Skip to main content

Progress in Reducing Disparities in Premature Mortality in the USA: a Descriptive Study



Eliminating health disparities among different segments of the US population is an overarching goal of the US Healthy People 2020 objectives.


Examine changes in educational, rural-urban, and racial disparities in premature mortality during the past 10 years.

Design and Participants

Descriptive analysis of US mortality data from 2007 to 2017.

Main Measures

Relative and absolute rural-urban, educational attainment, and Black-White disparities in premature mortality for all-cause and top 10 causes of death among persons ages 25–74 years, estimated as rate ratios and rate differences between ≤12 and ≥16 years of education, rural versus urban, and non-Hispanic Black (Black) versus non-Hispanic White (White), respectively, in 2007 and 2017.

Key Results

During 2007–2017, mortality rates in persons aged 25–74 years in the USA increased for several leading causes of death, especially in persons with <16 years of education, rural residents, and White people. As a result, disparity in mortality between 2007 and 2017 widened on both relative and absolute scales for all-cause and for 6 of the top 10 causes of death by education and for all-cause and for 9 of the top 10 causes by rural/urban residence. In contrast, Black-White disparities narrowed for all-cause and for all 7 causes that Black people had a higher rate than White people. For all-cause mortality for example, absolute disparities in the number of deaths per 100,000 person-years between 2007 and 2017 increased from 454.0 (95%CI, 446.0–462.1) to 542.7 (535.6–549.7) for educational attainment and from 85.8 (82.8–88.8) to 140.5 (137.6–143.4) for rural versus urban; in contrast, absolute Black-White disparity decreased from 315.3 (311.0–319.7) to 221.7 (218.1–225.3).


Educational and rural-urban disparities in premature mortality widened, whereas Black-White disparities narrowed in the USA between 2007 and 2017, though overall rates remained considerably higher in Black people.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. U.S. Department of Health and Human Services. HHS announces the nation’s new health promotion and disease prevention agenda. Accessed March 20, 2020.

  2. U.S. Department of Health and Human Services. Healthy People 2020 Framework. Accessed March 24, 2020.

  3. Koh HK, Blakey CR, Roper AY. Healthy People 2020: a report card on the health of the nation. JAMA. 2014;311(24):2475-2476.

    CAS  Article  Google Scholar 

  4. Koh HK, Graham G, Glied SA. Reducing racial and ethnic disparities: the action plan from the department of health and human services. Health Aff (Millwood) 2011;30(10):1822-1829.

    Article  Google Scholar 

  5. U.S. Department of Health and Human Services. National Stakeholder Strategy for Achieving Health Equity. Accessed March 24, 2020.

  6. U.S. Department of Health and Human Services. National Partnership for Action to End Health Disparities. Accessed March 24, 2020.

  7. Obama B. United States Health Care Reform: Progress to Date and Next Steps. JAMA. 2016;316(5):525-532.

    Article  Google Scholar 

  8. Benjamins MR, Silva A, Saiyed NS, De Maio FG. Comparison of all-cause mortality rates and inequities between Black and White populations across the 30 most populous US cities. JAMA Netw Open 2021;4(1):e2032086.

    Article  Google Scholar 

  9. Bor J, Cohen GH, Galea S. Population health in an era of rising income inequality: USA, 1980-2015. Lancet. 2017;389(10077):1475-1490.

    Article  Google Scholar 

  10. Elo IT, Hendi AS, Ho JY, Vierboom YC, Preston SH. Trends in non-Hispanic White mortality in the United States by metropolitan-nonmetropolitan status and region, 1990-2016. Popul Dev Rev 2019;45(3):549-583.

    Article  Google Scholar 

  11. National Center for Health Statistics. Vital Statistics Online Data Portal. Accessed November, 15, 2020.

  12. World Health Organization. International Statistical Classification of Disease and Related Health Problems: 10th Revision. In. Geneva, Switzerland: World Health Organization; 1992.

