Increasing Mortality Rates in the US, but Not From COVID-19.

This Viewpoint explores increasing mortality rates in the US due to a variety of causes unrelated to the COVID-19 pandemic.

Excess Death Rates by State During the COVID-19 Pandemic: United States, 2020‒2023.

Objectives. To estimate state-level excess death rates during 2020 to 2023 and examine differences by region and partisan orientation. Methods. We modeled death and population counts from the Centers for Disease Control and Prevention to estimate excess death rates for the United States, 9 census divisions, and 50 states. We compared excess death rates for states with different partisan orientations, measured by the party of the seated governor and the level of partisan representation in state legislatures. Results. The United States experienced 1 277 697 excess deaths between March 2020 and July 2023. Almost 90% of these deaths were attributed to COVID-19, and 51.5% occurred after vaccines were available. The highest excess death rates first occurred in the Northeast and then shifted to the South and Mountain states. Between weeks ending June 20, 2020, through March 19, 2022, excess death rates were higher in states with Republican governors and greater Republican representation in state legislatures. Conclusions. Excess death rates during the COVID-19 pandemic varied considerably across the US states and were associated with partisan representation in state government, although the influence of confounding variables cannot be excluded. (Am J Public Health. 2024;114(9):882-891. https://doi.org/10.2105/AJPH.2024.307731).

Excess US Deaths Attributable to High All-Cause Mortality Rates Among Youths Aged 0 to 19 Years.

This cross-sectional study compares US mortality rates among youths aged 0 to 19 years with rates in 16 high-income countries, calculates excess deaths from 1999 to 2019, and examines temporal trends through 2021.

Racial and Ethnic Disparities in All-Cause and Cause-Specific Mortality Among US Youth.

Importance: Mortality rates in US youth have increased in recent years. An understanding of the role of racial and ethnic disparities in these increases is lacking. Objective: To compare all-cause and cause-specific mortality trends and rates among youth with Hispanic ethnicity and non-Hispanic American Indian or Alaska Native, Asian or Pacific Islander, Black, and White race. Design, Setting, and Participants: This cross-sectional study conducted temporal analysis (1999-2020) and comparison of aggregate mortality rates (2016-2020) for youth aged 1 to 19 years using US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Data were analyzed from June 30, 2023, to January 17, 2024. Main Outcomes and Measures: Pooled, all-cause, and cause-specific mortality rates per 100 000 youth (hereinafter, per 100 000) for leading underlying causes of death were compared. Injuries were classified by mechanism and intent. Results: Between 1999 and 2020, there were 491 680 deaths among US youth, including 8894 (1.8%) American Indian or Alaska Native, 14 507 (3.0%) Asian or Pacific Islander, 110 154 (22.4%) Black, 89 251 (18.2%) Hispanic, and 267 452 (54.4%) White youth. Between 2016 and 2020, pooled all-cause mortality rates were 48.79 per 100 000 (95% CI, 46.58-51.00) in American Indian or Alaska Native youth, 15.25 per 100 000 (95% CI, 14.75-15.76) in Asian or Pacific Islander youth, 42.33 per 100 000 (95% CI, 41.81-42.86) in Black youth, 21.48 per 100 000 (95% CI, 21.19-21.77) in Hispanic youth, and 24.07 per 100 000 (95% CI, 23.86-24.28) in White youth. All-cause mortality ratios compared with White youth were 2.03 (95% CI, 1.93-2.12) among American Indian or Alaska Native youth, 0.63 (95% CI, 0.61-0.66) among Asian or Pacific Islander youth, 1.76 (95% CI, 1.73-1.79) among Black youth, and 0.89 (95% CI, 0.88-0.91) among Hispanic youth. From 2016 to 2020, the homicide rate in Black youth was 12.81 (95% CI, 12.52-13.10) per 100 000, which was 10.20 (95% CI, 9.75-10.66) times that of White youth. The suicide rate for American Indian or Alaska Native youth was 11.37 (95% CI, 10.30-12.43) per 100 000, which was 2.60 (95% CI, 2.35-2.86) times that of White youth. The firearm mortality rate for Black youth was 12.88 (95% CI, 12.59-13.17) per 100 000, which was 4.14 (95% CI, 4.00-4.28) times that of White youth. American Indian or Alaska Native youth had a firearm mortality rate of 6.67 (95% CI, 5.85-7.49) per 100 000, which was 2.14 (95% CI, 1.88- 2.43) times that of White youth. Black youth had an asthma mortality rate of 1.10 (95% CI, 1.01-1.18) per 100 000, which was 7.80 (95% CI, 6.78-8.99) times that of White youth. Conclusions and Relevance: In this study, racial and ethnic disparities were observed for almost all leading causes of injury and disease that were associated with recent increases in youth mortality rates. Addressing the increasing disparities affecting American Indian or Alaska Native and Black youth will require efforts to prevent homicide and suicide, especially those events involving firearms.

