Land of the Uninsured and Dying: The American Excess Death Problem

Mortality rates for American millennials and older Gen Z—individuals between ages 25 and 44—are 2.6 times higher than the rates of their peers in other wealthy countries.  Originally believed to be a mortality gap based on how countries addressed COVID-19, a recent study showed an American “excess death” problem that continued to grow in 2023 well after peak COVID-19 deaths for younger Americans.  Overall, between 1980 and 2023 “the continued consequences of US health system inadequacies, economic inequality, and social and political determinants of health” have cost an estimated 14.7 million Americans their lives.

In 2023 alone, there were approximately 700,000 Americans who lost their lives that would have survived if they lived in any other wealthy country.  When it comes to folks aged 25 to 44, 62% of annual deaths would be prevented in other wealthy countries.  This means that nearly two-thirds of American young adults who die each year do not need to die.

And it is about to get worse.

The Fight Over Affordable Care Act Enhanced Subsidies

The American excess death problem stems from societal inequities that tarnished the American health system beginning in the Reagan administration, but recent policies exacerbated the problem as American politicians seem to view health coverage as a more optional service each year.  The United States is the only wealthy country that does not guarantee health coverage for its citizens:

Check out "U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes" to see how far behind the U.S. health care system is relative to other wealthy countries.

The societal inequities related to health coverage are likely to become worse in the coming months as the Republican Congress plans to allow the Affordable Care Act (ACA) enhanced subsidies to expire at the end of 2025.  Each year, about 24 million Americans purchase health insurance from the ACA marketplace because their current employers do not offer insurance, they are self-employed, they work a combination of part-time jobs, or they are unemployed.

We would have been part of those 24 million Americans earlier this year when I stepped away from my 9-to-5 for a few months if not for temporary COBRA continuation coverage.  Since Patrick is self-employed, we had no other option for health insurance besides COBRA or an ACA plan.  It cost more than $1,500 a month for the two of us—the costs were approximately the same either way, so we opted for COBRA to stay on our same health plan—meaning only American couples who can spare around $20k of income can afford to pay for an ACA plan in full.  For larger families requiring coverage, the cost can be more.

We were fortunate enough to be able to cover the cost thanks to this wonderful business, but 22 million out of the 24 million Americans who purchase plans from an ACA marketplace exchange cannot afford the full premiums.  ACA enhanced subsidies help make health insurance more affordable for these Americans.  ACA subsidies can help those making up to 400% of the federal poverty line, depending on family size and other factors.  

The subsidies were introduced in 2021 as part of the American Rescue Plan Act for relief during the pandemic, and they were renewed in 2022 in the Inflation Reduction Act.  They are now set to expire at the end of 2025 unless new legislation prevents them from doing so.

One could argue that these subsidies were meant to be a band-aid at a time of turmoil during a global pandemic.  However, they really are a band-aid for the 40-year decay of the American healthcare system initiated by the Reagan administration.  While we need much more than a band-aid to fix the American healthcare system, taking away the band-aid that makes coverage available for 22 million people will cause more pain.

If enhanced subsidies disappear on January 1, 2026, the average out-of-pocket premium cost would rise by 75%.  Tax credits for those without workplace health insurance plans will disappear, hurting innovative entrepreneurs early in their journeys, individuals working at small businesses without employer-sponsored plans, and those making a living in the gig economy.  Over the next decade, 4.2 million of those 22 million Americans relying on ACA enhanced subsidies are predicted to become uninsured as the failing American healthcare system further decays.

This is why Congressional Democrats allowed a government shutdown to happen on October 1, 2025, by insisting that any funding legislation include an extension of the ACA tax credits.  They refused to let the broken system fail even more Americans.

Unfortunately, Congressional Republicans already decided to fail many more than 4.2 million Americans, but not until after midterm elections in November 2026.

The Delayed Disaster of the One Big Beautiful Bill Act

We already discussed the fiscal irresponsibility of the One Big Beautiful Bill Act, but the law also included the gutting of health coverage safety nets for Americans.  Surprised, because you have not felt a change since the bill became law?

You have not felt any changes yet because Congressional Republicans want you to vote for them in November 2026 before they reduce or take away your health insurance in January 2027.

We are not a partisan business, but this action is deceptive and cruel.  Medicaid eligibility requirements become much more rigid in January 2027, implementing work or education requirements or mandating individuals receive exemptions.  That may sound okay at first, but exemptions must be approved at the state level and will require regular eligibility redeterminations.  The Medicaid eligibility work requirement will require individuals receiving Medicaid to work or perform another activity for 80 hours a month, a 20-hour workweek.  Many individuals rely on Medicaid because they have a disability or provide round-the-clock care for a sick, elderly, or disabled friend or relative.  Expecting these individuals to work 20 hours a week is inhumane.

For some it is not just inhumane—it is impossible.  An estimated 10 million of these people are expected to lose health coverage over the next decade.  If ACA enhanced subsidies also disappear, that means 14.2 million Americans will lose health coverage over the next decade.

But at least there is hope for delaying the elimination of ACA enhanced subsidies: “Many Congressional Republicans are also eager to extend these subsidies for fear of health insurance sticker shock in advance of the November 2026 midterms,” according to Chris Krueger of TD Cowen’s Washington Research Group.  We may put off the problem inconveniencing 22 million Americans and putting coverage out of reach for 4.2 million for another year so voters do not realize that they are voting for politicians who have decided to take away their health coverage.

Republican lawmakers are banking on the public to be stupid enough to reelect them so they can allow multiple healthcare safety nets to expire in January 2027 and doom 14.2 million Americans, of all political parties, from red and blue states and districts, to losing health coverage.

More Excess Deaths

The 14.2 million Americans that will lose health insurance over the next ten years is almost as many as the 14.7 million American lives unnecessarily lost between 1980 and 2023 due to our broken healthcare system and societal inequities.

We are on track to have more American excess deaths in the next 10 years than the last 40+ years.  The United States needs a reality check when it comes to prioritizing health and health coverage.  We do not provide the access to preventative care to prevent disasters, we create societies that discourage healthy lifestyles, and we refuse to fund treatment when Americans need help because of these deficiencies.

The next time you vote, remember you get to decide how many young people die due to apathy.  You can decide whether the 700,000 excess deaths in 2023 become more than 1 million excess deaths in 2027.  You get to decide whether millennials like me, a 34-year-old right in the middle of this dying generation, get the opportunity to experience their 50s.

Or whether we are just another excess death to save you $10 in taxes.