September 2018 Losing Ground: Life Expectancy Trends in New York State Contents 1 Executive Summary 3 Background 4 A Period of Rapid Growth, then Decline 5 Changes in Death Rates 7 Changes in Years of Life Lost Rates 9 Future Outlook 10 Obesity and Life Expectancy 12 “Deaths of Despair” and Life Expectancy 15 Conclusion 16 Limitations 17 Appendix Executive Summary Life expectancy in New York State had been growing steadily for decades; from 1990 to 2010, it increased from 74.7 years to 80.4 years. After years of being below average, life expectancy in New York has been higher than national levels since 1996; by 2010, New Yorkers could expect to live 1.6 years longer than the average American. In a troubling reversal, the gains in life expectancy have begun stagnating in recent years, with New York State actually losing ground on life expectancy between 2014 and 2016. While New York still outpaces the nation (life expectancy peaked for the U.S. in 2013, at 78.9 years, and in New York State in 2014, at 80.7 years), the downward trend is cause for concern. Exhibit A, below, shows the dramatic shift in death rates in New York State since 2010, which coincides with the stagnated trend in life expectancy. E X H I B I T A . Trends in the Number of Deaths per 100,000 Population in New York State: 1990–2016 950 Number of Deahts per 100,000 Population 925 900 875 850 825 800 775 750 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd- results-tool. To shed light on the drivers of the recent decline in life expectancy, this report explores trends in the rates of death and years of life lost in New York State by various causes. Data used for this analysis was retrieved from the University of Washington’s Institute for Health Metrics and Evaluation (IHME) Global Burden of Disease (GBD) study. 1 Losing Ground: Life Expectancy Trends in New York State Executive Summary (continued) As Exhibit B illustrates, New Yorkers saw a decrease among most major causes of death in the years 1990–2010 and an increase in most causes for the years 2010–2016. Cardiovascular disease (particularly ischemic heart disease), certain cancers, and some neurological diseases saw particularly stark turnarounds for the worse between the two time periods. E X H I B I T B . Increases and Decreases in the Number of Deaths per 100,000 Population for Major* Causes of Death: 1990–2010 and 2010–2016 1990– 2010– 2010 2016 Ischemic heart disease   CA RD I OVASCU L A R D I S E AS ES Other cardiovascular diseases   N E U R O LO G I C A L D I S E A S ES Alzheimer’s disease and other dementias   Tracheal, bronchus, and lung cancer   CANCER Other cancers   OTH ER N O N - CO M M U N I CA B LE Chronic respiratory diseases DISEASES   * “Major causes of death” are those that cause at least 5% of all deaths in New York State. See Supplemental Chart E for Causes of Death included in “Other” Categories. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd- results-tool. The increasing trajectory of death rates for most major causes of death, rising obesity rates, and growing rates of so-called “deaths of despair” (including suicide and drug- and alcohol- related deaths) are especially concerning for future trends for life expectancy in New York State. Obesity rates have increased dramatically since 1990, and drug use and self-harm have seen increases in recent years as well. The deaths associated with these conditions have contributed to the overall rise in death rate since 2010. 2 Losing Ground: Life Expectancy Trends in New York State Background Within the developed world, high and steadily KEY FINDINGS increasing life expectancies have been the norm for generations. Prior analysis by the New zz There was a declining trend in rates York State Health Foundation revealed that life of death and years of life lost (YLLs) expectancy had increased, both in New York State across most causes from 1990 through and nationally, every year between 1990 and 2014 2010 in New York State. During these (with the exception of a decrease in New York years, life expectancy grew from 74.7 State in 2001, following the events of 9/11).1 to 80.4 years. After decades of advances, gains in life zz In a reversal of trends, death rates and expectancy have stalled. YLLs worsened for most major causes of death after 2010. The growth in life To better understand the reasons for the recent expectancy flattened during this time declines in life expectancy, we examined the and declined in 2015 and 2016. trends in the rates of death and years of life lost from 1990–2016, by cause, within New York State. zz Several trends raise concerns: the We use data from the Global Burden of Disease increasing trajectory of death rates (GBD) study, conducted by the Institute for Health for most major causes of death, rising Metrics and Evaluation (IHME) for the analysis. 2 obesity rates, and relatively high rates The data allows us to explore trends from various of drug overdose and other deaths of causes of death, including those related to obesity despair (including suicide and alcohol- and “deaths of despair” (suicide and drug- and related deaths). alcohol-related deaths). MORE INFORMATION ON DATA AND METHODS IHME uses data from various sources including mortality data from the Centers for Disease Control and Prevention (CDC)’s National Center for Health Statistics (NCHS), but applies corrections to eliminate codes associated with ill-defined causes of death as well as other adjustments. Because of these differences, numbers are slightly different than government mortality data from the CDC. More information is presented within the IHME codebook, available for download at http://ghdx.healthdata.org/gbd-results-tool. More details on the methods used to develop the Global Burden of Disease life expectancy and mortality related data, along with an analysis of trends across all U.S. states from 1990–2016, is available at: • The US Burden of Disease Collaborators. The State of US Health, 1990-2016 Burden of Diseases, Injuries, and Risk Factors Among US States. JAMA . 