February 13, 2015

Americans with fewer years of education have poorer health and shorter lives, and that has never been more true than today. In fact, since the 1990s, life expectancy has decreased for people without a high school education, and especially white women.

Education is important not only for higher paying jobs and economic productivity, but also for saving lives and saving dollars.

Saving lives

Policies that set kids up for success—in education and life generally—are smart strategies for reducing the prevalence of chronic diseases, such as diabetes and heart disease. More education leads to higher earnings that can provide access to healthy food, safer homes, and better health care. And policies in communities can help put children on track for better health and prosperity by strengthening schools, job opportunities, economic growth, safe and affordable housing, and transportation.

Saving dollars

Medical care is important, but actions outside of health care—education, jobs, and economic growth—may be the best way to stem spiraling health care costs ("bend the cost curve"). Disinvesting in education not only makes U.S. businesses less competitive in a global marketplace built on science and technology, but can also increase health care costs in the long run.

"Saving" money by cutting vital "non-health" programs can cost more in the end. We don’t help ourselves by creating a sicker population and workforce that require more expensive medical care.

Now, more than ever, people with less education face a serious health disadvantage

  • Shorter lives: Americans with less education are—now, more than ever—dying earlier than their peers. Between 1990 and 2008, the life expectancy gap between the most and least educated Americans grew from 13 to 14 years among males and from 8 to 10 years among females. The gap has been widening since the 1960s.1

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Education and health have always been linked, but never as greatly as they are now. For more than two decades researchers have noted a disturbing widening in the gradient: year by year, scientists have warned that the health gap between those with and without an education is growing ever larger. [See table]

  • Worse health: Americans with less education are—now, more than ever—more likely to have major diseases, such as heart disease and diabetes. By 2011, the prevalence of diabetes had reached 15 percent for adults without a high school education, compared with 7 percent for college graduates.10

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The widening gap in disease prevalence: Changes in life expectancy based on education are only the tip of the iceberg11 because they reflect a widening gap in sickness levels—the prevalence of the diseases—responsible for these deaths, such as heart disease, cancer, and lung disease. People with a poor education are more likely to struggle with chronic diseases.

In 2011, Rand Corporation researchers compared data for non-Hispanic whites (age 40-64 years) between 1978 and 2005.12 Among those without a high school education, the proportion who reported fair or poor health differed from college educated adults by 25% in the 1970s but grew to 36% by 2004. During these same years, non-Hispanic whites with advanced education experienced declines in chronic diseases such as arthritis, heart disease, lung disease, high blood pressure, and diabetes. However, non-Hispanic white adults with less education saw no such decline; they even experienced an increase in some conditions, resulting in a widening in the education gradient. [See Figure 1] Reports of fair or poor health increased among people with these diseases who had less than 12 years of education.

  • More risk factors: Those with less education are increasingly more likely to have risk factors that predict disease, such as smoking and obesity. By 2011, smoking was reported by 27 percent of people without a high school diploma or GED but by only 8 percent of those with a Bachelor’s degree.10

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The widening gap in risk factors for disease: The trends in disease rates by education mirror the widening gap in risk factors that predict disease. Over a period dating back to the 1960s, healthier behaviors have been taken up more readily by more educated Americans, creating a wider gap in healthy lifestyle.

  • Smoking: Between 1974 and 2010, smoking rates among adults with a Bachelor’s degree—which were already much lower than for those with less education--decreased proportionately by 69%, whereas smoking among adults without a high school diploma decreased by only 38%.9 [See Figure 2]
  • Physical activity and obesity: A similar pattern occurred with obesity. The prevalence of childhood obesity increased nationwide between 1988-1994 and 2007-2010, but the trends differed by educational status.ii In households headed by an adult with a Bachelor’s degree, the prevalence of obesity among girls increased from 5.4% to 7.1% but in households headed by an adult without a high school diploma it increased from 11.3% to 22.3%.9 [See Figure 3] [See Figure 4]
  • Greater disability: Americans with less education are more likely to have diminished physical abilities for health reasons or to be disabled.

