Life expectancy in the U.S. has been on the decline, according to the Centers for Disease Control and Prevention. While the COVID-19 pandemic killed more than 1 million people in America, 2014-2015 was actually an inflection point for mortality rates. What went wrong and what’s behind the downward trend? Our guests this week point out that drug overdoses, suicides and alcoholism have fueled an increase in what they term ‘deaths of despair.’ Anne Case is the Alexander Stewart 1886 Professor of Economics and Public Affairs, Emeritus at the Princeton University School of Public and International Affairs. Angus Deaton is a Nobel Prize Winner and Senior Scholar and the Dwight D. Eisenhower Professor of Economics and International Affairs Emeritus at the Princeton School of Public and International Affairs and the Economics Department. Together, they published their groundbreaking findings in 2015 and later co-authored “Deaths of Despair and the Future of Capitalism” in March of 2020. Case and Deaton join WITHpod to discuss what their findings reveal about capitalism and the U.S. healthcare system, education-related disparities in mortality, what might be done to reverse the surge in deaths and more.
Note: This is a rough transcript — please excuse any typos.
Chris Hayes: We should note this episode contains discussion of suicide. If you or someone you know is having suicidal thoughts or mental health related distress, dial 988 for the 24/7 988 Suicide & Crisis Hotline/ To text with a trained helper, text Save, S-A-V-E, to 741741.
Anne Case: The idea that after a century of decline, we would actually see mortality rates going up and it wasn't being reported, we thought, well, maybe we did something wrong. Maybe we should recheck our numbers, which we did. We took them on the road. We took them to medical schools and talked to our favorite demographers. And this came as a surprise to everyone. So, then we really started to dig.
Angus Deaton: What you've got here is a social epidemic of self-destruction. And that's a really horrible thing. I mean, it's bad enough when a pandemic comes along, but at least it's comprehensible. We can see what it is. We can put it in the context of society.
Chris Hayes: Hello and welcome to “Why Is This Happening” with me, your host, Chris Hayes.
The topic of today's podcast is something that I am really, really obsessed with and very focused on. And I think it is the number one policy challenge, the number one social challenge in America at this moment behind the green transition, climate change, and clean energy.
So, in my own personal ranking of priorities, like the biggest, most important thing we have to do is transition the country and the world off of fossil fuel production and also throw a ton of money at all sorts of crash programs to make sure that we're mitigating the effects of climate change to sucking carbon out of the air. That's number one.
But number two, right behind that in the context of the U.S., is dealing with the fact that something is happening in this country that should not be happening. And what's happening is that life expectancy is going down.
Now, the first response you might say to that is, well, yes, we went through a once in a century pandemic. At its peak, it was killing 2,500 to 2,600 people a day. And obviously, if you go through something like that, you're going to see life expectancy go down, and that's true.
But it's actually broader than that and more disturbing than that. Were it the case that life expectancy was climbing and climbing when we hit COVID, it went down for a few years, and at once started going back up, you would say, okay, and that's what's happened in a lot of the OECD countries, that's what's happened in a lot of peer countries.
You would say, okay, yeah, we had a pandemic, and that's going to wreak havoc on people's mortality and their health. But that's not the story in the U.S. In fact, it's a more depressing, and in some ways more mysterious and more difficult story. The real inflection point in U.S. life expectancy happens around 2014, 2015.
Now, we should say that as a general rule, as societies get more wealthy, as they get richer, life expectancy tends to extend for all the reasons you would think. First of all, there's the society as it gets wealthier, tends to have more money to invest in things like public health, in cleaning the air, in dealing with all the kinds of sources of mortality that are broadly functions of the kind of public goods and level of development.
There's also, can perform more in terms of healthcare and things like that. You would just expect this to be what we would call a sort of monotonic relationship, right? The X axis and the Y axis and a diagonal between them, right? The country gets richer, the lives get longer, the country gets richer, the lives get longer.
Well, something starts happening in 2014, 2015, where the U.S. starts to get off this track. It's not getting poorer at that point, but there's something happening to the data showing that mortality is increasing and that life expectancy is getting shorter. And we can get into, you know, what we mean when we say the words life expectancy.
And around that time, two very, very celebrated and famed economists, Dr. Anne Case and Dr. Angus Deaton, got together and they published a paper in which they started to look at this data, and they had noticed something strange was happening.
And they identify three, sort of, sources of this decline in causes of early death, alcohol0induced drug overdoses, these are called poisoning in the sort of official CDC data, and suicide. These were going up, and they were going up in a way that didn't quite make sense. It shouldn't be the case that what was happening was showing up. In this sort of brilliant turn of phrase, they sort of put these under the umbrella of deaths of despair, a phrase that you've maybe heard, and they wrote about the deaths of despair.
And basically, made the case that there's something going on here that's very wrong and very worrying. And again, this is 2014, 2015. Now, this trend continues, then COVID hits. We've seen sources of mortality, non-COVID mortality, shoot up overdoses, homicide, suicide, car fatalities, right?
So, we've actually seen this in some ways. The category has expanded overtime and the U.S. has now seen year after year after year of significant decline in life expectancy. And this, to me, is the challenge of our age. We are a wealthy country. We should be living longer, not shorter lives. We should have less violence and less suicide and less overdoses and less traffic fatalities and live longer, happier, flourishing lives.
And these two incredibly celebrated economists followed up with a book in 2020 called "Deaths of Despair and the Future of Capitalism." And as I start to think through what's going on with this, I thought I should go to the source. So, today, Dr. Anne Case, who's Alexander Stewart 1886 Professor of Economics and Public Affairs, Emeritus at Princeton University School of Public International Affairs, lecturer with the rank of professor, and Dr. Angus Deaton, Senior Scholar and Dwight D. Eisenhower Professor of Economics and International Affairs, Emeritus at the Princeton School of Public and International Affairs and Economics Department.
I should note they are married. So, this now, I think, is maybe our third conjugal podcast. I've had Kate on a bunch of times. I had one other group of married academics who co-wrote a book together.
So, Dr. Case and Dr. Deaton, thank you so much for joining us. I appreciate it.
Angus Deaton: Thank you for having us --
Anne Case: Thank you so much, Chris. It's great to be here.
Chris Hayes: Let's just start with the origins of, sort of, I think of it almost like a true crime mystery in some ways. I mean, at a societal level, right? Where there's something going on here that's bad. When did you first start to see the data? What was the inkling, the first sniffing around this topic?
