Countries with worse access to medical technology perform better than the US
For more than two decades, Americans have been dying at rates that set the United States apart from every comparable wealthy nation — not because of a lack of medical sophistication, but because of the conditions shaping daily life. A Boston University study published in JAMA Network Open has now mapped 12.7 million excess deaths between 1999 and 2022, finding that heart disease, stroke, and diabetes — not drug overdoses or despair — are the dominant engines of this mortality gap. The research suggests that what separates Americans from their peers in Canada, Japan, France, and elsewhere is not the quality of medicine available, but the social and economic terrain in which that medicine must operate.
- By 2022, Americans were dying at rates 38% higher than people in comparable wealthy nations, a gap that has been quietly widening for decades before the pandemic made it impossible to ignore.
- Cardiovascular and metabolic diseases — heart disease, stroke, high blood pressure, and diabetes — account for more than half of all excess American deaths, dwarfing the toll of drug overdoses despite receiving far less public urgency.
- Drug poisonings, alcohol-related deaths, and suicides concentrate their damage among younger Americans, with fentanyl's arrival in 2013 triggering a sharp acceleration that now costs over 130,000 excess lives annually.
- COVID-19 did not create the American mortality crisis — it exposed and amplified a pre-existing disadvantage, accounting for one in five excess deaths in 2020 and 2021.
- Researchers and senior authors warn that even promising new treatments like GLP-1 drugs cannot close a gap this wide on their own — the underlying social and economic conditions driving disease must be addressed directly.
Between 1999 and 2022, the United States accumulated 12.7 million deaths that researchers at Boston University School of Public Health call "missing Americans" — lives that statistical models suggest would have been saved had American mortality rates simply matched those of peer nations like Canada, Australia, France, Japan, and the United Kingdom. Published in JAMA Network Open, the study offers the most comprehensive accounting yet of what is pulling American life expectancy away from the rest of the wealthy world.
The findings challenge the dominant narrative of American mortality. While drug overdoses and suicides have commanded public health attention, the study finds that cardiovascular and metabolic diseases — heart disease, stroke, high blood pressure, and diabetes — are responsible for more than 40 percent of excess deaths, making them by far the largest driver of the gap. These are conditions the United States shares with its peers in terms of available treatment, yet Americans die from them at substantially higher rates.
A second, distinct pattern emerges among younger populations. Drug poisonings showed the steepest rise of any cause, climbing from near-parity with peer nations in 1999 to more than 130,000 excess deaths per year by 2022 — a trajectory that sharpened dramatically when fentanyl entered the drug supply in 2013. Alcohol-related diseases and suicides compound this burden, and when measured in years of life lost rather than raw counts, their societal weight is even heavier.
The mortality gap was already widening before COVID-19 arrived; the pandemic simply accelerated it, accounting for one in five excess American deaths in 2020 and 2021. Among Americans 85 and older, Alzheimer's disease and related dementias emerged as the leading cause of excess deaths by 2022, reflecting both an aging population and differences in how these conditions are managed across countries.
The United States does outperform peers in some areas — cancer mortality and influenza deaths were lower in 2022, reflecting genuine successes in screening and vaccination. But these gains have not been enough to offset the broader disadvantage. Lead author Dr. Jacob Bor noted that death certificates capture only the final link in a long causal chain, and that the social and economic conditions shaping American life are what ultimately drive higher disease rates. Senior author Dr. Andrew Stokes added that even transformative new medications cannot close a gap of this magnitude alone. The research points toward a conclusion that is both clarifying and demanding: the American mortality crisis is not a failure of medical technology, but of the conditions under which Americans live.
Over the past quarter-century, Americans have been dying at rates that would be shocking if they were not so familiar. Between 1999 and 2022, the United States experienced 12.7 million deaths that simply would not have happened had American mortality rates matched those of other wealthy nations. By 2022, the gap had widened to the point where Americans were dying at rates 38 percent higher than their counterparts in countries like Canada, Australia, France, Japan, and the United Kingdom—despite having access to the same advanced medical technology.
A new study published in JAMA Network Open, led by researchers at Boston University School of Public Health, offers the first comprehensive accounting of what is killing Americans at disproportionate rates. The researchers call these preventable deaths "missing Americans," and they have mapped where the excess mortality comes from with precision. The answer is not what public health conversations often emphasize. While drug overdoses, alcohol-related deaths, and suicides have dominated recent discussions about American mortality, the real driver of the mortality gap is far more mundane and far more consequential: heart disease, stroke, high blood pressure, and diabetes.
Cardiovascular and metabolic diseases together accounted for more than half of all excess American deaths in 2022. Heart disease alone was the leading cause of excess mortality in nearly every year of the study period. The researchers found that these conditions were responsible for 40 percent of the excess death burden, even though the relative risk—the ratio of American deaths to deaths in peer countries—was lower than for some other causes. This matters because it reveals where intervention could have the largest population-level impact. If the United States could simply bring its cardiovascular and metabolic disease mortality rates in line with other wealthy nations, it would substantially close the mortality gap.
