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From 1930 through the middle of the last century, the mortality rate in the United States was lower or commensurate with the mortality rates of other wealthy nations, such as Canada, France and Britain. However, in the late 1970s through the 1980s, U.S. health outcomes and mortality rates began to diverge from those of its peers.

By 2021, about half of all U.S. deaths under the age of 65 would have been avoided if the U.S. mortality rates were on par with those of other countries, according to a new study published by the National Academy of Sciences.

In other words, on average one out of every two deaths under the age of 65 in the U.S. would be averted in countries like Australia, Germany, Japan or Portugal. By the time COVID-19 hit, about 600,000 more people in the U.S. were dying each year than scientists would expect if mortality rates were equal to those of peer nations. COVID-19 then sent the number of “excess deaths” that exceed expected mortality rates skyrocketing.

Study co-author Jacob Bor, an assistant professor of global health and epidemiology at Boston University School of Public Health, said the media focused on drops in U.S. life expectancy during the COVID pandemic, but the study puts life expectancy data in the context of “what that actually means and how poorly we’re doing compared to other places.”

“Life expectancy doesn’t apply to an individual; it applies to a population,” Bor said in a statement. “[Our data] is a counterfactual: it gives us a sense of just how much life is being lost.”

Life expectancy measures the average number of years people live in a specific population. In 2021, the U.S. had the lowest life expectancy among the wealthiest nations for people assigned male or female at birth (73 years and 79 years, respectively).

Before COVID, the U.S. was experiencing an improvement in life expectancy, though not at the same pace as its peer nations. But while other nations saw life expectancy decline and then rebound to modern levels over the course of the pandemic, COVID-19 erased any slight growth in life expectancy the U.S. had seen in two decades. The result is that in the U.S. more people simply die younger than in other countries.

“The U.S. policy environment is the big story. This data shines a light on the ways all groups are suffering — before the pandemic and after — related to systemic gaps in the social safety net.”

Bor and his team call these deaths “missing Americans” to illustrate the number of lives that are “lost” when U.S. mortality rates are compared to other countries. To do this, the researchers compared the number of deaths recorded in the U.S. to the average number of recorded deaths of 21 wealthy nations going back to the 1930s. By the 1980s, the number of “excess deaths” in the U.S. was growing larger each year.

In the 1980s, Republican President Ronald Reagan slashed federal spending on Medicaid and other public health and safety net programs while deregulating the health care industry. “Reaganomics” coincided with the U.S. diverging from peer countries in terms of health outcomes, but that didn’t stop President Donald Trump and other Republicans from pursuing similar policies.

The study notes that “missing Americans” is a statistical construct that “cannot specify which deaths would have been averted, only the number that would have been averted if the United States had mortality rates of its peers.”

“The U.S. policy environment is the big story,” Bor said. “This data shines a light on the ways all groups are suffering — before the pandemic and after — related to systemic gaps in the social safety net that are really quite different in the U.S. compared to other nations.”

One of the most glaring systemic gaps is health coverage, and Bor said he was struck by how many people in the U.S. die earlier in life compared to other countries where health care is universal or heavily subsidized. The U.S. has public insurance programs that can provide health care for low-income adults and children, disabled people and the elderly, but not for hundreds of millions of adults under the age of 65.

The number of uninsured adults shrank under the Affordable Care Act as more people accessed marketplace plans, but subsidized health coverage is often slim, and 12 percent of adults under the age of 65 were uninsured in 2019 with COVID right around the corner.

“It doesn’t have to be that way. We have Medicare and Social Security after age 65. We have reasonable programs for children,” Bor said. “It’s working-age adults that we leave to their own devices, force them to privately insure for medical care and bear all the risk themselves: housing, violence, foods, environmental exposures.”

The maelstrom of death and policy disputes that followed COVID-19 were a predictable result of decades of divestment in the health of the U.S. population.

Health care coverage is not the only hole in the U.S. safety net, of course. The pandemic laid bare the cruel realities of economic inequality and a chronically underfunded public health system, with low-income and Black and Brown people bearing a disproportionate burden of COVID’s impact as life expectancy dropped, fatal drug overdoses increased, and the virus claimed more than 1 million lives while leaving others with long-term complications.

Bor said plenty of research has documented the disproportionate impact of the pandemic among frontline workers or Black and Native American people, for example, but white people in the U.S. are often the “reference category” in those studies that nonwhite demographics are compared to. However, that group — white Americans — accounts for the majority of “excess deaths” and is doing much worse relative to people living other countries.

“We’re comparing Black people to a group that’s already not doing well compared to peer nations,” Bor said.

The study looks at mortality rates through 2021, and despite a Democrat in the White House, the nation has continued to take steps in the wrong direction. The Supreme Court overturned the right to abortion in 2022, and red states responded by placing dangerous bans that are harming pregnant people. An estimated 2.1 million people — including children — are estimated to have recently lost their health coverage in post-pandemic purges of Medicaid rolls. Private insurance is expensive, and the industry is not known for being customer-friendly; about 60 percent of Americans report having problems with their health insurance over the past year.

While physicians and researchers roundly criticized health policies pushed by Trump both before and after COVID hit, the new study suggests public health and quality of life in the U.S. began a marked decline relative to other countries during the Reagan administration. The maelstrom of death and policy disputes that followed COVID-19 were a predictable result of decades of divestment in the health of the U.S. population, not to mention the administration that was in charge when the virus arrived.

“It’s not a coincidence that the U.S. had the highest mortality impact of COVID relative to other nations and the worst mortality rates pre-COVID,” Bor said.

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