Excess natural-cause mortality in US counties and its association with reported COVID-19 deaths.

In the United States, estimates of excess deaths attributable to the COVID-19 pandemic have consistently surpassed reported COVID-19 death counts. Excess deaths reported to non-COVID-19 natural causes may represent unrecognized COVID-19 deaths, deaths caused by pandemic health care interruptions, and/or deaths from the pandemic's socioeconomic impacts. The geographic and temporal distribution of these deaths may help to evaluate which explanation is most plausible. We developed a Bayesian hierarchical model to produce monthly estimates of excess natural-cause mortality for US counties over the first 30 mo of the pandemic. From March 2020 through August 2022, 1,194,610 excess natural-cause deaths occurred nationally [90% PI (Posterior Interval): 1,046,000 to 1,340,204]. A total of 162,886 of these excess natural-cause deaths (90% PI: 14,276 to 308,480) were not reported to COVID-19. Overall, 15.8 excess deaths were reported to non-COVID-19 natural causes for every 100 reported COVID-19 deaths. This number was greater in nonmetropolitan counties (36.0 deaths), the West (Rocky Mountain states: 31.6 deaths; Pacific states: 25.5 deaths), and the South (East South Central states: 26.0 deaths; South Atlantic states: 25.0 deaths; West South Central states: 24.2 deaths). In contrast, reported COVID-19 death counts surpassed estimates of excess natural-cause deaths in metropolitan counties in the New England and Middle Atlantic states. Increases in reported COVID-19 deaths correlated temporally with increases in excess deaths reported to non-COVID-19 natural causes in the same and/or prior month. This suggests that many excess deaths reported to non-COVID-19 natural causes during the first 30 mo of the pandemic in the United States were unrecognized COVID-19 deaths.

Immigrant mortality advantage in the United States during the first year of the COVID-19 pandemic.

OBJECTIVES: To investigate the mortality impact of the COVID-19 pandemic on US-born and foreign-born populations by race and Hispanic origin in the United States in 2020. METHODS: Death records from the National Center for Health Statistics and population data from CDC WONDER were used to estimate (1) age-standardized all-cause and cause-specific mortality at ages 25+, 25-64, and 65+ in 2017-2019 and 2020 by nativity, race, Hispanic origin, and sex; (2) changes in mortality between these two periods; and (3) the cause-specific contributions to these changes. RESULTS: Mortality increased in 2020 relative to 2017-2019 for all racial and Hispanic-origin groups. Adjusting for age, mortality increases were larger at ages 25+ among foreign-born males (390 deaths for 100,000 residents) and females (189) than among US-born males (223) and females (144). The large mortality rise among foreign-born Hispanic men (593) contributed to the narrowing of their mortality advantage relative to White men, from 426 to 134. An increase in mortality among both foreign-born and US-born Black males and females increased the Black-White mortality disparities by 318 for males and by 180 for females. Although COVID-19 mortality was the main driver of the increase among foreign-born residents, circulatory diseases and malignant neoplasms also contributed. CONTRIBUTION: We show that the COVID-19 pandemic had a greater impact on foreign-born populations than on their US-born counterparts. These findings highlight the need to address the underlying inequalities and unique challenges faced by foreign-born populations.

Return Migration Selection and Its Impact on the Migrant Mortality Advantage: New Evidence Using French Pension Data.

The migrant mortality advantage (MMA) has been observed in many immigrant-receiving countries, but its underlying factors remain poorly understood. This article examines the role of return migration selection effects in explaining the MMA among males aged 65+ using a rich, unique dataset from France. This dataset contains information on native-born and foreign-born pensioners who are tracked worldwide until they die, providing a rare opportunity to assess return migration selection effects and their impact on the MMA. Results provide evidence of substantial and systematic negative return migration selection among foreign-born males in France. Old-age returns, in particular, appear particularly affected by such selection; however, they are not frequent enough to explain the MMA at ages 65+. By contrast, returns at younger ages are much more frequent, and the MMA at ages 65+ essentially disappears once these earlier returns are considered. This study extends the literature on negative selection at return and its impact on the MMA by providing evidence that such negative selection may operate not only at older ages but throughout the life course, with impacts on the MMA that are larger than previously suggested.

Maternal Subjective Expectations about the Technology of Skill Formation Predict Investments in Children One Year Later.