Anne Case: So, we started sniffing around, I think, in 2013. Angus was writing a paper to see whether or not self-reported well-being held anything interesting in it. And so, he was looking over the country to see whether or not suicides correlated where people reported themselves to be their life evaluation was higher or lower. Turned out he found no correlation there at all. But what he saw was that suicides were going up.
And on the other side of the room, literally, I was looking at pain and that every year in the National Health Interview Survey, we get pretty good battery of questions on pain. And that from the 1990s onward, people were reporting more and more pain every year. And so, that was sort of the very beginning of it.
And then we thought, well, suicides are going up, but what's happening to mortality for people in midlife altogether? And then what we saw was that for whites, and was whites at that point because suicide was something that affects whites a lot more than any other race, suicides mortality for people in midlife was rising. And that was stunning. The idea that after a century of decline, we would actually see mortality rates going up, and it wasn't being reported.
We thought, well, maybe we did something wrong. Maybe we should recheck our numbers, which we did. We took them on the road. We took them to medical schools and talked to our favorite demographers. And this came as a surprise to everyone. So, then we really started to dig.
Angus Deaton: Right. And from that very early paper, in that first paper, we went back to the individual death certificates. You know, we got a record of every single death that had happened in all those years. And we were interested not only with what was killing people, but splitting up who was dying. And there was an early clue there that's in the original paper and much developed later. Turns out, if you've got a four-year BA, you're sort of protected against this.
So, the people who were dying were people who did not have a four-year BA. And it's very important to emphasize that's the majority of the population. So, as of now, about 60 percent of the population do not have a four-year college degree. And those are the people at risk.
And if you go back and look at their life expectancy or you look at life expectancy at 25, by which time most people have finished their education, then it turns out that the bad things had started happening much earlier. So, in fact, there's been really no increase in adult life expectancy for people without a BA since about 2009, which whereas those with a BA are, you know, just going on as before and getting longer and longer. All the things you so eloquently said ought to happen are happening to the educated minority.
So, you've got this great divide in American society, which of course parallels many other divides. The voting divides, the polarization between people with and without a college degree.
Chris Hayes: And I want to not linger too long on this somewhat nerdy side point, but it's a non-trivial statistical task that you set yourself to. Meaning, like, it wasn't like the data's just like there and it's like, why didn't people see this? When you talk about going to the death certificates, it's like, you had to go down the individual level and then aggregate back up --
Anne Case: Yes.
Chris Hayes: -- so that you can actually find the phenomenon, right? That's why no one had quite gotten it before, because whether people have a degree or not or where they are, under what conditions, there's broad public health data, but you were doing it in a much more sort of granular way.
Anne Case: Yeah, on our little computers, we have like 80 million death records for adults in America, going back to about 1990.
Chris Hayes: Wow.
Anne Case: In 1989, that was the year they put education on the standard U.S. death certificate.
Chris Hayes: Wow.
Anne Case: And it's really our only marker, which is why we started with that, and it actually turns out to be important across all these dysfunctions. But it's our only marker. We don't know income or occupation or whether your mother loved you. None of that is on your death record, but your education is.
So, that's how we started to try to like, pull the data apart. And actually, Angus said like, life expectancy for that group, the two-thirds of Americans without a BA, did start falling around 2009. But these increases in deaths from suicide and drugs and alcohol go back to the early 1990s for that group.
And this is a little nerdy, but until about 2010, we continued to make a lot of progress in this country against cardiovascular disease. And for reasons that aren't fully understood, we stopped making progress.
Chris Hayes: Uh-huh.
Anne Case: So, it was kind of like a tug of war, right? So, cardiovascular --
Chris Hayes: Right.
Anne Case: -- disease was keeping mortality rates down. Deaths of despair was pulling them up. And then deaths of despair got high enough that it actually started to pull up all-cause mortality.
Angus Deaton: And the cardiovascular disease really started slowing down, and for people without a BA, started going the wrong direction. And that had been the big driver, progress against heart disease through, you know, taking antihypertensives or statins.
Chris Hayes: Right.
Angus Deaton: That had been one of the big things that had saved lives in the last quarter of the 20th century. And that seems to be deserting us now, too.
Chris Hayes: So, how did you start to pull apart the individual drivers of this, you know, unexpected turn? So, you're saying the trend when you go back in the data of the deaths of despair, they actually go back to the early '90s. They were being drowned out by positive increases on the other side of the ledger, particularly having to do with heart disease, which I think is year in, year out the number one cause of mortality.
And particularly statins, right? Reducing people's cholesterol so that they don't have heart attacks.
Anne Case: And people stopped smoking, too. Yeah.
Chris Hayes: Yes. And the story of smoking is also an incredible story, right? It's the kind of story of progress that you hope to get, right, with the society, which is like, you know, it gets richer, it also has a sort of governmental public health function, and between those two things, figures out a way to stop people from killing themselves via smoking.
So, you have these two things. On one side of the ledger, the deaths of despair pulling on the other. They sort of overwhelm in around 2014 or 2015. In terms of the composition, though, when you're talking about these different things, tell us a little bit about this sort of three different sources of deaths of despair, at least as you started to go through the data. Maybe we should start with suicide because that was what Professor Deaton was looking at.
Angus Deaton: Well, I think the thing about suicide, we were very fortunate in a lot of the research and that we fell over things that we weren't really looking for and that turned out to be incredibly important later, like the educational divide.
But suicide is, you know, going back to Durkheim, who wrote this very famous book in the 19th century about suicide, was that suicide is something that happens when society disintegrates around people or there's social change, either good change or bad change, but which leaves people unmoored and adrift so that the social pillars that make their lives possible to flourish have gone away, have been destroyed.
And that can happen in good times as well as bad times. So, that suicide became a metaphor for the other things because alcoholic liver disease is something you do to yourself. It's not like COVID. It's not like a pandemic.
Similarly, with drug deaths, I mean, they're calcified as accidental poisonings. But, you know, as someone once put it, it wasn't an accident that that needle got in your arm. And so, what you've got here is a social epidemic of self-destruction. And that's a really horrible thing. I mean, it's bad enough when a pandemic comes along, but at least it's comprehensible. We can see what it is. We can put it in the context of society.
But when large numbers of people and people of a particular social class, those without a college degree, are destroying themselves, I think Anne put it, there are three ways. You do it very quickly with a gun. You do it slowly, more slowly with alcohol or with --
Anne Case: Yeah.