Neighborhood Predictors of Poor Prenatal Care and Well-Child Visit Attendance.

PURPOSE: Women and children continue to miss preventive visits. Which neighborhood factors predict inadequate prenatal care (PNC) and well-child visit (WCV) attendance remain unclear. DESCRIPTION: In a retrospective case-control study at Virginia Commonwealth University Health System, mothers with less than 50% adherence or initiation after 5 months gestation were eligible as cases and those with ≥ 80% adherence and initiation before 5 months were eligible as controls. Children in the lowest quintile of adherence were eligible as cases and those with ≥ 80% of adherence were eligible as controls. Cases and controls were randomly selected at a 1:2 ratio and matched on birth month. Covariates were derived from the 2018 American Community Survey. A hotspot was defined as a zip code tabulation area (ZCTA) with a proportion of controls less than 0.66. ZCTAs with fewer than 5 individuals were excluded. Weighted quantile regression was used to determine which covariates were most associated with inadequate attendance. ASSESSMENT: We identified 38 and 35 ZCTAs for the PNC and WCV analyses, respectively. Five of 11 hotspots for WCV were also hotspots for PNC. Education and income predicted 51% and 34% of the variation in missed PNCs, respectively; language, education and transportation difficulties explained 33%, 29%, and 17% of the variation in missed WCVs, respectively. Higher proportions of Black residents lived in hotspots of inadequate PCV and WCV attendance. CONCLUSION: Neighborhood-level factors performed well in predicting inadequate PCV and WCV attendance. The disproportionate impact impact of inadequate PCV and WCV in neighborhoods where higher proportions of Black people lived highlights the potential influence of systemic racism and segregation on healthcare utilization.

Life Expectancy Changes During the COVID-19 Pandemic, 2019-2021: Highly Racialized Deaths in Young and Middle Adulthood in the United States as Compared With Other High-Income Countries.

We estimated changes in life expectancy between 2019 and 2021 in the United States (in the total population and separately for 5 racial/ethnic groups) and 20 high-income peer countries. For each country's total population, we decomposed the 2019-2020 and 2020-2021 changes in life expectancy by age. For US populations, we also decomposed the life expectancy changes by age and number of coronavirus disease 2019 (COVID-19) deaths. Decreases in US life expectancy in 2020 (1.86 years) and 2021 (0.55 years) exceeded mean changes in peer countries (a 0.39-year decrease and a 0.23-year increase, respectively) and disproportionately involved COVID-19 deaths in midlife. In 2020, Native American, Hispanic, Black, and Asian-American populations experienced larger decreases in life expectancy and greater losses in midlife than did the White population. In 2021, the White population experienced the largest decrease in US life expectancy, although life expectancy in the Native American and Black populations remained much lower. US losses during the pandemic were more severe than in peer countries and disproportionately involved young and middle-aged adults, especially adults of this age in racialized populations. The mortality consequences of the COVID-19 pandemic deepened a US disadvantage in longevity that has been growing for decades and exacerbated long-standing racial inequities in US mortality.

Association Between Partisan Affiliation of State Governments and State Mortality Rates Before and During the COVID-19 Pandemic.