A growing literature reports significant socio-economic gaps in investments in the human capital of young children. Because the returns to these investments may be huge, parenting programs attempt to improve children's environments by increasing parental expectations about the importance of investments for their children's human capital formation. We contribute to this literature by investigating the relevance of maternal subjective expectations (MSE) about the technology of skill formation in predicting investments in the human capital of children. We develop and implement a framework to elicit and analyze MSE data. We launch a longitudinal study with 822 participants, all of whom were women in the second trimester of their first pregnancy at the date of enrollment. In the first wave of the study, during pregnancy, we elicited the woman's MSE. In the second wave, approximately one year later, we measured maternal investments using the Home Observation for the Measurement of the Environment (HOME) Inventory. The vast majority of study participants believe that the Cobb-Douglas technology of skill formation describes the process of child development accurately. We observed substantial heterogeneity in MSE about the impact of human capital at birth and investments in child development at age two. Family income explains part of this heterogeneity in MSE. The higher the family income, the higher the MSE about the impact of investment in child development. We find that a one-standard-deviation of MSE measured at pregnancy is associated with 11% of a standard deviation in investments measured when the child is approximately nine months old.

COVID-19 and excess mortality in the United States: A county-level analysis.

BACKGROUND: Coronavirus Disease 2019 (COVID-19) excess deaths refer to increases in mortality over what would normally have been expected in the absence of the COVID-19 pandemic. Several prior studies have calculated excess deaths in the United States but were limited to the national or state level, precluding an examination of area-level variation in excess mortality and excess deaths not assigned to COVID-19. In this study, we take advantage of county-level variation in COVID-19 mortality to estimate excess deaths associated with the pandemic and examine how the extent of excess mortality not assigned to COVID-19 varies across subsets of counties defined by sociodemographic and health characteristics. METHODS AND FINDINGS: In this ecological, cross-sectional study, we made use of provisional National Center for Health Statistics (NCHS) data on direct COVID-19 and all-cause mortality occurring in US counties from January 1 to December 31, 2020 and reported before March 12, 2021. We used data with a 10-week time lag between the final day that deaths occurred and the last day that deaths could be reported to improve the completeness of data. Our sample included 2,096 counties with 20 or more COVID-19 deaths. The total number of residents living in these counties was 319.1 million. On average, the counties were 18.7% Hispanic, 12.7% non-Hispanic Black, and 59.6% non-Hispanic White. A total of 15.9% of the population was older than 65 years. We first modeled the relationship between 2020 all-cause mortality and COVID-19 mortality across all counties and then produced fully stratified models to explore differences in this relationship among strata of sociodemographic and health factors. Overall, we found that for every 100 deaths assigned to COVID-19, 120 all-cause deaths occurred (95% CI, 116 to 124), implying that 17% (95% CI, 14% to 19%) of excess deaths were ascribed to causes of death other than COVID-19 itself. Our stratified models revealed that the percentage of excess deaths not assigned to COVID-19 was substantially higher among counties with lower median household incomes and less formal education, counties with poorer health and more diabetes, and counties in the South and West. Counties with more non-Hispanic Black residents, who were already at high risk of COVID-19 death based on direct counts, also reported higher percentages of excess deaths not assigned to COVID-19. Study limitations include the use of provisional data that may be incomplete and the lack of disaggregated data on county-level mortality by age, sex, race/ethnicity, and sociodemographic and health characteristics. CONCLUSIONS: In this study, we found that direct COVID-19 death counts in the US in 2020 substantially underestimated total excess mortality attributable to COVID-19. Racial and socioeconomic inequities in COVID-19 mortality also increased when excess deaths not assigned to COVID-19 were considered. Our results highlight the importance of considering health equity in the policy response to the pandemic.

Ecological factors associated with suicide mortality among non-Hispanic whites.

BACKGROUND: In this paper, we examine the ecological factors associated with death rates from suicide in the United States in 1999 and 2017, a period when suicide mortality increased in the United States. We focus on Non-Hispanic Whites, who experienced the largest increase in suicide mortality. We ask whether variation in suicide mortality among commuting zones can be explained by measures of the social and economic environment and access to lethal means used to kill oneself in one's area of residence. METHODS: We use vital statistics data on deaths and Census Bureau population estimates and define area of residence as one of 704 commuting zones. We estimate separate models for men and women at ages 20-64 and 65 and above. We measure economic environment by percent of the workforce in manufacturing and the unemployment rate and social environment by marital status, educational attainment, and religious participation. We use gun sellers and opioid prescriptions as measures of access to lethal means. RESULTS: We find that the strongest contextual predictors of higher suicide mortality are lower rates of manufacturing employment and higher rates of opiate prescriptions for all age/sex groups, increased gun accessibility for men, and religious participation for older people. CONCLUSIONS: Socioeconomic characteristic and access to lethal means explain much of the variation in suicide mortality rates across commuting zones, but do not account for the pervasive national-level increase in suicide mortality between 1999 and 2017.