Angus Deaton: -- drugs. It's sort of an intermediate thing. Yeah.
Anne Case: So, the other thing is that we had this amazing, stunning prescription drug epidemic, right? And that was initially what was responsible for this traumatic climb in drug overdoses. When Purdue Pharmaceutical, owned by the Sackler Family, decided to send marketers out all over America and try to push doctors into prescribing what is essentially heroin in pill form with an FDA label on it, that people responded to that. They wanted to numb themselves out.
But just to go back to something we talk about in the book, you know, Vicodin was around from the 1980s. It was one of the best-selling drugs in America. And it's as strong as morphine. It did not start an epidemic. So, I think the conditions, the social conditions had to be ripe for the drug epidemic to really take hold. And I think that that's what we saw when Purdue started to market OxyContin.
Chris Hayes: This to me is such an important thing to wrestle to the ground, both from an intellectual level, just in trying to actually be, you know, clear-eyed about what the causal mechanisms are, but also for the policy implications and the social implications. Because unlike the sort of deaths of despair, which was hiding underneath the data, right, the opioid epidemic was not, right? We knew --
Angus Deaton: Right.
Chris Hayes: And this was because both anecdotally reporting frontline folks who work in treatment and also the numbers, like we knew there was an opioid epidemic and it was very covered. It has continued to be very covered, and it's been brutal and, I mean, we hit our all-time record last year, I think.
What I found so revelatory about your paper when I first encountered it right after it was published was the Sackler story and the story of those doctors and the story of the kind of pushing this drug onto a populace is a true story, but incomplete. Because if you look and you say, well, there's these other deaths of despair that don't have anything to do with the actual chemical that we're talking about here, and something's driving those. Alcohol didn't get more readily available and people drinking themselves to death.
There's something upstream of that. That to me, it's like, well, what's that? And to go back to this pain question, I mean, part of the reason that there's all these painkillers floating around is because people are in tons of chronic pain. And so, there's this question of like, well, what's that about? What's happening to people that there's a demand as much as there's a sort of push of oversupply?
Anne Case: Yeah, the mind-body connection is something that we don't fully yet understand, but it is the case that a lot of pain develops without any obvious reason that it came about. That doesn't mean that people aren't in pain, but it's not like, oh, I broke my leg, so I'm in pain.
Chris Hayes: Right.
Anne Case: It's more, I have chronic lower back pain, I have sciatica. But because it's self-reported, a lot of times, people would just dismiss it. But pain has to be self-reported. We have no magic wand to see how much pain someone is in.
Chris Hayes: In a philosophical sense, I mean, conceptually, it is a subjective experience --
Anne Case: Yes.
Chris Hayes: That has to be self-reported.
Angus Deaton: Yeah, absolutely.
Anne Case: So, we think, though, and also self-reported health status was falling. People were reporting year-on-year more difficulty going about their daily lives, socializing with friends, which we know is incredibly important. But all of that is self-reported.
But I think what we added to it was a body count, you know.
Chris Hayes: Right.
Anne Case: It's not just self-reports when we say that deaths from alcoholic liver disease are on an upward trend and have been so for people without a BA as far back as we have education on the death records.
Angus Deaton: But there's a nexus of all these things going together. I mean, one of the things when Anne and I were on different sides of the room back in 2013, which we covered fairly early on, was that across space, pain and suicide are very closely correlated with one another.
So, pain predicts suicide better than guns predicts suicide, for example --
Chris Hayes: Wow.
Angus Deaton: -- I mean. And so, that's a really big deal. And also, as Anne was saying there, there's this social pain. You know, I think the pain guys now don't think of it in this Cartesian way of, I hurt my foot. It's more of the all pain is in the brain and it can come from social exclusion and social distress just as much as it can come from physical injury.
And, you know, there's this other thing beyond the pain, when you begin to look at people's marriages, you know, you begin to look at their attachment to institutions like churches and so on. The whole decline, the Putnam stuff of the decline in social capital, that is all adversely affecting people at the same time, too.
So, you just get this horrible mess. And, you know, there are a lot of causal chains going on here. And some of it, of course, has got to be traceable back to the loss of employment opportunities, the loss of good jobs for people who don't have a college degree, for example.
Chris Hayes: Yeah, just one, and I know this is something you guys have addressed, but just if people are listening to this, tracking it, the sort of inflection point around '89 or '90, that's a little bit of a methodological artifact, right? Because that's when we get the death certificate data.
So, I guess the question is, do we know if there's a divergence prior to that or is that just an unanswerable question?
Anne Case: No, it's interesting. In the data, what I have in my memory bank is looking at women, right? And headline writers would say, white men dying, which was not right. It's men and women are dying at higher rates. If you go back far enough in the data, women didn't kill themselves in this way.
Chris Hayes: Right.
Anne Case: So, back in 1990, the suicide rate or the drug overdose death rate for women with and without a BA was identical. And that was the point at --
Chris Hayes: Wow.
Anne Case: -- which they actually diverged.
Chris Hayes: Wow.
Anne Case: So --
Chris Hayes: Wow.
Anne Case: -- maybe we cut a break there.
Chris Hayes: Interesting. So, you're capturing enough of the parody to actually see the divergence in the data --
Anne Case: At that point --
Chris Hayes: -- right, gotcha.
Anne Case: For the men, I'd have to go --
Chris Hayes: Right.
Anne Case: -- because I --
Chris Hayes: Right, right.
Anne Case: -- don't remember offhand.
Angus Deaton: But the educational question is interesting, and we can't really go back before 1990 in full detail.
Anne Case: Yeah.
Angus Deaton: But there's a literature back to 1974, and there was a book by Kitagawa and Hauser that looked at educational disparities and whether they were growing or not. And there have been occasional papers ever since. And the general finding, I think, is that these gaps have always been there, that the gap between the educated and less educated has often been widening over time. But you've never got a situation, at least, in the United States, where one was going up and one was going down.
Chris Hayes: Right. Right.
Angus Deaton: Which is --
Chris Hayes: Right.
Angus Deaton: -- what's happening in the U.S. now.
Chris Hayes: Right.
Angus Deaton: And in fact, the only place --
Chris Hayes: Right. Right.
Angus Deaton: -- where you see that is after the collapse of the Soviet Union in --
Chris Hayes: Yeah (ph).