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The widening gap in disability: The ratio between the disability levels of those with grade school education (0-8 years) and those with some college education (13 or more years of education) increased between 1970 and 1990 among whites of both sexes and African American men;4 the pattern for white men is shown here. [See Figure 5]

Table Figure 1 Figure 2 Figure 3 Figure 4 Figure 5

Americans without a high school diploma are at greatest risk

  • Death rates are climbing: Adults with fewer than 12 years of education have been dying sooner since the 1990s. While overall life expectancy has generally increased, it has decreased for whites with fewer than 12 years of education, especially white women. Among whites with less than 12 years of education, life expectancy at age 25 fell by more than three years for men and by more than five years for women between 1990 and 2008.1

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High school dropouts: a population in declining health. Although health and life expectancy have improved for most Americans over time, the reverse is now happening among those who do not finish high school: their health is declining. Increasingly, the loss of a high school diploma marks the loss of a healthy life and matriculation into a population destined for greater illness.

The evidence is building:

  • Death rates among adults with less than 12 years of education increased between 1993 and 2001—by about 0.5% among blacks, 1.3% among white males, and 3.2% among white females. The increase was seen for every specific cause of death except HIV infection.6 [See Figure 6]
  • For men in 2006 without a high school education, life expectancy changed little from 1996, but among women it had declined by one year among women without a high school diploma.9
  • Comparing data for 1990 and 2008, life expectancy increased for blacks and Hispanics with less than 12 years of education, but it decreased among whites, especially white females. In 2008, white males with less than 12 years of education had the life expectancy of US men born in 1972; white females with this level of education had the life expectancy of US women born in 1964.1 [See Figure 7]

What’s happening?
A selection process is underway in America. Increasingly, non-graduates of high school are becoming a smaller and increasingly disadvantaged population.13

  • Mortality trends for white women have reversed: Life expectancy increased for other Americans but has fallen for whites with fewer than 12 years of education, especially white women. Among whites with less than 12 years of education, life expectancy at age 25 fell from 47.0 to 43.6 years for males and from 54.5 to 49.2 years for females.1

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The plight of women: the high price of a lost education. The above examples show that decreases in life expectancy among whites without a high school education are occurring more sharply among women. Women without a good education appear to suffer greater health setbacks than men.

It was not always this way: for decades, the link between education and life expectancy differed little by sex,3, 14 but after 1990 life expectancy began to increase more slowly for women than for men.2, 7 Death rates in 1986-2002 declined among college-educated non-Hispanic white women but increased among those with 0-11 years of education.15, iii [See Figure 8] Other evidence suggests a link between education and physical illness, heart disease, and depression that is greater among women than men.16, 17

Why is this? The reasons for the greater impact on women, particularly white women, remain unclear. One explanation is resource substitution theory, the hypothesis that “education improves well-being more for women, because socioeconomic disadvantage makes them depend more on education to achieve well-being.”18 However, evidence that women depend more on education for their health and survival than men remains inconclusive.19

Whatever the reason, the trend is worrying and consistent with other reports of a health disadvantage among American women.

  • According to a report from the National Research Council and the Institute of Medicine, U.S. women are less likely to reach age 50 than women in other high-income countries, and the trend is worsening.20 [See Figure 9]
  • Health Affairs reported that death rates among women increased in 43% of U.S. counties between 1992–96 and 2002–06; male mortality rates increased in only 3% of counties.21 [See map]
Figure 6 Figure 7 Figure 8 Figure 9 Map

Compared to those with a college education, Americans with less education:

  • Die earlier: At age 25, U.S. adults without a high school diploma can expect to die 9 years sooner than college graduates.

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Education and length of life: Education affects life expectancy. At age 25, U.S. adults without a high school diploma can expect to die 9 years sooner than college graduates.9 And a recent study found that college graduates with only a Bachelor’s degree were 26% more likely to die during the five-year study follow-up period than those with a professional degree. Americans with less than high school education in this study were almost twice as likely to die in the next five years than those with a professional degree.19 With every year of additional education, the probability of death decreases.iv, 22 [See Figure 10]

Education and the next generation’s survival: A mother's education affects her children. Babies whose mothers have less than 12 years of education are nearly twice as likely to die before their first birthdays as babies born to mothers with 16 or more years of schooling.23

  • Live with greater illness: Adults with less education are more likely to report diabetes and heart disease and to have worse health.

