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research-article2014
BBSXXX10.1177/2372732214549754Policy Insights from the Behavioral and Brain SciencesKaplan et al.
Health and Well-Being Policy Insights from the Behavioral and Brain Sciences 2014, Vol. 1(1) 189–194 © Federation of Associations in Behavioral & Brain Sciences 2014 DOI: 10.1177/2372732214549754 bbs.sagepub.com
Educational Attainment and Life Expectancy Robert M. Kaplan1, Michael L. Spittel2, and Tia L. Zeno2
Abstract National objectives for health concentrate on improving life expectancy and enhancing health-related quality of life. Although U.S. life expectancy has seen significant extensions over the last century, the rate of increase has been falling behind other wealthy countries, and these trends have been worsening over the last 30 years. In addition, the United States spends considerably more on health care in comparison with major trading competitors. Most policy approaches for enhancing health focus on increasing expenditures for medical care. Yet, medical care explains only about 10% of the variance in health outcomes, whereas behavioral and social factors outside of health care explain nearly 50%. Evidence suggests that educational attainment may be one of the strongest correlates of life expectancy. As a baseline, cancer screening and optimizing established risk factors for premature death typically extend life expectancy by less than 1 year. In contrast, remediating the health disparity associated with low educational attainment might enhance life expectancy by up to a decade. Amassing persuasive evidence on the health benefits of interventions to improve educational attainment will be challenging. To address this issue, a robust program of systematic research is needed. Keywords educational attainment, social determinants of health, life expectancy, social epidemiology, research needs
Tweet Educational attainment is one of the best predictors of life expectancy. But we don’t yet understand why.
Key Points •• U.S. life expectancy has improved in the last century, but is now falling behind other wealthy countries. •• Health spending does not explain U.S. life expectancy, but social and behavioral factors may. •• Education is one of the best predictors of life expectancy. •• Research to understand why and how can inform policy on health and education.
Introduction The mission of the National Institutes of Health (NIH) is defined as, “Science in pursuit of fundamental knowledge about the nature and the behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability” (http://www.nih.gov/ about/mission.htm). The first clause represents the basic science mission for which NIH is so well known. The second clause describes NIH’s responsibility to identify factors associated with the length of life, levels of illness, and the effects of disease on functioning and quality of life.
The accomplishments of the NIH are truly remarkable. NIH research and its application have identified the mechanisms underlying most common diseases, developed effective vaccines and medicines, and made remarkable advances in diagnostic technologies. Not only have NIH scientists unraveled the human genome, but they also have made countless contributions to the understanding of diseases that affect medical practice throughout the world. These truly remarkable accomplishments were achieved by (a) identifying the basic mechanisms of disease through clinical research and application of the latest diagnostic techniques in the clinic and (b) applying evidence-based interventions and effective therapies. The dominant model requires identifying the basic mechanisms of disease through clinical research and applying modern diagnosis in the clinic. Then, evidencebased interventions and effective therapies are applied. We might describe this process as “find it–fix it” or “diagnose the disease, then treat it.” Even with these impressive accomplishments, the underlying question continues to be, “How well are we doing in 1
Agency for Healthcare Research and Quality, Rockville, MD, USA National Institute of Health, Bethesda, MD, USA
2
Corresponding Author: Robert M. Kaplan, Agency for Healthcare Research and Quality, 540 Gaither Road, Room 3008, Rockville, MD 20850, USA. Email:
[email protected]
190 extending the lifespan and improving life quality?” Health services researchers have raised questions about the relationship between U.S. health care expenditures and the return on these investments in terms of lives saved (Davis, Stremikis, Squires, & Schoen, 2014). Among Organization for Economic Cooperation and Development (OECD) countries, the United States is an extreme outlier in terms of expenditures. We spend more than 17% of our gross domestic product (GDP) on health care, whereas most of our economic economics peers spend about 10%. If the United States reduced its expenditures in relation to its GDP to the level of most European countries, we would save more than $1 trillion per year—or about the same level as the total private debt held by the federal government. However, even though our health care expenditures are dramatically higher than any other country, U.S. life expectancy continues to lag behind other developed countries (Institute of Medicine, 2012). The Commonwealth Fund recently compared 11 nations on health outcomes, equity, and efficiency of health care. Among these high-income countries, the United States was by far the first in expenditures but last in quality, access, efficiency, and equity (Davis et al., 2014).
