In 2007, life expectancy at birth for American men and women was 75.6 and 80.8 years, ranking 37th and 37th, respectively, in the world. Across US counties, life expectancy at birth ranged from 65.9 to 81.1 years for men and 73.5 to 86.0 years for women (Figure ). Geographically, the lowest life expectancies for both sexes were in counties in Appalachia and the Deep South, extending across northern Texas. Counties with the highest life expectancies tended to be in the northern Plains and along the Pacific coast and the Eastern Seaboard. In addition to these broad geographic patterns, there are more isolated counties with low life expectancies in a number of western counties with large Native American populations. Clusters of counties with high life expectancies for males and females are seen in Colorado, Minnesota, Utah, California, Washington, and Florida.
(a) County life expectancy in 2007; (b) calendar years behind or ahead of the international frontier in 2007.
Another way of analyzing local patterns of life expectancy is to compare them to a life expectancy time series of the best-attained life expectancy in each year, measured by the average life expectancy in the top 10 countries. National life expectancy in the US in 2007 was lower than the international frontier by 3.2 years (13 years behind) for men and 3.2 years (16 years behind) for women. In 2000, county-level life expectancies range from nine years ahead of the international frontier to over 50 years behind for men and one year ahead of the international frontier to 45 years behind for women. In 2007, county-level life expectancies range from 15 years ahead of the international frontier to over 50 years behind for men and 16 years ahead to over 50 years behind for women (Figure ). Thirty-three counties for men and eight counties for women have higher life expectancies than the average of the 10 leading countries in 2007. Ninety-two counties for men and two counties for women have life expectancies that are comparable to that of the 10 leading countries before 1957.
During the period 2000 to 2007, life expectancy in the US and most of its counties fell behind the progress seen in other nations. Over this period, 357 counties for men and 168 counties for women were fewer years behind the frontier metric in 2007 than they were in 2000. In contrast, 661 counties for men and 1,373 counties for women fell more than five more years behind the frontier between 2000 and 2007. Sixty-seven counties for males and 222 counties for females fell 10 or more years further behind the frontier. Figure shows that for all counties, the distribution of years behind has shifted to the right from 2000 to 2007.
Distribution of 2000 and 2007 calendar years behind or ahead of the international frontier for US counties.
To further put US subnational variation in context, we have compared US counties with published data for three other high-income countries: Canada, the United Kingdom, and Japan. These published figures for life expectancy at the second administrative level have been computed by national statistical authorities using a variety of methods. While the methods are not completely comparable to ours, the methodological differences should not affect the broad patterns. For each of these datasets, we have compared local life expectancies to the international frontier (Figure ). Women in 99% of the 1,964 municipalities in Japan in 2005 have a life expectancy that is higher than the international frontier, whereas for men, 25 municipalities are 10 years or more behind the frontier. Compared with Canada and the UK, the US has many more widespread disparities affecting a much larger fraction of counties. Only 0.2% of British local authorities and 2% of Canadian health areas for males have life expectancies that are more than 30 years behind the international frontier, compared to 17% of US counties for males. Of note, Canada has a small number of communities largely composed of Inuit populations that perform poorly. This mirrors the outcomes seen for selected US Native American populations, but in Canada the poorest outcomes are actually worse than in the US.
Fraction of local areas in Japan, Canada, UK, and US falling into bins of calendar years behind or ahead of the international frontier.
We also computed life tables for 2007 for blacks at the county level where there are sufficient numbers of individuals in each race group to estimate a life table (Figure ). County life expectancies for black men, ranging from 59.4 to 77.2 years, are seven to over 50 years behind the international frontier, with 65% of counties having life expectancies that are over 50 years behind (Figure ). For black females, the range is from 69.6 to 82.6 years of life expectancy, which corresponds to eight to over 50 years behind the international frontier, although only 22% of counties are over 50 years behind. The pattern of life expectancy performance versus the international frontier for white Americans is similar to all races combined, reinforcing the point that poor relative performance of the US is not simply due to racial disparities.
(a) County life expectancy in 2007 for blacks; (b) calendar years behind or ahead of the international frontier in 2007 for blacks.
Figure shows the results of the uncertainty analysis by plotting the 90% confidence interval of years behind or ahead of the international frontier for years 2000 and 2007. The figure shows that the conclusions about falling further behind the international frontier for many US counties are robust to the size of the uncertainty intervals. For males, 1,406 counties fell further behind in 2007 (statistically significant at the 90% level), 78 counties experienced a significant improvement, and 1,663 counties were neither statistically ahead nor further behind the international frontier in 2007 as they were in 2000. The corresponding figures for females are 2,054 for falling further behind, 45 for improvement, and 1,048 counties with no change. A full list of life expectancies and years behind with 90% confidence intervals is available in the Web appendix (Additional file 1
). The Web appendix also features a figure comparing life expectancy in 2000 with 2007 for males and females with uncertainty intervals for each county in the US (Additional file 1
2000 versus 2007 calendar years behind the international frontier with 90% confidence intervals for all US counties.