The association between discrimination and health: findings on Russian, Somali and Kurdish origin populations in Finland.

Background: The Second European Union Minorities and Discrimination Survey recently demonstrated widespread discrimination across EU countries, with high discrimination rates observed in countries like Finland. Discrimination is known to negatively impact health, but fewer studies have examined how different types of perceived discrimination are related to health. Methods: This study examines (i) the prevalence of different types of perceived discrimination among Russian, Somali and Kurdish origin populations in Finland, and (ii) the association between different types of perceived discrimination (no experiences; subtle discrimination only; overt or subtle and overt discrimination) and health (self-rated health; limiting long-term illness (LLTI) or disability; mental health symptoms). Data are from the Finnish Migrant Health and Wellbeing Study (n = 1795). Subtle discrimination implies reporting being treated with less courtesy and/or treated with less respect than others, and overt discrimination being called names or insulted and/or threatened or harassed. The prevalence of discrimination and the associations between discrimination and health were calculated with predicted margins and logistic regression. Results: Experiences of subtle discrimination were more common than overt discrimination in all the studied groups. Subtle discrimination was reported by 29% of Somali origin persons and 35% Russian and Kurdish origin persons. The prevalence of overt discrimination ranged between 22% and 24%. Experiences of discrimination increased the odds for poor self-reported health, LLTI and mental health symptoms, particularly among those reporting subtle discrimination only. Conclusions: To promote the health of diverse populations, actions against racism and discrimination are highly needed, including initiatives that promote shared belonging.

Children's educational attainment, occupation, and income and their parents' mortality.

Using data from Finland, this paper contributes to a small but growing body of research regarding adult children's education, occupation, and income and their parents' mortality at ages 50+ in 1970-2007. Higher levels of children's education are associated with 30-36 per cent lower parental mortality at ages 50-75, controlling for parents' education, occupation, and income. This association is fully mediated by children's occupation and income, except for cancer mortality. Having at least one child educated in healthcare is associated with 11-16 per cent lower all-cause mortality at ages 50-75, an association that is largely driven by mortality from cardiovascular diseases. Children's higher white-collar occupation and higher income is associated with 39-46 per cent lower mortality in the fully adjusted models. At ages 75+, these associations are much smaller overall and children's schooling remains more strongly associated with mortality than children's occupation or income.

Contribution of smoking-attributable mortality to life expectancy differences by marital status among Finnish men and women, 1971-2010.

BACKGROUND: Smoking is known to vary by marital status, but little is known about its contribution to marital status differences in longevity. We examined the changing contribution of smoking to mortality differences between married and never married, divorced or widowed Finnish men and women aged 50 years and above in 1971-2010. DATA AND METHODS: The data sets cover all persons permanently living in Finland in the census years 1970, 1975 through 2000 and 2005 with a five-year mortality follow-up. Smoking-attributable mortality was estimated using an indirect method that uses lung cancer mortality as an indicator for the impact of smoking on mortality from all other causes. RESULTS: Life expectancy differences between the married and the other marital status groups increased rapidly over the 40-year study period because of the particularly rapid decline in mortality among married individuals. In 1971-1975 37-48% of life expectancy differences between married and divorced or widowed men were attributable to smoking, and this contribution declined to 11-18% by 2006-2010. Among women, in 1971-1975 up to 16% of life expectancy differences by marital status were due to smoking, and the contribution of smoking increased over time to 10-29% in 2006-2010. CONCLUSIONS: In recent decades smoking has left large but decreasing imprints on marital status differences in longevity between married and previously married men, and small but increasing imprints on these differences among women. Over time the contribution of other factors, such as increasing material disadvantage or alcohol use, may have increased.

Life Expectancy Among U.S.-born and Foreign-born Older Adults in the United States: Estimates From Linked Social Security and Medicare Data.