U.S. Life Expectancy in International Perspective International studies of life expectancy have gained particular attention in the last few years. These studies tend to show that the life expectancy advantage previously held by Americans is now on the decline. A study from the National Research Council considered current life expectancy for 50-year-old women between the years 1955 and 2010 (Crimmins, Preston, & Cohen, 2011). Current life expectancy was defined as the number of years of life on average remaining once a milestone age has been reached. The current life expectancy for 50-year-old women is the median number of years of life remaining following the 50th birthday. In 1955, Americans ranked 12th in the world on this indicator. By 2006, they had slipped to about 26th position, just below Korea and Malta. In a life expectancy comparison of 10 wealthy countries, American women were 3rd out of 10 in 1955 but dropped to 9th position by 2006. Japan, France, and Spain were among the many countries with more rapid increases in life expectancy. Japan, for example, was considerably below the United States in 1955 and now is many years ahead (Crimmins et al., 2011). In response to these findings, the Office of Behavioral and Social Sciences Research (OBSSR), along with the National Institute on Aging (NIA), sponsored a study that compared life expectancy in the United States against 17 peer countries (Woolf & Laudan, 2013). These comparison countries were primarily in Western Europe, but they also included Australia, Japan, and Canada. The results of the comparison are disturbing. Among the 17 countries, the United States showed the second highest mortality rate from non-communicable
Policy Insights from the Behavioral and Brain Sciences 1(1) diseases. Mortality from communicable diseases was fourth from the bottom for the United States. In addition, the United States exhibited the third highest AIDS rates, exceeded only by Brazil and South Africa: The incidence of AIDS in the United States was 122 per 1 million, which is about nine times the average of countries in the OECD (Woolf & Laudan, 2013). We have known for some time that the U.S. life expectancy rate at birth is not keeping pace with the rate in other developed countries. Although our life expectancies are increasing, the rate of increase is much slower than that of our competitors. This trend has been developing over the course of several decades. Perhaps the most surprising finding in the Institute of Medicine (IOM) study concerned years of life lost prior to age 50. The committee considered international differences in the probability of celebrating a 50th birthday. On this indicator, the United States was last among the 17 comparison countries for both men and women. The losses in U.S. life expectancy prior to age 50 are about double the rate observed in Sweden (Woolf & Aron, 2013). Perhaps most disturbing is the disproportionate impact of this problem on women. Among 21 high-income countries between the years 1980 and 2006, for men, the United States started at the low end of the distribution and worked its way to the bottom. For women, the United States started near the bottom and now has gone off the scale in relation to the comparison countries. These disappointing results leave us hungry to gain a better understanding of factors that might bring the United States back in line with its economic peers. The goal is no longer to be first among developed countries; on the contrary, it would be a remarkable accomplishment just to return to average. Demographers and epidemiologists have offered evidence for a variety of factors that may relate to life expectancy. This article focuses on one of these factors—educational attainment. We choose education because of its strong association with health and because it may serve as a leverage point for obtaining better health outcomes. Focusing on education as a determinant of health departs from the traditional “find it–fix it” model of health care. Many of the most important determinants of health are outside of the health care system (World Health Organization, 2011). Investments in sectors outside of health care have the potential to enhance health, even though the intervention is neither medicine nor medical care.
