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Indiana’s life expectancy falling further behind U.S.

Senior Demographer, Indiana Business Research Center, Indiana University Kelley School of Business

In 1959, Indiana’s life expectancy at birth was 70.5 years, a mark that was above the nation’s 69.9 years and ranked 18th-highest among states. Over the next 35 years, Indiana’s life expectancy trend mirrored that of the U.S., but the state began to lose ground in the mid-1990s (see Figure 1). While Indiana has been falling behind in this measure for 25 years now, the divergence has accelerated over the past decade, with the state’s gap relative to the U.S. widening by nearly a full year between 2008 and 2018.

Figure 1: Life expectancy at birth, three-year moving average

Line graph from 1961 to 2018 showing divergence between Indiana and U.S. life expectancy accelerating since the 1990s.

Source: United States Mortality Database. University of California, Berkeley (USA). Available at usa.mortality.org (data downloaded on 5/10/2021).

Even more troubling, Indiana’s life expectancy peaked in 2010 at 77.5 years and has largely been in decline since.1 As a result, Indiana’s life expectancy of 77.1 in 2018 is 1.9 years lower than the U.S. and places 40th nationally (see Figure 2).

Figure 2: Life expectancy at birth by state, 2018

U.S. state map. 80+ years = 11 states; 79 to 79.9 years = 15 states; 78 to 78.9 = 11 states; 76 to 77.9 = 9 states; Less than 76 = 5 states.

Source: United States Mortality Database. University of California, Berkeley (USA). Available at usa.mortality.org (data downloaded on 5/10/2021).

Indiana’s decline in life expectancy is occurring despite progress in the fights against the two dominant causes of death. Over the past decade, the state’s mortality rate from heart disease is down 10% and cancer mortality declined by nearly 14% (see Table 1).2

Table 1: Change in Indiana mortality rates for select leading causes of death

  2007-2009 average 2017-2019 average Change Percent change
Heart disease 201.4 180.9 -20.5 -10.2%
Cancer 192.4 166.3 -26.1 -13.6%
Chronic lower respiratory diseases 54.3 56.2 1.9 3.5%
Cerebrovascular diseases 45.5 40.3 -5.2 -11.4%
Drug- and alcohol-induced causes 19.0 38.3 19.3 101.6%
Unspecified dementia 26.2 34.1 7.9 30.2%
Alzheimer's disease 27.2 33.4 6.2 22.8%
Diabetes 24.2 25.9 1.7 7.0%
All other causes 236.9 259.8 22.9 9.7%
Total 827.1 835.2 8.1 1.0%

Note: Mortality rates represent the number of deaths per 100,000 residents and are age-adjusted.
Source: National Center for Health Statistics, CDC Wonder database

The primary driver of Indiana’s decline in life expectancy is the dramatic rise in deaths caused by substance abuse. The state’s mortality rate from drug- and alcohol-induced causes has more than doubled in the last 10 years. Drug overdoses alone have increased 107% over this same span and accounted for 71% of all drug- and alcohol-induced mortality during the 2017-2019 period.

This surge in mortality from substance abuse has an outsized impact on the life expectancy measure since it tends to claim the lives of younger people. Figure 3 drives this point home by highlighting the degree to which different age groups in Indiana have contributed to the overall change in life expectancy over the past decade. Better outcomes for Hoosiers in the 65-to-84 age group and in the 85 and older group help them boost Indiana’s life expectancy by a combined 0.37 years over this period. Ongoing improvements in infant mortality mean that the youngest age group continues to make a positive contribution to this measure as well. However, rising mortality among Indiana’s working-age adults has been large enough to overwhelm the gains in other age groups and cause an overall drop in life expectancy.

Figure 3: Age group contributions to total change in Indiana life expectancy

Bar chart showing three out of six age groups (15 to 24, 25 to 44, and 45 to 64) had negative contributions to the change in life expectency.

