What drives differences in life expectancy between the U.S. and comparable countries? - Peterson-KFF Health System Tracker (2025)

The United States spends more on health care than any similarly large and wealthy country. However, in 2023, Americans had a life expectancy of 78.4 years, compared to an average of 82.5 among peer countries. This chart collection examines deaths in the U.S. and comparable countries through 2021, by age group and cause, to highlight factors that contribute to this life expectancy gap. The countries included in the comparison are Australia, Austria, Belgium, Canada, France, Germany, Japan, Netherlands, Sweden, Switzerland, and the United Kingdom.

The U.S.’s premature death rate (408 deaths per 100,000 people under age 70) in 2021 was almost twice the average of these similarly large and wealthy countries (228 deaths). About a third (32%) of the difference in premature death between the U.S. and similar countries is due to deaths from cardiovascular diseases, chronic respiratory diseases and chronic kidney diseases (which, combined, caused 105 deaths per 100,000 population under 70 in the U.S. in 2021). Additionally, in 2021, COVID-19 made up 24% of the difference in premature death rates between the U.S. and peer nations, killing 64 Americans out of every 100,000 under 70.

Another 12% of the difference between the U.S. and its peers’ premature death rates is due to substance use, which caused 29 deaths per 100,000 people under age 70 in the U.S. in 2021. For the purposes of this analysis, substance use deaths are defined as deaths occurring as a direct result of consumption of alcohol or illicit drugs, excluding any deaths from chronic diseases and organ damage caused by long-term use.

Deaths at younger ages bring down life expectancy more than deaths among older age groups. In the younger adult age group (15- to 49-year-olds), the difference in death rate between the U.S. and peer countries is largely driven by more deaths due to chronic diseases, COVID-19, and substance use. Among 15 to 49-year-olds, the U.S. death rate was 2.5 times that of comparable countries (192 vs. 76 per 100,000).

The charts below illustrate how among the under-70 population, the U.S. diabetes death rate is about 2.5 times that of comparable countries, the liver disease death rate is 1.6 times as high, and kidney disease death rate is 3.8 times as high. Additionally, the U.S. substance use death rate is four times that of comparable countries in the under-70 population, and the homicide death rate is nearly 8 times the average of peer nations.

Life expectancy in the U.S. remains far below peer countries

In 1980, life expectancy at birth in the United States was similar to that in peer countries. Throughout the eighties, nineties and early aughts, life expectancy increased in all countries as scientific and medical technologies advanced. However, this upward trend was slower in the United States than in peer countries. After plateauing since 2010, U.S. life expectancy dropped precipitously in 2020 and 2021 due to the COVID-19 pandemic. There was a smaller decrease in comparable countries, exacerbating the gap in lifespan. In 2022 and 2023, as COVID-19 deaths began to wane, U.S. life expectancy began to increase again, though it has not fully returned to pre-pandemic levels, and the gap between the U.S. and peer countries persists.

The disparity in death rates between the U.S. and peers varies by age group

Since the 1990s, U.S. death rates have been higher than comparable countries for every under-70 age group, though the size of this gap varies significantly.

While the U.S. has consistently had a higher rate of deaths in childhood (ages 0-14) than peer nations, childhood deaths in the U.S. have declined since 1980 on a similar trajectory to comparable countries. There has been a consistent gap in childhood death rates between the U.S. and the comparable country average, with the U.S. seeing around 20 more deaths per 100,000 each year. Most deaths in childhood occur in the first year of life, and other research has suggested that some of the difference between the U.S. and peer countries’ infant mortality rates may be driven by worse health at birth, including low birthweight, often a symptom of racial disparities in the U.S. There are also differences in reporting and data collection between the U.S. and peer countries.

By contrast, death rates in early adulthood (age 15-49) have remained close to 1980 levels in the U.S., despite declining by over 50% in comparable countries. This has widened the gap from 20 to over 100 additional deaths per 100,000 population in 41 years. The U.S. has higher deaths in this age group from almost all causes, including chronic diseases, communicable diseases, substance use, and injuries. Throughout the past four decades, various risk factors impacting death rates in among younger adults have emerged in the U.S., including the AIDS epidemic, gun violence, and the opioid epidemic. The 2020-2021 jump in deaths in the U.S. in this age group represents the COVID-19 pandemic. However, these trends alone do not account for the entirety of the difference in death rates among young adults in the U.S. and peer countries – chronic diseases play a significant role, as detailed in the section below.

