In 2022 and 2023, the United States saw over 1.5 million more deaths than expected. Excess US deaths have been increasing for decades, with working-age adults disproportionately affected. This trend continued during and after the pandemic.
The study published in JAMA Health Forum by Minnesota Population Center researchers and collaborators at Boston University, 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 study found:
- U.S. death rates were one-third higher than death rates in 21 other wealthy nations, including Canada, Finland, Iceland and Portugal.
- In 2023, a staggering 45.9% of U.S. deaths under 65 years old would have been prevented if we had the death rate of other wealthy nations.
- Adults aged 25-44 in the U.S. are 2.5 times more likely to die than international peers.
- Excess deaths, meaning the number of deaths above the expected death rate, spiked during the COVID-19 pandemic and remain higher than peer nations in 2023, particularly for adults aged 25-44.
The findings reveal a continuing and worrying trend in worsening US mortality compared to other wealthy nations over the last four decades.
“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 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.”
“The US has been in a protracted health crisis for decades, with health outcomes far worse than other high-income countries,” says lead author Jacob Bor, associate professor of global health and epidemiology at Boston University School of Public Health. “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 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,” says lead author Jacob Bor, associate professor of global health and epidemiology at Boston University School of Public Health. “One out of every 2 US deaths under 65 years is likely avoidable. Our failure to address this is a national scandal.”
“These deaths reflect not individual choices, but policy neglect and deep-rooted social and health system failures,” says senior author Andrew Stokes, associate professor of global health at Boston University. “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.”
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 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.”
“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,” cautions Dr. Bor.
The study was also coauthored by Rafeya Raquib, research fellow in the Department of Global Health at SPH; Steffie Woolhandler, Distinguished Professor at the School of Urban Public Health at Hunter College; and David Himmelstein, lecturer in medicine at Cambridge Health Alliance/Harvard Medical School and Distinguished Professor at Hunter College.
See the original write up of this research by Jillian McKoy on the Boston University School of Public Health website.