2018;319(14):1444–1472. doi:10.1001/jama.2018.0158 1 New York State Health Foundation, “Trends in Life Expectancy for New Yorkers,” https://nyshealthfoundation.org/ resource/trends-life-expectancy-new-yorkers/, accessed July 2018. 2 The US Burden of Disease Collaborators. The State of US Health, 1990-2016. Burden of Diseases, Injuries, and Risk Factors Among US States. JAMA. 2018;319(14):1444–1472. doi:10.1001/jama.2018.0158. 3 Losing Ground: Life Expectancy Trends in New York State A Period of Rapid Growth, then Decline Life expectancy increased significantly throughout the United States—but especially in New York State—between 1990 and 2010. Life expectancy in New York State was lower than national life expectancy in 1990, but had eclipsed the national number by 1996. In 2010, life expectancy in New York reached 80.4 years, compared with 78.8 nationally (Exhibit C). After 2010, progress stalled. Life expectancy peaked for the U.S. in 2013, at 78.9 years, and in New York State in 2014, at 80.7 years. In New York State, life expectancy was largely stagnant during this period, increasing from 80.4 in 2010 to 80.7 in 2014, before decreasing in consecutive years down to 80.5 in 2016. These decreases represent an alarming reversal of decades of growth. E X H I B I T C . Life Expectancy Estimates for New York State and the United States, 1990–2016 81 80 In New York, life expectancy peaked in 2014 at 80.7 years Life Expectancy at Birth 79 Nationally, life expectancy 78 peaked at 78.9 years in 2013 77 76 75 New York State United States 74 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd- results-tool. 4 Losing Ground: Life Expectancy Trends in New York State Changes in Death Rates The rapid increase in life expectancy between 1990 and 2010 coincided with a 20% decline in the all-cause death rate, from 938 to 751 deaths per 100,000 population. As shown in Exhibit D below, death rates for most causes of death declined between 1990 and 2010 (illustrated by the bars on the left side of the chart). The largest declines were for HIV/AIDS and ischemic heart disease (IHD), which refers to cardiac problems caused by narrowed heart arteries that often lead to heart attacks. The IHD death rate declined by more than one- third (from 319 to 197 per 100,000) and the HIV/AIDS death rate fell by 81% (from 32 to 6 per 100,000). In 1990, one in three deaths in New York was caused by ischemic heart disease. By 2016, only one death in four was caused by IHD (see Supplemental Chart A in the Appendix). E X H I B I T D . Change in Deaths per 100,000 Population by Cause of Death in New York State, 1990–2010 Ischemic heart disease Stroke Other cardiovascular diseases Breast cancer Colon and rectum cancer Tracheal, bronchus, and lung cancer Other cancers Alzheimer's disease and other dementias Other neurological disorders Chronic respiratory diseases Cirrhosis and other chronic liver diseases Digestive diseases Other non-communicable diseases HIV/AIDS and tuberculosis Diarrhea, lower respiratory, and other common infectious diseases Neonatal disorders Maternal disorders Nutritional deficiencies Neglected tropical diseases and malaria Other communicable, maternal, neonatal, and nutritional diseases Diabetes mellitus Other urogenital, blood, Unintentional injuries and endocrine diseases Road injuries Interpersonal violence Self-harm Forces of nature, conflict and terrorism, and executions and police conflict Other transport injuries Alcohol use disorders Mental disorders Opioid use disorders Other drug use disorders -125 -100 -75 -50 -25 0 25 50 Change in Death Rate See Supplemental Chart A for full detail on levels of death rates over time and Supplemental Chart B, which shows the percent change in death rates for select periods. See Supplemental Chart E for Causes of Death included in “Other” Categories. Note: Change in death rate is calculated by subtracting the number of deaths per 100,000 in 1990 from the rate in 2010. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd- results-tool. 5 Losing Ground: Life Expectancy Trends in New York State Changes in Death Rates (continued) However, in the following years, the number of deaths per 100,000 population increased by 6.4% (from 751 in 2010 to 799 in 2016). This increase was spread across the majority of causes of death (illustrated by the bars on the right side of Exhibit E), including many of the causes that saw the largest decreases in the preceding decades. IHD, which had previously seen the most dramatic decline, increased by 4.1%. Alzheimer’s disease increased by 14%. The only causes that saw declines in death rate during this period were HIV/AIDS, neonatal disorders, road injuries, interpersonal violence, and forces of nature, conflict, terrorism, and execution; notably, these causes were all already declining from 1990–2010. E X H I B I T E . Change in Deaths per 100,000 Population by Cause of Death in New York State, 2010–2016 Ischemic heart disease Stroke Other cardiovascular diseases Breast cancer Colon and rectum cancer Tracheal, bronchus, and lung cancer Other cancers Alzheimer's disease and other dementias Other neurological disorders Chronic respiratory diseases Cirrhosis and other chronic liver diseases Digestive diseases Other non-communicable diseases HIV/AIDS and tuberculosis Diarrhea, lower respiratory, and other common infectious diseases Neonatal disorders Maternal disorders Nutritional deficiencies Neglected tropical diseases and malaria Other communicable, maternal, neonatal, and nutritional diseases Diabetes mellitus Other urogenital, blood, and endocrine diseases Unintentional injuries Road injuries Interpersonal violence Self-harm Forces of nature, conflict and terrorism, and executions and police conflict Other transport injuries Alcohol use disorders Mental disorders Opioid use disorders Other drug use disorders -6 -4 -2 0 2 4 6 8 10 Change in Death Rate See Supplemental Chart A for full detail on levels of death rates over time and Supplemental Chart B which shows the percent change in death rates for select periods See Supplemental Chart E for Causes of Death included in “Other” Categories. Note: Change in death rate is calculated by subtracting the number of deaths per 100,000 in 2010 from the rate in 2016. