Summary
The Global Burden of Disease (GBD) 2021 US state-level analysis extends the GBD framework to 371 diseases and 88 risk factors across all 50 US states plus Washington, D.C., for 1990–2021. The study documents a continuous relative decline in US life expectancy and healthy life expectancy (HALE) rankings against the world, the catastrophic impact of COVID-19, an +878% increase in drug use disorder mortality over the study period, and a finding that health improvement stalled after 2010 despite Affordable Care Act (ACA) coverage expansion.
Key Claims
- LE rank decline: US life expectancy (LE) rank fell from 35th/19th (male/female, 1990) to 46th/47th (2021) of 204 countries; HALE rank fell from 42nd/32nd to 69th/76th over the same period.
- National LE/HALE 2021: LE 77.1y (74.3 male, 80.0 female); HALE 64.4y (63.2 male, 65.7 female). Compared to 1990 LE of 75.6y — only 1.5 years gained over 31 years.
- State extremes (LE): Hawaii 81.2y (highest) vs. Mississippi 71.9y (lowest) in 2021; 2:1 age-standardised mortality rate ratio (Hawaii 433.2 vs. Mississippi 867.5 per 100,000). 14 states lost LE over the study period; West Virginia lost the most (−2.7 years total; −2.0 male, −3.0 female, 1990–2021).
- State extremes (HALE): Hawaii 68.3y vs. West Virginia 59.5y in 2021; WV ranked 141st for males and 137th for females among all 203 other countries and territories — worse than most of the world.
- Hawaii's relative decline: Best-performing US state fell from 6th/4th globally (male/female LE, 1990) to 28th/22nd (2021); from 14th/5th (HALE) to 39th/34th. Even the best US state is deteriorating relative to peers.
- 8 states worst in world for years lived with disability (YLDs): West Virginia, Kentucky, Oklahoma, Pennsylvania, New Mexico, Ohio, Tennessee, and Arizona had higher age-standardised YLD rates than any country in the world in 2021 (Afghanistan ranked 9th behind these states).
- Only 6 countries had higher national YLD rates than the US as a whole: Afghanistan, Lesotho, Liberia, Mozambique, South Africa, Central African Republic.
- Drug use disorders surge: Age-standardised mortality +878.0% (95% uncertainty interval [UI] 770.1–1015.5), 1990–2021; disability-adjusted life year (DALY) rank jumped from #26 (1990) to #2 (2021), surpassed only by COVID-19. State extremes: West Virginia +1105.1%, Florida +580.3%, Wyoming +482.2%. Drug use disorders were the leading DALY cause for males in 22 states in 2021 and for females in 22 states.
- Depressive disorders: YLD rate +56.0% (48.2–64.3), 1990–2021; #5 DALY cause in 2021. For females, mental health disorders had the highest age-standardised YLD rate, rising +59.8%.
- COVID-19: #1 cause of DALYs in 2021 in most states. Arizona: largest COVID-related LE decline (−2.8 years); Hawaii: smallest (−0.8 years). Racial disparities: Hispanic populations experienced higher COVID mortality than White populations despite lower baseline mortality for nearly every other cause.
- ACA finding: Improvements in health outcomes "appear to have stalled during the period of expanded access compared with the preceding two decades (1990–2010)," suggesting insurance coverage alone is insufficient for reducing health inequities.
- Improving causes (1990–2021): ischemic heart disease (IHD) mortality −56.1%, lung cancer −41.9%, breast cancer −40.9%; tobacco risk-attributable DALY rate −48.8%.
- Worsening causes: Drug use disorder mortality +878%, chronic kidney disease +158.3%, falls +89.7%, high fasting plasma glucose mortality +9.3%.
- Leading risk factors for death (2021): High systolic blood pressure, high fasting plasma glucose, tobacco. For ages 15–49, leading risk factors were drug use, high alcohol use, and dietary risks. High body mass index (BMI) was the leading Level 2 risk factor for DALYs overall.
- Washington, DC outlier: Gained 9.7 LE years 1990–2021, the largest state-level LE gain — driven largely by IHD decline and neonatal disorder improvements.
Concepts Introduced or Extended
Entities Mentioned
Quotes
"In 2021, eight states (West Virginia, Kentucky, Oklahoma, Pennsylvania, New Mexico, Ohio, Tennessee, and Arizona) had age-standardised rates of years lived with disability greater than any country in the world."
"Improvements in health outcomes as a result of better access to medical care appear to have stalled during the period of expanded access compared with the preceding two decades (1990–2010). This finding suggests that health policies that only increase the proportion of the US population with insurance are only one part of the comprehensive strategy that is needed."
"West Virginia—the lowest-ranked state in 2021—ranked 141st for males and 137th for females [in HALE]."
My Take
This paper is the 2021-vintage extension of the GBD 2013 US analysis. Its primary contribution is: (1) state-level granularity making the US-vs-world comparison far more damning — individual US states now rank below countries most Americans consider poor comparators; (2) quantification of COVID-19's geographic heterogeneity and its role in reversing the 2003–2019 LE improvement trend; (3) the ACA policy evaluation finding, which challenges a central plank of US health reform. For this wiki's purposes, the most policy-relevant finding is the drug use disorder DALY rank jump (#26→#2) paired with the state-level YLD extremes: eight states surpassing every country in disability burden. These states — West Virginia, Kentucky, Ohio, Pennsylvania, Oklahoma — are exactly the high-disability-insurance (DI)-incidence states documented by Lindner, Burdick, and Meseguer (2017) and the geographic epicenter of the deaths-of-despair crisis. The ACA finding is methodologically important: it cannot settle causality (confounders include the Great Recession, opioid epidemic acceleration post-2010, and population aging), but it documents that expanded insurance coverage, on its own, has not reversed morbidity expansion.