Do Premature Death Rates Differ by Race in the U.S.?

Papanicolas et al. (2025) study how premature mortality varies by race across U.S. states and what that implies for unrealized Medicare benefits. They ask whether Black and White adults differ in mortality before age 65. They use CDC Vital Statistics and CDC WONDER population data linked with Medicare Beneficiary Summary Files for 2012 and 2022. They find that premature mortality rose 27.2% overall (243 to 309 deaths per 100,000). Black adults had higher rates in both years, with an increase of 118 deaths per 100,000 (38.2%) versus 68 per 100,000 (27.7%) for White adults, showing widening racial disparities.

Why This Article Was Selected for The Policy Scientist

This article by Papanicolas et al. (2025) examines the sizable racial differences in premature mortality and their implications for Medicare eligibility. The authors have published widely on mortality and health system performance, and the topic is timely given recent increases in U.S. midlife mortality. The magnitude of the Black–White mortality gap is substantial and signals that different population groups do not experience Medicare in the same way. The national CDC and Medicare data are high quality and allow credible state-level comparisons. Methods are descriptive rather than causal; future work could use causal designs to isolate drivers of the observed racial differentials.

Full Citation and Link to Article

Papanicolas, I., Figueroa, J. F., & Orav, E. J. (2025). Racial disparities in premature mortality and unrealized Medicare benefits across U.S. states. JAMA Health Forum, 6(11), e254916. https://doi.org/10.1001/jamahealthforum.2025.4916 

Central Research Question

The central research question concerns how premature mortality among adults aged 18 to 64 varies across U.S. states, how these patterns differ between Black and White populations, and what implications these disparities may have for unrealized Medicare benefits. The authors are motivated by the fact that Medicare is financed broadly through payroll tax contributions during working life, with the expectation that individuals will access coverage at age 65. When individuals die prior to age 65, they forfeit the opportunity to utilize the benefits they have helped fund. Because life expectancy and mortality burdens vary substantially across racial groups, the authors examine whether certain populations face a structurally different Medicare experience by virtue of premature mortality. The research question is thus simultaneously descriptive and inferential: it asks how premature mortality has changed over the past decade, whether racial disparities have widened or narrowed, and how these mortality differences map onto the concept of unrealized Medicare benefits.

Previous Literature

The authors situate the study within a growing body of literature documenting declining life expectancy in the United States, especially among working-age adults. Prior research has shown that U.S. mortality trends diverge from those of many peer nations, with deaths of despair, chronic disease, and injury contributing to rising mortality. A set of studies have also linked these broader mortality trends to socioeconomic conditions—including income, wealth, and labor market inequality—and to structural barriers in access to health care. The literature further documents widening racial and ethnic disparities in life expectancy, with Black individuals historically experiencing higher mortality and lower life expectancy than White individuals. Prior research by Papanicolas and colleagues has examined cross-national mortality, avoidable deaths, and differences in health system performance. Other cited work has traced the evolution of midlife mortality across racial and ethnic groups, assessed wealth-mortality gradients across countries, and evaluated structural contributors to health inequities. The cumulative literature provides a backdrop for the present research by demonstrating that U.S. mortality disadvantages are not solely a function of health care delivery but reflect broader social and structural determinants. The present article builds upon that foundation by focusing specifically on premature mortality relative to Medicare eligibility, an angle that links demographic and epidemiological trends to policy design.

Data

The study draws on multiple high-quality national data sources. Mortality data are obtained from the Centers for Disease Control and Prevention (CDC) National Vital Statistics System microdata, which provides comprehensive information on deaths among individuals aged 18 to 64. Population estimates are drawn from CDC WONDER, enabling the computation of state-level mortality rates. To distinguish between deaths among Medicare beneficiaries and non-beneficiaries within the same age group, the authors use Medicare Beneficiary Summary Files, which identify individuals under 65 who qualify for Medicare due to disability or other conditions. The use of these combined data sources allows the authors to estimate age- and sex-standardized premature mortality rates for 2012 and 2022 for the full population and separately for Black and White individuals. These national administrative datasets are widely regarded as authoritative for mortality surveillance, given their large sample sizes, standardized reporting, and comprehensive population coverage. However, the authors note that inconsistencies in the coding of race and ethnicity across sources limit the analysis to Black and White populations, as these categories are most reliably harmonized. Despite this limitation, the data are sufficiently robust to support detailed cross-state comparisons and temporal assessments.