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd- results-tool. 6 Losing Ground: Life Expectancy Trends in New York State Changes in Years of Life Lost Rates Years of life lost (YLLs) are calculated by subtracting an individual’s age at death from the number of years that that individual could be expected to live. YLLs take into account the impact of age of death on life expectancy. Causes associated with younger ages of death will have a greater impact on life expectancy because of more years of life lost. For example, in the 1990s, the individuals who died of HIV/AIDS were typically young, so YLL rates were disproportionately high relative to death rates. Diseases such as Alzheimer’s, which occur in much older populations, cause fewer YLLs per death. Between 1990 and 2010, there was a 35% decline in the all-cause YLL rate, from 19,686 to 12,827 years per 100,000 population. Rates of years of life lost fell for most causes of death between 1990 and 2010 (see Exhibit F). E X H I B I T F . Change in YLLs per 100,000 Population by Cause of Death in New York State, 1990–2010 Ischemic heart disease Stroke Other cardiovascular diseases Breast cancer Colon and rectum cancer Tracheal, bronchus, and lung cancer Other cancers Alzheimer's disease and other dementias Other neurological disorders Chronic respiratory diseases Cirrhosis and other chronic liver diseases Digestive diseases Other non-communicable diseases HIV/AIDS and tuberculosis Diarrhea, lower respiratory, and other common infectious diseases Neonatal disorders Maternal disorders Nutritional deficiencies Neglected tropical diseases and malaria Other communicable, maternal, neonatal, and nutritional diseases Diabetes mellitus Other urogenital, blood, and endocrine diseases Unintentional injuries Road injuries Interpersonal violence Self-harm Forces of nature, conflict and terrorism, Other transport injuries and executions and police conflict Alcohol use disorders Mental disorders Opioid use disorders Other drug use disorders -2500 -2000 -1500 -1000 -500 0 500 1000 1500 Change in YLL Rate See Supplemental Chart C for detail on levels of YLL rates over time and Supplemental Chart D which shows the percent change in YLL rates for select periods. See Supplemental Chart E for Causes of Death included in “Other” Categories. Note: Years of Life Lost are determined by subtracting an individual’s age at death from the age to which that individual could reasonably be expected to live at birth. Change in YLL rate is calculated by subtracting number of YLL per 100,000 population in 2010 from rate in 2016. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd-results-tool. 7 Losing Ground: Life Expectancy Trends in New York State Changes in Years of Life Lost Rates (continued) Again, ischemic heart disease and HIV/AIDS experienced the most significant improvements. There were some exceptions to the improving trends. As with death rates, years of life lost from Alzheimer’s disease and other neurological conditions, as well as from opioid and other drug use disorders, grew worse over this time period. Between 2010 and 2016, the number of YLLs per 100,000 population grew 3.3%, to 13,256. Largely consistent with death rates, the largest increases in YLLs were related to certain cancers, neurological diseases, and endocrine diseases (see Exhibit G). This indicates that New Yorkers are dying younger or in greater numbers (or both) from these conditions. E X H I B I T G . Change in YLLs per 100,000 Population by Cause of Death in New York State, 2010–2016 Ischemic heart disease Stroke Other cardiovascular diseases Breast cancer Colon and rectum cancer Tracheal, bronchus, and lung cancer Other cancers Alzheimer's disease and other dementias Other neurological disorders Chronic respiratory diseases Cirrhosis and other chronic liver diseases Digestive diseases Other non-communicable diseases HIV/AIDS and tuberculosis Diarrhea, lower respiratory, and other common infectious diseases Neonatal disorders Maternal disorders Nutritional deficiencies Neglected tropical diseases and malaria Other communicable, maternal, neonatal, and nutritional diseases Diabetes mellitus Other urogenital, blood, and endocrine diseases Unintentional injuries Road injuries Interpersonal violence Self-harm Forces of nature, conflict and terrorism, and executions and police conflict Other transport injuries Alcohol use disorders Mental disorders Opioid use disorders Other drug use disorders -75 -50 -25 0 25 50 75 100 125 Change in YLL Rate See Supplemental Chart C for detail on levels of YLL rates over time and Supplemental Chart D which shows the percent change in YLL rates for select periods. See Supplemental Chart E for Causes of Death included in “Other” Categories. Note: Years of Life Lost are determined by subtracting an individual’s age at death from the age to which that individual could reasonably be expected to live at birth. Change in YLL rate is calculated by subtracting number of YLL per 100,000 population in 2010 from rate in 2016. