping from tight situations. And in Michigan, El-Sayed has some issues—although his support has been rising since he won the primary. Unless Democrats win at least two of these four—or pick up unexpected seats elsewhere —they would be stuck at 49 votes.

So, while the Democrats have a clear path to a majority, it is by no means a certainty. And even with a small majority and a filibuster in place, there would be real limits on what could be accomplished. Particularly since the Senate is impacted by the mother of all gerrymanders, two Senators per state regardless.

Current Republican Congressmen

I wonder what the Republican Congressmen not scrambling for their political lives are thinking. I remain utterly baffled by their willingness to ignore Trump’s personal corruption, disregard for the rule of law, flagrantly stupid policy choices and penchant for bizarre and divisive expressions. I continue to believe they know better.

A large part of me thinks there are many Republicans who are secretly hoping for a Blue Wave. They know what is going on is not in the best interests of the country but they don’t want their fingerprints on ending the MAGA party.

Ray Valek, a former colleague at the U of C Medical Center, acknowledges that many Republicans understand now that they are out ahead of their skis. They thought they could control Trump to a certain degree and have been willing to acquiesce since he gave cover to get what they have been after since the New Deal—fewer regulations, lower taxes and dollops of old-fashioned punish-the-poor morality. They might have preferred more of a scalpel approach, but Trump’s crazy hammer style has delivered what they want, at least till now. The question becomes whether more won’t have second thoughts as his impulsive and narcissistic style threatens to kill the whole goose.

Context

Like many Americans, I am holding my breath. I believe the Democrats will win the House and am optimistic they will also win the Senate. But it won’t be over until it is over.

There remains the possibility that Trump would try some direct intervention in the election, but I consider that remote. Cracks are beginning to surface in the Trump coalition and anything so overt would be likely to blow up in his face. Moreover, unless my wildest fantasies about this election come to pass, I suspect it unlikely that the election will produce such decisive margins they will be able to fundamentally change the course of the Administration. Smallish Democratic majorities will pester Trump but he will be able to mostly coast out his last two years, continuing to rake in grift. So why would he take the chance of blowing it all up?

Then again, we are talking about Donald Trump.

A Letter I Would Like to Send to Senator Thune

By Mike Koetting September 23, 2026

Like many Americans, I am frustrated at the unwillingness of the Republican Congress to rein in Donald Trump. I think his actions have gone well beyond matters of normal policy differences.

I want Republicans to actually provide a rationale for their inaction. I submitted a proposed op-ed to several newspapers in the form of a letter to Senator Thune asking him how they could ignore what was happening.

None printed it. My questions, however, remain unanswered. So, imagining there is any way I could get through to John Thune, I ask again.

The Honorable John Thune:

I suspect you and I disagree on a great many issues. Fair enough. The issues society faces are complex and there are a range of plausible solutions. Choices on any of them may reflect broader philosophical inclinations. Which is fine. The respectful clash of ideas produces a stronger democracy.

However, I assume, indeed, the assumption of democracy is that you are a man of good will, genuinely care about the welfare of all the American people and respect the rule of law. In that spirit, I would really like to hear your human explanation for why Congress is not doing more to rein in President Trump. Not the usual political rationalizations, but what you are really thinking and feeling.

I find it hard to believe you really think it’s a good idea to pursue a war with Iran. I don’t know all the circumstances, but as near as I can see, it was started without Congressional consultation, ignored readily available information that suggested that it would turn as it has, seems unlikely to achieve any of its objectives, is harming our ability to carry out other military objectives, and is damaging the American economy.

Do you and your colleagues really believe that “global warming” is a hoax? I recognize there are a range of possible responses to environmental issues, but under what circumstances does it really make sense to actively oppose alternative energy solutions? I don’t believe you are oblivious to the problems. And I find it hard to accept that you think if we ignore these issues, they will go away.