Angus Deaton: -- Russia itself and in the satellite countries when the educated people continued to make progress and the less educated mortality rates were going up.
Chris Hayes: Which is a shocking precedent.
Angus Deaton: Yes.
Anne Case: Yeah.
Chris Hayes: And to sit with for a second, because I do --
Anne Case: Yeah.
Chris Hayes: -- remember at some point prior to the publication of your first paper, I do remember having, at some point, encountered the mortality data post the fall of the Soviet Union. It's shocking data to look at, right, for a number of reasons.
One is that the story is like, communism is terrible. Free markets are great. And so, you would think, well, they've thrown off the yoke of tyranny and now they're free. And, like, what you see in the data is this is, like, insane decline in life expectancy. People were drinking themselves to death, killing themselves, all this sort of stuff.
So, you think, well, whoa, there's a complicated, awful story about social dislocation, you know, here.
Angus Deaton: Yes.
Chris Hayes: And I remember being very struck by that at the time, precisely because it was so different than like, triumphant images of the Berlin Wall, right?
Anne Case: Yeah.
Angus Deaton: But it's their time (ph) again, you know, that you've actually --
Chris Hayes: Right.
Angus Deaton: -- got, in principle, a good change, but it has terrible dislocation effects.
Anne Case: Also, there were some people who were going to benefit from the change. And then there were people --
Chris Hayes: Right.
Anne Case: -- who were too old to benefit or --
Chris Hayes: Right, right.
Anne Case: -- they just weren't in the right place at the right time to benefit. So, in a sense, it is a parallel to what we've seen in the U.S., because with globalization, with technological change, the people who benefit are people like --
Chris Hayes: With degrees.
Anne Case: Like us.
Chris Hayes: Yeah.
Anne Case: But there are a lot of people for whom, you know, having slightly cheaper glassware does not compensate them for the loss of a job they once held proudly.
Chris Hayes: More of our conversation after this quick break.
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Chris Hayes: So, you know, the phenomenon, I think we've spent some time on, right, that you have declining life expectancy for people in the 60% of the country that does not have college BAs, that there are several drivers you can disaggregate in that, there's suicides, accidental poisoning, which is overdoses, you know, liver failure.
And we think this is an inflection point around the 1990s. It really starts to show up in 2014-2015. Then we have COVID. We come out of COVID. And we still see those trends, right? Like, even when you take away the COVID aspect to it, and I think COVID actually probably exacerbated in the same way, I would imagine it has a disproportionate effect along the exact same educational lines we're talking about, if I had to guess, I haven't looked at the data.
But even if you remove the COVID, all COVID fatalities from the data in, say, 2020, 2021, 2022, like, are we still in the world in which these two things are going in different directions?
Angus Deaton: Yes, we've just written a paper about that. It's an NBER Working Paper. And you've got a big widening during COVID because of COVID, but an extension of the previous widening because of things that aren't COVID.
Now, of course, you could argue that COVID was, in some way, responsible for alcoholic liver deaths. You know, people drank a lot.
Chris Hayes: Sure, yes. I mean, I drank a lot more. I mean, I don't know about you guys, but I definitely drank a lot more during COVID.
Angus Deaton: And suicide went down, at least initially with COVID. There were some sort of --
Chris Hayes: Yes.
Angus Deaton: -- sense of national solidarity, but that seems to be creeping back now, too. So, I think we're still on this track. And so, you know, if we're thinking about public policy, it's not like there was this miraculous side benefit of COVID that it took us out of this horrible place --
Chris Hayes: No.
Angus Deaton: -- and put us on a better track. I think we're still on the bad track.
Anne Case: But one other little piece of the puzzle when we were pulling it apart was that these deaths from alcohol and deaths separately from suicide and deaths separately from drugs are much worse for birth cohorts that came up on later. So, people born in 1960 are at higher risk at any given age than people born in 1950. And those born in 1970 are in worse shape than those born in 1960 and so on.
So, we don't see this coming to an end. What we're seeing so far in the data is that younger people entering the labor market without much hope of finding a good job without a four-year degree, well, one thing that happens to them is they can't get married.
The marriage rates dropped. From 1980 to 1990, marriage rates dropped for people with and without a college degree. It was --
Angus Deaton: Yes.
Anne Case: -- just like people stopped getting married in quite as big numbers. But for people with a BA, now it's stable. For people without a BA, marriage rates continue to drop.
So, people don't have a stable home life. They'll cohabit, they'll have a kid, but then they split up. They may cohabit again, they may have another kid --
Chris Hayes: Yeah.
Anne Case: -- but none of it's very stable. And they've given up on organized religion, which regardless of what people think of organized religion, it's an institution that's been important in this country since its founding. If you needed --
Chris Hayes: Well, yes, and --
Anne Case: --solace --
Chris Hayes: -- and in human life, I mean --
Anne Case: Yes. It’s a --
Chris Hayes: -- not just here, obviously. Yeah.
Anne Case: It's a place where you go and people embrace you, and there's a certain amount of community you find there.
Chris Hayes: Yeah.
Anne Case: That's gone. Family life is gone. You don't have a good work life. So, going back to Durkheim, which is what it sent us back to, that's like a recipe for suicide. You know, the pillars that held you up are eroded, we think, because of a really bad job market.
Chris Hayes: Right. So, we've got a phenomenon here and then a sort of proximate cause, which is some sort of social unraveling, right? So, that people's connections both to each other, to institutions, to community, to family are coming apart. They are left lonelier and more alienated. And that loneliness and alienation are drivers of the kinds of behavior or actions that lead to this --
Anne Case: Yeah.
Chris Hayes: -- shorter life expectancy.
Angus Deaton: Though it's much the actions of Purdue and the other pharma companies --
Chris Hayes: Yes.
Angus Deaton: -- are sort of pouring --
Chris Hayes: Yes.
Angus Deaton: -- gasoline on that fire, right?
Chris Hayes: And particularly now, just to note, on top of that now is that just how deadly fentanyl is which is now --
Angus Deaton: Right.
Chris Hayes: -- through a series of substitutions essentially become the sort of leading cause of overdose deaths. I mean, fentanyl just is deadlier than what --
Angus Deaton: Yes.
Chris Hayes: -- than heroin. And so, it's killing more people, another sort of example of sort of gasoline on the fire that was going --
Angus Deaton: Right.
Chris Hayes: -- on.
