Evolution of the US nonmetropolitan mortality disadvantage by sex, state, and year, 1999-2019

To examine disparities in nonmetropolitan and metropolitan mortality by state and sex from 1999 to 2019.

We calculate age-standardized mortality rates for nonmetropolitan and metropolitan areas by state and sex and compute age-standardized differences in these rates within each state and relative to the national average. We further estimate the number of excess deaths in nonmetropolitan areas by state. These are deaths that would have been avoided if nonmetropolitan areas had the same age-specific death rates as metropolitan areas in the same state.

We document increasing nonmetropolitan mortality disadvantage since 1999 along with significant variation in the magnitude and timing of its emergence by state. Although stagnation in mortality was observed nationally in the mid-2010s, this was not true in all states or in all metropolitan and nonmetropolitan areas. Additionally, mortality trends became progressively more discordant across and within states. Despite this heterogeneity, we document a steady increase in the number of nonmetropolitan excess deaths from 8,400 in 1999 to 47,000 in 2019, representing 9.0% of all nonmetropolitan deaths.

National-level mortality trends mask geographic variation by nonmetropolitan and metropolitan areas within and across states. Further research is needed to identify factors that contribute to these divergent patterns.