I am surprised at the willingness to confirm as Attorney General the President’s personal lawyer who has made it clear he is willing to use the DOJ as the President’s agency of both vengeance and self-aggrandizement. Under what interpretation is this consistent with the rule of law that has served the country so well for the last 250 years?

The President’s brazen campaign of self-enrichment for him and his families is remarkable. Why do the standards to which all other presidents have been held no longer apply? In the face of this, why is Congress willing to give him and his family less IRS oversight than average Americans?

Does a Congressional majority believe that vaccinations are more dangerous than the diseases they prevent? How does Congress feel about reductions in food inspections and protections? Don’t the ongoing cuts of scientific research create worries for the future? Does the majority really believe this makes the nation stronger?

Immigration is a difficult issue. But do you and your colleagues believe the current approaches to dealing with this issue reflect the best instincts of America, let alone the economic consequences, the weakening of traditional safeguards and undercutting standards of humane treatment?

While there are no laws about Presidential decorum, how is the country served by having a President who is seemingly unbound by any notion of what leaders of a democracy should do to unite a country and is willing to enter all manner of divisive speech and behavior? How can this possibly be good for the country?

I know the politics of the situation make it hard for any one of you to get out too far on this. But you have a collective responsibility to look out for the entire country, not just members of your party. Isn’t your job as a leader to fight for that?

I don’t believe it is possible to argue with a straight face that the actions of Donald Trump on balance reflect the best interests of the American people. Could you honestly tell me otherwise? And, if not, how are the rest of us supposed to interpret the inaction of Congress?

As much as it may seem otherwise, these questions are not meant as political “gotcha” questions. They are certainly not because “I hate America.” And they don’t suggest anyone should adopt my political persuasions or vote for any candidate. These questions simply reflect my deeply held impression that what is happening now is such a break with fundamental principles and poses such threats to what has made the country special that I honestly cannot understand why it is being tolerated.

Fifty years ago, a group of Republican Congressmen went to Richard Nixon and told him that if he didn’t resign, he would get impeached. They recognized that democracy requires a mutually accepted set of operating rules and Nixon violated them. It is not inevitable that party loyalty would trump constitutional principles. It is a choice. Why Republicans in Congress are unwilling to stand up for the underlying principles of American democracy in the same way is something you and your colleagues need to answer.

Republicans Aren’t Cutting Health Care Costs—They’re Just Shifting Them

By Mike Koetting September 1, 2026

As various cuts to Medicaid and the Affordable Care Act (ACA) take effect, it becomes clear that they will substantially reduce the health care options available to millions of Americans.

This is awful.

But this note is not focused on the harm it does people impacted directly, rather on the fact that the entire premise of these cuts is fundamentally a lie. Despite any rationalizations by Republicans, the cuts in Medicaid and the ACA included in the Republicans’ budget bill are less reductions in health care costs and more shifts in who pays. In this case, it moves costs from the most wealthy (by reducing their taxes) to the rest of us (who pick up the pieces in various ways.) It is a stealth “tax” increase on those not specifically benefited from Republican Budget Bill.

If the country is ever going to have an honest discussion about health care, we need to understand the actual dynamics.

Continue reading “Republicans Aren’t Cutting Health Care Costs—They’re Just Shifting Them”

Fighting Adaptation to Reality

By Mike Koetting August 18, 2026

My last post argued that since serious environmental mitigation was politically implausible (at least for the time being), we needed to step up our efforts to adapt to changing environmental conditions. I am not talking about projections of what might happen. I am talking about responding to realities that are facing us here and now.

This post expands on that theme. I start with a few micro-case studies that illustrate some of the challenges. Then I try to place that in a larger focus.

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Fifty Years of Environmental Avoidance

By Mike Koetting August 4, 2026

I recently ran across an article contending that the 1972 Limits to Growth projections about environmental threats were on track. That reminded me that when these were first published, my friend Rick Casey, then at the National Catholic Reporter, commissioned me to write a review. Although long since moved on, he was able to track down the review for me.

