Abstract
Older age can be the best of times, marked by health and happiness, or the worst of times, marred by disease and distress. Late-life health disparities do not emerge suddenly on one’s 65th birthday; they can result from cumulative processes that span decades. Economic disadvantage and systems of racial oppression place individuals in health-depleting contexts over the life course. Stakeholders, including healthcare institutions, policymakers, employers, community organizations, and providers of home- and community-based services (HCBS), need to understand the social and economic patterning of late-life well-being to improve the quality of life for all older adults.
Key Words
health disparities, racial oppression, economic disadvantage, lifespan, late-life well-being, age-friendly ecosystems
Older age can be the best of times, marked by excellent physical and emotional health, mental acuity, a safe and comfortable home, a fulfilling retirement enjoying hobbies and time with loved ones, and the self-acceptance, contentedness, and wisdom that come from a lifetime of experience. Happiness levels peak in our 60s and 70s, and more than two-thirds of older adults say they are very happy with their family, friends, and homes (Pew Research Center, 2015). Yet old age also can be the worst of times, marred by illness and distress, compromised physical functioning, cognitive decline, loneliness, substandard housing, and experiences of abuse or mistreatment at the hands of the very people who should be providing care and protection (Carr, 2019a).
Extensive research has shown that older adults who live in poverty or who have been subjected to systemic racism and other forms of oppression face particularly steep challenges, most notably compromised health and quality of life, and ultimately shorter lifespans (see Herd et al., 2011, for review). Yet these disparities do not emerge suddenly upon one’s 65th birthday. Rather, late-life inequities are the result of slowly unfolding, cumulative processes that can span decades.
Childhood experiences such as poor quality or disrupted education can set one on a path to low-paying jobs without health benefits or a pension, insecure housing in polluted or unsafe neighborhoods, and unhealthy behaviors like smoking, eating unhealthy foods, or substance use to manage stress (Carr, 2019b). Recognizing the social factors that make some people vulnerable to health-depleting circumstances over the life course is a critical first step toward establishing age-friendly ecosystems.
Stakeholders, including healthcare institutions, policymakers, employers, community organizations, local government, public health advocates, and providers of home- and community-based services (HCBS) need to understand the social and economic patterning of late-life health and well-being, in order to develop tailored and coordinated programs that improve the quality of life for all older adults (Fulmer et al., 2023).
Late-Life Health Disparities in the United States: Patterns and Trends
One of the most significant achievements of the 20th and 21st centuries has been a dramatic increase in life expectancy. A baby boy born in 1900 could expect to live to age 46 on average, while a baby girl could expect to live until age 48. Today, newborn baby boys and girls are projected to live until ages 75 and 80, respectively (Kochanek et al., 2024). While people from all walks of life—rich and poor, men and women, Black and white—are living longer than they were a century ago, significant disparities exist. Women who drop out of high school die about 12 years earlier than women who earn a graduate degree, while the gap for men is a remarkable 16 years (Hummer & Hernandez, 2013).
An unhoused person living on the streets today survives until age 64 on average, about 15 years less than the average life expectancy (Richards & Kuhn, 2023). Impoverished men in the bottom 1% of the income distribution die 15 years younger than men in the top 1%, while the gap for women is 10 years (Chetty et al., 2016). Racial and ethnic gaps are stark and persistent: Hispanic persons live about 3 years longer than white people, and white people live about 5 years longer than Black people on average (Ndugga et al., 2024).
‘Poverty kills more U.S. adults each year than car accidents.’
How long we live reflects much more than our experiences in old age. Life expectancy at birth reflects mortality risk at every stage of life. Black people are more likely than whites, and economically disadvantaged persons more likely than financially secure persons, to succumb to complications at birth; fatal accidents, suicides, homicide, and overdose in their adolescent and young adult years; and premature death from diseases like diabetes and hypertension at midlife.
