Abstract
BACKGROUND: The nature and timing of increasing educational inequity in US life expectancy before the coronavirus disease 2019 pandemic suggest that long-term adverse labor market conditions secondary to globalization and technological change played a role for less-educated workers, but this has not been tested. METHODS: We exploit spatiotemporal variation in mortality and long-term economic conditions at the year and commuting zone level to estimate the relationship between macroeconomic restructuring and diverging mortality trends, 1990-2017, by race, sex, and education. Our measure of macroeconomic restructuring is based on the baseline industrial mix of an area, a measure that is plausibly exogenous to mortality. RESULTS: Mortality trends were substantially worse in commuting zones experiencing long-term economic stagnation than in others. For both White and Black adults, this relationship was strongest in the lowest quartile of the education distribution. Residence in commuting zones in the top quartile of our measure of economic conditions was associated with an additional 1-2 years lived between ages 25 and 84 compared with living in a commuting zone in the bottom quartile. The primary mediators of these divergent mortality trends were cancer, cardiovascular and metabolic diseases, and diseases of other internal body systems. Deaths from suicide or substance abuse did not contribute importantly toward accounting for the estimated impact of long-term economic stagnation on mortality. CONCLUSION: In our study, diverging trends in US life expectancy were associated with macroeconomic changes witnessed over the last half-century. The causes of death mediating this link were largely found in rates of death from stress-related internal diseases.