Note: Change is calculated using the 2006-2008 average and the 2016-2018 average. The age group decomposition of changes in life expectancy was done using methods developed by Eduardo E. Arriaga.3
Source: Indiana Business Research Center, using data from the United States Mortality Database. University of California, Berkeley (USA). Available at usa.mortality.org (data downloaded on 5/10/2021).

The story of rising mortality for working-age adults has been well-documented and much-discussed in recent years. Anne Case and Angus Deaton of Princeton University were among the first to document this shift in 2015.4 Their analysis revealed that this trend was most pronounced for non-Hispanic whites with lower levels of education and was unique to the U.S., with no other wealthy industrialized nation experiencing a similar phenomenon.

In March 2021, the National Academies of Sciences, Engineering and Medicine published an exhaustive report on this topic and highlighted the fact that U.S. life expectancy is falling behind other high-income peer nations. Furthermore, the authors noted that the black, Hispanic and Asian populations were also beginning to see upticks in mortality rates for working-age adults. Other subjects covered in this report include the role that prescription pain medication and other opioids have played in this crisis, as well as other potential contributing factors (mental health, socioeconomic status and changes in economic opportunity, to name a few).5

Rather than wade further into the discussion of potential root causes for this crisis, the remainder of this article will focus solely on mortality trends for Indiana’s prime-working-age population (i.e., ages 25 to 54). We will examine changes over time in the leading causes of death in this age group. We will also highlight disparities by race, ethnicity and gender, as well as show the geographic patterns of this crisis at the national level and among Indiana’s counties.

Mortality trends for Indiana’s prime-working-age population

Through the mid-1990s, the mortality rate for Hoosiers between the ages of 25 and 54 showed sustained improvement and consistently outperformed the U.S. average (see Figure 4). The state’s trend began to reverse around 1998, however, and Indiana’s mortality rate for this age group climbed by nearly 25% over the next two decades. What’s more, Indiana’s mortality rate for this age group was identical to the U.S. mark in 2001, but is now more than 20% higher than the nation.

Figure 4: Mortality rates for the population ages 25 to 54, three-year moving average

Line graph from 1970 to 2019, showing Indiana's mortality rate increasing relative to the U.S.

Note: Mortality rates represent the number of deaths per 100,000 residents and are age-adjusted.
Source: National Center for Health Statistics, CDC Wonder database

At the turn of this century, cancer and heart disease were the leading causes of death for the prime-working-age group in Indiana, just as they were for the population as a whole. The state’s mortality rates from these causes have both declined by roughly 25% since. Indiana’s mortality rate from substance abuse, meanwhile, has increased by nearly 3.5 times over the same period and is now the leading cause of death in this age group (see Figure 5). Drug overdoses accounted for 77% of these substance abuse deaths during the 2017-2019 period, while cirrhosis is responsible for 8% of the total. In raw numbers, the state’s substance abuse deaths in this age group jumped from an annual average of 373 for the 1999-2001 period to 1,596 for the 2017-2019 period.

Figure 5: Mortality rates by leading causes of death for Indiana population ages 25 to 54, three-year moving average

Line graph from 2001 to 2019 showing a staggering increase in drug- and alcohol-induced mortality rates relative to cancer, heart disease, suicide and transport accidents.

*Does not include drug- and alcohol-induced suicides
Note: Mortality rates represent the number of deaths per 100,000 residents and are age-adjusted.
Source: National Center for Health Statistics, CDC Wonder database

The mortality rate from suicide among Indiana’s prime-working-age population is also rising, with a 41% increase in this measure from the 2001 to 2019 periods. The U.S. as a whole is seeing this same troubling rise—although with a 33% uptick over this same stretch, the rate of increase nationally is slower than here in Indiana.

Trends by race, ethnicity and gender

Figure 6 shows the disparities in Indiana’s prime-working-age mortality rates by its largest race and ethnic groups. The state’s non-Hispanic white population was the first to show a steady increase in mortality rates, and this group has had a 28% rise in this measure between 2001 and 2019.