Angus Deaton: But, you know, one of the stories out there that we like to argue against is that this is just a drug epidemic that was caused by wicked pharma companies.
Chris Hayes: Right. Right.
Angus Deaton: And every opioid epidemic in history has been one that took hold in a time of social disintegration. And, you know, one example is there was a great epidemic at the end of the U.S. Civil War, which was only came to its end in the first years of the 20th century.
The other example we talk about in the book, which we've always found very enlightening, was the British East India Company, you know --
Chris Hayes: Yeah.
Angus Deaton: -- going in and starting the Opium War in order --
Chris Hayes: Yes.
Angus Deaton: -- to be free to addict the Chinese population.
Chris Hayes: Yes.
Angus Deaton: You know, and all those guys were like given knighthoods by Queen Victoria --
Chris Hayes: Yes. Yes.
Angus Deaton: -- in exactly the same way that Queen Elizabeth gave knighthoods to the Sacklers. And they were honored and all the rest of it. But they were drug pushers. They were like the cartel.
And, you know, the British government stepped in to protect them in exactly the way that the American government stepped in to protect the Sacklers and the pharma companies, at least early in the epidemic.
Anne Case: But this was a China where the dynasty was falling apart. So, as was the case in the U.S. South after the Civil War, there was so much social upheaval that the ground was fertile --
Chris Hayes: Right.
Anne Case: -- for people just wanting to numb themselves out to be elsewhere. And I think that the same could be said when Purdue Pharmaceutical targeted areas that they could see --
Chris Hayes: Yes.
Anne Case: -- on the map were places where people are in pain, places where people --
Chris Hayes: Pain clinics. Yeah.
Anne Case: -- --had lost their jobs, and starting the forest fire there.
Chris Hayes: So, yeah, I mean, the model here, right, is that you need the seed and the soil, right?
Anne Case: Yeah.
Chris Hayes: There's two parts of this that sort of have to come together to get the kind of phenomenon we're seeing. But I want to now move one step up sort of the causal chain, right? So, if it's like there's this phenomenon that you guys have identified in the data, there's this sort of proximate cause, which is a sort of social dislocation that we're also seeing in the data, right? And you can see it in weekly church attendance or marriage rates, all this stuff.
Then one step from that is like, well, what caused that, right? And I guess that's the next question. And I think the basic idea is globalization, right? I mean, whether it's actual, you know, normalization admission of China to the WTO, and there's really interesting work by some of your colleagues about just how much that itself was an enormous exogenous macroeconomic shock, labor markets, and all these things.
NAFTA, the sort of free trade neoliberal regime of beginning in the late '80s and through the '90s, I mean, that's sort of your view of the kind of ora (ph) cause here.
Angus Deaton: Plus automation. Automation.
Anne Case: But then, Chris, you have to remember automation and globalization came to Europe as well, right? And they didn't have these deaths of despair.
Chris Hayes: Yeah.
Anne Case: So, that --
Chris Hayes: So, that's right. That was gonna be my next question.
Anne Case: So, there has to be something else. And one of the things that we discuss at length in the book, and we could talk to you about forever is the role here played by the healthcare sector in the U.S. that over this period from post-war, right? We went on a path that was different from most European countries where we tied health insurance to jobs.
And the way we tied them to jobs is also a little bit odd, which is that basically everyone's healthcare insurance costs the same amount. So, that whether you're sitting in the C-suite or you're washing the windows of the C-suite, you cost the firm currently about $8,000, $9,000, if you're an individual; $20,000, if you have a family policy.
And what that means is for your low-end workers, they're just too expensive for you now. They're not worth it for you to pay them minimum wage plus whatever you have to put into their health insurance. So, in the U.S., all those jobs were outsourced.
So, you used to belong to the Hilton Hotels and you might've been really proud of it. And if you did a good job, you might've been able to move up. Well, those jobs aren't there anymore. You belong to the All Bright Cleaning Company (ph). And if you miss a day or two of work because you're sick, you're gone.
So, we think that the fact that the healthcare industry has become 20% of our economy is a big part of the story for why this happened in the U.S.
Chris Hayes: I mean, that’s the other thing that's so sick and bizarre about this entire thing when you take a step back is that you have this thing that shouldn't be happening in a wealthy society, which is decline in people's life expectancy, hundreds of thousands of people dying unnecessary early deaths while we spend more money on healthcare than any peer country. And that that part of the economy as a share of the overall pie, if I'm not mistaken, continues to grow. It's growing at a slightly lower rate than it was, say, five or six years ago, which is a good thing, I suppose.
But there's something like, it's almost dystopian to imagine society that, like, is both spending a ton of money on healthcare and getting worse outcomes and both trends just accelerating.
Angus Deaton: And that’s on the causal chain, too. I mean, you know, if you throw away 20% of GDP or perhaps, you know, almost a half of that is wasted in the sense that you could have the Swiss system for $8,000 per person less --
Chris Hayes: Right.
Angus Deaton: -- than you have the American system, you're not going to get a lot of other stuff. One of the things we can't have is a safety net like they have in Europe. And, you know, that's got to be part of the story, too.
And, you know, the people on the left tend to push us very early on to say, well, this just shows Europe has a safety net. We don't have a safety net. All these people die.
And, you know, we thought we had another story, and we do, but we're certainly prepared to think of that as one of the contributing factors.
Chris Hayes: Yeah. I mean, I guess the question I always keep having is like, well, why does it happen when it happens? But again, I have to keep reminding myself, this an important point, that it shows up in the data because of what's happening with cigarettes, with tobacco and heart disease, when it does. Not because that's when the things started happening, right?
Anne Case: Right.
Chris Hayes: So, the trend is proceeding when we start to see it.
Anne Case: We highlight the healthcare industry, but it's true for a lot of industries that they're just much better protected here. It looks like we've given up on antitrust in the U.S. so that hospitals are allowed to merge.
So, when I first started going to New York, there were many, many, many, many hospitals. Now, they belong to a few large conglomerates.
Chris Hayes: It's crazy. Yeah.
Anne Case: And instead of there being synergies that are going to bring the prices down, when hospitals merge, the data show, prices go up and quality falls.
Angus Deaton: And you've got the pharma companies who are charging twice as much or more than they charge anywhere else in the world, but they've moved their patents to the low tax jurisdictions around the world, so they don't pay any taxes anymore.