Among older adults, ages 50-69, U.S. death rates declined in line with other countries between 1980 and 2010. Death rates in this age group then plateaued in the U.S. in the 2010s while continuing to decline elsewhere.

Finally, the U.S. and many other countries saw a spike in deaths in all age groups during the COVID-19 pandemic, but in the U.S., deaths were 21% higher in 2021 vs. 2019, whereas in comparable countries the increase was less than 5%.

The U.S. has higher rates of many causes of death, particularly among young people

Top causes of death vary significantly across age groups. In the U.S. and all peer nations, children are most likely to die in infancy of prematurity or congenital birth defects, younger adults are more likely to die due to injuries and external factors, and older adults are more likely to die due to chronic diseases and infections.

However, the U.S. has significantly higher rates of death than the peer country average for most causes of death in most age groups. COVID-19 was a top cause of death for all adult age groups in the United States in 2021, with death rates two to six times higher than peer countries. Chronic diseases, such as cardiovascular, respiratory and kidney diseases, had higher death rates in the U.S. than peer countries across all age groups for which they appeared as top causes of death.

The U.S. also had significantly higher rates of death among younger populations due to external factors. Death rates were 3 to 4 times higher among children due to choking, homicide and transport accidents in the United States than peer countries. Among younger adults, rates of death due to substance use were more than five times higher in the U.S. than the comparable country average, and homicide and transport accidents (which includes car, bicycle, motorcycle, pedestrian and aircraft accidents) in the U.S. also had more than triple the death rates of peer countries.

Death rates in the 15-49 age group in the U.S. were higher in 2021 than any year since 1980

Within the U.S., the causes of death in younger age groups have shifted markedly over the previous four decades. These shifts are caused by a variety of factors, with declines in deaths attributed to improvements in medical treatments and technology, and the decline of smoking, and increases attributed to emergence of new infectious diseases.

Improvements in medical treatment and technology have brought down death rates significantly for certain factors. Neonatal disorders and congenital birth defects are still top causes of death in childhood, but the death rates for these conditions have decreased by nearly 65% since 1980. While there was initially a significant increase in the death rate from HIV/AIDS in the eighties and nineties, it declined rapidly with the availability of new treatments. Among people ages 50 to 69, rates of cardiovascular death have dropped by over 60% since 1980, and cancer deaths have declined by 40% since 1988. In addition to improvements in medicine, the decline of smoking in this time period is an important factor in the decrease in death rates due to cancer and cardiovascular conditions.

By contrast, new causes of death have had a large impact among younger adults, causing life expectancy to plateau in the 2010s and ultimately decrease significantly starting in 2020. The COVID-19 pandemic single-handedly caused a jump in deaths for all age groups, and a rise in substance use deaths in the 15-49 age group has also been a contributing factor.

While injuries (such as traffic accidents, violence, and substance use) and COVID-19 have the largest disparities in death rates between the U.S. and comparable countries, these factors comprise only some of the gap in life expectancy. In fact, in the 15 to 49 age group and the 50 to 69 age group, the U.S. had more deaths due to chronic and noncommunicable disease alone than many peer countries had overall.

While not every death before age 70 is preventable, these deaths are considered premature, because it is likely the individual may have lived to at least age 70 with changes in medical care, lifestyle, or other circumstances. Many charts in this chart collection focus on these premature deaths, because of their disproportionate impact on population life expectancy.

Cardiovascular diseases and cancer are the top two causes of death in the United States and comparable high-income peer nations

Cardiovascular disease (including heart disease, stroke, heart failure and cardiomyopathy, among others) and cancer (of all types) are the top two causes of death in most of the wealthiest nations in the world, including the United States and peer countries used in this analysis.

