Findings Health Outcomes | 2022 Annual Report

Executive Brief Foreword Introduction National HighlightsFindingsHealth Outcomes Social and Economic Factors Physical Environment Clinical Care State Rankings International Comparison COVID-era Disparities SurveyAppendixMeasures Table Data Source Descriptions MethodologyState Summaries
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HEALTH OUTCOMES | Mortality
The nation experienced large increases in premature death during the first year of the pandemic, with worsening racial/ethnic disparities. Provisional COVID-19 death rates were highest among Hawaiian/Pacific Islander, American Indian/Alaska Native, Hispanic and Black populations.
Premature Death
The leading causes of premature death (death before age 75) in 2020 were unintentional injury, cancer, heart disease, COVID-19, suicide, homicide, liver disease and diabetes, according to the National Center for Health Statistics WISQARS Years of Potential Life Lost (YPLL) Report. Factors contributing to premature death include social (education, unemployment and housing), environmental (distance to care and exposure to environmental hazards) and behavioral factors (smoking cessation, healthy eating and exercise).
Changes over time. Nationally, the premature death rate — years of potential life lost (YPLL) before age 75 per 100,000 population — increased 18% from 7,337 to 8,659 between 2019 and 2020, the sharpest increase over a single year in Annual Report history. The premature death rate significantly increased in 48 states and the District of Columbia, led by 31% in New York (5,825 to 7,651 YPLL per 100,000 population), 26% in Arizona (7,523 to 9,469) and 24% in New Jersey (6,239 to 7,759). The states without significant changes were Hawaii and New Hampshire. All racial/ethnic subpopulations experienced significant increases in the premature death rate between 2015-2017 and 2018-2020: 16% among Hispanic (4,595 to 5,321), 14% among American Indian/Alaska Native (11,301 to 12,842), 10% among Black (10,532 to 11,581), 7% among Asian/Pacific Islander (3,187 to 3,397) and 3% among white (7,821 to 8,069) populations.
Disparities. The premature death rate was 2.1 times higher in Mississippi (13,781 YPLL per 100,000 population) than in Hawaii (6,413), the states with the highest and lowest rates in 2020.
COVID-era impact by race/ethnicity. The disparity in the premature death rate between the American Indian/Alaska Native and Asian/Pacific Islander populations — the groups with the highest and lowest rates, respectively — widened between 2015-2017 and 2018-2020. The rate was 3.5 times higher among American Indian/Alaska Native (11,301 YPLL per 100,000 population) compared with Asian/Pacific Islander (3,187) populations in 2015-2017, and 3.8 times higher among American Indian/Alaska Native (12,842) compared with Asian/Pacific Islander (3,397) populations in 2018-2020. 
Related Measure: Premature Death Racial Disparity
Nationally, the premature death racial disparity — calculated as the ratio of the premature death rate of the racial/ethnic group with the highest rate (American Indian/Alaska Native population) to that of the non-Hispanic white population — increased 14% from 1.4 to 1.6 between 2015-2017 and 2018-2020.

COVID Deaths – Provisional
The COVID-19 pandemic has claimed more than 1,047,020 lives across the U.S. as of September 14th, 2022. In 2021, COVID-19 was the third-leading cause of death. Provisional death data suggest that more deaths due to COVID-19 occurred in 2021 than in 2020.

National estimate. Nationally, there were 102.6 deaths due to COVID-19 per 100,000 population in 2021, according to age-adjusted provisional data. This represents an increase over 2020, in which the COVID-19 death rate was 85.0 deaths per 100,000 population.
 
Disparities. The COVID-19 death rate was 5.3 times higher in Oklahoma (154.8 deaths per 100,000 population) than in Vermont (29.4), the states with the highest and lowest rates in 2021. The rate significantly varied by race/ethnicity and gender. It was 4.1 times higher among the Hawaiian/Pacific Islander (192.2) compared with the multiracial (47.2) population, and 1.6 times higher among males (130.5) than females (79.8).

Explore COVID-19 data.