The state’s non-Hispanic black population had seen strong improvements in mortality for this age group between 2003 and 2011, but these gains stalled for several years before beginning to climb in 2016. The mortality rate for Indiana’s black population in this age group increased by nearly 14% between 2015 and 2019. Again, substance abuse has been the primary cause of this recent reversal, with drug- and alcohol-induced mortality increasing by 82% for the state’s black population over this same period. Mortality rates for Indiana’s Hispanic and Asian residents are comparatively low, but they have also been climbing in recent years.

Figure 6: Mortality rates by race and ethnicity for Indiana population ages 25 to 54, three-year moving average

Line graph from 2001 to 2019 showing mortality rates for black, white, Hispanic and Asian groups

Note: Hispanic is an ethnicity, not a race. Hispanic residents may be of any race. All references to race groups exclude Hispanic residents of that race. Mortality rates for Asian residents are unavailable prior to 2005 due to insufficient data. Mortality rates represent the number of deaths per 100,000 residents and are age-adjusted.
Source: National Center for Health Statistics, CDC Wonder database

As Figure 7 shows, this trend is also impacting men and women alike. In fact, until a recent surge in prime-working-age mortality for men starting around 2016, women had seen a larger increase in this measure. That said, Indiana’s mortality rate for men in this group is roughly 1.5 times higher than for women as of 2019.

Figure 7: Mortality rates by gender for Indiana population ages 25 to 54, three-year moving average

Line graph from 2001 to 2019 showing increases in both male and female mortality rates.

Note: Mortality rates represent the number of deaths per 100,000 residents and are age-adjusted.
Source: National Center for Health Statistics, CDC Wonder database

Geographic patterns

Looking around the country, West Virginia has the highest level of prime-working-age mortality in the nation with an average annual rate of 416 deaths per 100,000 residents over the 2017-2019 period. The next-highest states were Mississippi (364), Kentucky (356) and New Mexico (356). With its mortality rate of 287 in this age group, Indiana ranks 14th-highest among states.

Figure 8: Mortality rates for population ages 25 to 54 by state, 2017-2019 annual average

U.S. state map. More than 350 = 4 states; 270 to 350 = 11 states; 230 to 269.9 = 17 states; 200 to 229.9 = 14 states; Less than 200 = 5 states.

Note: Mortality rates represent the number of deaths per 100,000 residents and are age-adjusted.
Source: National Center for Health Statistics, CDC Wonder database

Not all states with high mortality rates are experiencing a substance abuse crisis to the same degree as Indiana. Mississippi, for instance, has the nation’s second-highest mortality rate in this age group while also having the second-lowest mortality rate from drug- and alcohol-induced causes. Mississippi just happens to have longstanding problems with other causes of death, such as cancer, heart disease, hypertensive diseases, etc.

To best understand where recent shifts in certain causes of death are having the largest impact, it is useful to look at the rate of change in mortality over the last two decades. Figure 9 shows that Indiana’s 20% increase in prime-working-age mortality since 2001 is the ninth-highest uptick in the nation. Higher mortality growth rates appear to be most prevalent in the New England and Appalachia/Midwest (including Indiana) regions.

Figure 9: Top 10 increases in mortality rates for population ages 25 to 54 by state

Bar chart showing percent change in mortality for West Virginia, New Hampshire, Maine, Kentucky, New Mexico, Ohio, North Dakota, Vermont, Indiana and Montana.

Note: Change is calculated using the 2001 three-year average and the 2019 three-year average. Mortality rates are age-adjusted.
Source: National Center for Health Statistics, CDC Wonder database

At the county level here in Indiana, neighboring Fayette and Wayne counties stand out with extremely high prime-working-age mortality, with both showing rates greater than 500 deaths per 100,000 residents (see Figure 10). The next tier of high-mortality counties in this age group consists of either rural communities in southern Indiana or mid-sized communities with a strong industrial heritage in the north-central part of the state.

