The Effect Of Educational Attainment On Adult Mortality In The United .

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PoPulAtioN refereNce BureAuThe Population Reference Bureau infoRMs people aroundthe world about population, health, and the environment,and eMPoweRs them to use that information to aDvancethe well-being of current and future generations.ABout the Authorsis Centennial Commission Professor of Liberal Artsin the Department of Sociology and Population Research Centerat the University of Texas at Austin. His research interests centeron the accurate documentation and improved understanding ofhealth and mortality trends and disparities in the United States.elaine M. HeRnanDeZ is a postdoctoral fellow at the PopulationResearch Center, funded by an F32 National Institute of Child Healthand Human Development, Ruth L. Kirschstein National ResearchService Award. Her research addresses the structural forces thatcontribute to social inequalities in health.RoBeRt a. HuMMeRAcKNoWleDGMeNtsWe gratefully acknowledge a large number of individuals who assistedus with this Population Bulletin. Linda Jacobsen and Ellen Carnevaleat the Population Reference Bureau have been a joy to work withand have provided wonderful advice and edits along the way. MonicaHe created the first draft of a number of the figures, and we are verythankful for her assistance. Jennifer Montez and Dan Powers alsoprovided us with expert assistance and advice in the preparation ofthis Bulletin, for which we are very thankful. More generally, we thankthe “Ed-Mort” research group that originated at the University of Texasat Austin and University of Colorado at Boulder in 2005, but has sincespread to different parts of the country; a significant portion of theresearch we draw on in this Bulletin was written by this group (DustinBrown, Juanita Chinn, Justin Denney, Bethany Everett, Mark Hayward,Patrick Krueger, Joseph Lariscy, Ryan Masters, John Mirowsky,Jennifer Montez, Fred Pampel, Richard Rogers, Catherine Ross,Hyeyoung Woo, and Anna Zajacova).We also gratefully acknowledge financial support for this work bygrant 5 R24 HD042849, Population Research Center, awarded tothe Population Research Center at The University of Texas at Austinby the Eunice Kennedy Shriver National Institute of Child Health andHuman Development; by grant F32 HD070595, Emerging EducationalInequalities in Health, awarded to Elaine Hernandez in the PopulationResearch Center at The University of Texas at Austin by the EuniceKennedy Shriver National Institute of Child Health and HumanDevelopment; and by grant 1 R01 HD053696, Educational Differencesin U.S. Adult Mortality, awarded to Robert Hummer at The University ofTexas at Austin by the Eunice Kennedy Shriver National Institute of ChildHealth and Human Development.The Population Bulletin is published twice a year and distributed tomembers of the Population Reference Bureau. Population Bulletins arealso available for 7 each (discounts for bulk orders). To become a PRBmember or to order PRB materials, contact PRB, 1875 ConnecticutAve., NW, Suite 520, Washington, DC 20009-5728; Tel.: 800-877-9881;Fax: 202-328-3937; E-mail:; Website: suggested citation, if you quote from this publication, is: RobertA. Hummer and Elaine M. Hernandez, “The Effect of EducationalAttainment on Adult Mortality in the United States,” Population Bulletin68, no. 1 (2013). For permission to reproduce portions from thePopulation Bulletin, write to PRB: Attn: Permissions; or photo: 2013 shironosov/iStockPhoto 2013 Population Reference Bureau. All rights reserved.Funding for this Population Bulletin was provided by grant2R24HD042839-11 to the Center for Public Information on PopulationResearch at the Population Reference Bureau by the Eunice KennedyShriver National Institute of Child Health and Human Development.officersMargaret Neuse, Chair of the BoardIndependent Consultant, Washington, D.C.Stanley Smith, Vice Chair of the BoardProfessor of Economics (emeritus) and Director, Population Program,Bureau of Economic and Business Research, University of Florida,GainesvilleElizabeth Chacko, Secretary of the BoardAssociate Professor of Geography and International Affairs,The George Washington University, Washington, D.C.Richard F. Hokenson, Treasurer of the BoardPartner and Managing Director, Global Demographics, InternationalStrategy & Investment, New York.Wendy Baldwin, President and Chief Executive OfficerPopulation Reference Bureau, Washington, D.C.trusteesSir George Alleyne, Director Emeritus, Pan American HealthOrganization/ World Health Organization, Washington, D.C.Felicity Barringer, National Correspondent, Environment,The New York Times, San FranciscoMarcia Carlson, Professor of Sociology, Universityof Wisconsin, MadisonBert T. Edwards, Retired Partner, Arthur Andersen LLP, and formerCFO, U.S. State Department, Washington, D.C.Parfait M. Eloundou-Enyegue, Associate Professor of DevelopmentSociology and Demography, Cornell University, and Associate Director,Cornell Population Program, Ithaca, New YorkFrancis L. Price, President and Chief Executive Officer, InteractPerformance Systems and Magna Saxum Partners in Cleveland, Ohioand Anaheim, CaliforniaLinda J. Waite, Lucy Flower Professor in Urban Sociology,University of ChicagoMichael Wright, Managing Director for Coastal East Africa,World Wildlife Fund, Washington, D.C.

