Study reveals continuing and worrying trend in excess US deaths

There were over 1.5 million "missing Americans" in 2022 and 2023, deaths that would have been averted if US mortality rates matched those of peer countries. Excess US deaths have been increasing for decades, with working-age adults disproportionately affected, and this trend continued during and after the pandemic. 

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. This longer-run tragedy continued to unfold in the shadows of the COVID-19 pandemic."

Dr. Jacob Bor, study lead and corresponding author, associate professor of global health and epidemiology at BUSPH

Excess mortality is a nationwide problem, but the study revealed another staggering, yet persistent, statistic about younger and working-age Americans: 46 percent 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 percent, 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 2 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 percent 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 coauthor 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 healthcare access and social supports-that have continued to fuel premature deaths even after the acute phase of the pandemic ended."

Dr. Stokes coauthored a separate study earlier this year that found that drug-related deaths were the single largest cause of mortality among adults ages 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 healthcare, 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."

The study was also coauthored by Rafeya Raquib, research fellow in the Department of Global Health at BUSPH; Dr. Steffie Woolhandler, Distinguished Professor at the School of Urban Public Health at Hunter College; and Dr. David Himmelstein, lecturer in medicine at Cambridge Health Alliance/Harvard Medical School and Distinguished Professor at Hunter College.