Figure 10: Mortality rates for population ages 25 to 54 by county, 2017-2019 annual average

Indiana map. 500+ = 2 counties; 400 to 499 = 6 counties; 300 to 399 = 29 counties; 200 to 299 = 46 counties; Less than 200 = 7 counties.

Note: Mortality rates represent the number of deaths per 100,000 residents and are age-adjusted. Data were unavailable for Ohio and Warren counties.
Source: National Center for Health Statistics, CDC Wonder database

All but six of the 89 Indiana counties for which there is sufficient data to calculate change have had some increase in prime-working-age mortality over the last two decades, led by Pulaski County with a 137% uptick between the 2001 and 2019 periods (see Figure 11). In all, 16 Indiana counties have had an increase of 50% or greater over this period, and a total of 55 counties had a growth rate that exceeded the state’s 20% increase.

Figure 11: Top 10 increases in mortality rates for population ages 25 to 54 in Indiana counties

Bar chart showing percent change in mortality for Pulaski, Fayette, Crawford, Jennings, Wayne, Howard, Jay Delaware, Owen and Jackson counties

Note: Change is calculated using the 2001 three-year average and the 2019 three-year average. Mortality rates are age-adjusted.
Source: National Center for Health Statistics, CDC Wonder database

Conclusion

Simply put: U.S. life expectancy is falling further behind peer nations, and Indiana is among the states most at the center of this national crisis. The state’s increasing mortality rates for working-age adults over the last two decades has translated into an overall decline in life expectancy during the last one. Of course, this problem is easy to identify, but terribly difficult to grapple with.

Certainly, the immediate concern is for the health and well-being of Hoosiers who struggle with substance abuse and mental health issues, and our top priority is to aid those who are at risk of becoming a part of these statistics. However, this problem also has broader implications for the health and productivity of Indiana’s labor force and the competitiveness of the state’s economy. For each person who succumbs to a drug overdose, alcoholism or suicide, there are surely many, many more who struggle with these issues and are unable to fully contribute to the economy as a result.

Indiana is already set to begin an era of what we expect will be stagnant labor force growth, if not outright decline.6 Our prospects for outperforming these expectations over the next couple of decades grow more dim with the state’s steady decline in fertility rates.7 With these considerations in mind, reducing mortality rates for Indiana’s working-age population is not only an urgent public health concern, but is also a critically important step in building a labor force and economy that can compete in the future.

Notes

  1. Indiana’s post-peak low for life expectancy was 76.8 in 2017. This measure did improve in 2018, and preliminary data for 2019 indicate that another uptick is likely. However, the COVID-19 pandemic will surely trigger a sharp decline in life expectancy in 2020. The National Center for Health Statistics has already reported that life expectancy in the U.S. declined by a full year in the first half of 2020. See “Provisional life expectancy estimates for January through June, 2020” at www.cdc.gov/nchs/data/vsrr/VSRR10-508.pdf.
  2. In order to minimize the impact of any outliers that might occur in one year, comparisons of mortality trends over time rely on three-year averages rather than single years.
  3. Eduardo E. Arriaga, “Measuring and explaining the change in life expectancies,” Demography 21, no. 1 (February 1984): 83-96.
  4. Anne Case and Angus Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century,” Proceedings of the National Academy of Sciences 112, no. 49 (December 8, 2015): 15078-15083.
  5. National Academies of Sciences, Engineering, and Medicine, High and rising mortality rates among working-age adults (Washington, DC: The National Academies Press, 2021), https://doi.org/10.17226/25976
  6. Matt Kinghorn, “Indiana labor force projections: Slowdown on the horizon,” InContext, September-October 2018, www.incontext.indiana.edu/2018/sept-oct/article1.asp
  7. Matt Kinghorn, “A decade of declining births,” InContext, May-June 2019, www.incontext.indiana.edu/2019/may-jun/article2.asp