Population Bulletinthe effect ofeDucAtioNAl AttAiNMeNtoN ADult MortAlitY iNthe uNiteD stAtesBY R O B E R T A. HUMMER ANDELAINE M. HERNANDEZTABLE of CoNteNtsintRoDuction. 2figure 1. U.S. Life Expectancy at Birth by Gender, 1960-2011 . 2eDucational DiffeRences in aDult MoRtality . 3figure 2. Mortality Rates for White Men and Women Ages 25-64by Educational Attainment, 2001 . . 3figure 3. Relationship Between Educational Attainment andMortality for U.S. Adults . 4figure 4. Mortality Rate Differences Relative to PersonsWith 17 Years of Education, U.S. Women by Age . 4figure 5. Mortality Rate Differences Relative to PersonsWith 17 Years of Education, U.S. Women by Race/Ethnicity . 5figure 6. Mortality Rate Differences Relative to PersonsWith 17 Years of Education, U.S. Adults Ages 45-64, byPreventability of Cause . 6oveR tHe last 50 yeaRs . 6figure 7. Trends in Death Rates for Non-Hispanic Blacks andWhites by Gender, Age, and Educational Attainment, 1986-2006. 7figure 8. Remaining Years of Life for U.S. Adults at Age 25 byEducational Attainment, 2005 . 8Reasons foR tHe DiffeRences. 7figure 9. Conceptual Diagram Linking Educational Attainmentto Adult Mortality and Life Expectancy . 8Policy iMPlications . 10figure 10. Educational Attainment Among U.S. Adults Ages25-34, 1992-2012 . 12Box. Research Recommendations . 13conclusion . 14RefeRences . 15PoPulation RefeRence BuReauVol. 68, No. 1JUNE 2013POPULATION BULLETIN 68.1 2013www.prb.org1

THE EFFECT OFEDUCATIONAL ATTAINMENTON ADULT MORTALITYIN tHe UNIteD stAtesRemaining life expectancyat age 25 is about adecade shorter for peoplewho do not have a highschool degree comparedwith those who havecompleted college.SINCE1960educational differencesin mortality andlife expectancy haveclearly widened.66%The share of U.S. adultsages 25 to 34with less than abachelor’s degree.In 2011, U.S. mortality rates reached record lows for both women andmen; as a result, life expectancy at birth reached record highs: 81 yearsfor women and 76 years for men.1 These are impressive figures.As recently as 1960, women’s life expectancyat birth was only 73.1 years and men’s only66.6 years.2 Within 50 years, life expectancyat birth increased by 8 years for women andnearly 10 years for men (see Figure 1).Unfortunately, these increases in life expectancy mask very wide disparities amongpopulation groups. For example, remaininglife expectancy at age 25—an importantoverall indicator of adult population health—isabout a decade shorter for people who donot have a high school degree compared withthose who have completed college.3 Educational attainment appears to be very important in differentiating U.S. adults’ prospectsfor long life.These differences represent critical health andsocial issues with important implications forpolicymakers. Because well-educated individuals have a much longer life expectancy, is suchan accomplishment (or at least a substantialimprovement) possible for other subgroups?The potential to reduce these educationaldifferences in mortality and life expectancyunderscores the need to accurately describethem and understand why they exist. Armedwith such information, policymakers then havethe evidence to ensure that U.S. adults aresufficiently educated so that no group pays a“longevity penalty.”Despite the potential to reduce educationaldifferences in mortality, it may be overlyfiGure 1U.S. Life Expectancy at Birth by Gender, 1960-2011Life Expectancy (in years)8581.180Female75 73.1A growing body ofevidence suggests thatenhanced investmentsin education at thepopulation level may alsodouble as investmentsin the long-term healthand longevity of 751980198519901995200020052010 2011Sources: National Vital Statistics Reports 60, no. 3 (2011); and Donna L. Hoyert and Jiaquan Xu, “Deaths: Preliminary Data for 2011,”National Vital Statistics Reports 61, no. 6 (2012).2www.prb.orgPOPULATION BULLETIN 68.1 2013

