Contrast in Avoidable Mortality Trends Highlights Systemic US Health Challenges

A stark contrast in avoidable mortality trends exists between all US states and the European Union and Organisation for Economic Co-operation and Development (OECD) countries, suggesting that broad, systemic factors contribute to worsening population health in the US, according to a study published today in JAMA Internal Medicine.¹

Despite spending more on health care than any other country worldwide, the US has a lower life expectancy than most high-income nations. Life expectancy also varies significantly between states. The researchers highlighted that these disparities have widened as major health policy decisions, such as Medicaid expansion, are determined at the state level.

In contrast, other high-income countries take more centralized approaches, organizing health systems and investing in mitigating social determinants of health to improve outcomes.

The researchers emphasized that understanding mortality differences across states compared with other nations could clarify whether the US’s poorer health outcomes stem from systemic national issues or worsening state-level performance in areas where policy can prevent premature death. To explore this, they examined avoidable mortality across US states and 40 EU and OECD countries between 2009 and 2021.

These results suggest that the rise in avoidable mortality is driven by widespread factors across the entire US. | Image Credit: Roman - stock.adobe.com.

Commonly used by the OECD and EU, avoidable mortality refers to annual deaths in the population bef75 years that could have been prevented through timely, effective health care and public health interventions.² It can be further divided into preventable mortality, which includes deaths that could have been avoided through broader public health measures, and treatable mortality, which includes deaths that could have been averted with timely medical care.

The researchers calculated avoidable mortality rates for individuals aged 0 to 74 each year by state or country of residence using the OECD/Eurostat 2022 list of preventable and treatable causes of death.³ They also determined age- and sex-standardized rates using the total US population as the reference distribution.¹

Overall, the researchers examined the relationship between avoidable mortality and health care spending per capita in 2009, 2019, and 2020, calculating Pearson correlation coefficients separately for countries and US states.

Between 2009 and 2019, avoidable mortality increased in all US states (median, 29 deaths per 100,00 people; IQR, 20.1-44.2) while decreasing in most comparator countries (median, –14.4 deaths per 100,000 people; IQR, –28.4 to –8.0).

Similarly, the researchers found that variation in avoidable mortality widened across the US during this period (2009: median, 251.1 deaths per 100,000 people; IQR, 228.4-280.4; 2019: median, 282.8 deaths per 100,000 people; IQR, 249.1- 329.5). Conversely, it narrowed in comparator countries (2009: median, 201.5 deaths per 100,000 people; IQR, 166.2-320.8; 2019: 187.1 deaths per 100,000 people; IQR, 152.0-298.2).

However, during the COVID-19 pandemic (2019-2021), avoidable mortality increased for all US states (median, 101.5 deaths per 100,000 people; IQR, 64.7-143.1) and comparator countries (median, 25.8 deaths per 100,000 people; IQR, 9.1-117.7). The researchers highlighted that the states and countries with the highest baseline avoidable mortality had the largest increase in avoidable deaths during the COVID-19 pandemic period (Pearson ρ = 0.86; P < .001).

Overall, they found a consistent, negative, and statistically significant association between health spending and avoidable mortality among comparator countries (Pearson ρ = –0.7; P < .001) but no significant association within US states (Pearson ρ= –0.12; P = .41).

“Avoidable mortality has worsened across all US states, while other high-income countries show improvement; results suggest poorer mortality is driven by broad factors across the entirety of the US,” the authors wrote.

Lastly, the researchers acknowledged their study’s limitations, including that they only presented descriptive comparative findings. As a result, causal inferences could not be made. Despite their limitations, they expressed confidence in their findings and suggested areas for further research.

“Moving forward, US policymakers should more closely examine population health across states in international comparative studies with the US, particularly as health policy and responses to health shocks vary across states,” the authors concluded.

References

1. Papnicolas I, Niksch M, Figueroa JF. Avoidable mortality across US states and high-income countries. JAMA Intern Med. Published online March 24, 2025. doi:10.1001/jamainternmed.2025.0155
2. Kamarudeen S. Amenable mortality as an indicator of healthcare quality - a literature review. Health Stat Q. 2010;(47):66-80. doi:10.1057/hsq.2010.16
3. Avoidable mortality: OECD/Eurostat lists of preventable and treatable causes of death (January 2022 version). OECD/Eurostat. January 2022. Accessed March 24, 2025. https://www.oecd.org/health/health-systems/Avoidable-mortality-2019-Joint-OECD-Eurostat-List-preventable-treatable-causes-of-death.pdf