SEATTLE — If you live in the United States, your life span largely depends on your race and ethnicity, where you live and how much money you make, researchers have reported for years. But in the last two decades, the gap between those with longest and shortest lives has grown, according to a new report from the Institute of Health Metrics and Evaluation in Seattle.

As of 2021, life expectancy in the U.S. varied by more than 20 years based on race and ethnicity, among other factors. While Asian Americans generally lived the longest, to about 84 years old, the average life span for American Indian/Alaska Native populations was about 63.6 years, researchers found.

The new results, published in The Lancet in late November, are so stark they reinforce the notion that within the U.S., there are at least 10 different Americas, study authors wrote.

"We're going the wrong way, and these disparities are increasing," said Ali Mokdad, who worked on the report and who's the chief strategy officer for population health at the University of Washington. "Our health is not improving."

Life expectancy gap grows over last 20 years

Researchers found new evidence that an American's life expectancy continues to vary dramatically based on where they live, their economic conditions and their race and ethnicity. The COVID pandemic exacerbated disparities. While life expectancy is generally highest for Asian Americans, at 84 years in 2021, the figure dropped to 63.6 years among the study's American Indian/Alaska Native (AIAN) population.

The recent study builds on work the UW-based institute did 20 years ago when researchers examined health inequities based on intersectional factors of geography, race, income and homicide rate. At the time, they found gaps of 12.8 years for women and 15.4 years for men in life expectancy among eight separate Americas, defined as Asian, American Indian/Alaska Native, Black and white Americans in different parts of the country.

Now with more data available on Latino/Hispanic American populations, researchers added two more groups. The new report's 10 Americas includes:

* America 1: Asian individuals

* American 2: Latino/Hispanic individuals in other counties

* America 3: white, Asian, and American Indian/Alaska Native individuals in other counties

* America 4: white individuals in nonmetropolitan and low-income Northlands

* America 5: Latino/Hispanic individuals in the Southwest

* America 6: Black individuals in other counties

* America 7: Black individuals in highly segregated metropolitan areas

* America 8: white individuals in low-income Appalachia and Lower Mississippi Valley

* America 9: Black individuals in the nonmetropolitan and low-income South

* America 10: American Indian/Alaska Native individuals in the West

The findings included analyses of death records from the National Vital Statistics System and population estimates from the National Center for Health Statistics from 2000 to 2021.

In 2000, life expectancy among the groups ranged from an average of 70.5 years among Black Americans in non-metro and low-income areas in the South to 83.1 years among Asian Americans — a difference of about 12.6 years.

Ten years later, the gap widened to 13.9, with American Indian/Alaska Native groups recording the lowest life expectancy. Between 2000 and 2010, life expectancy actually increased for all groups, except for American Indian/Alaska Native populations in the West, who lost about a year.

"After 2010, there was a stagnation or slowing increase," Mokdad said. "It was mainly due to our risk factors, like the epidemic of obesity."

When the COVID-19 pandemic began in 2020, the figure took a plunge for all groups, especially American Indian/Alaska Native, Latino/Hispanic and some Black populations — which were hit hardest by virus-related deaths. The difference in life expectancy among groups jumped to 18.9 years.

"It's not an issue of health only," Mokdad said. "It's an income issue. It's an economic development issue. ... We need to stop dealing with health as a piecemeal (problem)."

Mokdad was full of suggestions, though he acknowledged some might be daunting solutions.

"Universal health care is very important," he said. "We're the only rich country that doesn't have universal health care. And we need to pay attention to preventable risk factors: obesity, physical inactivity, diet, smoking, alcohol."

He also pointed to factors like income, education and geography, which can make a big difference in overall health outcomes, he said.

"In the U.S., even if you intend to do the right thing, even if you intend to be healthy, the geography sometimes works against you," Mokdad said. For example, he lives in Seattle, where a number of large, well-resourced hospitals and health care clinics are nearby. But those options become fewer and farther apart as you leave the city, he said.

According to the study, the groups with the lowest life expectancy — American Indian/Alaska Native and Black populations in non-metro and low-income areas in the South — also tended to report lowest income per capita and proportion of college graduates. That's not a coincidence, Mokdad said.

"There is less investment in health among Native Americans, for example," he said. "There is less access to education, and fewer opportunities for employment. These are issues we need to address. It's not only about health; it's about well-being."

Systemic barriers, like those "rooted in a history of colonialism, genocide and forced assimilation," have also perpetuated health inequities for American Indian/Alaska Native communities, study authors wrote. Those obstacles include low rates of health insurance and chronic underfunding of the Indian Health Service, a federal agency tasked with providing health services to American Indians and Alaska Natives, the study says.

Meanwhile, Black American communities in the mid-2010s saw some of the most significant progress in improving life expectancy in the past 20 years. In 2015, the gap in life span between Black and white Americans shrank to about two years, down from 4.3 years in 2000. Researchers largely pointed to increased access to education, as well as reductions in HIV/AIDS mortality and homicide rates during that period, which both disproportionately impacted Black communities.

But since 2010, improvements in life expectancy seemed to stall, similar to other groups. While more population health research is needed to fully understand why, Mokdad said rising obesity — which contributes to higher blood pressure, diabetes and other chronic conditions — is probably a big factor.

In the paper, study authors called the extent of health disparities in the U.S. "truly alarming."

"In a country with the wealth and resources of the USA, it is intolerable that so many are living in conditions and with health outcomes akin to those of an entirely different country," authors concluded. "It is time for us to take collective action; to invest in equitable health care, education, and employment opportunities; and to challenge the systemic barriers that create and perpetuate these disparities."

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