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd- results-tool. 8 Losing Ground: Life Expectancy Trends in New York State Future Outlook By 2014, death rates for the top 10 causes of death, in terms of the proportion of deaths attributable to the cause in 2016, were on an upward trajectory (see Exhibit H). If this trend continues, life expectancy will continue to decrease in future years. Below, we discuss several concerning trends that are likely to increase the risk for such declines. E X H I B I T H . Cumulative Percent Change in Number of Deaths per 100,000 Population in New York State for Top Ten Causes of Death, 2010–2016 15% Alzheimer’s disease Cumulative Percent Change in Death Rates Since 2010 and other dementias 12% Other urogenital, blood, and endocrine diseases 9% Chronic respiratory Other cardiovascular diseases diseases Diarrhea, lower respiratory, and other common infectious Tracheal, bronchus, diseases and lung cancer 6% Stroke Other Colon and cancers rectum cancer 3% Ischemic heart disease 0% -3% 2010 2011 2012 2013 2014 2015 2016 CAUSES OF DEATH 2010 2016 2010-2016 RATE (PER 100,000) RATE (PER 100,000) PERCENT CHANGE Alzheimer’s disease and other dementias 67.9 77.4 14.0% Other urogenital, blood, and endocrine diseases 30 33.5 11.5% Other cardiovascular diseases 48.1 52 8.1% Other cancers 99.2 106.6 7.5% Chronic respiratory diseases 39.9 42.9 7.5% Diarrhea, lower respiratory, and other common infectious diseases 29.5 31.7 7.5% Tracheal, bronchus, and lung cancer 48 51.1 6.5% Stroke 29.5 31.3 6.1% Colon and rectum cancer 21.4 22.7 6.0% Ischemic heart disease 197.3 205.4 4.1% See Supplemental Chart A for full detail by cause of death on levels of death rates over time and Supplemental Chart B which shows the percent change in death rates for select periods. See Supplemental Chart E for Causes of Death included in “Other” Categories. Note: Top 10 causes are defined by 2016 distribution of deaths. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd- results-tool. 9 Losing Ground: Life Expectancy Trends in New York State Future Outlook (continued) OBESITY AND LIFE EXPECTANCY Obesity rates in New York State have almost tripled in the previous two and a half decades (from 9.3% in 1990 to 25.5% in 2016; see Exhibit I). Defined as having a Body Mass Index (BMI) greater than or equal to 30, obesity puts an individual at increased risk of premature mortality.3 It is associated with higher rates of cardiovascular disorders, including stroke4 and heart disease,5 diabetes,6 and chronic kidney disease.7 E X H I B I T I . New York State Obesity Rate, 1990–2016 30% 25% Proportion of Population that is Obese 20% 15% 10% 5% 0% 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Source: The State of Obesity, “The State of Obesity in New York,” https://stateofobesity.org/states/ny, accessed July 2018. 3 Adams, K.F.; Schatzkin, A.; Harris, T.B.; Kipnis, V.; Mouw, T.; Ballard-Barbash, R.; Hollenbeck, A.; and Leitzmann, M.F. (2006). Overweight, Obesity, and Mortality in a Large Prospective Cohort of Persons 50 to 71 Years Old. New England Journal of Medicine, 355, 763-778. https://www.nejm.org/doi/full/10.1056/nejmoa055643. 4 Kurth, T.; Gaziano, J.M.; and Berger, K. (2002). Body Mass Index and the Risk of Stroke in Men. JAMA Internal Medicine, 162(22), 2557-2562. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/754810. 5 Lavie, C.J.; Milani, R.V.; Ventura, H.O. (2009). Obesity and Cardiovascular Disease Risk Factor, Paradox, and Impact of Weight Loss, Journal of the American College of Cardiology, 53(21). http://www.onlinejacc.org/content/53/21/1925. 6 Wild, S. H., and Byrne, C. D. (2006). Risk factors for diabetes and coronary heart disease. BMJ : British Medical Journal, 333(7576), 1009–1011. http://doi.org/10.1136/bmj.39024.568738.43. 7 Wahba, I.M.; and Mak, R.H. (2007). Obesity and Obesity-Initiated Metabolic Syndrome: Mechanistic Links to Chronic Kidney Disease, Clinical Journal of the American Society of Nephrology, 2(3), 550-562. http://cjasn.asnjournals.org/ content/2/3/550.full. 10 Losing Ground: Life Expectancy Trends in New York State Future Outlook (continued) Between 2010 and 2016, death rates for many obesity-related diseases saw increases for the first time in decades. As previously noted, the ischemic heart disease death rate increased 4.1% during this time period, after declining by 64% between 1990 and 2010. The rate of deaths from stroke increased by 6.1% after declining by 26%. The risk of certain health complications increases every year a person remains obese.8 A more obese population leads to an increased prevalence of obesity-linked conditions and, eventually, an increase in the rate of deaths attributable to them. Several of the most common obesity-related health complications saw increases in death rate between 2014 and 2016, the years that life expectancy declined in New York (see Exhibit J). E X H I B I T J . Number of Deaths per 100,000 Population from Obesity-Related Causes in New York State, Select Years 250 205.4 197.3 196.0 200 Deaths per 100,000 Population 150 100 50.4 52.0 48.1 50 29.5 30.9 31.3 30.0 32.9 33.5 18.7 17.6 18.7 0 Ischemic Heart Disease Stroke Other Cardiovascular Diseases Diabetes Other Endocrine Diseases 2010 2014 2016 See Supplemental Chart A for full details regarding death rates. See Supplemental Chart E for Causes of Death included in “Other” Categories. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd- results-tool. The rising obesity rate is especially concerning, as many currently-obese individuals will face increasing health challenges as they age. Essentially, the obesity epidemic’s impact on life expectancy may just be beginning. 