America Has a Heart Problem, Not Just a Drug Problem

Twelve million, six hundred and seventy-five thousand, six hundred and forty-six. That is the number of Americans who died between 1999 and 2022 who, statistically speaking, would not have died had the United States performed as well as other wealthy nations on basic mortality metrics. A new analysis published in JAMA Network Open puts a name to this figure: the “missing Americans.” It is, researchers say, perhaps the starkest measure of a health system that has been quietly diverging from its peers for decades, with a gap that keeps widening.

The instinct, at least among researchers who study US mortality trends, has been to reach for a familiar explanation. Drug overdoses, alcohol-related deaths, suicides, the so-called “deaths of despair” that hollowed out working-class communities from Appalachia to the Rust Belt. That story is real. But it is only part of the picture, and arguably not the biggest part.

The new study, led by Jacob Bor at Boston University School of Public Health, amounts to what the authors call a “population autopsy” of the United States: a systematic accounting of every major cause of death, compared year by year against 17 other high-income countries including Australia, Canada, France, Japan, and the United Kingdom. What emerged challenges the standard framing of the American mortality crisis, even if it doesn’t exactly replace it. “In US population health research, examining the stagnation in US life expectancy that began in 2010 usually focuses on drug overdoses, alcohol-related deaths, and suicide, known as ‘deaths of despair,'” says Andrew Stokes, a co-author on the paper and associate professor of global health at BUSPH. “One dramatic finding from this study is that on an absolute scale, cardiometabolic diseases are key contributors to the increase in US death rates.”

In absolute terms, the numbers are striking. By 2022, cardiovascular conditions (heart disease, hypertension, stroke) accounted for roughly 40 percent of all excess US deaths compared to peer countries. Add in diabetes, kidney disease, and related metabolic conditions, and you’re looking at more than half of the entire mortality gap. Condensed to a single statistic: cardiometabolic disease was killing about 473,000 more Americans per year than would have been expected if the US performed like its wealthy counterparts.

Drug poisonings, by contrast, were 7.48 times more common in the US than in peer countries in 2022, a genuinely alarming relative difference. But in absolute terms they represented around 10 percent of excess US deaths. The contrast says something important about how mortality statistics can mislead. A cause of death can be relatively catastrophic for a country without being the primary driver of its overall death toll; the sheer prevalence of cardiovascular disease means even a modest relative disadvantage translates into an enormous body count.

“These findings pinpoint the issues that we should be focusing on if we want to address the US mortality disadvantage relative to peer countries,” says Bor. The policy framing matters here, and not just academically. In recent years, considerable political and public health attention has been devoted to the opioid crisis and deaths of despair, and rightly so. But if cardiometabolic disease is responsible for a far larger share of the gap with peer nations, then the response has perhaps been calibrated to the wrong emergency.

The temporal patterns in the data are worth dwelling on. From 1999 to 2009, excess US deaths from cardiovascular disease were actually declining, closing the gap slightly with other wealthy nations. Then, around 2009, the trend reversed, sharply and continuously, through to 2022. Diabetes, kidney, and metabolic conditions followed a near-identical trajectory: flat through the first decade, then a steep upward climb after 2010. Bor and his colleagues reckon this inflection is likely tied to the rise in obesity prevalence, particularly among middle-aged Americans, alongside a broader deterioration in cardiometabolic health that has accelerated since the late 2000s. The data show excess cardiovascular deaths climbing fastest among 45 to 64-year-olds, a full decade before the same trend emerged in older age groups, which suggests cohort effects rather than simply an ageing population getting sicker.

None of which is to minimise the “deaths of despair” story. Drug poisonings, alcohol, and suicide together accounted for roughly a quarter of the total increase in excess US deaths over the study period, and they dominated the mortality gap for Americans under 45. Drug poisoning deaths went from near-parity with peer countries in 1999 to more than 130,000 excess deaths per year by 2022, with a particularly sharp jump after fentanyl entered the US drug supply around 2013. In terms of years of life lost (a measure that weights early deaths more heavily), deaths of despair ranked second only to circulatory disease, reflecting how often they kill people in their 30s and 40s rather than their 70s and 80s.