Education and Longevity The association between educational attainment and life expectancy is apparent for both sexes and for a variety of ethnic groups (Montez, Hummer, & Hayward, 2012). In all groups, having less than a high school degree is associated with the shortest life expectancy. Showing results common to a variety of studies are data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS)
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Kaplan et al. study that enrolled 30,239 Black and White adults (45 years of age and older) between 2003 and 2007 (Howard et al., 2005). Demographic and cardiovascular risk information was collected, and participants were followed for health outcomes. Educational attainment was categorized as less than high school education, high school graduate, some college, or college graduate. Over 6.3 years of follow-up, 3,673 participants died. Risk of death steadily increased with lower levels of educational attainment. Although adjustment for income attenuated the relationship, the linear relationship remained intact. Adding demographic variables attenuated the relationship further, but it did not eliminate it. Next, the researchers added medical risk factors to the model, but controlling for these factors did not remove the association between education and life expectancy. Finally, they added behavioral factors, including smoking, diet, and life stress to the model. The complete model—including demographic, income, risk factor, and behavioral variables—still demonstrated a systematic and significant relationship between educational attainment and life expectancy. Establishing causation is difficult, but observational data from studies using different databases and different methodologies consistently reveal a strong and robust relationship between education and life expectancy (Kaplan, Howard, Stafford, & Howard, 2014).
Functional Form Understanding the pattern of the relationship between education and life expectancy has attracted significant attention (Hayward, Hummer, & Sasson, 2014). Studies of the form of the relationship have identified at least two patterns. Most studies treat education categorically, using milestones such as high school graduation, college graduation, or achievement of an advanced degree. This view is sometimes called “credentialism” because it assumes that a credential, such as a degree, opens up opportunities in labor markets. Credentials are associated with higher earnings and better social access. Several studies support the credentialism view. For example (Backlund, Sorlie, & Johnson, 1999), the National Longitudinal Mortality Study for the decade between 1979 and 1989 suggests three discrete blocks associated with mortality: less than high school education, some college, and college graduation. Several other studies support this pattern (Montez & Berkman, 2014). In contrast to the credentialism view, others point to the linear association—in which each increment of education is associated with an incremental improvement in health outcome. The systematic graded relationship between educational attainment and life expectancy remains linear even through the highest levels of education attainment. For example (Rogers, Everett, Zajacova, & Hummer, 2010), the benefit of education, in terms of hazard of death, remains constant for levels of education beyond college graduation. Those who have a master’s degree live longer than those who
have a bachelor’s degree, and those with doctoral degrees live even longer than those with master’s degrees (Montez, Hayward, Brown, & Hummer, 2009; Rogers et al., 2010). The National Longitudinal Mortality Study data from 1979 to 2001 allows examining the pattern of the relationship between education and mortality, stratified by sex, race, and age (Montez et al., 2012). A combination of credentialist (graded) and linear relationships emerges. Prior to high school graduation, there was a slow increase in life expectancy with additional years of education. Following high school graduation, the relationship between education and life expectancy was also linear, but the slope was steeper than that for the group that had not graduated from high school. In other words, there was a significant discontinuity in the slope for those with greater than a high school education. Investigating this issue linked the National Health Interview Survey to the National Death Index (Hayward et al., 2014) in an analysis including more than 7.4 million person years and more than 100,000 deaths. In general, the results confirm other findings (Montez and Berkman, 2014): A linear relationship emerges between years of education and mortality, but this slope became much steeper after high school graduation (Hayward et al., 2014). Two observations added to the complexity of these results. First, the linear relationship prior to high school graduation was not observed for African American participants. In addition, the results for African Americans changed over time. For African American men and women prior to about 1999, the relationship was flat until high school graduation. Data from the years 2000 to 2006 show a linear relationship between education and life expectancy for African American men, without a clear step function for high school graduation. For African American women, the benefit of high school graduation favors the “credentialism” view, and then another advantage accrued with a college degree. But African American women show a linear relationship between the achievement of these credentials, and the relationship is a step function all the way through college graduation and beyond (Montez, Hummer, Hayward, Woo, & Rogers, 2011). Overall, these results reveal differences by racial and ethnic groups and by point in the historical sequence. For most groups, each year of education provides some benefit in terms of life expectancy. However, a greater benefit accrues for the most socially advantaged groups, whereas the less advantaged groups may be more dependent on holding a credential. This may be tied to labor market opportunities and the advantage of having a credential to prove one’s worth. These data are observational, and we must be cautious in attributing any type of causation.