  13. Centers for Disease Control and Prevention. National Center for Health Statistics: National Vital Statistics System. Accessed December, 10, 2017.

  14. The United States Census Bureau. PUMS data, American Cummnity Survey. Available at: Accessed December, 20, 2019.

  15. Surveillance, Epidemiology, and End Results (SEER) Program ( SEER*Stat Database: Mortality - All COD, Aggregated With County, Total U.S. (1990-2017) <Katrina/Rita Population Adjustment>, National Cancer Institute, DCCPS, Surveillance Research Program, released December 2019. Underlying mortality data provided by NCHS (

  16. Albano JD, Ward E, Jemal A, et al. Cancer mortality in the United States by education level and race. J Natl Cancer Inst 2007;99(18):1384-1394.

    Article  Google Scholar 

  17. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer Statistics, 2021. CA Cancer J Clin 2021;71(1):7-33.

    Article  Google Scholar 

  18. Arias E, Heron M, Hakes J. The validity of race and Hispanic-origin reporting on death certificates in the United States: an update. Vital Health Stat 2. 2016;(172):1-21.

  19. Adler NE, Rehkopf DH. U.S. disparities in health: descriptions, causes, and mechanisms. Annu Rev Public Health 2008;29:235-252.

    Article  Google Scholar 

  20. Braveman P, Gottlieb L. The social determinants of health: it's time to consider the causes of the causes. Public Health Rep 2014;129 Suppl 2:19-31.

    Article  Google Scholar 

  21. Barnett JC, Vornovitsky MS. Health insurance coverage in the United States: 2015. In. Washington, DC: U.S. Government Printing Office; 2016.

    Google Scholar 

  22. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annu Rev Public Health 2011;32(1):381-398.

    Article  Google Scholar 

  23. Larson NI, Story MT, Nelson MC. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med 2009;36(1):74-81.

    Article  Google Scholar 

  24. Walker RE, Keane CR, Burke JG. Disparities and access to healthy food in the United States: a review of food deserts literature. Health Place 2010;16(5):876-884.

    Article  Google Scholar 

  25. Lovasi GS, Hutson MA, Guerra M, Neckerman KM. Built environments and obesity in disadvantaged populations. Epidemiol Rev 2009;31:7-20.

    Article  Google Scholar 

  26. Sallis JF, Floyd MF, Rodriguez DA, Saelens BE. Role of built environments in physical activity, obesity, and cardiovascular disease. Circulation. 2012;125(5):729-737.

    Article  Google Scholar 

  27. Bhatt J, Bathija P. Ensuring access to quality health care in vulnerable communities. Acad Med 2018;93(9):1271-1275.

    Article  Google Scholar 

  28. Cyr ME, Etchin AG, Guthrie BJ, Benneyan JC. Access to specialty healthcare in urban versus rural US populations: a systematic literature review. BMC Health Serv Res 2019;19(1):974.

    Article  Google Scholar 

  29. Hillier A, Chilton M, Zhao QW, Szymkowiak D, Coffman R, Mallya G. Concentration of tobacco advertisements at SNAP and WIC stores, Philadelphia, Pennsylvania, 2012. Prev Chronic Dis 2015;12:E15.

    Article  Google Scholar 

  30. Lucan SC, Maroko AR, Sanon OC, Schechter CB. Unhealthful food-and-beverage advertising in subway stations: targeted marketing, vulnerable groups, dietary intake, and poor health. J Urban Health 2017;94(2):220-232.

    Article  Google Scholar 

  31. Isgor Z, Powell L, Rimkus L, Chaloupka F. Associations between retail food store exterior advertisements and community demographic and socioeconomic composition. Health Place 2016;39:43-50.

    Article  Google Scholar 

  32. Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report - United States, 2013. MMWR Suppl. 2013;62(Suppl 3):1-184.

  33. Doogan NJ, Roberts ME, Wewers ME, et al. A growing geographic disparity: Rural and urban cigarette smoking trends in the United States. Prev Med 2017;104:79-85.

