Younger Americans dying at higher than expected rates
By Boston University, edited by Sadie Harley, reviewed by Robert Egan
In 2022 and 2023, more than 1.5 million deaths would have
been averted if the United States had mortality rates similar
to other high-income
countries, according to a new study led by Boston University School of
Public Health (BUSPH) researchers.
Published in JAMA Health Forum, the study refers to these excess
deaths as "missing Americans" because these deaths reflect people who
would still be alive if US mortality rates were equal to the average mortality
rate in other high-income countries.
The findings reveal a continuing and worrying trend in
worsening US mortality compared to other wealthy nations over the last four
decades.
While excess deaths per year peaked at the height of the
COVID-19 pandemic in
2021, excess deaths in 2023 still far exceeded prepandemic levels in 2019 and
closely matched the rising pre-pandemic trend.
After rising steadily since 1980, excess US deaths reached
1,098,808 in 2021, before dropping to 820,396 in 2022 and 705,331 in 2023,
after the acute phase of the pandemic. However, the 2023 figure was still tens
of thousands of deaths higher than the 2019 total of 631,247 missing Americans.
"The US has been in a protracted health crisis for decades, with health outcomes far worse than other high-income countries," says study lead and corresponding author Dr. Jacob Bor, associate professor of global health and epidemiology at BUSPH. "This longer-run tragedy continued to unfold in the shadows of the COVID-19 pandemic."
Excess mortality is a nationwide problem, but the study
revealed another staggering, yet persistent, statistic about younger and
working-age Americans: 46% of all US deaths among people under 65 years old
would not have occurred if the US had the age-specific death rates of its
peers.
This age-related disparity was evident before, during, and
after the pandemic, and the 2023 excess death rate was only slightly lower than
it was in 2021, at 50%, a finding detailed in a previous
study by the researchers.
"Imagine the lives saved, the grief and trauma averted,
if the US simply performed at the average of our peers," Dr. Bor says.
"One out of every two US deaths under 65 years is likely avoidable. Our
failure to address this is a national scandal."
For the study, Dr. Bor and colleagues from BUSPH, the
University of Minnesota, Hunter College, City University of New York, and the
Cambridge Health Alliance analyzed trends in US deaths from 1980 to 2021 and
then compared these trends with age-specific mortality rates in the US and 21
other high-income countries, such as Australia, Canada, France, Japan, and the
United Kingdom.
The analysis included 107,586,398 deaths in the US and
230,208,265 deaths in the other 21 countries. Between 1980 and 2023, there were
approximately 14.7 million excess US deaths relative to what would have been
observed if the US had the mortality rates of its peers. In 2023, excess deaths
accounted for nearly 23% of all deaths in the US.
The COVID-19 pandemic sharply exacerbated the
rise in US deaths in 2020 and 2021, more so than in other countries, and with
long-lasting consequences that continue to be realized. But the persistent
disparity in US mortality in comparison to its peers is largely driven by
crises that began long before the pandemic.
"The 700,000 excess American deaths in 2023 is exactly
what you'd predict based on prior rising trends, even if there had never been a
pandemic," said study co-author Dr. Elizabeth Wrigley-Field, associate
professor of sociology at the University of Minnesota.
"These deaths are driven by long-running crises
in drug overdose,
gun violence, car collisions, and preventable cardiometabolic deaths."
"These deaths reflect not individual choices, but
policy neglect and deep-rooted social and health system failures," says
senior author Dr. Andrew Stokes, associate professor of global health at BUSPH.
"The COVID-19 pandemic exposed structural weaknesses—including gaps in
health care access and social supports—that have continued to fuel premature
deaths even after the acute phase of the pandemic ended."
Dr. Stokes co-authored a separate study that found that drug-related deaths
were the single largest cause of mortality among adults aged 25–44.
Future research is needed to pinpoint specific causes of the
US' disparity in mortality rates, but the researchers say the nation should
look to the policies of its peer countries for insight into reducing health
inequities and improving population health outcomes.
"Other countries show that investing in universal
health care, strong safety nets, and evidence-based public health policies
leads to longer, healthier lives," says Dr. Stokes. "Unfortunately,
the US faces unique challenges; public distrust of government and growing
political polarization have made it harder to implement policies that have
proven successful elsewhere."
The whirlwind of executive actions and policies enacted
under the second Trump administration also threaten to stymie the potential for
these advancements, Dr. Bor says.
"Deep cuts to public health, scientific research,
safety net programs, environmental regulations, and federal health data could
lead to a further widening of health disparities between the US and other
wealthy nations, and growing numbers of excess—and utterly preventable—deaths
to Americans."
More information: Excess Deaths Before, During,
and After the COVID-19 Pandemic, JAMA Health Forum (2025). DOI:
10.1001/jamahealthforum.2025.1118
Journal information: JAMA Health Forum