HEALTH OUTCOMES | Behavioral Health
During the COVID-19 pandemic, drug deaths and non-medical drug use spiked and frequent mental distress continued to worsen. Meanwhile, the suicide rate decreased for the second consecutive year, with rates improving among the white population but worsening among the Hispanic population.
Drug Deaths
Heavy drug use and overdoses burden individuals, families, their communities, the health care system and the economy. Drug overdoses are a leading cause of injury death, increasing 56.5% between 2013 and 2019. Of the confirmed drug overdose deaths in the United States in 2020, roughly 75% involved an opioid.
Changes over time. Nationally, the drug death rate — deaths due to drug injury (unintentional, suicide, homicide or undetermined) per 100,000 population — significantly increased 30% from 21.5 to 27.9 between 2019 and 2020, the sharpest increase over a single year in Annual Report history. In 2020, 91,799 people in the U.S. died due to drug injury, an increase of 21,169 people since 2019. The drug death rate significantly increased in 36 states and the District of Columbia, led by 54% in West Virginia (50.4 to 77.4 deaths per 100,000 population), 53% in South Carolina (22.2 to 34.0) and 51% in Kentucky (31.3 to 47.3). Nearly all age, racial/ethnic and gender groups experienced significant increases in the drug death rate. The largest increase was 49% among those ages 15-24 (11.2 to 16.7). By race/ethnicity, drug deaths increased 45% among multiracial (12.8 to 18.6), 43% among Black (26.0 to 37.1), 38% among American Indian/Alaska Native (29.6 to 40.7), 37% among Hispanic (12.8 to 17.5), 36% among Asian (3.3 to 4.5) and 25% among white (25.5 to 32.0) populations. By gender, drug deaths increased 32% among males (29.4 to 38.9) and 23% among females (13.7 to 16.9).
Disparities. The drug death rate was 7.9 times higher in West Virginia (77.4 deaths per 100,000 population) than in South Dakota (9.8), the states with the highest and lowest rates in 2020. The rate significantly varied by race/ethnicity, gender and age. The drug death rate was:
9.0 times higher among the American Indian/Alaska Native (40.7) compared with the Asian (4.5) population.
4.1 times higher among those ages 35-44 (53.9) than those 65-74 (13.2). 
2.3 times higher among males (38.9) than females (16.9).
COVID-era impact by race/ethnicity. The disparity in the drug death rate between the American Indian/Alaska Native and Asian populations — the groups with the highest and lowest rates, respectively — widened by 9.9 deaths per 100,000 population between 2019 and 2020. The rates among the American Indian/Alaska Native and Black populations increased by 11.1 deaths per 100,000 population, and the rate among the Asian population increased by 1.2 deaths per 100,000 population.

Non-medical Drug Use – Past Year
The use of illicit drugs, including the use of prescription drugs without a doctor's guidance, can be dangerous and have long-lasting consequences. Short-term effects include heart attack, stroke, psychosis, overdose and death. Potential long-term effects include heightened risk for diseases like HIV, hepatitis and endocarditis and conditions such as heart disease and certain cancers and mental illnesses.
Changes over time. Nationally, the percentage of adults who reported using prescription drugs non-medically (including pain relievers, stimulants and sedatives) or illicit drugs (excluding cannabis) in the last 12 months significantly increased 29% from 12.0% to 15.5% between 2021 and 2022. Non-medical drug use significantly increased in 10 states, led by 82% in West Virginia (14.1% to 25.7%). All education, income and gender groups and some racial/ethnic groups experienced significant increases in non-medical drug use. By group, the largest increases were 46% among those with less than a high school education (3.5% to 5.1%), 45% among those with incomes $25-$74,999 (15.0% to 21.7%), 43% among females (10.1% to 14.4%) and 34% among white adults (12.5% to 16.7%).
Disparities. Non-medical drug use was 4.4 times higher in West Virginia (25.7%) than in Vermont (5.8%), the states with the highest and lowest prevalence in 2022. The prevalence varied most by race/ethnicity, education and income, and also significantly varied by gender. It was:
3.8 times higher among other race (31.7%) compared with Asian (8.4%) adults. Hawaiian/Pacific Islander (20.1%) adults also had a high prevalence.* 
3.8 times higher among those with some post-high school education (19.4%) than those with less than a high school education (5.1%). College graduates (18.0%) also had a high prevalence.*
2.6 times higher among those with incomes less than $25,000 (26.7%) than those with incomes of $75,000 or more (10.2%).

