Missing Americans: Unprecedented American Mortality Far Exceeds Other Wealthy Peer Nations

The study refers to these excess deaths as “Missing Americans” because it reflects the people who would otherwise still be alive if the American mortality rates were equal to peer wealthy countries. Comparing age-specific death rates from the United States of America to 21 other wealthy peer nations from 1993 through 2021 revealed that the current death rates in America are much higher than the others, and the number of excess deaths has never been larger. 

"The number of Missing Americans in recent years is unprecedented in modern times," says study lead and corresponding author Dr. Jacob Bor, associate professor of global health and epidemiology at BUSPH.

According to Dr. Bor, close to 50% of all Missing Americans died before they reached 65 years old in 2020 and 2021 and the level of excess mortality among working-age adults is particularly stark. "Think of people you know who have passed away before reaching age 65. Statistically, half of them would still be alive if the US had the mortality rates of our peers. The US is experiencing a crisis of early death that is unique among wealthy nations."

While the recent pandemic significantly exacerbated/contributed to a spike in mortality, which again was more so than in other countries, this study analyzing trends in American mortality from 1933 to 2021 compared with age-specific mortality rates from Japan, Canada, Australia, and 18 other European peer nations shows that the number of excess American deaths has been steadily accelerating over the last four decades. 

During WWII and the aftermath America had lower mortality rates than peer nations, during the 1960s and 1970s America had mortality rates that were similar to other peer wealthy nations, however, the number of Missing Americans began to increase year by year beginning in the 1980s to reach 622,534 excess deaths by 2019. Alarmingly the number of Missing Americans hurtled to 1,009,467 in 2020 to spike again in 2021 to a shocking 1,090,103. The total of Missing Americans from 1980 to 2021 reached an estimated heartbreaking and unprecedented 13.1 million people. 

This study demonstrates that this mortality crisis is a multiracial phenomenon, and emphasizes that it is not specific to minoritized groups. During early adulthood from ages 15-44 years old, the mortality rates among Black and Native Americans were five and eight times higher than the average of other wealthy peer nations. But two-thirds of the Missing Americans are White, and the death rates among White Americans are significantly higher than in other wealthy peer nations. 

"Living in the US is a risk factor for early death that is common across many US racial and ethnic groups. Whereas most health disparities studies assess differences between US racial/ethnic groups, such an approach renders the poor health of Whites invisible and grossly underestimates the health shortfall of minoritized groups," Dr. Bor says. "By using an international benchmark, we show that Americans of all races and ethnicities are adversely affected by the US policy environment, which places a low priority on public health and social protections, particularly for low-income people."

Looking forward to future years of life lost to premature death, the team estimates that in 2021 the excess American mortality translated to 26.4 million years of life lost compared to the mortality rates of peer wealthy nations. The researchers connect the massive excess mortality burden to the astounding failure of US policy to adequately address major public health issues such as the opioid epidemic, the obesity epidemic, economic inequality, food insecurity, workplace safety, mental health, access to healthcare, and environmental pollution. 

"We waste hundreds of billions each year on health insurers' profits and paperwork, while tens of millions can't afford medical care, healthy food, or a decent place to live," says study senior author Dr. Steffie Woolhandler, Distinguished Professor at the School of Urban Public Health at Hunter College, City University of New York. "Americans die younger than their counterparts elsewhere because when corporate profits conflict with health, our politicians side with the corporations."

This study leads to other questions that should be investigated in additional studies, like which areas within the nation are responsible for the most Missing Americans, and what were their causes of death? The researchers noted that they are not very optimistic that the American mortality rates will reverse in the near future based on their findings.

"The US was already experiencing more than 600,000 Missing Americans annually before the pandemic began, and that number was increasing each year. There have been no significant policy changes since then to change this trajectory," says Dr. Bor.

"While COVID-19 brought new attention to public health, the backlash unleashed during the pandemic has undermined trust in government and support for expansive policies to improve population health," said Dr. Bor. "This could be the most harmful long-term impact of the pandemic because expansion of public policy to support health is exactly how our peer countries have attained higher life expectancy and better health outcomes."