Background Coronavirus Disease 2019 (COVID-19) excess deaths refer to increases in mortality over what would normally have been expected in the absence of the COVID-19 pandemic. Several prior studies have calculated excess deaths in the United States but were limited to the national or state level, precluding an examination of area-level variation in excess mortality and excess deaths not assigned to COVID-19. In this study, we take advantage of county-level variation in COVID-19 mortality to estimate excess deaths associated with the pandemic and examine how the extent of excess mortality not assigned to COVID-19 varies across subsets of counties defined by sociodemographic and health characteristics. Methods and findings In this ecological, cross-sectional study, we made use of provisional National Center for Health Statistics (NCHS) data on direct COVID-19 and all-cause mortality occurring in US counties from January 1 to December 31, 2020 and reported before March 12, 2021. We used data with a 10-week time lag between the final day that deaths occurred and the last day that deaths could be reported to improve the completeness of data. Our sample included 2,096 counties with 20 or more COVID-19 deaths. The total number of residents living in these counties was 319.1 million. On average, the counties were 18.7% Hispanic, 12.7% non-Hispanic Black, and 59.6% non-Hispanic White. A total of 15.9% of the population was older than 65 years. We first modeled the relationship between 2020 all-cause mortality and COVID-19 mortality across all counties and then produced fully stratified models to explore differences in this relationship among strata of sociodemographic and health factors. Overall, we found that for every 100 deaths assigned to COVID-19, 120 all-cause deaths occurred (95% CI, 116 to 124), implying that 17% (95% CI, 14% to 19%) of excess deaths were ascribed to causes of death other than COVID-19 itself. Our stratified models revealed that the percentage of excess deaths not assigned to COVID-19 was substantially higher among counties with lower median household incomes and less formal education, counties with poorer health and more diabetes, and counties in the South and West. Counties with more non-Hispanic Black residents, who were already at high risk of COVID-19 death based on direct counts, also reported higher percentages of excess deaths not assigned to COVID-19. Study limitations include the use of provisional data that may be incomplete and the lack of disaggregated data on county-level mortality by age, sex, race/ethnicity, and sociodemographic and health characteristics. Conclusions In this study, we found that direct COVID-19 death counts in the US in 2020 substantially underestimated total excess mortality attributable to COVID-19. Racial and socioeconomic inequities in COVID-19 mortality also increased when excess deaths not assigned to COVID-19 were considered. Our results highlight the importance of considering health equity in the policy response to the pandemic. Author summary Why was this study done? The Coronavirus Disease 2019 (COVID-19) pandemic has resulted in excess mortality that would not have occurred in the absence of the pandemic. Excess deaths include deaths assigned to COVID-19 in official statistics as well as deaths that are not assigned to COVID-19 but are attributable directly or indirectly to COVID-19. While prior studies have identified significant racial and socioeconomic inequities in directly assigned COVID-19 deaths, few studies have documented how excess mortality in 2020 has differed across sociodemographic or health factors in the United States. What did the researchers do and find? Leveraging data from 2,096 counties on COVID-19 and all-cause mortality, we assessed what percentage of excess deaths were not assigned to COVID-19 and examined variation in excess deaths by county characteristics. In these counties, we found that for every 100 deaths directly assigned to COVID-19 in official statistics, an additional 20 deaths occurred that were not counted as direct COVID-19 deaths. The proportion of excess deaths not counted as direct COVID-19 deaths was even higher in counties with lower average socioeconomic status, counties with more comorbidities, and counties in the South and West. Counties with more non-Hispanic Black residents, who were already at high risk of COVID-19 death based on direct counts, also reported a higher proportion of excess deaths not assigned to COVID-19. What do these findings mean? Direct COVID-19 death counts significantly underestimate excess mortality in 2020. Monitoring excess mortality will be critical to gain a full picture of socioeconomic and racial inequities in mortality attributable to the COVID-19 pandemic. To prevent inequities in mortality from growing even larger, health equity must be prioritized in the policy response to the COVID-19 pandemic.