The second major category of excess deaths tells a different story, one concentrated among younger people. Drug poisonings, alcohol-related diseases, and suicides emerged as another leading cause of excess mortality, particularly among men and people under 45. Drug poisonings alone showed the fastest rate of increase, rising from near-parity with peer countries in 1999 to more than 130,000 excess deaths annually by 2022. The sharp acceleration came in 2013, when fentanyl entered the American drug supply. While these causes represent a smaller share of total excess deaths than cardiovascular disease, they carry an outsized burden when measured in years of life lost—a metric that captures the societal cost of losing young people in their prime working and family-building years.
The study, which analyzed cause-of-death data from the World Health Organization Mortality Database across 18 high-income countries, found that the excess mortality gap has been widening for decades. The annual number of excess deaths increased steadily through 2019, then rose sharply during the COVID-19 pandemic. In 2020 and 2021, COVID-19 alone represented one in five American excess deaths. Notably, the pandemic did not create the mortality disadvantage; it amplified an existing crisis.
Dr. Jacob Bor, the study's lead author, emphasized that death certificates capture only the most immediate cause of death, not the full causal chain. Social and economic factors that differ between the United States and other wealthy nations shape behavioral risk factors, which in turn drive higher rates of specific diseases. The researchers found that among people 85 and older, Alzheimer's disease and related dementias became the leading cause of excess deaths by 2022—a pattern that reflects both demographic aging and differences in how these conditions are managed across countries.
The findings present a puzzle that should trouble policymakers. The United States spends more on healthcare than any other nation and has access to cutting-edge medical technology. Yet Americans die at higher rates from conditions that are largely preventable or manageable. The researchers note that the United States does outperform peer countries in a few categories: cancer mortality (excluding lung cancer) and influenza deaths were lower in 2022, reflecting advances in screening, treatment, and vaccination. But these successes have not been enough to offset the broader mortality disadvantage.
Dr. Andrew Stokes, a senior author on the study, noted that while new medications like GLP-1 drugs could make a significant dent in cardiometabolic mortality, the scale of the problem suggests that medication alone cannot close the gap. Other wealthy nations with similar or even worse access to advanced medical technology perform substantially better on these metrics. The implication is clear: the American mortality disadvantage is not primarily a problem of medical innovation or access to drugs. It is a problem of the conditions under which Americans live—the social, economic, and behavioral factors that shape health across the lifespan. Addressing it will require policies that go far beyond the clinic.
Citações Notáveis
Countries that have the same, or even worse, access to advanced medical technology perform far better on these metrics than the US. We need to identify the policies that other countries have implemented.— Dr. Jacob Bor, Boston University School of Public Health
On an absolute scale, cardiometabolic diseases are key contributors to the increase in US death rates. If there was one thing we could address on a population scale, tackling cardiometabolic diseases would substantially reduce the US mortality gap.— Dr. Andrew Stokes, Boston University School of Public Health
A Conversa do Hearth Outra perspectiva sobre a história
Why does the US have higher death rates when we spend more on healthcare than anyone else?
Because spending on healthcare after someone gets sick is different from preventing them from getting sick in the first place. The study found that cardiovascular disease and diabetes are the main drivers—conditions shaped by diet, stress, physical activity, and access to preventive care. Those are social and economic questions, not just medical ones.
But the study mentions that drug overdoses are rising fastest. Shouldn't that be the priority?
It's a real crisis, especially for younger people. But in absolute numbers, it's smaller than the cardiovascular burden. A drug poisoning death is seven times more likely in the US than peer countries, but cardiovascular disease is still killing far more people overall. Both matter, but they require different solutions.
What do other wealthy countries do differently?
The study doesn't spell it out, but the researchers are asking that question. They're saying: Canada, France, Japan—they have the same medical technology we do, sometimes worse access to it, yet their people live longer. That suggests policy choices about housing, food security, work conditions, healthcare access before you're sick.
Is this fixable?
The researchers think so. They're not saying Americans are inherently less healthy. They're saying the conditions we've created—or allowed to persist—are driving disease. If you can change those conditions, you can change the outcomes. But it requires looking beyond the pharmacy.
What about COVID? Did it cause this gap?
No. COVID made it worse, but the gap had been widening since 1980. The pandemic just accelerated what was already happening. In 2020 and 2021, one in five excess American deaths was from COVID. But the other four were from the same diseases that were already killing us at higher rates.
So what happens next?
The researchers are calling for federal policy changes that address root causes. They're not saying don't develop new drugs. They're saying: also look at what's driving people toward heart disease and diabetes in the first place. That's where the real leverage is.