There are, it should be said, areas where the US genuinely outperforms its peers. Non-lung cancers and influenza mortality are both lower in the US than in comparable countries, which Stokes attributes at least partly to medical innovation. “We’ve come a long way with medical innovations to screen and treat cancers,” he says. The counterpoint is obvious: similar medical sophistication seems not to have closed the gap on heart disease, metabolic disease, or drug poisonings, all of which are influenced heavily by social and economic conditions that the healthcare system cannot easily reach.

That tension is perhaps the study’s deepest finding. “Countries that have the same, or even worse, access to advanced medical technology perform far better on these metrics than the US,” says Bor. “We need to identify the policies that other countries have implemented, and think about how we can emulate those policies in the US.” GLP-1 medications such as semaglutide (sold as Ozempic and Wegovy) have attracted considerable excitement as a potential lever on cardiometabolic mortality, and Bor acknowledges they could eventually make a dent. But he is careful to note they are not a substitute for the upstream policy changes that other wealthy countries have pursued: stronger safety nets, better access to primary care, food environments that don’t systematically push people toward obesity and metabolic dysfunction.

The study covers data through 2022. Earlier work by the same group suggests that by 2023, excess US deaths had returned to something like the pre-pandemic trend rather than the elevated pandemic-era peak, though that trend line was itself already grim. More than 314 million years of potential life were lost to the mortality gap between 1999 and 2022. Whether those numbers can be bent requires grappling, honestly, with a crisis that is more cardiometabolic than it is chemical, more structural than it is medical, and considerably larger than the story most people have been told.

https://doi.org/10.1001/jamanetworkopen.2026.6147

Frequently Asked Questions

Why do Americans die so much earlier than people in other wealthy countries?

A new large-scale analysis found that heart disease, stroke, diabetes, and related metabolic conditions account for more than half of the gap between US death rates and those of peer nations like France, Japan, and the UK. Drug overdoses, alcohol, and suicide are also major contributors, particularly for younger Americans, but the sheer volume of cardiovascular deaths means they dominate the overall count. The gap has been growing steadily since the 1980s and accelerated sharply around 2010.

Is the opioid crisis really the main driver of America’s life expectancy problem?

Not in absolute terms, though it’s a significant piece. Drug poisonings are nearly 7.5 times more common in the US than in comparable wealthy countries, but because cardiovascular disease is so prevalent, heart disease and stroke still account for roughly four times as many “excess” US deaths as drug overdoses do. The opioid and fentanyl crisis has had an outsized impact on younger Americans, and it contributes disproportionately to years of life lost, but it’s not the primary driver of the overall mortality gap.

Could weight-loss drugs like Ozempic actually close the gap between the US and other countries?

Possibly, to some extent. Researchers behind the new study acknowledge that GLP-1 medications could eventually reduce cardiometabolic mortality in the US, given how much of the excess death toll comes from heart disease, diabetes, and related conditions. But they caution that countries performing better than the US on these metrics have done so largely through policy differences, not pharmaceutical ones, including stronger social safety nets and healthier food environments. A drug that treats the consequences of a broken system isn’t quite the same as fixing the system.

Why did the US mortality gap with other wealthy countries get worse around 2010?

The data show a fairly clear inflection point around 2009 to 2010, when excess US deaths from cardiovascular and metabolic diseases stopped declining and began climbing sharply. Researchers think rising obesity rates in the US, particularly among middle-aged Americans, are likely a central factor, alongside deteriorating cardiometabolic health more broadly. The same inflection appears in diabetes and kidney disease data, and the trend showed up in 45 to 64-year-olds a full decade before it emerged in older age groups, which suggests it’s driven by specific generational exposures rather than just an aging population.