In recent decades, the geographic origins of America's foreign-born population have become increasingly diverse. The sending countries of the U.S. foreign-born vary substantially in levels of health and economic development, and immigrants have arrived with distinct distributions of socioeconomic status, visa type, year of immigration, and age at immigration. We use high-quality linked Social Security and Medicare records to estimate life tables for the older U.S. population over the full range of birth regions. In 2000-2009, the foreign-born had a 2.4-year advantage in life expectancy at age 65 relative to the U.S.-born, with Asian-born subgroups displaying exceptionally high longevity. Foreign-born individuals who migrated more recently had lower mortality compared with those who migrated earlier. Nonetheless, we also find remarkable similarities in life expectancy among many foreign-born subgroups that were born in very different geographic and socioeconomic contexts (e.g., Central America, western/eastern Europe, and Africa).

Health among Black children by maternal and child nativity.

OBJECTIVES: We examined 5 health outcomes among Black children born to US-born and foreign-born mothers and whether differences by mother's region of birth could be explained by maternal duration of US residence, child's place of birth, and familial sociodemographic characteristics. METHODS: Data were from the 2000-2011 National Health Interview Surveys. We examined 3 groups of children, based on mother's region of birth: US origin, African origin, and Latin American or Caribbean origin. We estimated multivariate regression models. RESULTS: Children of foreign-born mothers were healthier across all 5 outcomes than were children of US-born mothers. Among children of foreign-born mothers, US-born children performed worse on all health outcomes than children born abroad. African-origin children had the most favorable health profile. Longer duration of US residence among foreign-born mothers was associated with poorer child health. Maternal educational attainment and other sociodemographic characteristics did little to explain these differences. CONCLUSIONS: Further studies are needed to understand the role of selective migration and the behavioral, cultural, socioeconomic, and contextual origins of the health advantage of Black children of foreign-born mothers.

Family structure and multiple domains of child well-being in the United States: a cross-sectional study.

BACKGROUND: We examine the association between family structure and children's health care utilization, barriers to health care access, health, and schooling and cognitive outcomes and assess whether socioeconomic status (SES) accounts for those family structure differences. We advance prior research by focusing on understudied but increasingly common family structures including single father families and five different family structures that include grandparents. METHODS: Our data on United States children aged birth through 17 (unweighted N = 198,864) come from the 1997-2013 waves of the National Health Interview Survey, a nationally representative, publicly available, household-based sample. We examine 17 outcomes across nine family structures, including married couple, cohabiting couple, single mother, and single father families, with and without grandparents, and skipped-generation families that include children and grandparents but not parents. The SES measures include family income, home ownership, and parents' or grandparents' (depending on who is in the household) employment and education. RESULTS: Compared to children living with married couples, children in single mother, extended single mother, and cohabiting couple families average poorer outcomes, but children in single father families sometimes average better health outcomes. The presence of grandparents in single parent, cohabiting, or married couple families does not buffer children from adverse outcomes. SES only partially explains family structure disparities in children's well-being. CONCLUSIONS: All non-married couple family structures are associated with some adverse outcomes among children, but the degree of disadvantage varies across family structures. Efforts to understand and improve child well-being might be most effective if they recognize the increasing diversity in children's living arrangements.

Preterm birth among the Hmong, other Asian subgroups and non-Hispanic whites in California.

BACKGROUND: We investigated very preterm (VPTB) and preterm birth (PTB) risk among Hmong women relative to non-Hispanic whites and other Asian subgroups. We also examined the maternal education health gradient across subgroups. METHODS: California birth record data (2002-2004) were used to analyze 568,652 singleton births to white and Asian women. Pearson Chi-square and logistic regression were used to assess variation in maternal characteristics and VPTB/PTB risk by subgroup. RESULTS: White, Chinese, Japanese, Korean, Asian Indian, and Vietnamese women had 36-59% lower odds of VPTB and 30-56% lower odds of PTB than Hmong women. Controls for covariates did not substantially diminish these disparities. Cambodian, Filipino and Lao/Thai women's odds of VPTB were similar to that of Hmong women. But they had higher adjusted odds of PTB compared to the Hmong. There was heterogeneity in the educational gradient of PTB, with significant differences between the least and most educated women among whites, Chinese, Japanese, Asian Indians, Cambodians, and Laoians/Thais. Maternal education was not associated with PTB for Hmong, Vietnamese and Korean women, however. CONCLUSIONS: Studies of Hmong infant health from the 1980s, the decade immediately following the group's mass migration to the US, found no significant differences in adverse birth outcomes between Hmong and white women. By the early 2000s, however, the disparities in VPTB and PTB between Hmong and white women, as well as between Hmong and other Asian women had become substantial. Moreover, despite gains in post-secondary education among childbearing-age Hmong women, the returns to education for the Hmong are negligible. Higher educational attainment does not confer the same health benefits for Hmong women as it does for whites and other Asian subgroups.