8 Reis, J.P.; Loria, C.M.; and Lewis, C.E. (2013). Association Between Duration of Overall and Abdominal Obesity Beginning in Young Adulthood and Coronary Artery Calcification in Middle Age, JAMA, 310(3), 280-288. https:// jamanetwork.com/journals/jama/fullarticle/1713590. 11 Losing Ground: Life Expectancy Trends in New York State Future Outlook (continued) “DEATHS OF DESPAIR” AND LIFE EXPECTANCY A select set of deaths related to certain mental and behavioral disorders have become known in the scientific community as “deaths of despair.” These deaths are generally considered to include alcohol use disorders, drug use disorders, and self-harm.9 While they represent a small proportion of total deaths (see Exhibit K), increases in deaths of despair can have a disproportionate impact on life expectancy given their prevalence in younger populations. E X H I B I T K . Proportion of Deaths Resulting from “Deaths of Despair” in New York State 3% 2.7% 1990 2016 2% 2.0% 1.2% 1.2% 1% 0.6% 0.5% 0.4% 0.3% 0.2% 0.2% 0% Alcohol Use Opioid Use Other Drug Use Self-Harm Total Disorders Disorders Disorders See Supplemental Chart A for full details regarding death rates. See Supplemental Chart E for Causes of Death included in “Other” Categories. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd- results-tool. 9 Case, A., and Deaton, A. (2017). Mortality and morbidity in the 21st century. Brookings Papers on Economic Activity, 2017, 397–476. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640267/. 12 Losing Ground: Life Expectancy Trends in New York State Future Outlook (continued) In 1990, these factors combined to equal 4% of total YLLs in New York State, but by 2016 they made up 6.7% of all YLLs (see Exhibit L). Most significantly, opioid use disorders caused triple the proportion of deaths and YLLs in 2016 than they did in 1990. E X H I B I T L . Proportion of YLLs Resulting from “Deaths of Despair” in New York State 8% 6.7% 1990 2016 6% 4.1% 4% 3.0% 2.4% 2% 1.6% 1.4% 0.6% 0.8% 0.5% 0.5% 0% Alcohol Use Opioid Use Other Drug Use Self-Harm Total Disorders Disorders Disorders See Supplemental Chart B for full details regarding YLL rates. See Supplemental Chart E for Causes of Death included in “Other” Categories. Note: Years of Life Lost are determined by subtracting an individual’s age at death from the age to which that individual could reasonably be expected to live at birth. Change in YLL rate is calculated by subtracting number of YLL per 100,000 population in 2010 from rate in 2016. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd- results-tool. While the growth in the rate of deaths for some causes linked to deaths of despair has leveled off in recent years (Exhibit M), the levels are either above or nearing highs not previously experienced since the early 1990s. In particular, opioid abuse has seen large increases in New York State in recent years, and many experts agree that the current opioid epidemic 13 Losing Ground: Life Expectancy Trends in New York State Future Outlook (continued) will continue to claim lives, at current rates or higher, for the next several years.10, 11 Another potential driver of deaths of despair is the lack of economic opportunity that continues to plague some New York communities.12 Thus, even though deaths of despair remain a relatively small, but growing, proportion of total deaths and YLLs, it is possible that these disturbing trends contribute to additional decreases in life expectancy. E X H I B I T M . Deaths per 100,000 Population from “Deaths of Despair” in New York State, Select Years 10 9.6 9.7 9.2 9 Deaths per 100,000 Population 8 7 6 4.9 5 4.7 4.5 4.2 4.3 3.9 4 3.2 3.2 2.9 3 2 1 0 Alcohol use disorders Opioid use disorders Other drug use disorders Self-Harm 2010 2014 2016 See Supplemental Chart A for full details regarding death rates. See Supplemental Chart E for Causes of Death included in “Other” Categories. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd- results-tool. 10 National Survey on Drug Use and Health (NSDUH) special data request. (Personal communication September 14, 2017). 11 STAT, “STAT forecast: Opioids could kill nearly 500,000 Americans in the next decade,” https://www.statnews. com/2017/06/27/opioid-deaths-forecast/, accessed July 2018 12 New York State Community Action Association, “New York Annual Poverty Report,” http://nyscommunityaction.org/wp- content/uploads/2018/04/FINAL-VERSION-2018-POVERTY-REPORT-COMPLETE.pdf, accessed July 2018 14 Losing Ground: Life Expectancy Trends in New York State Conclusion The decline in life expectancy that New York has seen in the past two years cannot be attributed to any single cause. Most causes of death have been increasing in recent years. The largest increases in mortality and YLLs from 2010–2016 were related to cardiovascular diseases, Alzheimer’s disease, and certain cancers. Rising obesity rates may explain some of the increase in cardiovascular and endocrine diseases. The IHME lists high BMI as a risk factor for premature mortality, and the increasing obesity rates may be a factor in explaining the shift in trend of cardiovascular diseases from declining to increasing death and YLL rates. According to the IHME data, since 2010, high BMI has surpassed smoking as the risk factor accounting for the greatest number of related Disability- Adjusted Life Years (DALYs), also defined as years of healthy life lost.13 If the proportion of New York’s population that is obese continues to grow and those who are currently obese remain obese as they age, we can reasonably expect rates of death from obesity-linked conditions to increase as well. While deaths of despair have increased significantly since 1990, such deaths still accounted for less than 2.7% of total deaths in 2016. However, the growing YLL rate and the persistence of social and economic conditions leading to deaths of despair indicate that these causes of death will continue to negatively affect life expectancy in future years. Throughout the 1990s and 2000s, there were major advances in how cardiovascular diseases were treated, which helped increase life expectancy rates. Moreover, public policy initiatives to reduce smoking, and other factors—such as the decline in the HIV/AIDS epidemic, decline of crime rates, and advancements in medical technology—contributed to the rapid increase in life expectancy in New York State before 2010. It may be possible that those efforts have run their course and new advances are needed. More approaches, aimed at multiple causes of death, will be required to return to a positive life expectancy trend. 