So, I mean, you've got this what we think of as rent seeking by powerful interests protected by the federal government that are actually doing, you know, a lot more harm than they're doing good. And you put that into the mix and that seems like it's another thing we're paying more for everything.
But we haven't talked about unions. And I think the loss of unions has been a big important thing too.
Chris Hayes: Hold on one second. I want to talk about that, but just to stay on the healthcare --
Angus Deaton: Okay.
Chris Hayes: -- for one second, just because I want to make sure I understand. So, I want to talk about labor unions, because I agree, that's a really important part of the story. But I just want to make sure I'm understanding. Like, I guess my question is like, so if we go to like the Midlands in the U.K., or if we find a place that's been very exposed to, you know, deindustrialization or outsourcing globalization, automation, right, do we see some of the same behaviors, but not the same outcomes?
Like, you see what I'm saying? Like, is there a place where we can sort of causally identify like here is where the safety net is kind of keeping people from the worst kind of outcome, which is an early death, even if some of the same sorts of dislocations are happening.
Angus Deaton: Yes. You know, the deaths of despair are rising pretty fast in Britain. They're not at anything like the same level, but you see them, and you see them most strongly, like in the Northeast of England, where the --
Chris Hayes: Yeah.
Angus Deaton: -- deindustrialization --
Chris Hayes: Right.
Angus Deaton: -- has been worse.
Chris Hayes: Right.
Angus Deaton: We were just in Scotland last week and Scotland's the only other rich country that has a drug problem like the U.S.’ drug problem. And the death rates there are somewhat similar, especially in middle age. That's a place that's been deindustrialized on a massive scale.
And also, we wouldn't want to pin the causal thing on this, but it's certainly tantalizing idea, it's a place where there's enormous democratic deficit and that they're ruled by people they never voted for and who --
Chris Hayes: Right.
Angus Deaton: -- they have very little say over.
Chris Hayes: Yeah. So, let's now move to unions because that's part of the story too, it seems, and we're speaking here in the summer of 2023, where there's a remarkable uptick in union activity and militancy in the U.S., including organizing and things like that, partly born of a very tight labor market, which again, another seed in the soil sort of story about how useful and necessary that is to labor unions forming as we saw in say, you know, 1945, 1946.
But, Professor Deaton, you were saying that you think they're a big part of this story, too.
Angus Deaton: Well, in many aspects, I mean, I think that if you take the Bob Putnam stuff, you know, the guy who was bowling alone, was bowling in a union hall. You know, that union probably doesn't exist anymore in the hall. It's probably --
Chris Hayes: Yeah.
Angus Deaton: -- not there. So, there was a social function of unions. There was also a power function of unions in that they gave workers more power in the workplace. They did a lot of monitoring of safety, for instance. They rose wages. I mean, there's an enormous literature in economics going back forever on that. And they increased wages, not just for the people who belong to the union, but the other people too.
They were also very powerful in Washington. I mean, you now have a situation where Alphabet spends more on lobbying than all the unions put together, for example.
Chris Hayes: Wow. Wow.
Angus Deaton: So, there's very little source of worker power anymore, locally, federally, in the workplace, and in elections. And so, just as I was saying about Scotland, you get the sense of a working class set of people who have very little representation in Congress or very little power over what happens.
And, you know, it's not that surprising that they get very angry and dance up and down and attack the Capitol. I mean, not defending any of those things. But you could see why people would feel that a regime like the Clintons or even Obama, for instance, they were not getting much out of it.
Anne Case: I mean, if you go back then to the healthcare story, where there are six healthcare lobbyists for every member of Congress, right, so, they're always at the table, right, in the room, where it happens. Whereas people rightly think that they're not in the room and they're not even in, you know, the right city. They're entirely invisible to the people who are making decisions that are going to affect them.
So, they have very good reason to think that things are rigged, that, you know --
Chris Hayes: Right.
Anne Case: -- that this democracy is not working for them. And I have a lot of sympathy for that.
Chris Hayes: I mean, when you look at the, like, material facts of people's lives, I mean, one of the things to sort of revisit the great globalization debates of the early 1990s, which I was, you know, I was young, but very in tuned to them. The sort of neoliberal consensus view and many people in your field's view was basically the basics of trade theory are pretty clear, and they have been since the wealth of nations, that reducing trade barriers produces winners and losers, but the winners net out more than the losers.
It grows the pie, so to speak. You can address the people who'd lose out in specific places through redistribution from winners to losers, right? This is the big (ph) story. There's this thing called the Trade Adjustment Assistance.
But one of the things that critics at the time would say, and I think is borne out some way by your research, so I want to get your feedback on this, is that there's certain things you can't redistribute. So, you can't redistribute a sense of place. If you take a town and you empty it out of all the jobs, you can't redistribute Akron (ph) or --
Anne Case: Yeah.
Chris Hayes: -- you can't redistribute social solidarity. People are actually physically tied to places and those places matter to their lives and give their lives meaning in a way that capital does not in a way that no amount of trade adjustment assistance or checks being cut to move between the winners and losers can ever make up for, because it's fundamentally a misunderstanding of the nature of humans in place.
Anne Case: Absolutely.
Angus Deaton: You said that better than we would say it.
Anne Case: Absolutely true. Dead on.
Angus Deaton: But, you know, we don't even pay the cash either. You know --
Chris Hayes: Right. No, that's the other thing. It's not like we actually did compensate the losers in any --
Anne Case: Right.
Chris Hayes: -- actually material sense that would have been compensatory.
Angus Deaton: The unions talk about this as burial insurance, you know. The (ph) --
Chris Hayes: Right. Yes. Right. Yeah. Right. Yeah.
Angus Deaton: And we quote this speech by Phil Graham, you know, arguing against the trade adjustment fund or whatever it was, in which he says this is the sort of thing that communist countries used to do and even they're trying to stop doing it, and now we're doing it too. And of course, the people who benefited from the trade don't want to give up their gains.
So, I think the political economy of this is you're never really going to cut the checks. I think in the past, people did move more readily, and I think that's become hard for a number of reasons that we could talk about. But even that safety valve I think has gone.
Anne Case: Absolutely. So, the middle of the distribution of jobs in cities has been hollowed out. So, the jobs people could have gotten with a high school diploma, if they moved to an expensive city, they can't get a job with any higher --
Chris Hayes: Right.
