Dr. Jesse Pines
The United States is one of the richest, most technologically advanced countries on earth. It also spends more on health care than any other nation. Yet Americans, on average, die younger than people across much of Europe.
In 2023, U.S. life expectancy was about 78.4 years. Across the European Union, it was about 81.5 years, with preliminary estimates rising to roughly 81.7 years in 2024, a gap of about three years. The gap is even larger when the U.S. is compared with peer high-income countries like the UK and Australia. And the gap exists despite the U.S. devoting roughly 17% of GDP to health care, nearly double the share in many other wealthy countries.
So, what explains the mismatch between spending and survival?
It is not one silver bullet. It is a stack of disadvantages that start early, compound over time, and show up as higher rates of preventable death. The COVID-19 pandemic widened an already existing gap. The deeper story is about who dies earlier, and why.
Why Young and Midlife Deaths Matter So Much
Life expectancy is especially sensitive to deaths that happen in young adulthood and midlife. A death at 25 or 45 pulls down the average far more than a death at 85. Compared with peer countries, the U.S. has markedly higher mortality under age 75, with an especially pronounced disadvantage in young adulthood and midlife.
For example, Americans aged 25-29 experience death rates nearly 3 times higher than their counterparts in peer countries. However, it is particularly pronounced for American women, whose mortality rates were higher than in 16 peer nations for all causes of death.
“Deaths of Despair” and the Overdose Crisis
The single category that has widened the U.S. gap the most over the past decade is drug overdose, especially opioids and increasingly polysubstance exposure. These deaths concentrate in younger and middle-aged individuals. This makes their impact on life expectancy outsized.
In particular, between 1999 and 2013, a study reported that mortality from drugs, alcohol, and suicide increased substantially among Americans without a college degree. Educational disparities in these “deaths of despair” are much steeper in the U.S. than in Europe. Over time, this turned into a sustained erosion of survival for groups that once saw steady improvements.
This reflects systemic failure on multiple levels. The U.S. has been uniquely exposed to a hazardous drug supply, the legacy of aggressive pharmaceutical marketing and high opioid prescribing in prior decades, and uneven access to evidence-based treatment. Medications for opioid use disorder remain underused. Harm-reduction infrastructure is inconsistent. Recovery supports vary dramatically by geography and insurance status. When overdoses rise, life expectancy falls quickly.
Violence and Traffic Deaths
Injuries are another area where the U.S. performs far worse than peers, particularly at younger ages, in particular firearms and interpersonal violence. Compared with other high-income nations, the U.S. has far higher firearm death rates, including homicide, suicide, and unintentional injuries. In fact, the U.S. firearm homicide rate is approximately 25 times higher than other high-income countries. These deaths cluster in adolescence and early adulthood, precisely the ages that drive life expectancy.
Motor vehicle death rates are also substantially elevated. In 2019, the U.S. population-based death rate was 11.1 per 100,000. This is the highest among 29 high-income countries and 2.3 times the average of the other 28 countries (4.8 per 100,000). Safer road design, speed management, vehicle standards, and enforcement practices matter. The U.S. has not been as consistent in deploying them.
Chronic Disease Starts Earlier and Is Treated Less Reliably
Alongside injuries, the U.S. carries a heavy burden of chronic illness, including cardiovascular disease, diabetes, and kidney disease. Some of this is tied to risk factors such as obesity, sedentary behavior, and diet. But the problem is not only what Americans are exposed to. It is also how reliably the system detects and manages disease early, year after year.
Many European countries have stronger primary care foundations and more consistent access to routine preventive care and chronic disease management. The U.S. excels at high-end medicine. At elite centers, outcomes for complex cancer surgery or cutting-edge therapies can be extraordinary. But the longevity gap is driven less by rare feats of tertiary care and more by the boring middle of medicine: blood pressure control, diabetes management, mental health care, addiction treatment, pregnancy care, and continuity over years.
The U.S. system is fragmented, administratively complex, and sometimes financially punishing. That translates into delayed care, medication nonadherence, gaps in follow-up, and untreated conditions. Over time, those failures accumulate into avoidable strokes, heart attacks, amputations, and deaths.
Social Policy Shapes Health Long Before the Doctor’s Office
Health is often created upstream from medical care delivery. Compared with many European countries, the U.S. has higher child poverty, weaker income supports, less affordable childcare, less paid leave, and higher housing insecurity. These conditions influence stress, nutrition, sleep, educational attainment, and exposure to environmental risk. They also shape the ability to access preventive care and maintain stable routines that support health.
The U.S. also has enormous variation in life expectancy by geography, income, education, and race and ethnicity. In 2014, life expectancy ranged from approximately 66 years in the lowest counties to 87 years in the highest counties—a more than 20-year difference. That enormous range illustrates that policy, environment, and system design matter.
Why Spending More Does Not Buy More Longevity
If the U.S. spends so much, why are outcomes worse? One answer is that a large share of U.S. spending goes to prices and administration. A 2018 JAMA study found that administrative costs alone accounted for 8% of U.S. healthcare spending, vs. 1-3% in peer nations. Americans pay more for hospital care, physician services, procedures, and prescription drugs. The system also devotes substantial resources to billing, insurance churn, prior authorization, and related overhead.
Another answer is that spending is unevenly distributed. Some people receive too much low-value care. Others receive too little care, too late. When preventive care, chronic disease control, and timely access are inconsistent, you can spend heavily and still lose years of life.
What Could Actually Close the Longevity Gap
If the U.S. really wanted to move life expectancy meaningfully, it would need to focus on the causes of early death and the systems that prevent it.
- Reduce overdose deaths – Work upstream to reduce the supply of drugs entering the country. Scale evidence-based addiction treatment, including medications. Expand naloxone access. Invest in harm reduction and recovery supports. Improve continuity of care after emergency visits, hospitalization, and incarceration, when risk is highest.
- Reduce firearm deaths – Focus on strategies with evidence behind them, including safe storage practices, extreme risk protection orders, community violence interruption programs, and better crisis response systems that connect people to care.
- Make roads safer – Speed management, safer street design, vehicle safety, and impaired-driving prevention can drive large population-level gains. Countries that have reduced traffic deaths treat road safety as a public health system, not just an individual responsibility.
- Strengthen primary care and chronic disease management – Make preventive visits easier to access. Improve hypertension and diabetes control. Reduce medication cost barriers. Invest in team-based primary care that can follow patients over years, not just episodes.
- Invest in mothers and children – Early-life conditions have lifelong effects. Policies that reduce child poverty, support families, and improve maternal health tend to generate long-term health dividends.
- Treat health as a systems outcome -Housing, education, food environments, work conditions, and community safety are health policy whether we label them that way or not.
Ultimately, the U.S. longevity gap is the predictable result of higher risk from overdoses and injuries, heavier chronic disease burden, fragmented access to consistent care, and weaker social supports interacting with deep inequality. Addressing it in a meaningful way will require careful planning and political will.
The encouraging part is that the U.S. already contains examples of near-peer longevity. Closing the gap means making those outcomes normal rather than exceptional by spreading evidence-based approaches in public health, injury prevention, primary care, and social policy.