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Education and rates of disease: Less education, greater illness.

It's a recurring pattern that begins at birth—with higher rates of low birth weight among low-educated women9—and continues throughout life. Adults with less education are more likely to report diabetes and heart disease and to have diminished health status.9, 10 [See Figure 11] [See Table 1]

  • Generate higher medical care costs: The growing percentage of Americans in poor health intensifies demands on the health care system and fuels the rising costs of health care.
  • Are less productive at work: A good education is important to work productivity on many levels, not just in cognitive skills but also in performing basic everyday tasks.

Education and workforce productivity for U.S. businesses: along with higher rates of disease, Americans without a high school education have dramatically higher rates of physical disabilities, such as inability to climb steps, stand, stoop, or lift large or heavy objects. [See Table 2] A good education is important to work productivity on many levels, not just in cognitive skills but in the basic measures of functional status.

  • Experience more psychological distress: Stress is higher among poorly educated Americans, and this can have harmful biological effects.

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Education and psychological wellbeing and mental health: Stress is higher among poorly educated Americans. Compared to people with a Bachelor’s degree, people without a high school diploma are more than four times as likely to report being nervous and six times as likely to be sad “all or most of the time.”v, 10 Somatic pain complaints that are related to stress or depression, such as headache and back pain, are also more common among Americans with less education. [See Figure 12]

  • Have less healthy lifestyles: People with a high school education or less are more likely to have risk factors for disease—to smoke, to smoke while pregnant, to be physically inactive, to be obese, or to have children who are obese.10
Figure 10 Figure 11 Table 1 Table 2 Figure 12

What about race?

For generations in the United States, life expectancy has been higher among whites than blacks. But the differences in life expectancy by levels of education are now greater among whites than among people of color.

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For example, in 2008 the difference in life expectancy between those with the most and the least education was 10 years for white females, but 7 years and 3 years, respectively, for black and Hispanic females. It was 13 years for white males but 10 years and 6 years for black and Hispanic males.1 [See Figure 13]

Mortality differences across sexes and races have been falling at the same time that socioeconomic differences in mortality have been rising.7 Increasingly, education—and the social factors associated with education—are transcending the influence of race on health. Blacks with more education have longer lives than whites with less than a high school education. Racial disparities persist—highly educated blacks (at least 16 years of education) live 4 years less than comparably educated whites—but they can expect to live 8 years longer than whites with less than 12 years of education.1

Even a few additional years of education can make a difference for health. Across racial and ethnic groups, life expectancy improves with increasing years of education. College graduates live longer than adults with only some college education, and in particular, those with even some year of college education and no Bachelor's degree live longer than those with no education beyond high school.

Figure 13 Figure 14 Figure 15

What's the cause? Why does education matter more to health now?

  • In today's knowledge economy, education paves a path to good jobs: Completing more years of education confers health benefits after leaving school, such as better health insurance, access to medical care, and the resources to live a healthier lifestyle and to reside in healthier homes and neighborhoods.

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The “downstream” benefits of a good education: In today’s knowledge economy, Americans with limited education face greater economic challenges. [See Figure 14] A strong education is vital for the best jobs and higher earnings (see box below). The health benefits that accrue from a good education often occur “downstream” after leaving school, such as better health insurance, access to medical care, and the resources to live a healthier lifestyle and to reside in healthier homes and neighborhoods.

Education and Income

Technological innovations, globalization, and outsourcing of jobs that were traditionally domestic have sharply lowered demand for low-skilled jobs, “contribut[ing] to the decline in the relative wages of unskilled workers.”24 Skills and educational attainment are thus increasingly important in today’s economy, which has progressively been shifting from
a manufacturing-based economy to a service-based economy and the growth of industries requiring workers with advanced knowledge of science, technology, and mathematics and skills in professional disciplines such as law, business, and medicine.25

Current statistics underscore the importance of education to jobs and earnings in this environment [See bar chart]. Americans who lack a high school diploma have the highest rates of unemployment (12.4%) and the lowest median weekly earnings ($477 per week), whereas workers with professional degrees had the lowest rate of unemployment (2.1%), and the highest median weekly earnings ($1,735 per week).26 College graduates earn twice as much as high school graduates, 84% more over a lifetime.27

