Every state in the country saw an increase in avoidable, premature deaths during the first two years of the COVID-19 pandemic, according to a new report released last week by a foundation focused on improving the country’s health care system.

The maternal mortality rate nearly doubled between 2018 and 2021, the report also found.

“Still reeling from the COVID-19 pandemic, states are trying to reverse a stunning rise in preventable deaths from multiple causes,” the report from the Commonwealth Fund read. “These premature deaths have lowered the nation’s average life expectancy, with people of color experiencing the steepest declines.”

Premature deaths are defined by the foundation as a combination of deaths resulting from preventable causes — preventable infections, injuries or illnesses, as well as gun-related deaths — and deaths caused by conditions that would otherwise be treatable with adequate access to health care, such as some cancers and chronic illnesses like diabetes.

Some states saw more drastic rises in preventable deaths, with Louisiana, Mississippi, New Mexico, Arizona and Texas all experiencing a more than 35% increase between 2019 and 2021. Pandemic-induced delays in Americans receiving care “may have contributed to the increase,” according to the report.

Black, Hispanic, American Indian and Alaska Native communities experienced larger drops in life expectancy between 2019 and 2021 than their white and Asian-American counterparts, the report concluded. The authors of the report pointed to the United States’ history of structural racism, insufficient health insurance policies, and a lack of quality patient care for certain racial and ethnic groups as factors that contributed to the decline.

Fatal drug overdoses, alcohol-induced deaths, suicide and gun-related deaths “increased rapidly after the arrival of COVID-19 and reached record levels in 2021,” the researchers wrote.

Drug overdose deaths nearly tripled from 38,329 in 2010 to 106,699 in 2021, according to Centers for Disease Control and Prevention data cited in the report.

Gun-related deaths rose 23% between 2019 and 2021, the report said, crediting an increase in mass shootings and suicides. 

“As we emerge from the worst of the pandemic, it’s become clear that Americans — especially teens — are not getting the mental health care they need,” the report said. “Recent data point to alarming increases in the shares of teens who have persistent feelings of sadness and who attempt or seriously consider suicide.”

Citing a survey by the federal Substance Abuse and Mental Health Services Administration, the report notes 60% of Americans ages 12 to 17 who had a “major depressive episode” did not receive treatment in 2020. In one state, South Carolina, the number was nearly 77%.

Among adults, 55% of those with mental illness did not receive treatment, with 42% of those who didn’t get treatment naming cost as the main deterrent.

Medical debt was also a factor the Commonwealth Fund considered as they examined why Americans were not pursuing or did not have access to treatment that could have stemmed the rise in premature deaths.

In February 2022, just under 13% of the 230 million people who received credit reports in the United States that month had medical debt in collections, not counting debt owed directly to hospitals and other health care providers.

Southern states were much more likely to have larger portions of their population with medical debt in collections, including over one-fifth of residents in West Virginia, South Carolina, North Carolina and Oklahoma.

The foundation’s report also examined maternal mortality rates, finding disconcerting trends that led to the United States to have a rate nearly twice as high as other high-income countries. The rates among people of color are even worse than the overall numbers, with Black women seeing an increase in deaths from just over 37 per 100,000 live births to just under 70 per 100,000 between 2018 and 2021.

White women saw their deaths per 100,000 increase from roughly 15 to over 26 in the same time period.

Women of American Indian and Alaska Native heritage experienced the worst increase of the demographic groups examined in the report: in 2019, those communities saw around 49 deaths per 100,000 live births. In 2021 it was nearly 119 per 100,000.

“During the pandemic, maternal deaths rose considerably amid the severe disruptions in health care delivery. COVID-19 was an additional clinical risk factor and slow vaccine uptake raised the risk of death for those who were pregnant,” the report said.

COVID-19 contributed to nearly one-third of maternal deaths in 2020 and 2021, according to an October 2022 report prepared by the U.S. Government Accountability Office for lawmakers in Congress.

The Commonwealth Fund’s report found prenatal and postpartum care access is lacking for many Americans who do not have insurance coverage or struggle to find providers who accept their plans.

Texas and Florida had the highest rates in that category, with each recording that 29% of mothers in their states who went on to give birth failed to receive prenatal care in the first trimester.

“As states struggle to find ways to maintain access to coverage and care as pandemic-era policies expire, the overturning of Roe v. Wade has further fractured reproductive health care access,” the report’s authors wrote. “Which state you live in now determines whether you have access to a full range of reproductive health care services. And for low-income women and women of color, the stakes are even higher.”

States with new abortion laws and restrictions on reproductive health providers have fewer maternal care professionals than states without them, with a 32% smaller ratio of obstetricians to births and 59% smaller ratio of certified nurse midwives to births. The disparities could continue to grow due in part to some maternity care providers being “reluctant to work in states where they might face legal challenges to their practice,” a December 2022 report by the Commonwealth Fund noted.

To combat the rise in premature deaths and maternal mortality, the report from last week listed 20 recommendations for state and federal policymakers, including growing and diversifying the United States’ health care workforce, expanding Medicaid access, dramatically ramping up the nation’s behavioral health and addiction treatment infrastructure, and reigning aggressive medical debt collection from hospitals and other providers. 

“These challenges are considerable,” the report concluded. “The policies presented here show, however, that states and the federal government have a wide range of options for making progress in the near term and for improving the health of all U.S. residents over time.”