Original Investigation
March 24, 2025
Avoidable Mortality Across US States and High-Income Countries
Irene Papanicolas, Maecey Niksch, Jose F. Figueroa
JAMA Intern Med. Published online March 24, 2025. doi:10.1001/jamainternmed.2025.0155
Question How did avoidable mortality vary across US states compared with 40 high-income countries between 2009 and 2021?
Findings In this retrospective study, between 2009 and 2021, avoidable mortality increased in all US states, primarily due to increases in preventable deaths, while it decreased in comparable high-income countries. Health spending was significantly negatively associated with avoidable mortality for other high-income countries but not across US states.
Meaning 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.
Abstract
Importance Although there are increasing differences in health policy and population health across US states over the past decade, little is known about how US states compare with other countries on avoidable mortality.
Objective To compare trends in avoidable mortality across US states and countries in the European Union (EU) and the Organisation for Economic Co-operation and Development (OECD).
Design, Setting, and Participants Retrospective, population-based, repeated cross-sectional study comparing changes in avoidable mortality among decedents aged 0 to 74 years in 50 US states (and Washington, DC) and 40 high-income countries between 2009 and 2021. Data analysis was conducted from May to July 2024.
Main Outcomes and Measures Avoidable mortality comprising both preventable deaths related to prevention and public health and treatable deaths related to timely and effective health care treatment.
Results Between 2009 and 2019, total avoidable mortality increased in all US states (median [IQR], 29.0 [20.1 to 44.2] deaths per 100 000 people), while it decreased in most comparator countries (−14.4 [−28.4 to −8.0]). During this period, variation in avoidable mortality widened across US states (2009: median [IQR], 251.1 [228.4 to 280.4]; 2019: 282.8 [249.1 to 329.5]), but narrowed in comparator countries (2009: 201.5 [166.2 to 320.8]; 2019: 187.1 [152.0 to 298.2]). During the COVID-19 pandemic (2019-2021), avoidable mortality increased for all US states (median [IQR], 101.5 [64.7 to 143.1]) and comparator countries (25.8 [9.1 to 117.7]). The states and countries that experienced the greatest increase in avoidable deaths during the COVID-19 period were those with the highest baseline avoidable mortality (Pearson ρ = 0.86; P < .001). Health spending and avoidable mortality have a consistent, negative, and significant association among comparator countries (2019: Pearson ρ = −0.7; P < .001) but no statistically significant association within US states (2019: Pearson ρ = −0.12; P = .41).
Conclusions and Relevance This cross-sectional study found that the stark contrast in avoidable mortality trends between all US states compared with EU and OECD countries suggests that broad, systemic factors play a role in worsening US population health. While other countries appear to make gains in health with increases in health care spending, such an association does not exist across US states, raising questions regarding US health spending efficiency.
