'A national scandal': US excess deaths rose even after pandemic, far outpacing peer countries

COVID-19
Public Health
Grave markers with flowers

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Excess deaths in the United States kept rising even after the peak of the COVID-19 pandemic, with more than 1.5 million in 2022 and 2023 that would have been prevented had US death rates matched those of peer countries, estimates a Boston University (BU)-led study today in JAMA Health Forum.

The data show a continuation of a decades-old trend toward increasing US excess deaths, mainly among working-age adults, largely driven by drug overdoses, gun violence, auto accidents, and preventable cardiometabolic causes, the researchers say.

"The US has been in a protracted health crisis for decades, with health outcomes far worse than other high-income countries," says lead and corresponding author Jacob Bor, ScD, said in a BU news release. "This longer-run tragedy continued to unfold in the shadows of the COVID-19 pandemic."

US death rates waned slower starting in 1980

The investigators analyzed all-cause death data in the United States and 21 other high-income countries (HICs) in the Human Mortality Database from January 1980 to December 2023. They calculated annual age-specific death rates for the United States and the population-weighted average of other HICs. 

Mortality rates decreased more slowly in the US than in other high-income countries (HICs) between 1980 and 2019, resulting in growing numbers of excess US deaths compared with other HICs.

The team counted the number of US deaths that would have been expected each year had the country experienced the age-specific death rates of other HICs, computed ratios of observed-to-expected US deaths, and estimated the number of excess deaths attributable to the US mortality disadvantage. They fit a linear regression model to determine whether the number of excess US deaths in 2023 differed from the 2014 to 2019 prepandemic trend.

"Mortality rates decreased more slowly in the US than in other high-income countries (HICs) between 1980 and 2019, resulting in growing numbers of excess US deaths compared with other HICs," the study authors noted. 

Rates more than double comparable nations in young adults

From 1980 to 2023, 107.5 million people died in the United States, and 230.2 million people did so in other HICs. During this period, an estimated 14.7 million excess US deaths occurred, peaking during the COVID-19 pandemic in 2021. 

Yet there were still more than 1.5 million excess deaths in 2022 and 2023, and rates remained substantially elevated compared with those from before the pandemic. Other HICs saw less-pronounced pandemic surges.

Gaps between the United States and other HICs widened before and during the pandemic, especially among younger adults, before shrinking in 2022 and 2023. Age-standardized death rate ratios comparing the United States with other HIC averages were 1.20 in 2010 (20% higher), 1.28 in 2019, 1.46 in 2021, and 1.30 in 2023. Death rates among US adults aged 25 to 44 years were 2.6 times higher than in other HICs in 2023.

Deep cuts to public health likely to widen disparity

Excess deaths attributable to the US mortality disadvantage peaked in 2020 and 2021, at 1 million in 2020 and 1.1 million in 2021, before declining to 820,396 in 2022 and 705,331 in 2023. These numbers followed four decades of increasing excess deaths, reaching 631,247 in 2019. In 2023, excess US deaths made up 22.9% of all deaths and 46.0% of those among people younger than 65 years.

Imagine the lives saved, the grief and trauma averted, if the US simply performed at the average of our peers. 

Jacob Bor, ScD

"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," coauthor Elizabeth Wrigley-Field, PhD, of the University of Minnesota, said in the release. "These deaths are driven by long-running crises in drug overdose, gun violence, car collisions, and preventable cardiometabolic deaths."

Senior author Andrew Stokes, PhD, of BU, said that other countries demonstrate that investing in universal healthcare, strong safety nets, and evidence-based public health policies leads to longer, healthier lives. "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," he said.

Bor said, "Imagine the lives saved, the grief and trauma averted, if the US simply performed at the average of our peers. One out of every two US deaths under 65 years is likely avoidable. Our failure to address this is a national scandal."

"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," he added.

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