Africans in the American Labor Market.

The number of migrants to the United States from Africa has grown exponentially since the 1930s. For the first time in America's history, migrants born in Africa are growing at a faster rate than migrants from any other continent. The composition of African-origin migrants has also changed dramatically: in the mid-twentieth century, the majority were white and came from only three countries; but today, about one-fifth are white, and African-origin migrants hail from across the entire continent. Little is known about the implications of these changes for their labor market outcomes in the United States. Using the 2000-2011 waves of the American Community Survey, we present a picture of enormous heterogeneity in labor market participation, sectoral choice, and hourly earnings of male and female migrants by country of birth, race, age at arrival in the United States, and human capital. For example, controlling a rich set of human capital and demographic characteristics, some migrants-such as those from South Africa/Zimbabwe and Cape Verde, who typically enter on employment visas-earn substantial premiums relative to other African-origin migrants. These premiums are especially large among males who arrived after age 18. In contrast, other migrants-such as those from Sudan/Somalia, who arrived more recently, mostly as refugees-earn substantially less than migrants from other African countries. Understanding the mechanisms generating the heterogeneity in these outcomes-including levels of socioeconomic development, language, culture, and quality of education in countries of origin, as well as selectivity of those who migrate-figures prominently among important unresolved research questions.

Do black-white racial disparities in breastfeeding persist in the military community?

We conduct a comparative analysis of breastfeeding behavior between military and civilian-affiliated mothers. Our focus is on African American mothers among whom breastfeeding rates are lowest. The military context may mitigate conditions associated with low breastfeeding prevalence by (a) providing stable employment and educational opportunities to populations who face an otherwise poor labor market and (b) providing universal healthcare that includes breastfeeding consultation. Using pregnancy risk assessment monitoring system (PRAMS) data for which we received special permission from each state to flag military affiliation, we analyze civilians and military affiliate in breastfeeding initiation using logistic regression and breastfeeding duration using Cox proportional hazard analysis. We find that breastfeeding is more prevalent among all women in the military setting and that the black-white gap in breastfeeding duration common among civilians is significantly reduced among military affiliates. Breastfeeding is a crucial component of maternal and child health and eliminating racial disparities in its prevalence is a public health priority. This study is the first to identify the military as an important institutional context that deserves closer examination to glean potential policy implications for civilian society.

Weight histories and mortality among finnish adults: the role of duration and peak body mass index.

BACKGROUND: Many studies use information on weight histories to examine the association between body weight and mortality. A recent paper in Epidemiology (2013;25:707-710) developed a typology of the most common weight-history specifications. METHODS: We use data from a sample of Finnish adults to explore the associations of body weight and mortality, using existing specifications and also peak body mass index (BMI), a new specification. RESULTS: We confirm earlier findings that longer time in a high BMI state is predictive of mortality. Peak BMI (the highest BMI attained in life or available in the data) is also positively associated with mortality. CONCLUSIONS: The specifications of duration in a high BMI state and peak BMI are both valuable for understanding the relationship between lifetime weight dynamics and mortality. The collection of information on peak body weight may be useful when collection of more detailed weight histories is not feasible.

Variation in birth outcomes by mother's country of birth among non-Hispanic black women in the United States.

Rates of prematurity (PTB) and small-for-gestational age (SGA) were compared between US-born and foreign-born non-Hispanic black women. Comparisons were also made between Sub-Saharan African-born and Caribbean-born black women and by maternal country of birth within the two regions. Comparisons were adjusted for sociodemographic, health behavioral and medical risk factors available on the birth record. Birth record data (2008) from all states (n = 27) where mother's country of birth was recorded were used. These data comprised 58 % of all singleton births to non-Hispanic black women in that year. Pearson Chi square and logistic regression were used to investigate variation in the rates of PTB and SGA by maternal nativity. Foreign-born non-Hispanic black women had significantly lower rates of PTB (OR 0.727; CI 0. 726, 0.727) and SGA (OR 0.742; CI 0.739-0.745) compared to US-born non-Hispanic black women in a fully adjusted model. Sub-Saharan African-born black women compared to Caribbean-born black women had significantly lower rates of PTB and SGA. Within each region, the rates of PTB and SGA varied by mother's country of birth. These differences could not be explained by adjustment for known risk factors obtained from vital records. Considerable heterogeneity in rates of PTB and SGA among non-Hispanic black women in the US by maternal nativity was documented and remained unexplained after adjustment for known risk factors.