13 U.S. Burden of Disease Collaborators (2018). The State of US Health, 1990-2016, JAMA, 319(14), 1444-1472. https:// jamanetwork.com/journals/jama/fullarticle/2678018. 15 Losing Ground: Life Expectancy Trends in New York State Limitations Data used here are from the Institute for Health Metrics and Evaluation (IHME), Global Burden of Disease study, for all deaths aggregated at the national level and for the State of New York. IHME data aggregations were not available at a sub-State level for the years of data analyzed. We did not do an in-depth analysis by important cohorts such as age, gender, and race. Race data was not available. We did examine overall trends in death rates by age and gender (Supplemental Chart F). Similar patterns as compared with the overall population were found for most age and gender cohorts. There were declines in death rates across all age groups and genders between 1990 and 2010, followed by some increases among the older age groups across both genders between 2010 and 2016. Further stratifying the data could point more precisely to which populations are experiencing higher rates of premature mortality. National analyses that have stratified death rates and life expectancy by age and/or gender also found similar turnarounds for the worse across a broad spectrum of causes of death, including obesity and deaths of despair-related causes, across all demographic groups.14 Although the IHME data does not have race breakdowns, such data is available from the CDC Wonder system. However, this data cannot be exactly matched to IHME data because of differences in coding. National analyses have used CDC Wonder data and found similar overarching conclusions to the ones discussed in this report.16 The data is also not age-adjusted. The average age of New York State residents is increasing, so higher death rates are to be expected. However, an increase in the number of elderly deaths may not have a negative impact on overall life expectancy. Additionally, some deaths have multiple causes. For example, deaths by suicide and overdose are only placed into one category. As a result, some causes of death may be responsible for more deaths and YLLs than the data would reflect. 14 Woolf, S. H., Chapman, D. A., Buchanich, J. M., Bobby, K. J., Zimmerman, E. B., & Blackburn, S. M. (2018). Changes in midlife death rates across racial and ethnic groups in the United States: Systematic analysis of vital statistics. Bmj. doi:10.1136/bmj.k3096. 16 Ibid. 16 Losing Ground: Life Expectancy Trends in New York State Appendix Supplemental Chart A: Rank of Causes of Death by Proportion of Total Deaths in New York State, Select Years Category Causes of Death 1990 2010 2014 2016 Total Deaths 169,724 146,136 152,408 158,252 Rate (per Rate (per Rate (per Rate (per 100,000) Proportion Rank 100,000) Proportion Rank 100,000) Proportion Rank 100,000) Proportion Rank Ischemic heart disease 318.8 34.0% 1 197.3 26.3% 1 196.0 25.4% 1 205.4 25.7% 1 Cardiovascular Diseases Stroke 40.0 4.3% 6 29.5 3.9% 9 30.9 4.0% 9 31.3 3.9% 9 Other cardiovascular diseases* 49.1 5.2% 4 48.1 6.4% 4 50.4 6.5% 4 52.0 6.5% 4 Breast cancer 20.9 2.2% 12 14.3 1.9% 13 14.3 1.9% 13 14.9 1.9% 13 Colon and rectum cancer 30.8 3.3% 10 21.4 2.9% 10 21.7 2.8% 10 22.7 2.8% 10 Cancer Tracheal, bronchus, and lung cancer 57.6 6.1% 3 48.0 6.4% 5 49.2 6.4% 5 51.1 6.4% 5 Other cancers* 108.1 11.5% 2 99.2 13.2% 2 103.5 13.4% 2 106.6 13.3% 2 Alzheimer’s disease and other dementias 46.4 4.9% 5 67.9 9.0% 3 74.7 9.7% 3 77.4 9.7% 3 Neurological Diseases Other neurological disorders* 9.0 1.0% 20 12.7 1.7% 16 13.4 1.7% 16 13.7 1.7% 16 Chronic respiratory diseases 35.2 3.8% 7 39.9 5.3% 6 41.9 5.4% 6 42.9 5.4% 6 Other Non-Communicable Cirrhosis and other chronic liver diseases 16.2 1.7% 15 13.4 1.8% 15 14.1 1.8% 15 14.4 1.8% 15 Diseases Digestive diseases 15.3 1.6% 16 13.5 1.8% 14 14.1 1.8% 14 14.5 1.8% 14 Other non-communicable diseases* 8.4 0.9% 22 4.8 0.3% 19 4.8 0.3% 26 4.8 0.6% 19 HIV/AIDS and tuberculosis HIV/AIDS and tuberculosis 31.9 3.4% 8 5.9 0.6% 22 4.1 0.6% 20 4.3 0.5% 22 Diarrhea, lower respiratory, and other common infectious diseases 31.2 3.3% 9 29.5 0.8% 8 31.2 0.5% 23 31.7 4.0% 8 Communicable, maternal, Neonatal disorders 8.7 0.9% 21 3.5 3.9% 25 3.3 4.0% 8 3.2 0.4% 25 neonatal, and nutritional Maternal disorders 0.4 0.0% 29 0.4 0.5% 30 0.4 0.4% 24 0.4 0.0% 29 diseases Nutritional deficiencies 0.7 0.1% 28 0.6 0.1% 28 0.7 0.1% 30 0.7 0.1% 27 Neglected tropical diseases and malaria 0.0 0.0% 31 0.0 0.1% 32 0.0 0.1% 28 0.0 0.0% 31 Other communicable, maternal, neonatal, and nutritional diseases* 2.7 0.3% 24 1.4 0.0% 27 1.4 0.0% 32 1.4 0.2% 26 Diabetes mellitus 18.1 1.9% 13 18.7 0.2% 11 17.6 0.2% 27 18.7 2.3% 11 Endocrine Diseases Other urogenital, blood, and endocrine diseases* 22.7 2.4% 11 30.0 2.5% 7 32.9 2.3% 11 33.5 4.2% 7 Unintentional injuries 16.5 1.8% 14 14.2 4.0% 12 15.0 4.3% 7 15.2 1.9% 12 Road injuries 15.1 1.6% 17 8.5 1.9% 18 8.0 1.9% 12 8.4 1.0% 18 Interpersonal violence 12.0 1.3% 18 4.9 1.1% 20 4.6 1.0% 18 4.8 0.6% 20 Injury Self-harm 10.9 1.2% 19 9.2 0.7% 17 9.6 0.6% 21 9.7 1.2% 17 Forces of nature, conflict and terrorism, and executions and police conflict 0.1 0.0% 30 0.2 1.2% 31 0.1 1.2% 17 0.1 0.0% 30 Other transport injuries* 1.1 0.1% 27 0.6 0.0% 29 0.6 0.0% 31 0.6 0.1% 28 Alcohol use disorders 3.0 0.3% 23 2.9 0.1% 24 3.2 0.1% 29 3.2 0.4% 24 Mental and Behavioral Mental disorders 0.0 0.0% 32 0.0 0.4% 33 0.0 0.4% 25 0.0 0.0% 32 Disorders Opioid use disorders 2.1 0.2% 26 4.2 0.0% 21 4.9 0.0% 33 4.7 0.6% 21 Other drug use disorders* 2.3 0.2% 25 3.9 0.5% 23 4.5 0.6% 22 4.3 0.5% 23 Note: Data is for both sexes combined. *See Supplemental Chart E for Causes of Death included in “Other” Categories. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd-results-tool. Losing Ground: Life Expectancy Trends in New York State 17 Appendix (continued) Supplemental Chart B: Percent Change in the Number of Deaths per 100,000 Population by Cause of Death in New York State, Select Time Periods Category Causes of Death 1990-2000 2000-2010 2010-2014 2014-2016 Ischemic heart disease -16.7% -25.7% -0.7% 4.8% Cardiovascular Diseases Stroke -18.4% -9.6% 4.8% 1.3% Other cardiovascular diseases* -3.6% 1.4% 4.8% 3.1% Breast cancer -18.4% -16.2% 0.3% 3.9% Colon and rectum cancer -15.8% -17.4% 1.4% 4.5% Cancer Tracheal, bronchus, and lung cancer -6.5% -10.9% 2.6% 3.9% Other cancers* -6.6% -1.7% 4.3% 3.0% Alzheimer’s disease and other dementias 23.1% 18.8% 10.1% 3.5% Neurological Diseases Other neurological disorders* 19.9% 18.0% 5.9% 2.2% Chronic respiratory diseases 15.0% -1.6% 5.0% 2.3% Cirrhosis and other chronic liver diseases -27.6% 14.2% 5.2% 2.4% Other Non-Communicable Diseases Digestive diseases -12.9% 1.3% 4.5% 2.3% Other non-communicable diseases* -36.5% -9.7% -0.6% 1.3% HIV/AIDS and tuberculosis HIV/AIDS and tuberculosis -57.3% -56.5% -30.4% 4.7% Diarrhea, lower respiratory, and other common infectious diseases -9.8% 5.0% 5.7% 1.7% Neonatal disorders -44.7% -26.3% -7.9% -1.2% Communicable, maternal, neonatal and Maternal disorders -32.3% 51.6% 3.3% -2.3% nutritional diseases Nutritional deficiencies 13.5% -24.8% 7.2% 3.8% Neglected tropical diseases and malaria -9.5% 25.9% 14.0% -3.8% Other communicable, maternal, neonatal, and nutritional diseases* 15.9% -56.8% 1.0% 4.9% Diabetes mellitus 7.7% -4.1% -5.9% 6.3% Endocrine Diseases Other urogenital, blood, and endocrine diseases* 11.7% 18.2% 9.7% 1.7% Unintentional injuries -16.8% 3.3% 5.8% 1.4% Road injuries -29.4% -20.8% -5.0% 4.1% Interpersonal violence -49.9% -18.5% -6.6% 3.8% Injury Self-harm -22.5% 9.9% 3.8% 0.8% Forces of nature, conflict and terrorism, and executions and police conflict -27.8% 108.9% -27.9% -34.8% Other transport injuries* -34.8% -13.3% -1.7% 3.8% Alcohol use disorders -9.7% 5.3% 9.4% 2.1% Mental disorders 24.3% 5.3% 0.8% 1.0% Mental and Behavioral Disorders Opioid use disorders 33.7% 49.8% 17.2% -3.5% Other drug use disorders* 10.2% 55.9% 13.3% -3.6% Note: Data is for both sexes combined. *See Supplemental Chart E for Causes of Death included in “Other” Categories. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd-results-tool. Losing Ground: Life Expectancy Trends in New York State 18 Appendix (continued) Supplemental Chart C: Rank of Causes of Years of Life Lost (YLLs) by Proportion of Total YLLs in New York State, select years Category Causes of Death 1990 2010 2014 2016 Total YLLs 3,564,010 2,497,235 2,539,737 2,626,282 Rate (per Rate (per Rate (per Rate (per 100,000) Proportion Rank 100,000) Proportion Rank 100,000) Proportion Rank 100,000) Proportion Rank Ischemic heart disease 4,561.8 23.2% 1 2,475.0 19.3% 1 2,418.0 18.8% 1 2,515.6 19.0% 1 Cardiovascular Diseases Stroke 663.8 3.4% 8 414.0 3.2% 9 420.4 3.3% 9 427.9 3.2% 9 Other cardiovascular diseases* 890.7 4.5% 5 741.1 5.8% 4 759.2 5.9% 4 781.0 5.9% 4 Breast cancer 486.6 2.5% 15 303.4 2.4% 17 301.6 2.3% 17 313.6 2.4% 16 Colon and rectum cancer 556.1 2.8% 12 378.1 2.9% 11 383.0 3.0% 11 399.6 3.0% 10 Cancer Tracheal, bronchus, and lung cancer 1,215.7 6.2% 4 895.1 7.0% 3 907.4 7.0% 3 946.1 7.1% 3 Other cancers* 2,286.0 11.6% 2 1,875.8 14.6% 2 1,928.4 15.0% 2 1,991.4 15.0% 2 Alzheimer’s disease and other dementias 410.1 2.1% 19 531.7 4.1% 6 573.0 4.4% 6 589.1 4.4% 6 Neurological Diseases Other neurological disorders* 176.8 0.9% 22 197.2 1.5% 22 205.1 1.6% 23 209.9 1.6% 22 Chronic respiratory diseases 597.4 3.0% 11 573.2 4.5% 5 595.8 4.6% 5 611.4 4.6% 5 Other Non-Communicable Cirrhosis and other chronic liver diseases 463.1 2.4% 17 343.1 2.7% 13 353.4 2.7% 12 361.6 2.7% 12 Diseases Digestive diseases 257.5 1.3% 21 204.5 1.6% 21 210.9 1.6% 22 215.8 1.6% 20 Other non-communicable diseases* 540.5 2.7% 13 231.7 1.8% 19 216.3 1.7% 21 217.5 1.6% 19 HIV/AIDS and tuberculosis HIV/AIDS and tuberculosis 1,510.8 7.7% 3 208.6 1.6% 20 138.3 1.1% 25 149.1 1.1% 24 Diarrhea, lower respiratory, and other common infectious diseases 621.3 3.2% 10 438.2 3.4% 8 450.0 3.5% 8 457.7 3.5% 8 Communicable, maternal, Neonatal disorders 753.4 3.8% 6 306.7 2.4% 16 282.3 2.2% 18 279.0 2.1% 17 neonatal, and nutritional Maternal disorders 20.4 0.1% 28 20.6 0.2% 29 20.8 0.2% 29 20.6 0.2% 29 diseases Nutritional deficiencies 8.4 0.0% 29 6.8 0.1% 31 7.2 0.1% 30 7.4 0.1% 30 Neglected tropical diseases and malaria 1.1 0.0% 31 1.0 0.0% 32 1.1 0.0% 32 1.0 0.0% 32 Other communicable, maternal, neonatal, and nutritional diseases* 98.5 0.5% 26 36.1 0.3% 27 35.1 0.3% 27 36.9 0.3% 27 Diabetes mellitus 347.1 1.8% 20 332.1 2.6% 14 310.5 2.4% 16 330.2 2.5% 14 Endocrine Diseases Other urogenital, blood, and endocrine diseases* 416.8 2.1% 18 474.0 3.7% 7 512.0 4.0% 7 518.7 3.9% 7 Unintentional injuries 508.9 2.6% 14 311.8 2.4% 15 310.7 2.4% 15 314.9 2.4% 