One million missing: America’s crisis of early death

Call it American exceptionalism. Despite the fact that the US is the richest country in the world, it’s also one of the least healthy. American average life expectancy is lower than other wealthy countries and rates of chronic disease and obesity in the US are much higher. While lower-income and racial and ethnic minorities face larger life expectancy gaps than wealthy white Americans, even health outcomes for the richest lag behind other countries.

The COVID pandemic threw these long-standing disparities into overdrive. The average American life expectancy fell by nearly two years from 2019 to 2020 while similarly wealthy countries experienced only a 0.58 year drop. 

If the US had mortality rates similar to other wealthy countries, more than one million Americans would not have died in 2021.

How many people are impacted by America’s lower life expectancy? In a preprint analysis of excess death rates, members of the Lancet Commission on public policy and health in the Trump era answer the question: How many deaths could have been avoided if the US had mortality rates similar to other wealthy countries? Jacob Bor, assistant professor of global health at Boston University, and colleagues used data from the Human Mortality Database to compare mortality rates across 18 wealthy countries and identify rates of excess mortality in the US by age group. Data from the Centers for Disease Control and Prevention was used to compare age-stratified mortality in the US by racial/ethnic groups.

To find out how many deaths could have been avoided if the US had mortality rates similar to its peers — what the authors refer to as “missing Americans,” they applied the average age-stratified mortality rates of other wealthy countries to the US population and subtracted this from the actual number of deaths in the US.

The authors found that even before Covid-19, higher excess mortality rates in the US led to hundreds of thousands of missing Americans each year. Starting in the 1970s, excess mortality in the US began to veer away from other wealthy countries, excess mortality increasing for younger Americans in particular after 2000. In 2018, there were about 461,000 excess deaths — more than the number of deaths caused by Covid-19 in 2020 and 2021. In 2019 there were about 626,000 missing Americans. That means our country’s substandard mortality rates resulted in the same number of deaths as Covid-19 before the pandemic even hit.

The pandemic led excess deaths to increase dramatically, especially for young people. From 2019-2021, the mortality rate for people under age 65 increased ten times more in the US than in other wealthy countries. In 2020 there were more than 990,000 missing Americans, and there were more than one million missing Americans in 2021. Nearly half of the 1,092,293 excess deaths in 2021 were people under age 65. While the majority of excess deaths in the US were among white Americans, the proportion of excess deaths among Black Americans and Native Americans were greater than expected.

Responding to the crisis

This report shows that are sacrificing hundreds of thousands of lives each year by not acting to ensure our country’s health and wellbeing. What are other wealthy countries doing that we are not, and how can we better follow their example? There are dozens of differences, but research points to a few broad categories worth exploring.

We can’t ignore the differences in preventable deaths from lack of access to healthcare. According to a recent report from the Commonwealth Fund, rates of “avoidable mortality” in America are far higher than other wealthy countries. Avoidable mortality refers to deaths from preventable or treatable conditions, such as diabetes, certain infections, breast and colon cancer, appendicitis, and renal failure.

The average rate of avoidable death pre-Covid was 272 per 100,000 people in the US, worse than 30 other OECD countries. Even the US states with the lowest rates of avoiding death lag behind 25 other OECD countries. The states with the highest rates (Mississippi and West Virginia, with avoidable mortality rates of more than 400 per 100,000 people) are worse than all other OECD countries.

In other wealthy nations, healthcare coverage is universal and cost-sharing is minimal. In the US, however, our fragmented and unaffordable healthcare system makes it more difficult for people to access the same primary care and preventive services. Filling the gaps in healthcare coverage; offering more assistance for premiums, deductibles, and co-pays; providing more community-based primary care services; and training more primary care clinicians are needed to make healthcare more accessible.

Another challenge to accessing preventive care in the US: primary care providers are paid less in the fee-for-service system, leading to a “conveyer belt” style of care that doesn’t allow for real relationship-building. We need to better improve primary care in underserved communities by providing incentives — both financial incentives and the reduction of administrative burden– and by expanding our investment in training primary care clinicians.

At the same time, healthcare access is only a small part of what makes us healthy. Social factors like food security, educational access, economic equality, and a clean and safe environment determine our health much more than medical care — and the US underperforms on these factors as well. Ironically, the amount the US spends on medical care may be crowding out investments that federal and state governments could be making to social drivers of health. Rebalancing government spending towards essential social services is crucial for our nation’s health. Given that Black and Native Americans are over-represented among the missing Americans, these communities should be prioritized for investments in both social services and preventive healthcare.

The avoidable loss of more than one million Americans in a year is incredibly sobering. Each of these deaths is the result of policy choices that set us apart from our peers (and not in a good way). This report should be a call to action for policymakers to rebuild the health and social safety nets, which are currently letting too many Americans fall through the cracks.