Turns out, it held up fairly well. But, before that….

Continue reading “Fifty Years of Environmental Avoidance”

Trump’s Last Speech Was More Telling Than We Are Recognizing

By Mike Koetting July 21, 2026

In the Sixties, there was a bumper-strip that said: “What if they had a war and nobody came?” Donald Trump’s address to the country last week was like that. Half of the major networks didn’t even bother to carry this windbag of previously debunked claims. The next day, virtually the entire country shrugged at the old recitations. There is a temptation to leave it there.

But there was actually something so unusual about this address that it demands more attention than what the country gave it. The speech was built around, and enthusiastically pointed to, a large stack of declassified analyses of possible election fraud. But that “evidence,” claims notwithstanding, showed that our elections were remarkably safe. Some foreign actors fiddling around the edges and a handful of potentially ineligible immigrants voting but mostly a long and careful summary that shows our elections have not been threatened.

In other words, he posted and called attention to his own speech’s rebuttal. This is so beyond normal, had we not been anesthetized by the endless stream of lies and absurd claims, we might have paid more attention.

Continue reading “Trump’s Last Speech Was More Telling Than We Are Recognizing”

Deterioration in Political Discourse Leads to Deteriorated Thinking

By Mike Koetting July 7, 2026

A recent Pew Center poll found Republicans were much more skeptical of emerging climate problems than Democrats. I wasn’t at all surprised—and I’ll bet you’re not either.

My second thought was to wonder why this should be. After all, if I asked a random sample of Chicagoans whether the White Sox will make the playoffs this year, I would not expect to see a marked difference in response by political parties. And while there are no end of uncertainties, the factual bases for arguments about environmental predictions are much stronger than predicting baseball outcomes. But here we are with political leaning outstripping other considerations.

Wasn’t Always So

In the 1970’s, as we first started to understand the problems we had unleased, the environment was a totally bi-partisan concern. Richard Nixon enthusiastically presided over the creation of the EPA. By 1997, there was starting to be a spread between Democrats and Republicans on core climate issues—whether climate warming was happening and whether it was caused by humans—but it was only a modest 8%. By 2024, that gap had climbed to 35%.

Continue reading “Deterioration in Political Discourse Leads to Deteriorated Thinking”

The Impact of Government Is in the Details

By Mike Koetting June 23, 2026

As we approach the Fourth of July, there will be a great deal of celebration of the best ideals of democracy and the government that has sprung forth from our initial documents. Important as they are—particularly in these times when they are so severely threatened—I figure enough other people are writing about those. Instead, I use a particular case to illustrate how the broad policy visions of our democratic process get incorporated into specific policy choices and concrete decisions. The themes set direction; the specifics of these decisions determine the actual impact of government on people’s lives.

Continue reading “The Impact of Government Is in the Details”

Taxes: The Elite Aren’t Paying Their Share

By Mike Koetting June 9,2026

This post is the second of two on the American tax structure. The previous one focused on payroll taxes; today’s post addresses other taxes. Again, the material draws heavily from The Second Estate, a superb book by Ray Madoff, a law professor at Boston College. I highly recommend it if the topic interests you. It is short and a surprisingly easy read. An even shorter version of her thinking is available in an interview with Erza Klein. Today’s post is not trying to summarize what she said but to focus on the macro implications.

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The title of Ray Madoff’s book, The Second Estate, refers to the official distinctions in prerevolutionary France between the three strata of society—clergy, nobles and commoners. Members of the Second Estate, the nobility, enjoyed special privileges, which included freedom from taxes. She suggests that the wealthiest people in America have created a new form of the Second Estate.

It is common knowledge that today’s economy features an economic distribution as extreme, probably more extreme, than the Gilded Age at the end of the 19th Century. However, the difference between the top and the bottom is so large and the labels thrown around so much that it is easy to lose track of how great those differences are.

Continue reading “Taxes: The Elite Aren’t Paying Their Share”