simplistic to assume that they are easily responsive to increased future investments in the education of U.S. children.Higher levels of schooling do not necessarily cause peopleto live longer. Other factors, such as parental education andincome, may be related to both high educational attainmentand longevity among U.S. adults. If so, then even the bestintentioned policy efforts to reduce educational differences inmortality may be of little value. In short, this area of scientificinquiry and policy interest is controversial.In this Population Bulletin, we examine educational differences in U.S. adult mortality and life expectancy. We providea balanced and up-to-date portrait of the key results andimplications of research in this area. We address five major issues: What is the current association between educational attainment and adult mortality? Have educational differences inadult mortality changed over the past 50 years? Why do suchwide educational differences in adult mortality now exist?What are the policy implications of recent education-mortalityresearch? And what are the implications of recent work in thisarea for future education-mortality research?Educational Differences inAdult MortalityHighly educated adults in the United States have lower yearlymortality rates than less-educated people in every age, gender, and racial/ethnic subgroup of the population.The most common method of documenting annual mortalityrate differences by educational attainment is to divide the adultpopulation over age 25 into three or four educational attainmentcategories and then calculate mortality rates for each of them.The most typical categories include individuals who have:education. Individuals who have only completed high schoolor some college display mortality rates in between those withthe highest and lowest levels of educational attainment. Thus,each increase in educational attainment is associated with alower mortality rate for both white women and men.Although useful for a basic understanding of educationaldifferences in adult mortality, this description presents twoproblems. First, education level is often reported inaccuratelyon U.S. death certificates. The most common error occurswhen educational attainment is reported as 12 years (highschool graduation) when, in fact, the deceased person didnot complete high school.5 Second, using only three or foureducational attainment categories could fail to capture evenwider education-mortality differences among subgroups ofthe population. For example, individuals who earned professional or graduate degrees (master’s degrees, law degrees,medical degrees, or doctoral degrees) may have even lowermortality rates than individuals whose highest education levelis a bachelor’s degree.To overcome the inaccurate reporting of education level,researchers have increasingly relied on data from national surveys of U.S. adults rather than death certificate- and censusbased official mortality data. Survey-based mortality data setsuse self-reports of respondents’ own educational attainment(and other social-demographic characteristics), and respondents are then followed for many years to determine wholives and who dies over the subsequent follow-up period.To address the limitation of too few educational categories,researchers have increasingly specified a larger number ofattainment categories. Less than a high school degree or its equivalent.fiGure 2 A high school degree or its equivalent.Mortality Rates for White Men and Women Ages 25-64 byEducational Attainment, 2001 Some college but not a bachelor’s degree. A bachelor’s degree or higher.Such documentation is usually based on official U.S. mortality data from a single year. Data on the number of peoplewho died within each educational category is derived fromdeath certificates and serves as the numerator for the mortality rates, while the total number of people in each categorycomes from census-based counts or estimates and servesas the denominator.U.S. data for adults ages 25 to 64 shows wide variationin mortality rates by educational attainment for both whitewomen and men (see Figure 2).4 The mortality rate for whitewomen who have not completed high school is nearly fourtimes higher than the rate for white women with 16 or moreyears of education. An even wider disparity is evident for thesame categories of white men: Men with less than a highschool degree have a mortality rate more than four timeshigher than those who have completed at least 16 years ofPOPULATION BULLETIN 68.1 2013Mortality Rate (per 100,000 population)931White WomenWhite Men596553322296178 12 Years12 Years13-15 Years21314616 YearsEducational AttainmentSource: Ahmedin Jemal et al., “Widening of Socioeconomic Inequalities in U.S.Death Rates, 1993-2001,” PLoS ONE 3, issue 5 (2008): 1-8.www.prb.org3