Frequent Mental Distress
Frequent mental distress aims to capture the population experiencing persistent and likely severe mental health issues, defined by 14 or more days of poor mental health a month. A strong relationship exists between the 14-day period and clinically diagnosed mental disorders such as depression and anxiety.
Changes over time. Nationally, the prevalence of frequent mental distress increased 11% from 13.2% to 14.7% of adults between 2020 and 2021. Frequent mental distress significantly increased in seven states, led by 41% in Alaska (9.9% to 14.0%), 29% in Illinois (10.0% to 12.9%) and 21% in Maine (12.6% to 15.2%). Some racial/ethnic, income, age, gender and education groups experienced significant increases in frequent mental distress. By group, the largest increases were 45% among Asian adults (7.4% to 10.7%), 13% among those with incomes less than $25,000 (20.7% to 23.4%) and $25-$49,999 (14.1% to 15.9%), 12% among those ages 18-44 (16.5% to 18.4%), and 10% among both males (10.9% to 12.0%) and those with a high school diploma or GED degree (13.1% to 14.4%).†
Disparities. Frequent mental distress was 1.8 times higher in West Virginia (19.3%) than in Hawaii (10.7%), the states with the highest and lowest prevalence in 2021. The prevalence varied most by income, age and race/ethnicity, and also significantly varied by education and gender. It was: 
2.5 times higher among those with incomes less than $25,000 (23.4%) than those with incomes of $75,000 or more (9.4%).†
2.2 times higher among those ages 18-44 (18.4%) than those 65 and older (8.5%). 
2.0 times higher among multiracial (21.9%) compared with Asian (10.7%) adults. American Indian/Alaska Native (20.9%) adults also had a high prevalence and Hawaiian/Pacific Islander (12.0%) adults also had a low prevalence.‡

Suicide
Suicide was the 12th-leading cause of death in the United States in 2020. Mental illness and substance use disorders are the most significant risk factors for suicidal behaviors. In addition, environmental factors such as stressful life events and access to lethal means such as firearms or drugs may increase the risk of suicide.
Changes over time. Nationally, the suicide rate — deaths due to intentional self-harm per 100,000 population — significantly decreased 3% from 14.5 to 14.0 between 2019 and 2020, and 5% (from 14.8) since its peak in 2018. In 2020, 45,979 people in the U.S. died by suicide, a decrease of 1,532 people since 2019. The suicide rate significantly decreased 10% in Florida (15.5 to 13.9 deaths per 100,000 population) and Pennsylvania (14.5 to 13.1) and 6% in California (11.3 to 10.6) between 2019 and 2020. Some age, gender and racial/ethnic groups experienced significant decreases in the suicide rate. By group, decreases were: 
13% among those ages 55-64 (19.4 to 16.9), 8% among ages 45-54 (19.6 to 18.0) and 6% among ages 65-74 (15.5 to 14.5).
8% among females (6.1 to 5.6) and 2% among males (23.4 to 22.9).
5% among the white population (18.2 to 17.3).
During this time, the suicide rate significantly increased 5% among those ages 25-34 (17.5 to 18.4).
Disparities. The suicide rate was 4.2 times higher in Wyoming (31.8 deaths per 100,000 population) than in New Jersey (7.6), the states with the highest and lowest rates in 2020. The rate in the District of Columbia (5.4) was lower than the rate in any state. The rate significantly varied by gender, race/ethnicity and age. It was: 
4.1 times higher among males (22.9) than females (5.6).
3.4 times higher among the American Indian/Alaska Native (23.1) compared with the Asian (6.7) population. 
1.5 times higher among those ages 85 and older (20.9) than those 15-24 (14.2). Those ages 65-74 (14.5) also had a low rate.§
HEALTH OUTCOMES | Physical Health
Rates of multiple chronic conditions, obesity and high cholesterol worsened. Data released in September 2022 show nearly one-third of adults with COVID-19 reported experiencing symptoms lasting three months or longer.
Multiple Chronic Conditions
Chronic conditions are medical conditions that last more than a year, require ongoing medical attention and/or limit daily life activities. As the number of chronic conditions an individual experiences increases, the risks of the following outcomes also increase: physical, social and cognitive limitations; unnecessary hospitalizations; adverse drug events; and mortality.
Changes over time. Nationally, the percentage of adults who had three or more chronic conditions increased 5% from 9.1% to 9.6% between 2020 and 2021. This comes after a drop between 2019 and 2020, when the percentage of adults with multiple chronic conditions decreased 4% nationally. State changes in the prevalence of multiple chronic conditions were not notable. The prevalence of multiple chronic conditions significantly increased 8% among those with incomes less than $25,000 (20.2% to 21.9%).‡ Three of the eight chronic conditions included in this measure increased 5% or more: Cancer (excluding skin) increased 10% (6.8% to 7.5%) and arthritis and depression increased 5% (24.5% to 25.8% and 19.5% to 20.5%, respectively).
Disparities. The prevalence of multiple chronic conditions was 3.2 times higher in West Virginia (18.1%) than in Hawaii (5.6%), the states with the highest and lowest prevalence in 2021. The prevalence varied most by age, race/ethnicity, income and education, and also significantly varied by gender and metropolitan status. It was: 
6.4 times higher among those ages 65 and older (20.5%) than those 18-44 (3.2%).
5.7 times higher among American Indian/Alaska Native (15.5%) compared with Asian (2.7%) adults.
4.1 times higher among those with incomes less than $25,000 (21.9%) than those with incomes of $75,000 or more (5.3%).†
2.9 times higher among those with less than a high school education (17.4%) compared with college graduates (6.1%).†