Anne Case: -- wages and they could get back home and they're paying very high rents. But I wanted to just say, like you cannot replace place, people that we've talked to would also say, I don't want your money. I want a job, right? Jobs bring self-respect, jobs bring a sense of a lot of self-esteem attached to them.
And that what we need, I think, to think about is how do we train people starting K-12 who are not college bound for whatever reason, they may not want to go to college, to be productive members of society where they have self-esteem, and they are respected by the educated elite. That's what people want.
Chris Hayes: We'll be right back after we take this quick break.
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Chris Hayes: So, now let’s talk about this as a policy problem, right? And I don't want to skip too far to that because what you're describing, and what I think is so gripping about the account here, is that it's a policy problem, but it's almost a spiritual question at some level, right?
I mean, these questions about social connectedness, alienation, these are things that it's very hard to think of what the right tax code solution would be to people feeling alienated or lonely.
Angus Deaton: If only. If only.
Chris Hayes: Yeah, right. So there are certain things that from a public health standpoint, I mean, you could, there's certain low-hanging fruit. I mean, I think one of them, for instance, is like, if you could remove half of the guns in the U.S., I think you'd get lower suicide fatalities. I think that's almost certainly the case.
It doesn't help that a lot of people who have suicidal ideation are living in homes with guns. And that's, by far, the most deadly form of attempted suicide. It's way, way higher than the other forms. And so, that's one example, right, of like a public health intervention.
But I think if we just sort of focus on these sort of drivers, are there obvious places where you guys see interventions, policy-wise, before we get up to the like restoring a vital middle class in the country?
Angus Deaton: Well, I think, you know, Anne may not agree with this, but we're encouraged, for instance, by the Biden industrial policy. You know, I mean, that's something that the neoliberals have ruled out too. And they said, well, the government can't do this. I've never been persuaded that the government couldn't do it.
And, you know, the IRA for all its faults as well as its strengths, seems to be creating jobs. It's certainly creating investment. And so, you know, I don't see anything wrong with that. And as for the internationalists, you know, we were just at Glasgow, and there were people there who were, you know, beating the free trade drum and saying tariffs are not going to help.
But, you know, all of that may or may not be true. But, you know, if you make two-thirds of your own population so angry with you that they're going to come for you with pitchforks, then what you do internationally is neither here nor there, because we're going to be in a civil war domestically.
So, those things just have to take priority over foreign aid or helping Chinese or helping Indians, all of which are great things in themselves. But we've got to find some way of attending to this domestic problem where we're going to tear ourselves apart.
Chris Hayes: Yeah. I mean, to me, I did a monologue on this before the president's State of the Union in which I said, if I were writing the State of the Union, I would announce a commission that was focused on this question on life expectancy and set a moon landing target.
We are going to increase life expectancy in this country, particularly for people without BAs in the next three years, whatever it is. And I want to report from you guys about, give me 10 things we can do to get there. Because it seems to me it has to be named and identified as an actual explicit metric --
Anne Case: Yeah.
Chris Hayes: -- as a governing score. I mean, to me, it's the score. If people are dying early, what are we doing? What's the whole point of all this? Really? Like, okay, we have cheap televisions. I don't know, like --
Anne Case: Right.
Chris Hayes: But the only resource that matters in the end is the one precious life that we have on this planet and some sense of joy and social solidarity and love and mutual recognition while we're here.
Angus Deaton: We're with you --
Anne Case: Entirely. But, you know, when you talk about, is there any low-hanging fruit, one of the things, there's a new organization called The Paper Ceiling, which is trying to identify places where currently it says only BAs can apply for a job, but the BA isn't actually needed.
Chris Hayes: Yes.
Anne Case: And the state of Pennsylvania, and I think some other states are going to follow it in terms of making jobs, you're going to have to tell me why a BA is necessary for this particular job. So, I think it just became a screen at the time that the job market went online. So, instead of a couple hundred applications, you had to sort through a couple thousand applications. So, it was a screen to make it easier for you to --
Chris Hayes: Right.
Anne Case: -- narrow down candidates. Well, if you actually tell people, no, you can't discriminate in that way unless there's a reason for it, then I think that would help an enormous number of people.
Chris Hayes: So, the governor of Pennsylvania, the Democratic governor there --
Anne Case: Right.
Chris Hayes: -- when he was first elected actually announced this. And this was, I think, a governor's executive order, essentially, for the hiring for the state, right?
Anne Case: Yeah.
Chris Hayes: That we're going to take these jobs that were classified as requiring BAs. I do think that, like, one of the big ideas that I think there's been real movement on is, the old idea, I think, was that a college degree was like what a high school degree was, you know, 50 or 60 years earlier. And it was just sort of an inevitable process whereby 16 years, you know, K-16 basically would become what everyone does for education.
Angus Deaton: Right.
Chris Hayes: So, if people without BAs are being left behind, well, that was just temporary until the gap closed and everyone was getting four-year college degrees. And what we've seen is that's just not going to happen, right? I mean, that's part of it is that accepting that, there are going to be tens of millions of Americans without four-year degrees, what does life look like for them that is fulfilling and also economically manageable is a different question than how long will it take till everyone gets a college degree.
Angus Deaton: Right. And we're not going up. So, we were in Scotland, as we said, and 50% of the cohort is going to college. And in England, there's also been a huge increase, so it's up to about 35%. So, we're not against people getting educated, but we're against its --
Chris Hayes: No, clearly.
Angus Deaton: -- arbitrary rules --
Chris Hayes: Right.
Angus Deaton: -- that stop people getting jobs because of them. I have two other policy suggestions --
Chris Hayes: Please.
Angus Deaton: One of which we've talked about, which is single-payer healthcare, you know. If you could get healthcare --
Chris Hayes: Yes.
Angus Deaton: -- costs under control, I've been quoting a sentence from Alan Blinder's book about the financial crisis, who just says, you know, if we can't control healthcare costs, we will never control the deficit problem. And if --
Chris Hayes: Yeah.
Angus Deaton: -- we can control healthcare costs, we will control the deficit problem. So, you know, if you think how much that poisons politics all by itself --
Chris Hayes: Yes.
Angus Deaton: -- that would be a big deal. There's also a wonderful book by Graetz and Shapiro arguing that a value-added tax is actually something you could build effective coalitions around and might actually happen. And it's the value-added tax that funds the social safety net in Europe. So --
Chris Hayes: Yes. Yes.
