The Fund supports networks of state health policy decision makers to help identify, inspire, and inform policy leaders.
A bipartisan group of state health policymakers from both the executive and legislative branches who are focused on improving population health.
Networks of state officials, advocates, and others aiming to invest in and transform primary care.
A program dedicated to advancing state-based efforts to make health care more affordable for residents, employers, and states.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
A leadership development program for early and mid-career state government officials who are committed to improving the health of all people in their communities.
A leadership program for senior state government officials who are committed to improving population health.
The Fund focuses on creating an affordable health care system built on strong primary care and partnerships that improve health outcomes for all.
Improving state leaders’ ability to enact and implement evidence-based health policies.
Advancing policies that create a more prevention- and primary care-oriented health system.
Improving population health through policies that contain health care cost growth.
Our state health policy resources offer relevant data analysis and best practices.
The Fund publishes reports, issues briefs, and case studies on state health policy issues.
Short takes on health policy issues from Milbank staff and guest authors.
Insights from Milbank President Debra Lubar on state health policymaking.
Reported articles and Q&As on timely health policy issues, as well as foundation updates.
Milbank Memorial Fund and Milbank Quarterly webinars featuring state health policymakers and researchers.
Updates and expert contact information for reporters.
The Milbank Memorial Fund is a private foundation that works to improve population health and health equity.
September 23, 2026
Quarterly Article
Steven H. Woolf
Sep 2, 2026
Aug 19, 2026
Jun 29, 2026
Back to The Milbank Quarterly
Policy Points:
Context: US life expectancy is shorter than in other high-income countries, and the gap has widened over time. This article examines the mortality patterns that help explain the widening gap, considers the root causes that might be to blame, and discusses potential policy solutions.
Methods: Sources of mortality data included the United Nations Department of Economic and Social Affairs, US Mortality Database, Centers for Disease Control and Prevention, and Organisation for Economic Cooperation
and Development. The analysis examined life expectancy and age-specific mortality rates by country, cause-specific US mortality rates from 1999 through 2023, and cause-specific mortality rates in 16 high-income countries for comparison. Al literature review examined potential explanations for the US health disadvantage, including the growing role of states and partisan polarization. This was supplemented by an analysis of state-level life expectancy and gubernatorial party affiliation for 1941–2022 and a comparison of state life expectancy in 2017–2021 with countries reporting similar life expectancy.
Findings: As of 2023, US life expectancy ranked 38th among countries with a population greater than 1 million, and the populations of 60 countries faced a lower risk of dying before age 40 than did Americans. Causes of death responsible for changes in all-cause mortality varied by age group. Leading contributors among infants and children included sudden unexplained infant deaths and external causes (e.g., transport, homicide, suicide). Young adults (ages 25–44) experienced the largest relative increases in all-cause mortality of any age group, including a 71.2% increase between 2010 and 2021, driven by deaths from external causes, notably drug overdoses, and early-onset diseases (e.g., hypertensive disease, endocrine and metabolic disorders, alcoholic liver disease). Middle-aged adults experienced increased mortality from similar causes (hypertensive diseases, endocrine and metabolic disorders, external causes), as well as higher death rates from nervous and genitourinary system diseases. Mortality from COVID-19, which emerged in 2020 as the third leading causes of death among middle-aged adults, almost doubled in 2021, despite the availability of vaccines. Older adults experienced increased mortality from neurologic diseases and endocrine and metabolic disorders and the highest mortality rates from COVID-19. Since 2010, the gap in all-cause mortality between the United States and 16 high-income countries has been driven by higher death rates from circulatory diseases, external causes, nervous system diseases, respiratory diseases, and endocrine and metabolic disorders. Explanations for the US health disadvantage include proximal causes (e.g., opioid epidemic, access to firearms, the obesogenic food environment, affective disorders), as well as systemic factors such as deficiencies in the health care system, socioneconomic precarity, a lax regulatory environment, and structural racism. State-level life expectancy and mortality rates have increased over time and appear associated with policy and increasingly partisan orientations.
Conclusions: The United States faces a mortality crisis that requires attention not only to specific causes of death but also systemic issues that compromise health. That better health outcomes are achievable is demonstrated by the growing list of high-income and middle-income countries that have achieved higher life expectancy than the United States. Policies that would close the gap, which have historically attracted weak political support in the United States and are now being actively opposed at the federal level, can be pursued by states and communities with greater commitments to improving population health.