Published on March 6, 2020
Death: it might be an uncomfortable topic, but understanding who dies and how is a critical measure of the nation’s health. Many discussions about health outcomes begin at life expectancy, which is currently 78.7 years at birth in the US, well below the life expectancies of dozens of other countries. When people die and how are critical drivers of life expectancy. Furthermore, causes of death in the US vary significantly not just by age, but geography.
Two diseases account for nearly half of all deaths in the United States: heart disease and cancer. While the age-adjusted death rate* for cancer has declined since 2012, the age-adjusted death rate for heart disease has remained relatively flat. According to the Centers for Disease Control and Prevention (CDC), the decline in heart disease risk could initially be attributed to decreases in smoking and lung cancer. More recently, the decline is attributed to improved treatment for heart issues, plus further reductions in risk factors like cholesterol, high blood pressure, and smoking. The recent increase in heart disease-related deaths, however, may be due to increases in body mass index and diabetes.
Diabetes death rates have also been roughly flat since 2009. Obesity has increased by 14% since then and diabetes prevalence has increased by 31%.
The CDC does not yet have comprehensive data on deaths caused by COVID-19, the coronavirus caused by SARS-CoV-2. It does, however, have comprehensive data on deaths from flu and pneumonia, illnesses to which coronavirus is frequently compared. In 2018, 11,164 Americans died of the flu, and 47,956 died of pneumonia, accounting for 0.4% and 1.7% of all deaths that year, respectively. The pneumonia-related death rate has fallen by more than half since 1999, perhaps partially due to increasing rates of pneumonia vaccination (CDC), whereas flu-related deaths have been increasing since 2016. 78% of flu-related deaths in 2018 were among those 65+, as were 84% of pneumonia-related deaths.
Another cause of death frequently heard in the news is dubbed “deaths of despair.” These are deaths due to suicide, drug and alcohol poisoning, and alcoholic liver diseases and cirrhosis. According to the definition used by the Congressional Joint Economic Committee, roughly 150,000 (5%) of the 2.8 million deaths in 2018 were deaths of despair. Deaths of despair are one of the fastest-growing causes of death and according to the CDC, were a key factor in the decline of life expectancy over the past several years.
As the chart below shows, drug-related deaths of despair grew the fastest, peaking at 66,000 deaths in 2017. That’s roughly 20.3 deaths per 100,000 people. The drug-related death rate fell 4.4% from 2017 to 2018, contributing to a 0.1-year life expectancy increase. However, suicide and alcohol-related deaths (mostly liver diseases and alcohol-related cirrhosis) have steadily increased each year.
What Americans die of is primarily determined by their age. For people 5-24, accidents (over a third of which are drug overdoses) are the leading cause of death, followed by suicide and homicide. Accidents are the leading cause of death for people aged 25-44, followed by suicide and cancer. For those 65 and older, the top causes of death are roughly the same as the top causes of death for the overall population (heart disease and cancer). This is because those 65 and older made up 74% of all deaths in 2018.
When it comes to death, it also matters where one lives. While heart disease and cancer are the two largest causes of death nationwide, other causes become are homogenous by location. For example, the age-adjusted death rate for accidents (a large portion of which is drug overdoses) in West Virginia in 2018 was 90.3 deaths per 100,000 people. That’s four times the death rate in Massachusetts (20.2). Accident deaths are predominately concentrated in less urbanized states. States like California, New Jersey, and New York have among the lowest rates of accident-related deaths.
A similarly diverse geography appears when looking at deaths caused by suicide. Suicide rates are highest in the Mountain and Western regions. These regions have relatively high concentrations of Native Americans, who have the highest suicide rates of any race and ethnic group.
The government spends more than $1 trillion on health per year. Understanding why death rates continue to increase among specific populations and locations provides critical insights into where the US health care system is succeeding and failing. It can also provide insight into why the life expectancy of the United States continues to lag behind other advanced countries.
The causes of death that are relatively well-addressed by the current healthcare system—heart disease, cancer, and diabetes—are killing fewer Americans than before. However, the increased prevalence of risk factors like obesity and high cholesterol levels have recently hampered some of these improvements. The causes of death rooted in complex mental health and substance abuse issues, such as drug overdoses and suicide, comprise a relatively small portion of deaths, but are increasing faster than most other causes.
Other than in the last two visualizations, this piece uses a measure called the age-adjusted death rate. The age-adjusted death rate takes the death rate per 100,000 individuals (deaths / population * 100,000) and weights it according to the population size of each age group. This is an appropriate way to measure how various causes of death change across populations or years.
Here’s an example of why death rates are age-adjusted: Start by comparing the death rate due to Alzheimer’s disease in 1999 to the rate in 2017. Alzheimer’s disease predominately affects those 65+, a population that grew from 12.5% of the population in 1999 to 15.7% in 2017. If we saw the death rate due to Alzheimer’s increasing, but didn’t have an age-adjusted rate, it would be hard to tell if Alzheimer’s was getting worse or if the population was just aging. Age-adjusting helps control for differences in population composition, allowing for comparisons across states or years. However, when discussing the death rates of specific age groups, age-adjusted rates aren’t necessary. For more details on calculating age-adjusted death rates, please see page 69 of the CDC’s 2018 National Vital Statistics Report.
For tracking deaths of despair, the ICD-10 codes described in research from the Congressional Joint Economic Committee were used.
For other causes of death, the ICD-10 113 list causes of death were used. For most causes of death, the rankable cause of death was used as this is typically what the CDC uses when describing the top causes of death over time. For example, heart disease refers to "Diseases of heart (ICD-10 codes I00-I09,I11,I13,I20-I51)," and cancer refers to " Malignant neoplasms (ICD-10 codes C00-C97)"
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