Methods

The authors conduct a retrospective cohort analysis with state-level aggregation. They define premature mortality as deaths occurring between ages 18 and 64, subtracting deaths among under-65 Medicare beneficiaries to approximate the population that contributed to but did not benefit from Medicare. They compute standardized mortality rates for 2012 and 2022 using direct age- and sex-standardization to the U.S. population distribution. For racial analyses, they compare Black and White standardized rates by state and nationally for both years. Significance testing is performed using two-sided tests with a P<.05 threshold. Analyses are implemented using R (version 4.4.3) and SAS (version 9.4). Although the analytical strategy is systematic and transparent, it is descriptive rather than causal. The study does not attempt to model counterfactual scenarios or estimate causal effects of policy or environmental variables on mortality outcomes. Rather, it quantifies the scale and distribution of premature mortality as inputs to policy discussions. From a methodological perspective, the approach is sufficient to characterize disparities and trends, though it cannot identify mechanisms or causal pathways. Future research using quasi-experimental or causal inference techniques could clarify which policy levers most strongly modulate premature mortality trajectories or racial differentials.

Findings/Size Effects

The study finds that premature mortality rose markedly between 2012 and 2022. Nationally, the standardized premature mortality rate increased from 243 to 309 deaths per 100,000 adults aged 18 to 64, a 27.2% increase. By state, Mississippi exhibited the highest rate in 2012 (337 deaths per 100,000), while West Virginia exhibited the highest rate in 2022 (488 deaths per 100,000). Minnesota had the lowest rate in 2012 (185 deaths per 100,000), and Massachusetts had the lowest in 2022 (225 deaths per 100,000). These patterns indicate substantial heterogeneity across states, with certain regions experiencing more severe increases. Racial differentials were consistently large. In 2012, Black adults had a premature mortality rate of 309 deaths per 100,000 versus 247 for White adults, a difference of 62 deaths per 100,000. By 2022, Black premature mortality rose to 427 deaths per 100,000, while White premature mortality rose to 316 deaths per 100,000. These figures reflect increases of 118 deaths per 100,000 (38.2%) for Black individuals and 68 deaths per 100,000 (27.7%) for White individuals. Thus, although premature mortality increased for both groups, the relative and absolute increases were larger for Black adults. State-level racial disparities were significant in most states, with exceptions including New Mexico, Rhode Island, and Utah. These results underscore the scale and persistence of racial inequities, with implications for Medicare coverage given that individuals who die before reaching eligibility cannot realize program benefits. The authors note that the observed patterns align with broader evidence that mortality among working-age U.S. adults is increasing, and that Black populations experience disproportionate burdens across multiple mortality domains.

Conclusion

The study concludes that premature mortality among working-age U.S. adults increased substantially between 2012 and 2022 and that racial disparities widened, with Black individuals facing persistently higher and faster-rising mortality than White individuals. These trends have direct relevance for Medicare, since individuals who die before age 65 effectively subsidize a program from which they do not benefit. Although the study does not estimate unrealized financial benefits directly, the descriptive evidence suggests a structural misalignment between financing and realized coverage that varies systematically by race. The findings highlight potential equity concerns within Medicare’s entitlement structure and suggest that rising mortality and widening racial gaps may warrant policy scrutiny, particularly as Medicare financing continues to evolve. The authors also note limitations related to racial and ethnic coding, which constrained the analysis to Black and White populations. Nonetheless, the study provides a clear empirical foundation for future work exploring the policy implications of mortality disparities and eligibility design. Further research using causal inference could help identify which policies—such as Medicaid expansion, disability determination procedures, or preventive health investments—most effectively mitigate premature mortality and narrow racial gaps.