Separation Over Time The previous section suggests that the advantage of educational attainment has increased in recent years, and the point is worth restating. Demographic studies show that
192 educational attainment is changing. In 1990, approximately 78% of the population had a high school degree, but by 2008, this had dropped to 73%. At the other end of the spectrum, the number of individuals with a college degree significantly increased between 1990 and 2008. Educational disparities have increased over time. Those with little education and those who are well educated vary by race and ethnicity (Montez & Berkman, 2014). For both men and women, Hispanic individuals are less likely to obtain a high school education, whereas White individuals are most likely to have a college degree. African Americans fall between Hispanic and White respondents in high school completion rates (Olshansky et al., 2012). Not only has the slope of the relationship between educational attainment and mortality become steeper since the mid1980s, but geographic differences may have developed among regions of the United States. Data from the 1986-2006 National Health Interview Survey linked to the National Death Index reveals trends in the gradient within four different regions of the United States (Montez & Berkman, 2014). These trends were not uniform among regions. For women, there was a relatively narrow gradient in the Northeast 30 years ago. Over time, the gradient became larger. But the explanation seems to be that less educated women in the Northeast did not lose ground, but that more educated women had steeper gains. Some other regions, particularly in the Deep South, showed an increase in female mortality among the less educated. Although the gradient tended to widen for men, it actually narrowed slightly among men living toward the West Coast.
Policy Insights from the Behavioral and Brain Sciences 1(1) educational attainment and life expectancy may be explained by the personalities of the people who stay in school. The third hypothesis suggests that education stimulates individuals to engage in healthier activities. Health habits may play an important role (Cutler & Lleras-Muney, 2010). For example, the probability of being a current smoker systematically declines for individuals with more than a high school education. In fact, each additional year of education sees a further decline in the probability of smoking. Similar relationships occur for other factors, such as vigorous activity, being overweight, and the number of days a person consumed five or more alcoholic drinks in the past year. Other investigators suggest that cumulative stress may result in biological processes, such as shortening telomere length. The length of telomeres on chromosomes declines with age and may be an indicator of remaining life expectancy. Some evidence suggests that a systematic relationship exists between educational attainment and the length of telomeres (Adler et al., 2013). Another argument is that highly educated people are better able to take advantage of evolving new technologies. They have the economic resources to purchase them and the training to use them to their full capacity. People with more education might be better able to consume information about health and medicine. In addition, they may have the resources to obtain the most expensive health care services that may not be easily accessed by those with more limited resources. To date, few studies have tried to evaluate all these hypotheses, and the relationship between educational attainment and life expectancy is still not well understood.