Policy Points The increasing political polarization of states reached new heights during the COVID-19 pandemic, when response plans differed sharply across party lines. This study found that states with Republican governors and larger Republican majorities in legislatures experienced higher death rates during the COVID-19 pandemic-and in preceding years-but these associations often lost statistical significance after adjusting for the average income and health status of state populations and for the policy orientations of the states. Future research may help clarify whether the higher death rates in these states result from policy choices or have other explanations, such as the tendency of voters with lower incomes or poorer health to elect Republican candidates. CONTEXT: Increasing polarization of states reached a high point during the COVID-19 pandemic, when the party affiliation of elected officials often predicted their policy response. The health consequences of these divisions are unclear. Prior studies compared mortality rates based on presidential voting patterns, but few considered the partisan orientation of state officials. This study examined whether the partisan orientation of governors or legislatures was associated with mortality outcomes during the COVID-19 pandemic. METHODS: Data on deaths and the partisan orientation of governors and legislators were obtained from the Centers for Disease Control and Prevention and the National Conference of State Legislatures, respectively. Linear regression was used to measure the association between Republican representation (percentage of seats held) in legislatures and (1) age-adjusted, all-cause mortality rates (AAMRs) in 2015-2021 and (2) excess death rates during three phases of the COVID-19 pandemic, controlling for median household income, the prevalence of four risk factors (obesity, chronic obstructive pulmonary disease, heart attack, stroke), and state policy orientation. Associations between excess death rates and the governor's party were also examined. FINDINGS: States with Republican governors or greater Republican representation in legislatures experienced higher AAMRs during 2015-2021, lower excess death rates during Phase 1 of the COVID-19 pandemic (weeks ending March 28, 2020, through June 13, 2020), and higher excess death rates in Phases 2 and 3 (weeks ending June 20, 2020, through April 30, 2022; p < 0.05). Most associations lost statistical significance after adjustment for control variables. CONCLUSIONS: Mortality was higher in states with Republican governors and greater Republican legislative representation before and during much of the pandemic. Observed associations could be explained by the adverse effects of policy choices, reverse causality (e.g., popularity of Republican candidates in states with lower socioeconomic and health status), or unmeasured factors that predominate in states with Republican leaders.

The Lives Lost to Inequities: Avertable Deaths From Neurologic Diseases in the Past Decade.

BACKGROUND AND OBJECTIVES: Mortality rates for neurologic diseases are increasing in the United States, with large disparities across geographical areas and populations. Racial and ethnic populations, notably the non-Hispanic (NH) Black population, experience higher mortality rates for many causes of death, but the magnitude of the disparities for neurologic diseases is unclear. The objectives of this study were to calculate mortality rates for neurologic diseases by race and ethnicity and-to place this disparity in perspective-to estimate how many US deaths would have been averted in the past decade if the NH Black population experienced the same mortality rates as other groups. METHODS: Mortality rates for deaths attributed to neurologic diseases, as defined by the International Classification of Diseases, were calculated for 2010 to 2019 using death and population data obtained from the Centers for Disease Control and Prevention and the US Census Bureau. Avertable deaths were calculated by indirect standardization: For each calendar year of the decade, age-specific death rates of NH White persons in 10 age groups were multiplied by the NH Black population in each age group. A secondary analysis used Hispanic and NH Asian populations as the reference groups. RESULTS: In 2013, overall age-adjusted mortality rates for neurologic diseases began increasing, with the NH Black population experiencing higher rates than NH White, NH American Indian and Alaska Native, Hispanic, and NH Asian populations (in decreasing order). Other populations with higher mortality rates for neurologic diseases included older adults, the male population, and adults older than 25 years without a high school diploma. The gap in mortality rates for neurologic diseases between the NH Black and NH White populations widened from 4.2 individuals per 100,000 in 2011 to 7.0 per 100,000 in 2019. Over 2010 to 2019, had the NH Black population experienced the neurologic mortality rates of NH White, Hispanic, or NH Asian populations, 29,986, 88,407, or 117,519 deaths, respectively, would have been averted. DISCUSSION: Death rates for neurologic diseases are increasing. Disproportionately higher neurologic mortality rates in the NH Black population are responsible for a large number of excess deaths, making research and policy efforts to address the systemic causes increasingly urgent.

Falling Behind: The Growing Gap in Life Expectancy Between the United States and Other Countries, 1933-2021.