These disparities extend beyond the length of life; they also encompass the diseases from which we suffer. Socioeconomic and racial disparities are documented for nearly every major health condition—including Alzheimer’s disease and related dementias (ADRD), cancer, COVID-19, diabetes, heart disease, HIV/AIDS, obesity, and more. These disparities are tightly tied to social determinants of health (SDOH), more so than to genes or biological factors (Office of Disease Prevention and Health Promotion, 2023).
SDOH refer to conditions in the environments where people are born, live, learn, work, play, worship, and grow old that affect a wide range of health and quality-of-life outcomes. Consistent with the SDOH approach, epidemiologist Sandro Galea and colleagues (2011) have gone so far as to argue that poverty kills more U.S. adults each year than car accidents, dropping out of high school is linked with more deaths than heart attacks, and racial segregation outranks cerebrovascular disease as a root cause of death.
Social programs can help to improve older adults’ health and well-being. Social Security provides a guaranteed monthly income for most older adults, while Supplemental Security Income (SSI) provides an added boost for low-income older adults. Medicare, the national health insurance program for older adults, covers the costs of many of their healthcare needs, while Medicaid, the national health insurance program for low-income persons, helps to cover long-term care expenses.
Yet because so many later-life health problems are a consequence of adversities that have accumulated gradually throughout one’s childhood, teen, and working years, the benefits provided by old-age policies may be “too little, too late” to meet the needs of the most underserved Americans whose bodies and minds start to falter in their 50s and 60s, or even younger. Rather, public investments in school funding, early life food security programs, affordable health insurance for workers who are too young for Social Security, paid family leave for parents and older caregivers, and supports for behavioral health and workplace safety also are essential for enhancing the health and economic security of older adults (Lu et al., 2023).
Understanding Late-Life Health Disparities: Cumulative Inequality Perspectives
Cumulative inequality frameworks help us to understand the roots of late-life health inequities. Cumulative disadvantage theories argue that advantage begets further advantage, and disadvantage begets further disadvantage, such that relatively modest inequalities in early life amplify over time (Dannefer, 2003). It’s easy to understand how disparities between the “haves” and “have nots” could increase with advancing age.
Imagine that two elementary school classmates, Alex and Taylor, differ in one way: one is born into a family that struggles financially, and the other is born into a financially comfortable family. Alex, the child born into poverty, might drop out of high school to help support their family, taking whatever low-paying or even physically dangerous job is available to a young person who lacks a high school diploma. Their strenuous work might lead to minor aches and pains in the short term. Over time, Alex’s muscle aches intensify and they might soothe the pain with a few beers each night. After showing up for work with a hangover, Alex loses their job and health insurance and can’t afford to get the healthcare they need, worsening their health problems. Alex is eligible for Medicaid but couldn’t easily find a doctor willing to accept a new Medicaid patient because the reimbursement rates were too low and red tape too burdensome.
This scenario, where one adversity begets another, may widen the divide between Alex and Taylor, the classmate who had the good fortune to graduate high school, earn a college degree, find a good job with health insurance, buy a home in a neighborhood with grocery stores and walking paths, and afford top-notch healthcare. While the differences between these two childhood friends might have been barely noticeable when they were young, over time these differences widened such that Alex struggled financially and health-wise during the retirement years, whereas Taylor enjoyed comfort and good health.
‘Weathering refers to the physiological deterioration that Black people experience as a result of relentless exposure to stress.’
Cumulative disadvantage theories emphasize the power of resources like education and job security, yet other frameworks recognize that no single resource—whether education, health insurance, or promising medical innovations—benefits all people equally. This is particularly true for Black people in the United States, given deeply entrenched systems of racial inequality. “Diminishing returns” perspectives recognize that a purportedly health-enhancing resource like more years of schooling do not bring the same economic or health benefits to Black people as they do for white people (Assari, 2018). For instance, due to discrimination in workplace hiring and promotions, Black college graduates hold lower-paying jobs with fewer fringe benefits, live in poorer neighborhoods, and inherit, accumulate, or pass down less wealth relative to their white counterparts. These processes dampen the health-enhancing benefits of education (Bell et al., 2020).