Risk Factors
Often, existing health conditions put people at risk of further, more severe illness. Obesity, high blood pressure and high cholesterol are risk factors for heart disease and stroke. These risk factors are modifiable, meaning that people can take action to reduce their risk and stave off future disease.
Changes over time. Nationally, the prevalence of obesity∥ among adults increased 6% (31.9% to 33.9%) between 2020 and 2021, a new record high. High cholesterol¶ among adults increased 7% (33.3% to 35.7%) between 2019 and 2021. During these periods, obesity significantly increased in five states, led by 12% in both New Mexico (30.9% to 34.6%) and Montana (28.5% to 31.8%). High cholesterol significantly increased in 14 states, led by 31% in South Dakota (28.1% to 36.7%). Most age, racial/ethnic, gender, education and income groups experienced significant increases in at least one of these risk factors.
Disparities. Obesity was 1.6 times higher in West Virginia (40.6%) than in Hawaii (25.0%) in 2021; however, the prevalence in the District of Columbia (24.7%) was lower than the prevalence in any state. High cholesterol was 1.3 times higher in West Virginia (41.0%) than in Montana (30.5%), the states with the highest and lowest prevalence rates in 2021. The prevalence of obesity varied most by race/ethnicity and high cholesterol varied most by age. Both also significantly varied by education, income, gender and metropolitan status.



Long COVID
After individuals have been infected with COVID-19, it is possible for them to experience long-term effects from the infection. Symptoms may start with an initial COVID-19 infection or appear later. Even people who did not experience symptoms from a COVID-19 infection can develop long COVID.
National estimate. Nationally, 29.6% of adults who reported ever testing positive or being told by a health care provider that they had COVID-19 experienced symptoms lasting three months or longer when surveyed in September 2022.

Disparities. Long COVID was 2.3 times higher in West Virginia (49.4%) than in Vermont (21.5%), the states with the highest and lowest prevalence in September 2022. The prevalence significantly varied by education, race/ethnicity, age and gender. It was:

— 1.9 times higher among those with less than a high school education (42.5%) compared with college graduates (22.6%).
— 1.7 times higher among Hispanic (33.2%) compared with Asian (19.1%) adults. Black (29.6%) adults also had a high prevalence.**
— 1.7 times higher among those ages 50-59 (33.9%) than those 80 and older (20.4%). Those ages 40-49 (31.9%) and 60-69 (29.6%) also had a high prevalence and those ages 70-79 (25.3%), 18-29 (27.1%) and 30-39 (28.7%) also had a low prevalence.**
— 1.5 times higher among females (35.1%) than males (23.5%).

Explore COVID-19 data.


* The values of the two highest groups were not significantly different from each other based on non-overlapping 95% confidence intervals
† Education and income subpopulations are among adults ages 25-44
‡ The values of the two highest groups and the two lowest groups were not significantly different from each other, respectively, based on non-overlapping 95% confidence intervals.
§ The values of the two lowest groups were not significantly different from each other based on non-overlapping 95% confidence intervals.
∥ Obesity is defined as the percentage of adults with a body mass index of 30.0 or higher based on reported height and weight.
¶ High cholesterol is the percentage of adults who reported having their cholesterol checked and were told by a health professional that it was high.
** The values of the two highest groups and four lowest groups were not significantly different from each other, respectively, based on non-overlapping 95% confidence intervals.
Note: 2021 national Behavioral Risk Factor Surveillance System estimates exclude Florida and 2019 estimates exclude New Jersey. See Appendix for details.