Objectives. To document the evolution of the US life expectancy disadvantage and regional variation across the US states. Methods. I obtained life expectancy estimates in 2022 from the United Nations, the Human Mortality Database, and the US Mortality Database, and calculated changes in growth rates, US global position (rank), and state-level trends. Results. Increases in US life expectancy slowed from 1950 to 1954 (0.21 years/annum) and 1955 to 1973 (0.10 years/annum), accelerated from 1974 to 1982 (0.34 years/annum), and progressively deteriorated from 1983 to 2009 (0.15 years/annum), 2010 to 2019 (0.06 years/annum), and 2020 to 2021 (-0.97 years/annum). Other countries experienced faster growth in each phase except 1974 to 1982. During 1933 to 2021, 56 countries on 6 continents surpassed US life expectancy. Growth in US life expectancy was slowest in Midwest and South Central states. Conclusions. The US life expectancy disadvantage began in the 1950s and has steadily worsened over the past 4 decades. Dozens of globally diverse countries have outperformed the United States. Causal factors appear to have been concentrated in the Midwest and South. Public Health Implications. Policies that differentiate the United States from other countries and circumstances associated with the Midwest and South may have contributed. (Am J Public Health. 2023;113(9):970-980. https://doi.org/10.2105/AJPH.2023.307310).

The New Crisis of Increasing All-Cause Mortality in US Children and Adolescents.

This Viewpoint discusses increased rates in pediatric mortality by age and cause between 1999 and 2021.

Excess Deaths Will Continue In The United States Until The Root Causes Are Addressed.

Estimates of excess deaths in 2020-21 only begin to capture the devastating health impact of the COVID-19 pandemic in the US. More deaths will occur, and a larger number of Americans will experience disease complications as delays in accessing care and increasing socioeconomic precarity take their toll. No other high-income country experienced as high a death rate during the pandemic. For decades Americans have experienced poorer health outcomes than people in peer countries because of deficiencies in the health care system, adverse socioeconomic conditions, unhealthy physical and social environments, systemic racism, and policies that jeopardize health. The pandemic exposed problems in each of these areas and highlighted the power of policy makers, including those in state government, to alter health outcomes.

U.S. state policy contexts and mortality of working-age adults.

The rise in working-age mortality rates in the United States in recent decades largely reflects stalled declines in cardiovascular disease (CVD) mortality alongside rising mortality from alcohol-induced causes, suicide, and drug poisoning; and it has been especially severe in some U.S. states. Building on recent work, this study examined whether U.S. state policy contexts may be a central explanation. We modeled the associations between working-age mortality rates and state policies during 1999 to 2019. We used annual data from the 1999-2019 National Vital Statistics System to calculate state-level age-adjusted mortality rates for deaths from all causes and from CVD, alcohol-induced causes, suicide, and drug poisoning among adults ages 25-64 years. We merged that data with annual state-level data on eight policy domains, such as labor and taxes, where each domain was scored on a 0-1 conservative-to-liberal continuum. Results show that the policy domains were associated with working-age mortality. More conservative marijuana policies and more liberal policies on the environment, gun safety, labor, economic taxes, and tobacco taxes in a state were associated with lower mortality in that state. Especially strong associations were observed between certain domains and specific causes of death: between the gun safety domain and suicide mortality among men, between the labor domain and alcohol-induced mortality, and between both the economic tax and tobacco tax domains and CVD mortality. Simulations indicate that changing all policy domains in all states to a fully liberal orientation might have saved 171,030 lives in 2019, while changing them to a fully conservative orientation might have cost 217,635 lives.

Changes in the Relationship Between Income and Life Expectancy Before and During the COVID-19 Pandemic, California, 2015-2021.

