In the United States, we’ve grown to expect that as time goes on, people get healthier—life expectancy rises, fewer people die of preventable or treatable conditions, and so on. That’s how it has happened for decades.

But a recent report from our partners at the Commonwealth Fund found that this is no longer the case for middle-aged white people—and the reason might surprise you.

Previous studies have linked the rise in white people’s death rates to suicide and substance abuse, but the new report found there is more to the story: we have stopped making progress against nearly all of the leading causes of death for this demographic. Think things such as heart disease, diabetes, and respiratory disease.

This is especially sad because these diseases are often preventable and treatable. So where are we going wrong?

Without more research, we can only speculate. But it’s likely that it has more to do with what happens outside of the doctor’s office than inside it.

The early 21st century has been tough for many middle-aged white Americans: their incomes have declined, fewer are employed, and fewer are married. Without a functional social safety net to help get Americans to a healthier economic and social place, they are left to flounder.

This means we have to address the social determinants of health—education, poverty, and more—if we want to see the death rate decline any time soon.

In the meantime, we should continue to work to ensure that everyone has access to affordable health insurance and health care.

For more information and some great graphics, check out the Commonwealth Fund’s Medium post on the report.