Age patterns of racial/ethnic/nativity differences in disability and physical functioning in the United States.

BACKGROUND: Rapid population aging and increasing racial/ethnic and immigrant/native diversity make a broad documentation of U.S. health patterns during both mid- and late life particularly important. OBJECTIVE: We aim to better understand age- and gender-specific racial/ethnic and nativity differences in physical functioning and disability among adults aged 50 and above. METHODS: We aggregate 14 years of data from the National Health Interview Survey and calculate age- and gender-specific proportions of physical functioning and two types of disability for each population subgroup. RESULTS: Middle-aged foreign-born individuals in nearly every subgroup exhibit lower proportions of functional limitations and disability than U.S.-born whites. This pattern of immigrant advantage is generally reversed in later life. Moreover, most U.S.-born minority groups have significantly higher levels of functional limitations and disability than U.S.-born whites in both mid- and late life. CONCLUSIONS: Higher levels of functional limitations and disability among U.S.-born minority groups and immigrant populations in older adulthood pose serious challenges for health providers and policymakers in a rapidly diversifying and aging population.

COVID-19 and All-Cause Mortality by Race, Ethnicity, and Age Across Five Periods of the Pandemic in the United States.

Racial/ethnic and age disparities in COVID-19 and all-cause mortality during 2020 are well documented, but less is known about their evolution over time. We examine changes in age-specific mortality across five pandemic periods in the United States from March 2020 to December 2022 among four racial/ethnic groups (non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Asian) for ages 35+. We fit Gompertz models to all-cause and COVID-19 death rates by 5-year age groups and construct age-specific racial/ethnic mortality ratios across an Initial peak (Mar-Aug 2020), Winter peak (Nov 2020-Feb 2021), Delta peak (Aug-Oct 2021), Omicron peak (Nov 2021-Feb 2022), and Endemic period (Mar-Dec 2022). We then compare to all-cause patterns observed in 2019. The steep age gradients in COVID-19 mortality in the Initial and Winter peak shifted during the Delta peak, with substantial increases in mortality at working ages, before gradually returning to an older age pattern in the subsequent periods. We find a disproportionate COVID-19 mortality burden on racial and ethnic minority populations early in the pandemic, which led to an increase in all-cause mortality disparities and a temporary elimination of the Hispanic mortality advantage at certain age groups. Mortality disparities narrowed over time, with racial/ethnic all-cause inequalities during the Endemic period generally returning to pre-pandemic levels. Black and Hispanic populations, however, faced a younger age gradient in all-cause mortality in the Endemic period relative to 2019, with younger Hispanic and Black adults in a slightly disadvantageous position and older Black adults in a slightly advantageous position, relative to before the pandemic.

Differences Between Reported COVID-19 Deaths and Estimated Excess Deaths in Counties Across the United States, March 2020 to February 2022.

Accurate and timely tracking of COVID-19 deaths is essential to a well-functioning public health surveillance system. The extent to which official COVID-19 death tallies have captured the true toll of the pandemic in the United States is unknown. In the current study, we develop a Bayesian hierarchical model to estimate monthly excess mortality in each county over the first two years of the pandemic and compare these estimates to the number of deaths officially attributed to Covid-19 on death certificates. Overall, we estimated that 268,176 excess deaths were not reported as Covid-19 deaths during the first two years of the Covid-19 pandemic, which represented 23.7% of all excess deaths that occurred. Differences between excess deaths and reported COVID-19 deaths were substantial in both the first and second year of the pandemic. Excess deaths were less likely to be reported as COVID-19 deaths in the Mountain division, in the South, and in nonmetro counties. The number of excess deaths exceeded COVID-19 deaths in all Census divisions except for the New England and Middle Atlantic divisions where there were more COVID-19 deaths than excess deaths in large metro areas and medium or small metro areas. Increases in excess deaths not assigned to COVID-19 followed similar patterns over time to increases in reported COVID-19 deaths and typically preceded or occurred concurrently with increases in reported COVID-19 deaths. Estimates from this study can be used to inform targeting of resources to areas in which the true toll of the COVID-19 pandemic has been underestimated.