Moreover, a college education—even from a top-notch institution—cannot guarantee protection against the health-depleting stressors that many Black Americans encounter throughout their lives. One classic study compared older white physicians who graduated in the 1950s and 1960s from Johns Hopkins University Medical School, to Black physicians who graduated in the same era from Meharry Medical College. By the time they reached their 60s and 70s, the Black doctors had double the rates of diabetes and hypertension relative to the white doctors, a gap the researchers attributed to the distinctive psychological strains of upward social mobility for Black persons (Thomas et al., 1997).
African American doctors who lived in largely white neighborhoods and workplaces experienced tokenism and discrimination, stressors that compromised their health (Jackson & Stewart, 2003). Epidemiologist Arline Geronimus and colleagues (2006) argued that the accumulation of stressors that disproportionately fall upon Black Americans—like economic adversity and political or social marginalization—can lead to a process she calls “weathering.” Weathering refers to the physiological deterioration that Black people experience as a result of relentless exposure to stress; these physical declines lead to premature disease and death.
Public health and healthcare advocates place great emphasis on the power of forward-looking health policies and biomedical advances to boost the health of historically oppressed and economically disadvantaged older adults. Although programs like Medicare and Social Security have helped to improve health and quality of life for all people in the United States, the benefits have been greatest for those who already enjoy the greatest advantages, perpetuating disparities (Carr, 2019a).
Sociologists Bruce Link and Jo Phelan (1995, p. S29) have argued that even if new scientific knowledge or promising medical interventions are developed, or a new public benefit is introduced, it is the most educated, wealthy, and well-connected individuals who are best equipped to take advantage of these advances. Major medical breakthroughs over the past century, such as effective cancer screenings and surgical techniques like angioplasty are used most often and most effectively by those with access to doctors working in top-notch hospitals using cutting-edge technologies, or those with the social capital needed to advocate for their preferred treatments.
Public health campaigns against risky behaviors like smoking also are most likely to benefit those who are literate and who have the means to kick unhealthy habits and adopt healthy new behaviors. For instance, 50 years ago, smoking rates were similar across education groups, with about 40% to 45% of U.S. adults smoking. Across the past 5 decades, though, as ad campaigns against smoking have intensified, just 6.5% of college graduates continue to smoke, compared to a quarter of high school dropouts (Drope et al., 2018). As a result, socioeconomic disparities in lung cancer deaths have widened over time. Policymakers and practitioners need to refine their messaging and delivery of health education and social programs so they meet the needs of those social groups facing the greatest obstacles to healthy aging.
Understanding Mechanisms: Potentially Modifiable Factors
Older adults can’t swallow a pill or undergo a surgery that magically erases the long-term impacts of early nutritional deficits, poverty, systemic racism, subpar healthcare access, or living in a neighborhood with high levels of pollution and few grocery stores. That’s why disparities persist despite older adults’ near-universal access to healthcare through Medicare (Carr, 2019a). Access to healthcare is critically important as older adults seek treatments and medication for chronic illnesses, yet it cannot undo the physical, emotional, and cognitive health assaults that have accumulated over the life course. Addressing health disparities among older adults requires the engagement of stakeholders from multiple domains, including employers, healthcare providers, public health professionals, policymakers, and other sectors of the age-friendly ecosystem. These solutions also require individual, family, community, and societal level efforts. Two broad sites of intervention include reducing the far-ranging stressors to which some individuals are exposed, and providing supports to help persons from all backgrounds to manage these stressors.
Structural supports for healthy behaviors also could help reduce health disparities across the life course.
