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

Abstract Background and Objectives The distribution of life expectancy at age 65 (LE65) in the United States is characterized by profound sex- and locality-related disparities. Quantifying the disease-specific drivers of these disparities prior to the COVID-19 pandemic provides a critical baseline for understanding subsequent health shocks. Research Design and Methods Using CDC WONDER data (1999–2018) and Pollard’s decomposition method, we analyzed cause-specific contributions to disparities in LE65, establishing a pre-pandemic baseline for trends in years of life lost (YLL) at age 65. Results Sex-related disparities (YLLsex) narrowed, particularly in disadvantaged localities, driven by reductions in YLL from macrovascular diseases and lung cancer. Conversely, locality-related disparities (YLLloc) widened, especially for females, due to increasing YLL from Alzheimer’s disease and the persistent impacts of diabetes, chronic lower respiratory diseases, and heart failure. This created a pre-existing landscape of vulnerability concentrated in low-LE states. Discussion and Implications The two decades before COVID-19 saw a critical divergence: progress in reducing sex-based gaps was offset by rapidly widening geographic disparities. The systemic failures that drove the increasing burden of chronic conditions in disadvantaged regions likely predetermined the populations most vulnerable to the pandemic's shock. Our findings highlight that building future resilience requires targeted investments to address these specific, pre-existing health challenges.