Patterns, causes and policy implications of regional differences in COVID-19 mortality in the United States: A secondary analysis of excess mortality estimates

Abstract

Abstract In 2021 the “Red Covid,” narrative emerged: states and counties that are predominantly Republican and/or supported Trump experienced widespread vaccine hesitancy and eventually opposed mask and vaccine mandates. Our analysis of excess mortality quantifies this effect. After the first wave, death rates in the South were more than double those in the Northeast; 45% of deaths were in the South, with 38% of the population. Although there have been many correlational studies of this phenomenon, our analysis uses excess mortality estimates, aggregated by Census region and six pandemic phases, to establish the magnitude of this effect. We show that, if every region had the same mortality rate as the lowest regional rate in each period, more than 418,763 COVID-19 deaths were in this sense "avoidable." The analysis also shows that the U.S. has been a divided nation at almost since the start of the pandemic. We estimate that 198,642 deaths could have been averted during the Summer of 2020 and the Alpha wave, before vaccines were widely available. This strongly suggests that implementation of and adherence to NPIs made a difference. Similarly, while vaccination is a personal choice, as many Republicans argue, our estimates of 221,360 deaths averted after vaccines became available demonstrate the population-level consequences of that choice. Beyond the substantive results, this analysis demonstrates the importance of excess mortality estimates as part of the public health surveillance toolkit. Official mortality counts rely on complete recording of COVID-19 as a cause of death, COVID-19 deaths are under reported for many reasons. Between Jan. 3, 2020 and April 30, 2022, public health officials reported 978,567 COVID-19 deaths in the U.S. According to our calculations, however, the excess mortality associated with COVID-19 totaled 1,335,292, during that period, 37% more COVID-19 deaths than reported. Moreover, the proportion of COVID-19 deaths reported as such varied markedly over time and region, and reporting was generally less complete in the regions and periods with the highest mortality rates. Analyses of recorded COVID-19 deaths, just as of cases, therefore, would attenuate regional differences.