Social stress comes in many forms (Carr, 2014). Stress can be an acute event, like the death of a loved one or a major surgery, or an ongoing and chronic strain, like caring for a sick spouse, working for an unreasonable boss, or walking nervously through an unsafe neighborhood every evening. Years of exposure to acute and chronic stressors can overwhelm one’s cardiovascular, immune, and central nervous systems and bring about disease and premature death. People with fewer socioeconomic resources and ethnic minorities have higher levels of stress exposure at every point in their lives, placing them at greater risk for health problems. Investments in secure and affordable housing, education, and job training to help people obtain higher-quality work, family leave, or other social supports for beleaguered caregivers, and behavioral health programs that help manage the psychosocial strains that accompany inequality could be effective in mitigating stress exposure and its consequences.
Structural supports for healthy behaviors also could help reduce health disparities across the life course. Unhealthy behaviors like smoking, drinking, drug use, a sedentary lifestyle, and a high-fat/high-salt diet increase the risk of conditions like lung cancer, cirrhosis of the liver, arthritis, dementia, obesity, diabetes, and more (Galea et al., 2011).
Maintaining a healthy lifestyle is not just a personal choice, but is powerfully shaped by communities and social policies. People living in low-income neighborhoods cannot easily access healthy and affordable foods at local grocery stores or farmers’ markets. Access issues are compounded by the fact that fast food corporations, soda and snack food companies, cigarette manufacturers, and alcohol distributors explicitly target Black people, inner-city residents, and low-income populations in their marketing campaigns (Kraft et al., 2020). Older adults living in rundown or crowded neighborhoods also may lack safe places to walk and get basic exercise.
Efforts to reduce inequities in older adults’ quality and length of life must extend beyond health policy to encompass educational, housing, employment, nutrition, economic, and family policies and programs. These approaches need to reach beyond old age and instead tackle the early and midlife roots of late-life inequalities. Thoughtfully designed policies and interventions also must recognize that older adults are not isolated individuals, but instead are embedded in families and communities.
These programs also should be tailored to meet the distinctive social, cultural, linguistic, and economic needs of communities, rather than adopting a “one size fits all” approach. Listening to the voices of community members is essential to effective and targeted program design. Age-friendly initiatives that ensure a coordinated, cohesive, and complete system of care for older adults, and that engage professionals and practitioners from diverse sectors are key to ensuring that future generations from all backgrounds can enjoy good health, physical comfort, meaningful personal relationships, a sense of purpose, and dignity in old age.
Deborah Carr, PhD, is A&S Distinguished Professor of Sociology and director of the Center for Innovation in Social Science at Boston University. She may be contacted at carrds@bu.edu.
Photo credit: Mc_Mon
References
Assari, S. (2018). Blacks’ diminished return of education attainment on subjective health; mediating effect of income. Brain Sciences, 8(9), 176. https://doi.org/10.3390/brainsci8090176
Bell, C. N., Sacks, T. K., Tobin, C. S. T., & Thorpe Jr, R. J. (2020). Racial non-equivalence of socioeconomic status and self-rated health among African Americans and Whites. SSM-Population Health, 10, 100561. https://doi.org/10.1016/j.ssmph.2020.100561
Carr, D. (2014). Worried sick: How stress hurts us and how to bounce back. Rutgers University Press.
Carr, D. (2019a). Golden years? Social inequality in later life. Russell Sage Foundation.
Carr, D. (2019b). Early-life influences on later life well-being: Innovations and explorations. The Journals of Gerontology: Series B, 74(5), 829–831. https://doi.org/10.1093/geronb/gbz054
Chetty, R., Stepner, M., Abraham, S., Lin, S., Scuderi, B., Turner, N., ... & Cutler, D. (2016). The association between income and life expectancy in the United States, 2001-2014. Jama, 315(16), 1750-1766.