Importance: The COVID-19 pandemic caused a large decrease in US life expectancy in 2020, but whether a similar decrease occurred in 2021 and whether the relationship between income and life expectancy intensified during the pandemic are unclear. Objective: To measure changes in life expectancy in 2020 and 2021 and the relationship between income and life expectancy by race and ethnicity. Design, Setting, and Participants: Retrospective ecological analysis of deaths in California in 2015 to 2021 to calculate state- and census tract-level life expectancy. Tracts were grouped by median household income (MHI), obtained from the American Community Survey, and the slope of the life expectancy-income gradient was compared by year and by racial and ethnic composition. Exposures: California in 2015 to 2019 (before the COVID-19 pandemic) and 2020 to 2021 (during the COVID-19 pandemic). Main Outcomes and Measures: Life expectancy at birth. Results: California experienced 1 988 606 deaths during 2015 to 2021, including 654 887 in 2020 to 2021. State life expectancy declined from 81.40 years in 2019 to 79.20 years in 2020 and 78.37 years in 2021. MHI data were available for 7962 of 8057 census tracts (98.8%; n = 1 899 065 deaths). Mean MHI ranged from $21 279 to $232 261 between the lowest and highest percentiles. The slope of the relationship between life expectancy and MHI increased significantly, from 0.075 (95% CI, 0.07-0.08) years per percentile in 2019 to 0.103 (95% CI, 0.098-0.108; P < .001) years per percentile in 2020 and 0.107 (95% CI, 0.102-0.112; P < .001) years per percentile in 2021. The gap in life expectancy between the richest and poorest percentiles increased from 11.52 years in 2019 to 14.67 years in 2020 and 15.51 years in 2021. Among Hispanic and non-Hispanic Asian, Black, and White populations, life expectancy declined 5.74 years among the Hispanic population, 3.04 years among the non-Hispanic Asian population, 3.84 years among the non-Hispanic Black population, and 1.90 years among the non-Hispanic White population between 2019 and 2021. The income-life expectancy gradient in these groups increased significantly between 2019 and 2020 (0.038 [95% CI, 0.030-0.045; P < .001] years per percentile among Hispanic individuals; 0.024 [95% CI: 0.005-0.044; P = .02] years per percentile among Asian individuals; 0.015 [95% CI, 0.010-0.020; P < .001] years per percentile among Black individuals; and 0.011 [95% CI, 0.007-0.015; P < .001] years per percentile among White individuals) and between 2019 and 2021 (0.033 [95% CI, 0.026-0.040; P < .001] years per percentile among Hispanic individuals; 0.024 [95% CI, 0.010-0.038; P = .002] years among Asian individuals; 0.024 [95% CI, 0.011-0.037; P = .003] years per percentile among Black individuals; and 0.013 [95% CI, 0.008-0.018; P < .001] years per percentile among White individuals). The increase in the gradient was significantly greater among Hispanic vs White populations in 2020 and 2021 (P < .001 in both years) and among Black vs White populations in 2021 (P = .04). Conclusions and Relevance: This retrospective analysis of census tract-level income and mortality data in California from 2015 to 2021 demonstrated a decrease in life expectancy in both 2020 and 2021 and an increase in the life expectancy gap by income level relative to the prepandemic period that disproportionately affected some racial and ethnic minority populations. Inferences at the individual level are limited by the ecological nature of the study, and the generalizability of the findings outside of California are unknown.

Changes in Life Expectancy Between 2019 and 2020 in the US and 21 Peer Countries.

Importance: Prior studies reported that US life expectancy decreased considerably in 2020 because of the COVID-19 pandemic, with estimates suggesting that the decreases were much larger among Hispanic and non-Hispanic Black populations than non-Hispanic White populations. Studies based on provisional data suggested that other high-income countries did not experience the large decrease in life expectancy observed in the US; this study sought to confirm these findings according to official death counts and to broaden the pool of comparison countries. Objective: To calculate changes in US life expectancy between 2019 and 2020 by sex, race, and ethnicity and to compare those outcomes with changes in other high-income countries. Design, Setting, and Participants: This cross-sectional study involved a simulation of life tables based on national death and population counts for the US and 21 other high-income countries in 2019 and 2020, by sex, including an analysis of US outcomes by race and ethnicity. Data were analyzed in January 2022. Exposures: Official death counts from the US and 21 peer countries. Main Outcomes and Measures: Life expectancy at birth and credible range (CR) based on 10% uncertainty. Results: Between 2019 and 2020, US life expectancy decreased by a mean of 1.87 years (CR, 1.70-2.03 years), with much larger decreases occurring in the Hispanic (3.70 years; CR, 3.53-3.87 years) and non-Hispanic Black (3.22 years; CR, 3.03-3.40 years) populations than in the non-Hispanic White population (1.38 years; CR, 1.21-1.54 years). The mean decrease in life expectancy among peer countries was 0.58 years (CR, 0.42-0.73 year) across all 21 countries. No peer country experienced decreases as large as those seen in the US. Conclusions and Relevance: Official death counts confirm that US life expectancy decreased between 2019 and 2020 on a scale not seen in 21 peer countries, substantially widening the preexisting gap in life expectancy between the US and peer countries. The decrease in US life expectancy was experienced disproportionately by Hispanic and non-Hispanic Black populations, consistent with a larger history of racial and ethnic health inequities resulting from policies of exclusion and systemic racism. Policies to address the systemic causes of the US health disadvantage relative to peer countries and persistent racial and ethnic inequities are essential.