Missing Americans: Early Death in the United States, 1933-2021

Studies have quantified excess mortality in the United States during the COVID-19 pandemic relative to pre-COVID-19 US death rates. However, even before the pandemic, US residents died at younger ages than people in other wealthy nations, particularly from drug overdoses, suicides and cardiometabolic disorders. 

In a new working paper published in medRxiv, Jacob Bor and colleagues quantify the number of “Missing Americans,” US deaths that would have been averted each year if US mortality rates had equaled those of other wealthy nations from 1933-2021. Using newly-released mortality data compiled by the Human Mortality Database (HMD) and the US Centers for Disease Control and Prevention (CDC), Bor and colleagues compared mortality trends in the US with mortality trends in 18 other wealthy countries. First, they contextualized the COVID-19 pandemic within long-term historical trends. Then they examined the impact of the pandemic on the US mortality disadvantage: the number of “Missing Americans” in 2019, the change in mortality associated with the COVID-19 pandemic in the US and peer countries, and the impact of the pandemic on the number of “Missing Americans”. Third, Bor and colleagues assessed trends in the burden of excess mortality borne by US racial and ethnic groups, given persistent racial disparities in life expectancy, rising mortality among white Americans, and differential mortality impacts of the pandemic.

Main findings:

• The annual number of excess deaths in the US increased steadily beginning in the late 1970s, reaching 626,353 in 2019. 
• In 2020, the COVID-19 pandemic caused the largest single-year increase in mortality for the US and many other wealthy countries since World War II. 
• Excess deaths surged during the COVID-19 pandemic. In 2021, 1.1 million US deaths, including 1 in 2 deaths under age 65 years, would have been averted if the US had the mortality rates of other wealthy nations.
• In 2021, 25 million years of life were lost due to excess mortality relative to peer nations
• Half of all deaths under 65 years and 91 percent of the increase in under-65 mortality since 2019 would have been avoided if the US had the mortality rates of its peers in 2021.
• Although the majority were white, Black and Native Americans made up a disproportionate share of “Missing Americans”.

How can the US reduce the number of “Missing Americans” lost to early death each year? Bor and colleagues suggest starting by expanding current US policies with demonstrated health impact, ensuring that all US residents have access to health care and public benefits. Recent evidence indicates that Medicaid improves economic security and reduces mortality, that minimum wage increases and tax credit expansions reduce suicide, that unemployment insurance subsidies improve food security, that childhood programs (e.g., access to nutritional assistance and early childhood education) have health impacts and other benefits many times the initial investment and that firearm and environmental regulation works. Learning from peer nations, the US could extend social protections and universal health coverage to non-elderly adults and enhance the regulation of pollutants and firearms.

It is unknown whether US excess deaths will persist at 2021 levels into the future, or if the number of “Missing Americans” will revert towards pre-COVID levels. Underlying factors for high COVID-19 mortality, such as low vaccination rates, high rates of diabetes, obesity, hypertension and widespread gaps in access to health services for low- and middle-income people have not been resolved. Additionally, public health measures such as mask requirements that helped protect the unvaccinated have now been scaled back, raising the prospects that elevated mortality related to COVID-19 may continue. However, even if COVID-19 mortality were fully eliminated, the US would still likely suffer over 600,000 excess deaths each year, with most occurring among Americans under 65 years. Bor and colleagues argue preventing future “Missing Americans” will require policies that redress the consequences of structural racism and bolster the economic and social determinants of population health.