Cardiovascular diseases are extremely common, particularly in older adults. They can occur at younger ages, or have severity exacerbated, due to lifestyle (diet, smoking, drug and alcohol use) but also due to genetics or other factors. Improvements in medicine have brought down cardiovascular disease death rates significantly in the past four decades, but progress stalled in the United States since 2010 and premature death rates have increased slightly since, while continuing to decline in peer nations.

Notably, Americans are almost twice as likely as counterparts in peer countries to die of cardiovascular diseases before age 70. Any successful efforts to prevent, treat and cure cardiovascular diseases in the U.S. will have a positive impact on the overall life expectancy.

There are several likely reasons for this gap in premature cardiovascular deaths. Americans have higher rates of obesity and substance use than peer countries, which can increase risk. Additionally, cardiovascular diseases are often chronic and require diagnosis, monitoring, and medical and pharmaceutical management to keep patients alive and well. This can be more difficult to access in the United States than other peer nations, due to cost and access barriers to healthcare.

The other top cause of death across all age groups in all countries is cancer. Cancer can occur due to environmental or lifestyle factors including the use of tobacco and alcohol, as well as unknown etiologies. Cancer death rates have remained notably static compared to other causes of death in the previous four decades, both in the U.S. and in peer countries. While in the United States, individuals are overall less likely to die of cancer than in comparable countries, this difference only exists among elderly populations and is likely because Americans have already died of other causes first.

Among people under 70, the U.S. cancer death rates are close to the comparable country average, and both have remained relatively unchanged since 1980. This indicates that cancer deaths are likely not a factor in the decline of life expectancy in the U.S., or in the gap between the U.S. and peer countries.

Chronic diseases that are causing increased death rates in the U.S., primarily among younger populations, are key causes of the life expectancy gap

While cardiovascular diseases and cancer remain the most common causes of premature death in the U.S. and peer countries, other chronic diseases make up a significant portion of the death rate as well. In the United States, death rates from chronic diseases of the liver, kidneys and respiratory system, as well as diabetes, are increasing – particularly in younger populations. Meanwhile, in peer nations, the death rates from the same diseases in the same age groups have largely remained flat or decreased in recent decades.

There are many reasons these chronic health issues may result in death before age 70, but the most significant are social determinants of health, influenced by individual, societal and policy choices that limit choices for some groups. Diabetes prevalence and severity is strongly correlated with diet, while respiratory diseases are linked to smoking, and cirrhosis and other chronic liver conditions are often the result of heavy alcohol use. As with cardiovascular disease, barriers to healthcare access can prevent proper diagnosis and management of these conditions, leading to premature death.

Causes of death other than chronic diseases are also driving the life expectancy gap by causing increased deaths in the U.S., primarily among younger populations

Chronic diseases cause most deaths in the U.S. and peer countries. However, deaths due to external factors such as substance use, accidents, suicide and violence also contribute significantly to the life expectancy of a population, because these deaths occur more commonly in young people.

Within the U.S., deaths due to substance use (including alcohol and recreational drugs such as opioids, amphetamines and cocaine) are currently more than six times higher than they were 1980. This is largely due to the overprescription of opioids and the introduction of fentanyl to many street drugs. In 2021, the U.S. substance use death rate for people aged 15-49 was over five times that of the same age group in comparable countries (35 vs. 6.5 deaths per 100,000), and the overall substance use death rate for people under 70 was four times that of comparable countries (28.6 vs 6.4 per 100,000).

Substance use and suicide are strongly associated with mental health conditions that are difficult to treat, especially with the access barriers that exist primarily in the U.S.

The other common external causes of death among young Americans specifically are homicide (being shot, stabbed, or otherwise killed by another person) and transport accidents (chiefly car accidents). The prevalence of weapons – notably firearms – is a key reason the U.S. homicide rate is higher than that of other nations. Additionally, the U.S. has more and larger vehicles than most peer nations, and lack of public transportation means that the average American spends more time in the car than citizens of other countries, increasing the number of accidents and fatalities per capita. Though the rates of transport accidents and homicides remain significantly higher in the U.S. than peer nations, both have declined significantly in recent decades.