Explanations of the Relationship Between Education and Life Expectancy
Benefits of Education Attainment
At least three prominent mechanisms have been proposed to explain the relationship between education and life expectancy. A neuroplasticity hypothesis suggests that early life experience has profound effects on the developing brain (Shonkoff, 2003, 2014; Shonkoff & Fisher, 2013). The effects of stimulation on the number of active synapses decrease logarithmically with advancing age. This hypothesis suggests that most of the benefits occur within the first 1,000 days of life. Thus, it argues that investments should be made early in the life span, such as pre-kindergarten. The second hypothesis argues that personality characteristics associated with obtaining more education are also causally related to longer life (Friedman et al., 1995; Martin et al., 1995). For example, conscientious individuals are more likely to complete advanced education (Kern & Friedman, 2008). The same individuals are more likely to have good health habits, including dietary conservatism, regular exercise, and avoidance of high-risk behaviors. So, a likely alternative explanation for this observation is that consciousness is associated with both staying in school and engaging is good health practices. The association between
Whatever the reasons, the benefit of educational attainment for life expectancy is strong. In medicine, significant effort is spent on debates about the advantage of certain interventions. For example, the number of quality-adjusted life years gained by performing Pap smears every year as opposed to every third year is modest—only about a day (Hagen et al., 2001). The advantage of yearly mammography screening versus not screening is only about 1 month of life expectancy (Gotzsche & Jorgensen, 2013). The difference in life expectancy between those with elevated low-density lipoprotein (LDL) cholesterol versus normal cholesterol is about 6 months (Clarke et al., 2009). In contrast, the difference in life expectancy between those with less than a high school education and those with an advanced degree is 10 to 12 years (Montez & Hayward, 2014). If we could eliminate homicide, the United States would have approximately 12,000 fewer deaths each year. Eliminating deaths from automobile crashes would result in 30,000 fewer deaths per year, whereas eliminating diabetes would reduce the number of deaths by about 80,000. However, if the life expectancies of those with less than a
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Kaplan et al. high school education could be made equal to those with more than a high school education, there would be an estimated 240,000 fewer deaths per year (Galea, Tracy, Hoggatt, Dimaggio, & Karpati, 2011). Although studies of the relationship between educational attainment and mortality are not randomized trials, and there is likely to be debate about how many years are added by education, the magnitude of the relationship and the consistency across studies and databases make the strength of the effect difficult to ignore.
Relationship Between Education and Changes in Life Expectancy We do not know whether the relationship between educational attainment and life expectancy is causal. A variety of analyses have attempted to address this question. Some have looked at natural experiments, for example, taking advantage of natural experiments in the United Kingdom (Clark & Roayer, 2013). In 1947, England increased the legal age at which one could drop out of school from 14 to 15 years of age. For the birth cohort born in 1933, approximately half dropped out of school as soon as the law permitted voluntary termination of formal education. In 1972 (1958 birth cohort), another change bumped the threshold for dropping out of school from 15 to 16 years of age. These policy changes resulted in significant increases in educational attainment. It was expected that there would be a regression discontinuity showing greater increases in life expectancy when these individuals became older adults. However, the expected increases in life expectancy were not observed. The findings led some economists to conclude that the relationship between education and life expectancy is not causal. On the other hand, terminating education at age 15 versus 14 is perhaps not really the appropriate strength of intervention to evaluate this hypothesis. Among youth with low motivation or desire to remain in school, forcing them to stay for an additional 9-month school year may be of little value. In summary, the goal of extending life and improving life quality may be well served by a better understanding of the social determinants of health. Although some social determinants may be difficult to change, others potentially could be modified. Enhancing health outcomes through improved educational attainment is an attractive alternative, although we still need better evidence that interventions to improve educational attainment will increase life expectancy.
Conclusions International studies suggest that the rate of increase in life expectancy for Americans is falling behind that of other economically advantaged countries. Despite remarkable improvements in medical and surgical therapies, we must also confront limitations of medical science. Most estimates suggest that medical care accounts for only a small portion of
the variation in life expectancy (Schroeder, 2007). Indeed, behavioral and social factors are likely to play a substantial role in determining how long we live (Murray et al., 2012). Educational attainment may be an important leverage point that potentially could help address the problems that arise from health disparities (Montez & Berkman, 2014). We are only at the early stages of understanding the relationship between social factors and life expectancy. New research is beginning to illuminate the role of education, social circumstance, and health habits on life expectancy. However, research in this area is only in its earliest phases, and it is likely to face skepticism because the application of traditional methods, including randomized controlled trials, is difficult. We need creative new methodologies and more research that will help us better understand health determinants and the interventions that may help extend life and improve quality of life. Authors’ Note The opinions expressed in this article are those of the authors and do not necessarily represent the positions of the Agency for Healthcare Research and Quality, the National Institutes of Health, or the U.S. Department of Health and Human Services.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: All three authors were employed by the National Instututes of Health, Office of Behavioral and Social Sciences Research while this article was developed.
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