By using survey-based mortality data sets and more extensive measurement schemes of educational attainment, several recent studies have shown that educational differencesin adult mortality are even wider than typically documentedusing the standard approach. As an example, U.S. adultswho have master’s, doctoral, or professional degrees—agrowing subgroup of American adults—have been shownto exhibit even lower mortality rates than those who havebachelor’s degrees.6fiGure 3Relationship Between Educational Attainment and Mortalityfor U.S. AdultsHigh School DegreeHighSignificant reduction inodds of death for thosewith high school degreeOdds of DeathBut the association between educational attainment andadult mortality may be even more complex. Jennifer Montezand colleagues recently assessed whether standard educational categories or a different way to measure educationalattainment best predicted the odds of U.S. adults dying overa 20-year period following their inclusion in a major U.S.survey.7 For both women and men, they found that the mostaccurate depiction of the relationship between educationalattainment and the odds of adult mortality included threecomponents: a slight linear decline in the odds of mortalityas educational attainment increased from 0 to 11 years, asignificant reduction in the odds of mortality for adults whoobtained a high school degree, and a steep linear decline inthe odds of mortality as educational attainment increasedbeyond a high school degree (see Figure 3). Thus, obtaining a high school degree is very important for lowering theyearly odds of mortality among U.S. adults; moreover, theLowYears of Educationsource: Jennifer Karas Montez et al., “Educational Attainment and Adult Mortality in the UnitedStates: A Systematic Analysis of Functional Form,” Demography 49, no. 1 (2012): 315-36.fiGure 4Mortality Rate Differences Relative to Persons With 17 Years of Education, U.S. Women by AgePercent Higher Mortality Rate Relative to 17 Years of Education202Years of Education177 8 years9-11 years12 years1276713-15 years12216 years595248372238227Ages 25-44152Ages 45-64Ages 65-84Source: Robert A. Hummer and Joseph T. Lariscy, “Educational Attainment and Adult Mortality,” in International Handbook of Adult Mortality, ed. Richard G. Rogers and Eileen M. Crimmins(New York: Springer, 2011).4www.prb.orgPOPULATION BULLETIN 68.1 2013

women. In particular, less-educated men have especially highmortality rates from causes such as lung cancer, respiratorydiseases, accidents, and homicide. In contrast, men withhigh levels of education not only have much lower mortalityrates than less-educated men, they also have mortality ratesthat are not too much higher than those of highly educatedwomen.9 Clearly, high educational attainment helps men closethe gender mortality gap with women; but at the same time,less-educated men have mortality rates far higher than thoseof less-educated women.declines in mortality above the high school degree level areeven steeper.AGe, GeNDer, AND rAceEducational differences in adult mortality are wide in everyage, gender, and racial/ethnic group in the United States.Nonetheless, there are some variations that suggesteducational attainment may be operating somewhat differentlyacross population subgroups to influence adult mortality. First,educational differences in mortality are wider among youngeradults compared with older adults. A recent study using anationally representative survey of U.S. adults found thatwomen ages 25 to 44 with nine to 11 years of schooling hada 202 percent higher mortality rate over a 16-year follow-upperiod than similarly aged women who had completed at least17 years of education (see Figure 4, page 4).8 Among womenages 65 to 84, mortality was 38 percent higher among thegroup with nine to 11 years of education compared with thosewho had 17 or more years of education. At the same time,because mortality rates are far higher in older adulthood thanin younger adulthood, even relatively small mortality differencesby educational attainment in older adulthood are meaningfulbecause of the heavy concentration of deaths in older ages.Finally, educational differences in mortality are wider amongU.S. white adults than among either black or Hispanicadults. Highly educated whites have far lower mortalityrates and longer life expectancies than whites with lowlevels of education. Although highly educated black andHispanic women also have lower mortality rates than theirless-educated counterparts, compared to white womenthe “high education payoff” does not seem to be as strongamong these minority groups (see Figure 5).10 One possiblereason is that blacks and Hispanics are more likely to attendand graduate from lower-quality high schools and collegescompared with whites, and may not reap the same health andlongevity benefits from their education as whites. In addition,black and Hispanic adults, even those with high education,encounter discrimination in various forms and contextsthroughout their lives that affects their prospects for longevity.Recent studies also show that educational differences inU.S. adult mortality are somewhat wider among men thanfiGure 5Mortality Rate Differences Relative to Persons With 17 Years of Education, U.S. Women by Race/EthnicityPercent Higher Mortality Rate Relative to 17 Years of EducationYears of Education138 8 years1289-11 years12012 years13-15 years9216 years95786762615645442382Hispanic WomenNon-Hispanic Black WomenNon-Hispanic White WomenSource: Robert A. Hummer and Joseph T. Lariscy, “Educational Attainment and Adult Mortality,” in Inte rnational Handbook of Adult Mortality, ed. Richard G. Rogers and Eileen M. Crimmins(New York: Springer, 2011).POPULATION BULLETIN 68.1 2013www.prb.org5