College graduates enjoy greater economic mobility and greater potential to “climb the income ladder.”28 According to the Brookings institution and the Pew Charitable Trusts, 74% of adult children with college degrees [have] incomes greater than their parents.29 Not so for workers with less than a high school education, whose wage growth is more stagnant. The average 50 year-old high-school drop-out earns $16.50 per hour, only $3.75 per hour more than a young high-school drop-out ($12.75 per hour).30 Workers without a high school diploma are more likely to be among the “working poor” (20.1%) than high school graduates, even those who have not earned college degrees (9.2%).26

  • Early childhood shifts the odds for success—in health and education: Children who grow up in struggling, stressful homes or neighborhoods pay a double price: the living conditions disturb their education, and stress and other life conditions can cause lasting biological harms and cause youth to take up unhealthy or risky behaviors, such as smoking or violence.

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The link between education and downstream earnings doesn’t fully explain the connection between education and health. Education is a marker, but there are often other root causes that exist “upstream” before a child even reaches school age.

“Upstream” factors shift the odds for success—in health and education: Children who grow up in struggling, stressful homes or neighborhoods pay a double price: the living conditions disturb their education, but the stress can trigger lasting biological effects and cause youth to take up unhealthy or risky behaviors as coping mechanisms, such as smoking or violence. Early living conditions shape health trajectories for a lifetime,31 not just success at school.vi Low-income neighborhoods with weak tax bases often have failing schools that lack the resources and teachers to offer a good education. The correlation between educational setbacks and poor health may have more to do with these root causes, which begin taking their toll even before children reach grade school.

Connect the dots

Education matters to health, and so do the conditions in neighborhoods and communities that harm the health of young children, trigger unhealthy or risky behaviors, and undermine the success of students and schools. Policies that address early child care, housing, transportation, food security, unemployment, and economic development are important to both education and health.