    CAS  Article  Google Scholar 

  34. Befort CA, Nazir N, Perri MG. Prevalence of obesity among adults from rural and urban areas of the United States: findings from NHANES (2005-2008). J Rural Health 2012;28(4):392-397.

    Article  Google Scholar 

  35. National Center for Health Statistics. Health, United States, 2018. Hyattsville, MD. 2019.

  36. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291.

    CAS  Article  Google Scholar 

  37. Valero-Elizondo J, Hong JC, Spatz ES, et al. Persistent socioeconomic disparities in cardiovascular risk factors and health in the United States: Medical Expenditure Panel Survey 2002-2013. Atherosclerosis. 2018;269:301-305.

    CAS  Article  Google Scholar 

  38. Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006;144(10):705-714.

    Article  Google Scholar 

  39. Denniston MM, Jiles RB, Drobeniuc J, et al. Chronic hepatitis C virus infection in the United States, National Health and Nutrition Examination Survey 2003 to 2010. Ann Intern Med 2014;160(5):293-300.

    Article  Google Scholar 

  40. Woolf SH, Schoomaker H. Life expectancy and mortality rates in the United States, 1959-2017. JAMA. 2019;322(20):1996-2016.

    Article  Google Scholar 

  41. Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS. Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science. 2018;361(6408).

  42. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A 2015;112(49):15078-15083.

    CAS  Article  Google Scholar 

  43. Raghupathi V, Raghupathi W. The influence of education on health: an empirical assessment of OECD countries for the period 1995-2015. Arch Public Health 2020;78:20.

    Article  Google Scholar 

  44. U.S. Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020.

  45. Trivedi AN, Nsa W, Hausmann LR, et al. Quality and equity of care in U.S. hospitals. N Engl J Med 2014;371(24):2298-2308.

    CAS  Article  Google Scholar 

  46. Williams DR, Priest N, Anderson NB. Understanding associations among race, socioeconomic status, and health: patterns and prospects. Health Psychology. 2016;35(4):407-411.

    Article  Google Scholar 

  47. Bailey ZD, Krieger N, Agenor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453-1463.

    Article  Google Scholar 

  48. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff (Millwood) 2002;21(2):60-76.

    Article  Google Scholar 

  49. Koh HK, Rajkumar R, McDonough JE. Reframing prevention in the era of health reform. JAMA. 2016;316(10):1039-1040.

    Article  Google Scholar 

  50. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. N Engl J Med 2010;363(14):1296-1299.

    CAS  Article  Google Scholar 

  51. Sommers BD, Blendon RJ, Orav EJ, Epstein AM. Changes in utilization and health among low-income adults after medicaid expansion or expanded private insurance. JAMA Intern Med 2016;176(10):1501-1509.

    Article  Google Scholar 

  52. Rostron BL, Boies JL, Arias E. Education reporting and classification on death certificates in the United States. Washington, DC: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2010.

  53. Phelan JC, Link BG, Tehranifar P. Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav. 2010;51 Suppl:S28-40.

    Article  Google Scholar 

Download references


We acknowledge the Intramural Research Department of the American Cancer Society for supporting this study.


Supported by the Intramural Research Department of the American Cancer Society (Ma, Yabroff, Siegel, Cance, and Jemal).

Author information

Authors and Affiliations



Concept and design: Ma, Jemal

Acquisition, analysis, or interpretation of data: all authors

Drafting of the manuscript: Ma, Jemal

Critical revision of the manuscript for important intellectual content: all authors

Statistical analysis: Ma

Ma had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Corresponding author

Correspondence to Ahmedin Jemal D.V.M., Ph.D.

Ethics declarations

Role of the Funder/Sponsor

The funders of the study had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 118 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ma, J., Yabroff, K.R., Siegel, R.L. et al. Progress in Reducing Disparities in Premature Mortality in the USA: a Descriptive Study. J GEN INTERN MED (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • leading causes of death
  • disparities
  • Healthy People 2020 goal
  • United States
  • premature mortality