Angus Deaton: -- if we had a value-added tax and we got rid of the healthcare costs, boy, you know --
Chris Hayes: Yes.
Angus Deaton: -- we'd be in much better shape. I'm a bit worried about your commission, though. If you get too many public health people on there, they'll say things like, it's all obesity. You know, we just got to stop people getting fat.
Chris Hayes: Well, no, it would be a mix of expectations. In my fantasy commission, you guys would be on the commission, you know, others as well. You'd have a mix of perspectives across sort of fields and ideological. But you're correct. And I think obesity is one of those things that became the sort of obsessive focus as the proximate cause for America's, you know, health issues for a very long time.
Angus Deaton: Right.
Chris Hayes: Even though, of course, if you look at the data, it tracks exactly what you would expect along lines of social class, right? So, it's like, it looks like effect as well, right? It looks like a dependent variable much more than an independent one.
Anne Case: I think in the end of the day, whenever the end of the day comes, we will see obesity as part of the same problem.
Chris Hayes: Exactly.
Anne Case: I mean --
Chris Hayes: Yes.
Anne Case: -- people need to soothe the soul, right? And some people do it with alcohol and some people do it --
Chris Hayes: Right.
Anne Case: Some people do it with ice cream.
Chris Hayes: Right. Yeah.
Anne Case: I actually think that it is part of the reason that it's very hard to get the obesity under control because people who are trying to help don't necessarily see it in that light.
Chris Hayes: Yes. And I think it's also a very similar situation when you talk about demand and supply, when you're talking about pain and opioids, right? There's both, right? So, there's an enormously entrenched, powerful industry trying to basically push corn syrup into every product that Americans consume.
Angus Deaton: Yeah.
Chris Hayes: And there's demand in so far as it is a means by which people soothe themselves. And to the degree that they're feeling bad, feeling, you know, all the kinds of forms of loneliness, alienation, or low self-esteem or self-doubt or all those things, like those two things can come together in precisely the same kind of ways.
I mean, I do think, just to end on a sort of hopeful note, I think, and this has been a theme of the podcast, is that COVID in some ways, marked the end of a certain chapter that basically begins, to my mind, around ‘89 with the sort of fall of the Berlin Wall and the beginning of the kind of neoliberal globalization end of history moment.
And that the intellectual underpinnings of that consensus have really fallen apart. I think the financial crisis knocked them down quite a bit, but I think subsequent other things. And I would say that your work has been part of that as well. And a lot of that work has emerged from incredibly decorated economists like yourself, even though I think the profession was sort of the driver of that intellectual consensus for a long time.
But I do think that there is something coming out the other side of a vision of what a sort of functioning, thriving, and affluent society looks like that is not the vision that was really kind of the Davos consensus for those 40 years. And I think your work is a huge part of that. I do think some of the things the Biden administration has done, I think there's real momentum there intellectually that I think can move us to perhaps something on the other side of it that looks, there's much more human flourishing.
Angus Deaton: It can't roll up fast enough is the answer. There's a lot of resistance. We were at this Glasgow event, which was celebrating Adam Smith's 300th birthday. There were plenty of holdouts for the old consensus.
Chris Hayes: Well, sure. Yes, yes, yes, yes. Well, particularly at that kind of event.
Angus Deaton: Well, not just that kind of event, you know. If Smith --
Chris Hayes: Although Smith was more of a lefty than people realize. I mean, Smith was way more interventionist and way more complicated in his actual vision than --
Angus Deaton: That's what my address was about. It was not Smith that did this to us. It was --
Chris Hayes: Yes, exactly right.
Angus Deaton: -- Chicago and the Smith followers.
Chris Hayes: Yes, that’s right. That's right. That's right.
Angus Deaton: So, that would be something, but it's going to be a big fight in economics. And I think there are people on both sides, very fiercely on both sides. And I agree with you that something will come out of this, but it's very hard to see exactly what it is. And like you, I think we're encouraged by what's happening in the Biden administration and long may that go on.
Dr. Anne Case and Dr. Angus Deaton are both Professors of Economics. Dr. Case is an Emeritus at Princeton University School of Public International Affairs and Alexander Stewart 1886 Professor of Economics and Public Affairs. Dr. Angus Deaton, Senior Scholar in the Dwight D. Eisenhower Professor of Economics and International, Affairs Emeritus at Princeton School of Public and International Affairs and the Econ Department.
Their book is called, "Deaths of Despair on the Future of Capitalism" and published in March of 2020. And it was a great, great, great honor to have you both on the podcast. Thank you so much for sharing your time.
Angus Deaton: Thank you so much.
Anne Case: Really terrific to talk to you, Chris. Thanks so much for having us.
Angus Deaton: It's been a real privilege.
Chris Hayes: Once again, great thanks to Dr. Deaton and Dr. Case. Um, that was really, really fascinating. One of my favorite conversations we've done in WITHPod, even though it's very macabre material. But it's something I'm really focused on.
We should note that the Sackler Family denies any liability or responsibility for the opioid crisis. They maintain, they acted ethically and within the law. The family has acknowledged that OxyContin addiction and abuse played a role in the epidemic.
After years of litigation, federal and state litigation, a New York federal court of appeals this May approved a deal that would grant the Sackler Family immunity from current and future civil lawsuits related to their role in Purdue Pharma's opioid business. Purdue Pharma pleaded guilty in 2007 and 2020 to federal criminal charges related to its role in the crisis.
This new immunity from future civil litigation would come in exchange for a $6 billion settlement. This settlement must still be approved by a bankruptcy court judge before it can be finalized. If it reaches final approval, a portion of the money paid from the family's personal holdings will be given to individuals and survivors of people harmed by opioid addiction and overdoses. It would also require the Sackler's give up control of Purdue Pharma.
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"Why Is This Happening?" is presented by MSNBC and NBC news produced by Doni Holloway and Brendan O'Melia, engineered by Bob Mallory, and featuring music by Eddie Cooper. You can see more of our work, including links to things we mentioned here, by going to nbcnews.com/whyisthishappening?
Tweet us with the hashtag #WITHpod, email WITHpod@gmail.com. Follow us on TikTok by searching for WITHpod. “Why Is This Happening?” is presented by MSNBC and NBC News, produced by Doni Holloway and Brendan O'Melia, engineered by Bob Mallory and features music by Eddie Cooper. You can see more of our work, including links to things we mentioned here, by going to nbcnews.com/whyisthishappening.