References

  1. Olshansky SJ, Antonucci T, Berkman L, et al. Differences in life expectancy due to race and educational differences are widening, and many may not catch up. Health Aff. 2012;31(8):1803-1813.
  2. Feldman JJ, Makuc DM, Kleinman JC, Cornoni-Huntley J. National trends in educational differentials in mortality. Am J Epidemiol. 1989 May;129(5):919-33.
  3. Pappas G, Queen S, Hadden W, Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med. 1993 Jul 8;329(2):103-9.
  4. Crimmins EM, Saito Y. Trends in healthy life expectancy in the United States, 1970-1990: gender, racial, and educational differences. Soc Sci Med. 2001 Jun;52(11):1629-41.
  5. Steenland K, Henley J, Thun M. All-cause and cause-specific death rates by educational status for two million people in two American Cancer Society cohorts, 1959-1996. Am J Epidemiol. 2002 Jul 1;156(1):11-21.
  6. Jemal A, Ward E, Anderson RN, Murray T, Thun MJ. Widening of socioeconomic inequalities in U.S. death rates, 1993-2001. PLoS One. 2008 May 14;3(5):e2181.
  7. Meara ER, Richards S, Cutler DM. The gap gets bigger: changes in mortality and life expectancy, by education, 1981-2000. Health Aff (Millwood). 2008 Mar-Apr;27(2):350-60.
  8. Congressional Budget Office. Growing Disparities in Life Expectancy. Economic and Budget Issue Brief. April 17, 2008.
  9. National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012.
  10. Schiller JS, Lucas JW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2011. National Center for Health Statistics. Vital Health Stat 10(256). 2012.
  11. Marmot M, Ryff CD, Bumpass LL, Shipley M, Marks NF. Social inequalities in health: next questions and converging evidence. Soc Sci Med. 1997 Mar;44(6):901-10.
  12. Goldman D, Smith JP. The increasing value of education to health. Soc Sci Med. 2011 May;72(10):1728-37.
  13. Begier B, Li W, Maduro G. Life expectancy among non-high school graduates. Health Aff (Millwood). 2013 Apr;32(4):822.
  14. Preston SH, Elo IT. Are educational differentials in adult mortality increasing in the United States? J Aging Health. 1995 Nov;7(4):476-96.
  15. Montez JK, Zajacova A. Trends in mortality risk by education level and cause of death among US White women from 1986 to 2006. Am J Public Health. 2013 Mar;103(3):473-9.
  16. Ross CE, Mirowsky J. Gender and the health benefits of education. The Sociological Quarterly 2010; 51:1–19.
  17. Thurston RC, Kubzansky LD, Kawachi I, Berkman LF. Is the association between socioeconomic position and coronary heart disease stronger in women than in men? Am J Epidemiol. 2005 Jul 1;162(1):57-65.
  18. Ross CE, Mirowsky J. Sex differences in the effect of education on depression: resource multiplication or resource substitution? Soc Sci Med. 2006 Sep;63(5):1400-13.
  19. Ross CE, Masters RK, Hummer RA. Education and the gender gaps in health and mortality. DemoFigurey. 2012 Nov;49(4):1157-83.
  20. Woolf SH, Aron L, eds. U.S. Health in International Perspective: Shorter Lives, Poorer Health. Panel on Understanding Cross-National Health Differences Among High-Income Countries. National Research Council, Committee on Population, Division of Behavioral and Social Sciences and Education, and Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: The National Academies Press, 2013.
  21. Kindig DA, Cheng ER. Even as mortality fell in most US counties, female mortality nonetheless rose in 42.8 percent of counties from 1992 to 2006. Health Aff (Millwood). 2013 Mar;32(3):451-8.
  22. Rogers RG, Everett BG, Zajacova A, Hummer RA. Educational degrees and adult mortality risk in the United States. BiodemoFigurey Soc Biol. 2010;56(1):80-99.
  23. Braveman P, Egerter S. Overcoming obstacles to health: report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. Princeton, NJ: Robert Wood Johnson Foundation; 2008.
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  25. Nightingale D, Fix M. Economic and Labor Market Trends. Future of Children [serial online]. Summer 2004 2004;14(2):49-59. Available from: Education Research Complete, Ipswich, MA. Accessed September 17, 2013.
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  27. Carnevale AP, Jayasundera T, Cheah B. The college advantage: Weathering the economic storm. 2012:52. http://search.proquest.com/docview/1140131519?accountid=14780.
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  30. Messacar D, Oreopoulos P. Staying in School: A Proposal for Raising High-School Graduation Rates. Issues in Science & Technology [serial online]. Winter2013 2013;29(2);55-61. Available from: Education Research Complete, Ipswich, MA. Accessed September 19, 2013.
  31. Conti G, Heckman JJ. Understanding the early origins of the education-health gradient: A framework that can also be applied to analyze gene-environment interactions. Perspect Psychol Sci. 2010;5(5):585-605.
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Notes

  1. They also found that those with 0 to 8 years of education experienced decreases in the length of healthy life, causing educational differentials in healthy life expectancy to widen over time.
  2. Among adults, the increase in obesity was largest for men with at least some college and for women with at least some college or a Bachelor’s degree or higher, resulting in a narrowing of the education gradient in adult obesity.9
  3. Montez and Zajacova found that the gradient had not changed significantly for some causes of death, but had for others. The gradient increased—for lung cancer, cerebrovascular disease, chronic lower respiratory disease, diabetes, and Alzheimer’s disease. Death rates for heart disease fell for all women. Earlier modeling studies yielded mixed results on the influence of education on mortality among women.19, 32, 33
  4. Researchers have documented discrete health states associated with each stage of education: high school education but no diploma, high school diploma but no college, college education but no degree, and college degree.34, 35
  5. Survey data from the 1990s found that depression decreased more steeply for women than for men as the level of education increased. The gender gap in depression largely disappeared among persons with a college degree or higher.18 Earlier research from the 1970s described a link between education and markers of happiness, excitement in life, subjective health, and satisfaction with community—particularly among white women.36
  6. [See Figure 15]
  7. Children also perform better in school when they are healthy. Although this “reverse causality” can explain some of the observed association between education and health, it does not account for the poor health outcomes that occur among adults who previously obtained a limited education.
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