Over the Last 50 YearsfiGure 6Mortality Rate Differences Relative to Persons With17 Years of Education, U.S. Adults Ages 45-64, byPreventability of CausePercent Higher Mortality Rate Relative to 17 Years of Education127High Preventability CausesLow Preventability Causes10093412115 88361414009-1112Years of Education13-15016Source: Jo C. Phelan et al., “Fundamental Causes of Social Inequalities in Mortality:A Test of the Theory,” Journal of Health and Social Behavior 45, no. 2 (2004): 265-85.cAuse-sPecific MortAlitYA number of recent studies have found that educational differences in mortality vary across causes of death. For example,deaths that are more closely linked to social and behavioralrisk factors (lung cancer, respiratory diseases, homicide, andaccidents) are associated with wide educational differences inmortality rates, while there are narrower educational differences in mortality rates for causes less amenable to humancontrol (such as cancers other than lung cancer).11In an innovative analysis, Jo Phelan and colleagues ratedthe preventability of causes of death.12 Causes such as lungcancer, homicide, and most forms of accidents were rated ashighly preventable, while causes such as multiple sclerosisand cancer of the gallbladder were rated as having low preventability because there is little scientific knowledge abouthow to prevent or treat them. Phelan and colleagues foundthat U.S. adults ages 45 to 64 with nine to 11 years of education had a 93 percent higher mortality rate than individualswith 17 or more years of schooling for highly preventablecauses of death (see Figure 6). For causes with low preventability, similarly aged adults with nine to 11 years of educationhad just a 14 percent higher mortality rate compared withpersons who had 17 or more years of education. Althoughadults with 12, 13 to 15, or 16 years of education also hadhigher mortality rates than those with 17 or more years ofschooling for causes with high preventability, their mortalityrates for causes with low preventability were not higher thanthe rates for those with 17 or more years of education. Thus,educational attainment is most closely associated with mortality rates for causes under greater human control. However,for all major causes of death, highly educated persons die atlower rates than persons with lower levels of education.6www.prb.orgIn the early 1970s, Evelyn Kitagawa and Philip Hauser published a path-breaking study of educational attainment andadult mortality in the United States.13 Using data from 1960,they compared remaining life expectancy at age 25 for whitefemales and males by educational attainment. Men who hadcompleted high school but no higher were expected to live upto two years longer than less educated men and about oneyear less than men who had completed at least one year ofcollege. Women’s life expectancy differences were somewhatwider at the time: women who had completed at least one yearof college were expected to live about four years longer thanwomen who had only completed high school and up to nineyears longer than women with the least education.Levels of educational attainment in U.S. society have risensubstantially since this landmark study, and scholars haveamassed a large body of scientific research examining trendsin educational differences in adult mortality rates and life expectancy since that time. Samuel Preston and Irma Elo foundthat educational differences in mortality widened for all adultmen between 1960 and the late 1980s, but narrowed forwomen between ages 25 and 64. For women who were ages65 and older, educational differences in mortality remainedsimilar to those found by Kitagawa and Hauser.14Over the past five years, a number of studies have used datafrom the late-1980s through the late 2000s to examine trendsin the association between educational attainment and adultmortality.15 Even with a variety of data sets and methodological approaches, all arrived at the same general and important conclusion: Educational differences in mortality and lifeexpectancy have widened over the past 20 to 25 years. In fact,age-specific mortality rates among black and white womenwho did not complete high school actually increased over thepast two decades. Moreover, the pace of mortality decline hasbeen steepest among highly educated individuals in most age,sex, and racial/ethnic groups (see Figure 7, page 7).Ryan Masters and colleagues further established that thesegrowing educational differences in adult mortality dependedon birth cohort—a group of people born during the same timeperiod.16 They found that by solely studying these trends on ayear-to-year basis, researchers are missing an important pieceof the puzzle: Educational-mortality differences are actuallygrowing wider by birth cohort. In other words, educational attainment is playing a more prominent role as a differentiator ofmortality rates for younger cohorts of Americans. This cohortbased widening of educational differences in mortality is important for two reasons. First, these results indicate that highlyeducated adults in more recent birth cohorts are better positioned and equipped than ever before to live long lives. Second, this pattern strongly suggests that policymakers shoulddevote increasing attention to the educational opportunitiesand trajectories of very recent birth cohorts of Americans, giventhe strengthening relationship between educational attainmentand adult mortality as new cohorts move into adulthood.POPULATION BULLETIN 68.1 2013

