Why do Americans die earlier than Europeans?

A recent paper by demographers Sam Preston and Yana Vierboom showed that there are an additional 400,000 deaths in the USA in 2017 that would not have occurred it the USA experienced European death rates. That is about 12% of all American deaths and higher than the COVID-19 death toll of around  380,000 in 2020.  In a Guardian article earlier this month they identified major factors contributing to this US “mortality penalty” including overweight and obesity, drug overdose, lack of health insurance, suicide, lack of gun control and racism. These deaths tend to occur at younger ages than Covid deaths on average, so that total potential years of life lost are three times greater for the excess deaths than for Covid in 2020 (13 million versus 4.4 million).

Preston and Vierboom used data from the Human Mortality Database (HMD) for their analysis. They calculated death rates based on the five largest European countries, whose combined population size is very similar to that of the United States: Germany, England and Wales, France, Italy, and Spain. They also argued that using these larger European countries  to provide a mortality standard would avoid unrealistic expectations that might result from comparisons including small countries with possibly exceptional combinations of factors affecting mortality (e.g., climate, diet, social history, and healthcare delivery).

A few days ago, I downloaded updated data from the HMD and replicated and extended their analysis to include years up to and including 2020, drawing on recent data from Eurostat and national health statistics agencies (see here for details of data, sources and methods).

The figure above shows the ratio of US death rates to the average death rates for the five European countries (the “European standard”) by age, in 2000, 2010, 2019 and 2020. US mortality rates are consistently higher than the European standard for all ages below 80 years and the ratio has gotten progressively worse throughout the 21st century. The peak ratio for 25-29 year olds corresponds to death rates for US 25-29 year olds that are three times higher than those of the European standard.

The next figure shows the annual trend in total excess deaths in the USA above the number than would have occurred if the US population had been subject to the age-sex specific death rates of the European standard. This excess rose from 219,000 in the year 2000 to 410,000 in 2019 and 616,000 in 2020. Although there were over 380,000 Covid deaths in the USA in 2020, the European standard also includes substantial numbers of Covid deaths, and the Covid excess for the USA is “only” 136,000 deaths.

I next estimated the contribution of various factors to the US excess death rate using information on cause-specific deaths and death attributable to selected risk factors in Europe and the USA. I also made estimates of the excess deaths associated with lack of health insurance or under-insurance in the USA compared to Europe where all the countries have universal health insurance, based on a study of the death rates in the non-insured in the USA. Together, the six factors identified in the following graph account for around 80% of excess deaths in the USA. 

For 2020, the leading cause of excess deaths was overweight and obesity (around 154,000 deaths), followed by Covid-19 (136,000 deaths), drug use and overdose (103,000 deaths) and lack of health insurance (74,000 deaths). Excess deaths due to homicide and suicide were smaller at 20,200 and 11,200 respectively. If the USA had the European standard death rates for gun homicides and gun suicides, it would have 15,900 fewer gun homicides and 19,200 fewer gun suicides. Around 40% of the latter would still commit suicide by other means. The figure also illustrates the dramatic rise in drug overdose deaths, the vast majority due to opioids both prescription and illicit, which has occurred over the last decade. In a previous post, I examined this in more detail and noted that, in 2019, the USA accounted for an astonishing 40% of estimated global drug deaths.

Why does the US perform so poorly in these areas? Preston and Vierboom argue that a lack of federal oversight and regulation, powerful lobbying structures, deindustrialization of American jobs, and systemic racism combine to create “an annual tsunami” of excess deaths. And that is even without the complete mishandling of the response to Covid by the Trump administration and many state governments.

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