Disease-specific drivers of sex- and locality-related disparities in life expectancy at age 65: two decades of progress before COVID-19.

Abstract

Background and objectives: The distribution of life expectancy at age 65 (LE₆₅ ) in the United States is characterized by profound sex- and locality-related disparities. Quantifying the disease-specific drivers of these disparities prior to the coronavirus disease 2019 (COVID-19) pandemic provides a critical baseline for understanding subsequent health shocks.

Methods: Using CDC WONDER data (1999-2018) and Pollard's decomposition method, we analyzed cause-specific contributions to disparities in LE₆₅, establishing a pre-pandemic baseline for trends in years of life lost (YLL) at age 65.

Results: Sex-related disparities (YLL_sex) narrowed, particularly in disadvantaged localities, driven by reductions in YLL from macrovascular diseases and lung cancer. Conversely, locality-related disparities (YLL_loc) widened, especially for females, due to increasing YLL from Alzheimer's disease and the persistent impacts of diabetes, chronic lower respiratory diseases, and heart failure. This created a pre-existing landscape of vulnerability concentrated in low-LE states.

Discussion and implications: The 2 decades before COVID-19 saw a critical divergence: progress in reducing sex-based gaps was offset by rapidly widening geographic disparities. The systemic failures that drove the increasing burden of chronic conditions in disadvantaged regions likely predetermined the populations most vulnerable to the pandemic's shock. Our findings highlight that building future resilience requires targeted investments to address these specific, pre-existing health challenges.