fiGure 7Trends in Death Rates for Non-Hispanic Blacks and Whites by Gender, Age, and Educational Attainment, 1986-2006Less Than High SchoolHigh SchoolSome CollegeCollegeNon-Hispanic Black WomenMortality rate (per 100,000 population)Non-Hispanic White WomenMortality rate (per 100,000 population)15001500Ages 55-64Ages 45-5410001000500500019861992199319992000- 19862006 1992199319992000200601986199219931999Non-Hispanic Black Men150010001000500500019861992199319992000- 19862006 19921993199920002006Mortality rate (per 100,000 population)Ages 55-64Ages 45-542000- 19862006 1992Non-Hispanic White MenMortality rate (per 100,000 population)1500Ages 55-64Ages 45-5419931999200020060Ages 55-64Ages 45-5419861992199319992000- 19862006 19921993199920002006source: Jennifer Montez et al., “Trends in the Educational Gradient of U.S. Adult Mortality From 1986 Through 2006 by Race, Gender, and Age Group,” Research on Aging 33, no. 2 (2011):145-71.This body of research documenting trends in educationaldifferences in mortality since 1960 has demonstrated thateducational attainment has become a very strong differentiator of men’s mortality and longevity over the past 50 years.And more recent evidence clearly points to widening educational differences in mortality for women as well. Given thesewidening differences over the past few decades, Brian Rostron and colleagues recently used mortality rates from 2005to develop new estimates of remaining life expectancy at age25 in a number of U.S. states (see Figure 8, page 8).17 Theirestimates suggest very wide contemporary educational differences in remaining life expectancy for both U.S. women andmen, likely the widest in history. At age 25, women with lessthan a high school degree were estimated to live an averageof 50 additional years, while women with a graduate or professional degree were estimated to live 62 additional years—adifference of 12 years. The gap was even wider for men: Menwith less than a high school degree were estimated to live anadditional 44 years on average, but men with a graduate orPOPULATION BULLETIN 68.1 2013professional degree were expected to live an additional 60years—a difference of 16 years.Reasons for the DifferencesIt is challenging to meticulously document educational differences in adult mortality; key limitations exist in the literature.For example, the scientific community knows almost nothingabout the association between quality or content of education and mortality. But the results in the previous section doprovide solid evidence, from multiple data sources, that currenteducational differences in U.S. adult mortality are probably thewidest in America’s history. Why then is educational attainmentso strongly related to mortality and life expectancy today?Researchers need a tremendous amount of high-quality datato fully unpack why educational attainment is so stronglyassociated with mortality and longevity. To start, researchersneed to know why some individuals receive graduate degreeswww.prb.org7

nisms that link higher educational attainment to lower rates ofmortality and greater longevity.fiGure 8Remaining Years of Life for U.S. Adults at Age 25 byEduc

Attainment on Adult Mortality in the United States," Population Bulletin 68, no. 1 (2013). For permission to reproduce portions from the Population Bulletin, write to PRB: Attn: Permissions; or e-mail: . Educational Attainment, 2005 . 8 Reasons fo R tHe DiffeRences .

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