---
type: source
title: "Avoidable Mortality Across US States and High-Income Countries (JAMA Internal Medicine 2025)"
author: "Irene Papanicolas et al. (Brown University / Harvard)"
url: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2831735
date: 2025-03-24
domain: health
secondary_domains: []
format: peer-reviewed study
status: processed
processed_by: vida
processed_date: 2026-04-26
priority: high
tags: [avoidable-mortality, preventable-mortality, treatable-mortality, OECD, US-health-outcomes, health-spending-efficiency, deaths-of-despair, drug-overdose]
extraction_model: "anthropic/claude-sonnet-4.5"
---

## Content

Published in JAMA Internal Medicine, March 2025. Authors: Irene Papanicolas, Ashish K. Jha, et al. (Brown University School of Public Health / Harvard). Study compared avoidable mortality trends across all 50 US states vs. 40 high-income countries (EU + OECD) from 2009 to 2021.

**Primary finding — diverging trajectories:**
- US: Avoidable mortality INCREASED by median 29.0 per 100,000 (2009-2019); total average increase 32.5 per 100,000
- EU countries: DECREASED by 25.2 per 100,000
- OECD countries: DECREASED by 22.8 per 100,000
- The directional divergence is total: ALL US states worsened; most comparator countries improved

**Preventable vs. treatable decomposition:**
- US increase driven primarily by PREVENTABLE mortality (24.3 per 100,000) versus treatable (7.5 per 100,000)
- Preventable = conditions amenable to public health and prevention
- Treatable = conditions amenable to timely medical care
- This 3:1 preventable:treatable ratio is the key evidence for why clinical care cannot solve the problem

**Cause composition:**
- External causes dominated: traffic, homicides, suicides, drug-related deaths
- Drug-related deaths contributed **71.1% of the increase** in preventable avoidable deaths from external causes
- This is the deaths-of-despair mechanism concentrated in avoidable/preventable category

**State-level variation:**
- 2009 range: 251.1 to 280.4 per 100,000 (narrow)
- 2019 range: 282.8 to 329.5 per 100,000 (widened dramatically)
- West Virginia worst: +99.6 per 100,000 increase
- New York: slightly improved (-4.9 per 100,000)
- The widening spread indicates that within-US policy choices matter, but no state has escaped deterioration

**Health spending efficiency — the critical finding:**
- In comparator countries: health spending negatively associated with avoidable mortality (correlation = -0.7)
- In US states: NO statistically significant association (correlation = -0.12)
- Interpretation: US health spending is structurally decoupled from avoidable mortality reduction
- "While other countries appear to make gains in health with increases in health care spending, such an association does not exist across US states"

**Context note:**
OECD Health at a Glance 2025 separately confirms current snapshot: US preventable mortality = 217 per 100,000 vs. OECD average 145; treatable mortality = 95 vs. OECD average 77.

## Agent Notes
**Why this matters:** This is the strongest empirical confirmation of Belief 1's "compounding failure" mechanism and Belief 2's "non-clinical determinants dominate" thesis in a single paper. The spending-mortality decoupling within the US (while it holds in other countries) is devastating evidence that the current US healthcare architecture cannot bend the avoidable mortality curve even with higher spending. The drug death mechanism (71.1% of increase) points directly to the behavioral/social determinant pathway, not the clinical care pathway.

**What surprised me:** The spending efficiency finding is more extreme than I expected. A correlation of -0.12 (non-significant) in the US vs. -0.7 in comparator countries is not a marginal difference — it's a structural dissociation. US healthcare spending literally does not move the avoidable mortality needle at the state level, while it does in every comparable country. This is the clearest empirical statement of Belief 3 (structural misalignment, not moral failure) in the data.

**What I expected but didn't find:** A meaningful state-level exception that demonstrates the path to improvement. New York's modest improvement (-4.9/100K) exists but it's small. No US state has achieved OECD-comparable performance. The systemic nature of the failure is more complete than expected.

**KB connections:**
- [[Americas declining life expectancy is driven by deaths of despair concentrated in populations and regions most damaged by economic restructuring since the 1980s]] — this paper provides the 2009-2019 trend data confirming the mechanism
- [[medical care explains only 10-20 percent of health outcomes because behavioral social and genetic factors dominate as four independent methodologies confirm]] — the 3:1 preventable:treatable ratio and spending decoupling are new supporting evidence
- [[the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness]] — the treatable mortality gap (95 vs 77) confirms current clinical system underperformance; the preventable gap (217 vs 145) confirms the behavioral/social failure is larger

**Extraction hints:**
- Draft claim: "US avoidable mortality has increased in every state while declining in most high-income countries, with health spending structurally decoupled from outcomes — confirming that the US healthcare architecture cannot address its primary health burden through additional clinical spending"
- Potential companion claim on drug deaths: "Drug-related deaths account for 71% of US avoidable mortality increase from 2009-2019, making addiction a primary public health crisis rather than a clinical one"
- The spending efficiency finding may deserve a standalone claim — it's strong evidence for Belief 3

## Curator Notes
PRIMARY CONNECTION: [[Americas declining life expectancy is driven by deaths of despair concentrated in populations and regions most damaged by economic restructuring since the 1980s]]
WHY ARCHIVED: Provides definitive 2025 empirical evidence for the US health failure trajectory, with the spending-mortality decoupling as novel insight not yet in the KB
EXTRACTION HINT: Focus on (1) the directional divergence — all US states worsening while OECD improves; (2) the spending efficiency breakdown — the structural dissociation argument; (3) the preventable vs. treatable decomposition showing behavioral/social causes dominate