15 Road injuries 724.3 3.7% 7 355.1 2.8% 12 326.0 2.5% 14 341.2 2.6% 13 Interpersonal violence 662.0 3.4% 9 262.0 2.0% 18 240.0 1.9% 19 249.1 1.9% 18 Injury Self-harm 478.1 2.4% 16 379.9 3.0% 10 389.1 3.0% 10 392.5 3.0% 11 Forces of nature, conflict and terrorism, and executions and police conflict 6.3 0.0% 30 10.1 0.1% 30 6.2 0.0% 31 4.3 0.0% 31 Other transport injuries* 50.6 0.3% 27 25.8 0.2% 28 24.9 0.2% 28 25.8 0.2% 28 Alcohol use disorders 110.0 0.6% 23 99.2 0.8% 25 107.4 0.8% 26 109.4 0.8% 25 Mental and Behavioral Mental disorders 0.7 0.0% 32 0.8 0.0% 33 0.8 0.0% 33 0.9 0.0% 33 Disorders Opioid use disorders 103.7 0.5% 25 189.3 1.5% 23 223.0 1.7% 20 215.4 1.6% 21 Other drug use disorders* 105.6 0.5% 24 163.1 1.3% 24 185.2 1.4% 24 178.4 1.3% 23 *See Supplemental Chart E for Causes of Death included in “Other” Categories. Note: Years of Life Lost are determined by subtracting an individual’s age at death from the age to which that individual could reasonably be expected to live at birth. Change in YLL rate is calculated by subtracting number of YLL per 100,000 population in 2010 from rate in 2016. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd-results-tool. Losing Ground: Life Expectancy Trends in New York State 19 Appendix (continued) Supplemental Chart D: Percent Change in Years of Life Lost (YLL) per 100,000 Population by Cause of Death in New York State, Select Time Periods Category Cause of Death 1990-2000 2000-2010 2010-2014 2014-2016 Ischemic heart disease -24.7% -27.9% -2.3% 4.0% Cardiovascular Diseases Stroke -25.6% -16.1% 1.5% 1.8% Other cardiovascular diseases* -12.3% -5.1% 2.4% 2.9% Breast cancer -23.2% -18.8% -0.6% 4.0% Colon and rectum cancer -19.0% -16.1% 1.3% 4.3% Cancer Tracheal, bronchus, and lung cancer -13.3% -15.1% 1.4% 4.3% Other cancers* -13.3% -5.3% 2.8% 3.3% Alzheimer’s disease and other dementias 15.3% 12.5% 7.8% 2.8% Neurological Diseases Other neurological disorders* 1.7% 9.8% 4.0% 2.3% Chronic respiratory diseases 2.5% -6.4% 3.9% 2.6% Cirrhosis and other chronic liver diseases -34.9% 13.8% 3.0% 2.3% Other Non-Communicable Diseases Digestive diseases -17.4% -3.8% 3.1% 2.3% Other non-communicable diseases* -46.0% -20.7% -6.6% 0.6% HIV/AIDS and Tuberculosis HIV/AIDS and tuberculosis -62.4% -63.3% -33.7% 7.8% Diarrhea, lower respiratory, and other common infectious diseases -26.6% -3.9% 2.7% 1.7% Neonatal disorders -44.7% -26.3% -7.9% -1.2% Communicable, Maternal, Neonatal and Maternal disorders -34.8% 54.6% 1.4% -1.2% Nutritional Diseases Nutritional deficiencies 4.0% -21.8% 5.7% 2.2% Neglected tropical diseases and malaria -15.3% 8.5% 7.4% -3.2% Other communicable, maternal, neonatal, and nutritional diseases* -6.1% -61.0% -2.6% 5.0% Diabetes mellitus 1.0% -5.3% -6.5% 6.3% Endocrine Diseases Other urogenital, blood, and endocrine diseases* 1.3% 12.2% 8.0% 1.3% Unintentional injuries -33.4% -8.0% -0.3% 1.3% Road injuries -35.2% -24.3% -8.2% 4.6% Interpersonal violence -50.9% -19.3% -8.4% 3.8% Injury Self-harm -25.5% 6.7% 2.4% 0.9% Forces of nature, conflict and terrorism, and executions and police conflict -28.4% 126.0% -38.4% -31.4% Other transport injuries* -39.2% -15.9% -3.8% 3.7% Alcohol use disorders -13.7% 4.5% 8.3% 1.9% Mental disorders 21.2% 5.8% 1.4% 1.4% Mental and Behavioral Disorders Opioid use disorders 24.0% 47.2% 17.8% -3.4% Other drug use disorders* 2.4% 50.9% 13.5% -3.6% *See Supplemental Chart E for Causes of Death included in “Other” Categories. Note: Years of Life Lost are determined by subtracting an individual’s age at death from the age to which that individual could reasonably be expected to live at birth. Change in YLL rate is calculated by subtracting number of YLL per 100,000 population in 2010 from rate in 2016. Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd-results-tool. Losing Ground: Life Expectancy Trends in New York State 20 Appendix (continued) Supplemental Chart E: Causes included in “other” categories of death Specified Cause of Death Conditions Included Other Cardiovascular Diseases Rheumatic heart disease, cardiomyopathy, myocarditis, atrial fibrillation and flutter, aortic aneurysm, peripheral artery disease, endocarditis Other Cancers Lip & oral cavity cancer, nasopharynx cancer, other pharynx cancer, esophageal cancer, stomach cancer, liver cancer, gallbladder and biliary tract cancer, pancreatic cancer, larynx cancer, skin cancer, cervical cancer, uterine cancer, ovarian cancer, prostate cancer, testicular cancer, kidney cancer, bladder cancer, brain and nervous system cancer, thyroid cancer, mesothelioma, lymphoma, multiple myeloma, leukemia Other Neurological Diseases Parkinson’s disease, epilepsy, multiple sclerosis, motor neuron disease Other Non-Communicable Diseases Congenital birth defects, skin and subcutaneous diseases, sense organ diseases, oral disorders Other Communicable, Maternal, Neonatal and Sexually transmitted infections (STIs) other than HIV, hepatitis Nutritional Disorders Other endocrine, urogenital and blood diseases Chronic kidney disease, urinary tract diseases, gynecological diseases, hemoglobinpathies and hemolytic anemias Other transport injuries Cyclist injury, railroad injury, watercraft injury, airplane or aviation injury Other drug use disorders Cocaine use disorders, amphetamine use disorders, cannabis use disorders Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange: http://ghdx.healthdata.org/gbd-results-tool. Losing Ground: Life Expectancy Trends in New York State 21 Appendix (continued) Supplemental Chart F: Annual Percent Change in Deaths per 100,000 Population by Age and Sex in New York State, Select Time Periods 2% 1% 0% -1% -2% -3% -4% Under 5 5-14 15-49 50-69 70+ Male Female 1990-2010 2010-2016 Losing Ground: Life Expectancy Trends in New York State 22