Dannefer, D. (2003). Cumulative advantage/disadvantage and the life course: Cross-fertilizing age and social science theory. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 58(6), S327–S337. https://doi.org/10.1093/geronb/58.6.S327
Drope, J., Liber, A. C., Cahn, Z., Stoklosa, M., Kennedy, R., Douglas, C. E., Henson, R., & Drope, J. (2018). Who's still smoking? Disparities in adult cigarette smoking prevalence in the United States. CA: A Cancer Journal for Clinicians, 68(2), 106–115. https://doi.org/10.3322/caac.21444
Fulmer, T., Dash, K., Shue, J., Chang, J., Huang, J., & Maglich, A. (2023). Age-friendly ecosystems: Expert voices from the field. Geriatrics, 8(4), 68. https://doi.org/10.3390/geriatrics8040068
Galea, S., Tracy, M., Hoggatt, K. J., DiMaggio, C., & Karpati, A. (2011). Estimated deaths attributable to social factors in the United States. American Journal of Public Health, 101(8), 1456–1465. https://doi.org/10.2105/AJPH.2010.300086
Geronimus, A. T., Hicken, M., Keene, D., & Bound, J. (2006). “Weathering” and age patterns of allostatic load scores among Blacks and Whites in the United States. American Journal of Public Health, 96(5), 826-833. https://doi.org/10.2105/AJPH.2004.060749
Herd, P., Robert, S. A., & House, J. S. (2011). Health disparities among older adults: Life course influences and policy solutions. In K. E. Ferraro & D. Carr (Eds), Handbook of aging and the social sciences (pp. 121–134). Academic Press.
Hummer, R. A., & Hernandez, E. M. (2013). The effect of educational attainment on adult mortality in the United States. Population Bulletin, 68(1).
Jackson, P. B., & Stewart, Q. T. (2003). A research agenda for the Black middle class: Work stress, survival strategies, and mental health. Journal of Health and Social Behavior, 442–455. https://psycnet.apa.org/doi/10.2307/1519789
Kochanek, K. D., Murphy, S. L., Xu, J. Q., & Arias, E. (2024). Mortality in the United States, 2022 [NCHS Data Brief, no 492]. United States Centers for Disease Control and Prevention, National Center for Health Statistics.
Kraft, A. N., Thatcher, E. J., & Zenk, S. N. (2020). Neighborhood food environment and health outcomes in U.S. low-socioeconomic status, racial/ethnic minority, and rural populations: A systematic review. Journal of Health Care for the Poor and Underserved, 31(3), 1078–1114. https://doi.org/10.1353/hpu.2020.0083
Link, Bruce G., and Jo Phelan. Social conditions as fundamental causes of disease. Journal of health and social behavior (1995): 80-94.
Lu, N., Nie, P., & Siette, J. (2023). The roots of healthy aging: Investigating the link between early-life and childhood experiences and later-life health. BMC Geriatrics, 23(1), 639. https://doi.org/10.1186/s12877-023-04297-z
Office of Disease Prevention and Health Promotion. (2023). Healthy people 2030. U.S. Department of Health and Human Services. https://odphp.health.gov/healthypeople/objectives-and-data/social-determinants-health
Pew Research Center. (2015). The Aging Experience in the U.S., Germany and Italy. May 2015. https://www.pewresearch.org/social-trends/2015/05/21/3-the-aging-experience-in-the-u-s-germany-and-italy/
Richards, J., & Kuhn, R. (2023). Unsheltered homelessness and health: A literature review. AJPM Focus, 2(1), 100043. https://doi.org/10.1016/j.focus.2022.100043
Ndugga, N., Hill, L., & Artiga, S. (2024, June 11). Key data on health and health care by race and ethnicity. KFF. https://www.kff.org/key-data-on-health-and-health-care-by-race-and-ethnicity
Thomas, J., Thomas, D. J., Pearson, T., Klag, M., & Mead, L. (1997). Cardiovascular disease in African American and white physicians: The Meharry cohort and Meharry-Hopkins cohort studies. Journal of Health Care for the Poor and Underserved, 8(3), 270–283. https://doi.org/10.1353/hpu.2010.0526
