Premature mortality during COVID-19 in the U.S. and peer countries

While those who are older have been at the higher risk of becoming seriously ill due to COVID-19 infections, COVID-19 has also affected mortality rates among younger people.

In this brief, we examine changes in excess mortality and prematurity of those deaths in the U.S. and peer countries for 2020 and 2021. Using Centers for Disease Control and Prevention (CDC) weekly excess deaths data and the World Health Organization (WHO) all-cause excess death data, we compare excess mortality in the U.S. and other large and wealthy countries through 2021 (the latest period these modelled estimates were available). We also estimate the years of life lost, a measure of the prematurity of those excess deaths, during the COVID-19 pandemic. Excess deaths are the number of deaths beyond what would have been expected in a typical year and can be due directly or indirectly to COVID-19, as well as other causes.

We find that between March 2020 and the end of 2022, the U.S. experienced nearly 1.7 million excess deaths. When compared to other countries for the period 2020-2021—the most recent data available for all these countries—and adjusted for population size, the U.S. had the highest excess mortality rate among similarly large and wealthy countries. In addition to experiencing more excess deaths overall, the U.S. also saw a higher rate of death among younger people, and thus a larger increase in premature deaths per capita than peer countries. We also find that the per capita rate of years of life lost during the COVID-19 pandemic in the U.S. was over twice that of the U.K., the country with the next highest rate.

The U.S. experienced nearly 1.7 million excess deaths from late March 2020 through the end of 2022


Excess deaths are defined as the difference between the observed number of deaths in specific periods and the expected number of deaths based on historical data. Using CDC data, the chart above shows the total number of deaths from all-causes between late March 2020 through the end of December 2022 and the number of deaths that exceed the average number of deaths between 2015 and 2019.

Although excess deaths can be due to any cause, it is clear that COVID-19 was directly or indirectly responsible for most of these deaths, as peaks in excess mortality correspond to peaks in COVID-19 waves. The highest number of excess deaths in one week occurred the week of January 2, 2021, a few months before COVID-19 vaccines were widely available. Since that peak, other notable points include the week of September 11, 2021, during the height of the Delta variant surge, and the week of January 22, 2022, during the peak of the Omicron variant wave.

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Among peer countries, the U.S. had the highest excess mortality per capita for 2020 and 2021 combined


In the chart above, we look at WHO’s data on all-cause excess mortality rates per capita during the first two years of the COVID-19 pandemic (2020 and 2021) across the U.S. and peer nations. These WHO estimates are lagged and the latest data are only available through December 2021. We compared per capita excess mortality for the U.S. and other similarly large, wealthy OECD countries.

In the U.S., the excess mortality rate was similar in 2020 and 2021 with 141 excess deaths per 100,000 people and 142 excess deaths per 100,000 people, respectively. In 2020, Belgium had a higher excess mortality rate than the U.S. with 148 excess deaths per 100,000 people. In 2021, Germany had a higher excess mortality rate than the U.S. with 154 excess deaths per 100,000 people.

Examining both years together, the U.S. had the highest excess mortality rate among peer nations with 283 excess deaths per 100,000 people. This rate is 21% and 27% higher than Germany and the U.K., respectively, the countries with the next two highest excess mortality rates.

Australia and Japan experienced lower mortality rates across the two years than would have been predicted based on prior years’ average deaths. Excess mortality rate was lower than expected by 56 per 100,000 people and 16 per 100,000 people between 2020 and 2021 in Australia and Japan, respectively.

The U.S. had by far the highest rate of premature deaths in 2020 and 2021 among peer countries


Using the WHO data on all-cause excess mortality by age groups, we calculated the years of life lost in the U.S. and other large and wealthy countries up to the age of 75 for 2020 and 2021. While some excess deaths over the age of 75 also likely occurred at ages younger than the person otherwise would have died or younger than a given country’s life expectancy, we used age 75 for all countries based on the OECD Health Statistics methodology. We estimate the number of years of life lost by subtracting the midpoint of the age band in which the death occurred from age 75. The total number of years of life lost is the sum of the number of deaths in a given age band times the average number of years of life lost for each age band. To calculate the per capita rate, we divide the total number of years of life lost by the population under age 75 in each country. Age bands with negative excess deaths were counted as 0 in this analysis.

We find the U.S. had the highest per capita rate of years of life lost among similarly large and wealthy countries in 2020 and 2021 combined. The per capita rate of years of life lost per in the U.S. was over twice the rate in the U.K., the country with the next highest rate.

This is largely driven by the higher mortality rate among younger people in the U.S. Among excess deaths that occurred before age 50, the U.S. had the highest rate among peer countries. The next highest rate was in Canada, with about half as many years of life lost per capita among those under the age of 50 years.

