A new analysis published in The Milbank Quarterly shows just how unusual the U.S. mortality experience is compared with other wealthy nations.
The analysis found that life expectancy in West Virginia and Mississippi looked less like that of other U.S. states than that of countries including Azerbaijan, Bangladesh, Bulgaria and Iraq. At about 71 years, it was also lower than life expectancy in countries such as North Korea and Syria. Meanwhile, Hawaii’s life expectancy was about 81 years — comparable to Germany, Greece and the United Kingdom.
The study’s interactive map allows reporters to see dramatic variation in life expectancy across the United States and to compare individual states with other countries.
Localizing a national story
For the article, Steven H. Woolf, M.D., MPH, considered not only state policy choices but other factors that cause illness and death, he said in an interview. Woolf is the director emeritus and senior advisor at the Virginia Commonwealth University Center on Society and Health. He’s also a professor and the C. Kenneth and Dianne Wright Distinguished Chair in Population Health and Health Equity.
“A big focus is on choices that states are making that are compromising health outcomes, but also other factors that we know affect health, including things like education and income,” he explained. “Things like smoking, obesity rates and poverty rates are also major contributors.”
Other factors include a state’s economy, the cost of food and other commodities and median household income, Woolf commented. “Those are all things that affect health, and they may affect health regardless of who the politicians are in office and what policy choices they make,” he noted.
Why are more young people dying?
For journalists, one of the most concerning trends in the research is the mortality rate among 25- to 44-year-olds in your state, county or metropolitan area. “As I explain in the paper, the probability that an American will not live beyond age 45 is higher now than it was a decade ago,” Woolf warned. “We’re moving in the wrong direction.”
Between 2010 and 2021, those young adults experienced a 71.2% increase in all-cause mortality, the largest relative increase of any age group, the analysis found. A major factor was drug overdoses, but the increase also included early-onset diseases such as alcoholic liver disease, hypertension and endocrine and metabolic disorders.
“For a century now, the leading causes of death among young people have been external causes,” Woolf explained. Those external causes include car accidents, drownings, falls and other fatalities that historically have been more likely to kill a young person than diseases, he added.
“That’s a change we’re seeing now, meaning those external causes remain hugely important and one major driver in particular is drug overdose deaths, which has an outsized role in explaining the increase in mortality in young adults,” Woolf commented.
In addition, researchers are seeing more excess deaths due to diseases in young adults, such as diabetes and chronic liver disease and hypertensive heart disease, he noted.
“These are all conditions that, as a doctor, I used to encounter and treat in somebody in their 50s, 60s, 70s,” he noted. “The fact that they are not only occurring at these younger ages but become advanced enough to actually take a life is a newer and very worrying phenomenon.”
Where we live affects health
Woolf’s analysis is valuable because state-level data reporters can use it to localize the story and investigate further. After all, where you live is a social determinant of health.
The analysis shows that the United States’ mortality disadvantage and life expectancy are not evenly distributed among states. Some of the lowest levels are concentrated in parts of the South, Appalachia and rural communities.
Wide disparities also extend across demographic groups. In 2023, life expectancy ranged from 70.1 years among American Indian and Alaska Native populations to 85.2 years among non-Hispanic Asian populations. Differences by race and ethnicity, income and education can similarly disappear when mortality is reported only as a national average.
Use the data to find the next story
The interactive map is particularly useful as a reporting tool. Start with your state. See which countries have comparable life expectancy. Then ask what is driving the difference.
A state-level comparison can generate questions such as: Which causes of death account for the gap? Are deaths among younger adults increasing? How do neighboring counties compare? What happens when you break the numbers down by race, ethnicity, rurality, income or education? Which policies or changes in health care access could help explain the patterns?
Life expectancy is one indicator, and cross-national comparisons have limitations. But the comparisons can help make an otherwise abstract mortality gap tangible—and point reporters toward the people and systems behind the numbers.
Political polarization: An important factor
Woolf said his research shows that politics is not necessarily a significant factor in rising illness and death rates.
“In the paper, I go back in time to show how partisan leadership shifted over time,” he said. “Some of the same states that are currently struggling under Republican leadership also were struggling decades earlier when Democrats were in charge.
“So, it’s not necessarily the case that the poor health outcomes that make these states comparable to developing countries are all due to policy choices,” he added. “What I try to develop in the article is this clear trend of increasing polarization that has occurred. With that, there’s been a widening gap in health outcomes that most likely represents some degree of policy choices.
“If so, then that becomes interesting to investigate,” Woolf suggested. “What are some of those policy choices that we’ve made in our state that could explain why we’re being left behind, whether that’s not expanding Medicaid or tobacco taxes or other policies that have health implications?”
A reporting checklist
The analysis also suggests other ways to turn a national mortality story into local ones:
- Follow the cause. Don’t stop at “overdose,” “heart disease” or “diabetes.” Examine the trends underneath each category such as economic conditions, the deceased’s neighborhood or access to public transit, for example.
- Compare places. Neighboring counties or states can have widely different mortality patterns. Ask about differences in health care access, demographics, economics, environment and policy.
- Disaggregate. Race, ethnicity, sex, age, income, education and geography can reveal disparities hidden by statewide averages.
- Examine policy alongside outcomes. But distinguish an association from evidence of causation and seek researchers who can explain alternative explanations.
- Look for preventable deaths. The most useful questions may be which deaths are increasing, where do they occur, and what conditions preceded them?
Resources
- US Life Expectancy and Increasing Mortality Rates: An Analysis of the Crisis, Steven H. Woolf, The Milbank Quarterly, 2026
- Rising US life expectancy isn’t what it seems, Nicole Karlis, Salon, Aug. 11, 2026
- How does U.S. life expectancy compare to other countries?, Shameek Rakshit, Lynne Cotter, and Matt McGough, Peterson KFF Health System Tracker, March 31, 2026
- U.S. life expectancy hits a new high as deaths from overdoses and COVID fall, Rob Stein, NPR, Jan. 29, 2026
- Mortality in the United States, 2024, CDC, National Center for Health Statistics, NCHS Data Brief No. 548, Jan. 29, 2026