Gaps between the U.S. and comparable countries in premature excess mortality are reflected in gaps in life expectancy


After life expectancy at birth in the U.S. and peer countries generally increased from 1980-2019, the COVID-19 pandemic caused a decline in most countries in 2020. From 2020 to 2021, life expectancy at birth began to rebound in most comparable countries while it continued to decline in the U.S.

The increasing gap in life expectancy at birth between the U.S. and comparable countries reflects higher mortality and premature mortality in the U.S. during the COVID-19 pandemic compared to peer countries, especially among people under the age of 50. As life expectancy data presented here are period life expectancy estimates based on age-specific excess mortality observed in each year, increases in mortality during the COVID-19 pandemic, especially large increases in mortality among young people, result in decreases in life expectancy at birth.

Discussion

Not only did the U.S. experience more deaths per capita during the pandemic, those who died in the U.S. also died at younger ages than in similarly large and wealthy countries. Our analysis of years of life lost during the pandemic indicates the gap in premature deaths between the U.S. and peer countries has likely increased during the COVID-19 pandemic. This increasing gap in premature deaths is also seen in an increasing gap in life expectancy between the U.S. and peer countries.

Most Americans could have been vaccinated by early June 2021 in the U.S. Through early 2022, over 234,000 COVID-19 deaths could have been averted with timely vaccinations. The U.S. continues to have the lowest COVID-19 vaccination rate among peer countries.

The higher excess mortality rate among younger people in the U.S. is likely in part due to higher COVID-19 health risk factor rates among younger people in the U.S. and may also reflect differences in public health resources across the countries. Additionally, younger people of color in the U.S. suffered disproportionately during the COVID-19 pandemic. The majority of excess deaths in both 2020 and 2021 are directly attributable to COVID-19, and many of those excess deaths that are not attributed to COVID-19 may be undiagnosed COVID-19 deaths or deaths indirectly caused by COVID-19, particularly early in the pandemic when widespread testing was not available. However, increases in drug overdose, suicide, and firearm deaths in the U.S. may also be contributing factors to the U.S.’s high premature excess death rates in 2020 and 2021.

Methods

The WHO global excess deaths associated with COVID-19 data were used to calculate the excess deaths through 2021 in both the U.S. and peer countries. Peer countries were selected among OECD member nations having both above median GDP and above median GDP per capita. The WHO provides estimates of excess deaths associated with COVID-19. For the country comparison, years of life lost during the COVID-19 pandemic were calculated by summing the number of excess deaths within each age group. Negative excess deaths within a specific age group were included as 0 in this analysis. Age groups were broken at ages 24, 39, 49, 59, and 69 years. Next, those counts were multiplied by the number of years from the mid-point of the age range up to 75 years. Although average life expectancy among some peer countries is higher, we used 75 years based on the existing OECD methodology. Remaining years were calculated from ages 12, 32, 45, 55, and 65 years to the age limit for age groups 0-24, 25-39, 40-49, 50-59, and 60-69, respectively. The decision to use these points to calculate years of life lost during the COVID-19 pandemic may make the gap between the U.S. and peer countries different as the age at excess death might be larger than the midpoint. For each country, 2020 OECD population counts by age groups were used to estimate measures per 100,000 people.

Using OECD methodology for age group cut points, younger people were considered those from ages 0-59 years, and older people were considered those above age 60 for excess mortality and ages 60-69 for years of life lost during the COVID-19 pandemic.

A limitation of this analysis is that years of life lost during the COVID-19 pandemic were based on excess deaths by age groups rather than excess deaths at each age. Our results of years of life lost during the COVID-19 pandemic are similar to other earlier studies of years of life lost in the U.S. due to COVID-19. Our estimates of years of life lost are likely underestimated due to a few reasons. First, although we limited the years of life lost calculation up to an age limit of 75, excess deaths due to COVID-19 above 75 years are also premature deaths by some amount of time; therefore, estimates presented here are likely underestimated for the overall years of life lost during the COVID-19 pandemic. Second, we incorporated excess life years saved among the youngest ages 0-24 years in the overall estimate of excess mortality (but not years of life lost during the COVID-19 pandemic). Deaths among children ages 0-14 decreased in both 2020 and 2021 in most countries. Reports indicate deaths due to accidents and influenza have been lower among children due to social distancing and lockdown measures implemented during the pandemic. Any count of excess deaths that was less than 0 was not included in calculations of the rate of years of life lost.

The Peterson Center on Healthcare and KFF are partnering to monitor how well the U.S. healthcare system is performing in terms of quality and cost.

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