Racial Disparities in Premature Mortality and Unrealized Medicare Benefits Across US States
By Irene Papanicolas, PhD; Maecey Niksch, BA; Jinru Wei, MS
October 23, 2025
Introduction
Medicare is often regarded as a universal benefit for most US citizens and legal permanent residents. The program is financed through payroll tax contributions during individuals’ working lives with the expectation of coverage at age 65 years for most people.1 However, those who die prematurely are unable to realize the benefits they helped fund—raising equity concerns for populations with lower life expectancies.
In 2022, the mean life expectancy in the US was 77.5 years, down from 78.9 years in 2014,2 partly due to rising mortality among working-age adults and widening disparities across racial and socioeconomic groups.3-5 As health declines begin earlier6—especially for Black individuals—a growing number may not reach Medicare eligibility. This inequity in unrealized Medicare benefits underscores the need to understand how premature mortality before age 65 years has varied over time and by race.
Methods
For this cohort study, using Centers for Diseases Control and Prevention (CDC) National Vital Statistics System microdata and CDC WONDER population estimates, we obtained state-level, all-cause deaths for adults aged 18 to 64 years in 2012 and 2022. We subtracted deaths of Medicare beneficiaries aged 18 to 64 years, identified from Medicare Beneficiary Summary Files, from total deaths among those aged 18 to 64 years in each state and calculated the premature mortality rate, age- and sex-standardized to the US population distribution (eMethods in Supplement 1). We examined overall premature mortality rates across US states and Washington, DC, for 2012 and 2022. Next, we compared premature mortality rates across states and by race (eTable in Supplement 1) for 2012 and 2022. Given differences in how race and ethnicity were coded across data sources, we restricted analyses to Black and White populations, for whom coding was most consistent and reliable. A 2-sided P < .05 was considered significant. Analyses were conducted in R, version 4.4.3 (R Foundation) and SAS, version 9.4 (SAS Institute). This study, conducted between March and May 2025, followed STROBE reporting guidelines and was approved by Brown University’s IRB, which waived informed consent given the use of deidentified data for a secondary analysis.
Results
Premature mortality in the US increased from 243 to 309 deaths per 100 000 adults between 2012 and 2022, an increase of 27.2% (Table). Mississippi (2012) and West Virginia (2022) had the highest mortality rates, (337 and 488 deaths per 100 000, respectively), while Minnesota (2012) and Massachusetts (2022) had the lowest (185 and 225 deaths per 100 000, respectively). In analyses stratified by race, Black adults had higher premature mortality than White adults in 2012 (309 vs 247 per 100 000) and 2022 (427 vs 316 per 100 000). Age- and sex-standardized mortality rates increased by 118 deaths per 100 000 for Black adults (38.2%) and 68 deaths per 100 000 for White adults (27.7%) (Figure). Most states showed significantly higher premature mortality among Black vs White adults (all P < .05), except for New Mexico, Rhode Island, and Utah.
Discussion
Between 2012 and 2022, mortality among adults aged 18 to 65 years in the US increased by over 27%. During this period, racial disparities in premature mortality widened substantially, with Black individuals experiencing persistently higher and worsening rates compared with White individuals across most states. These results raise concerns about structural inequities within the Medicare entitlement and financing system. Despite contributing to Medicare throughout their working lives, Black individuals in the US are less likely to live long enough to reach the qualifying age for coverage.
This study’s limitations include analyses limited to Black and White individuals given known limitations and discrepancies in the coding of race and ethnicity between the CDC and Medicare data (eMethods in Supplement 1). This study highlights the need to confront structural inequities driving early mortality and to reconsider Medicare eligibility and health financing for populations with differing life expectancies. Reducing rising premature mortality and racial disparities, particularly among Black individuals, will require coordinated health and social policy reforms that ensure timely and equitable access to affordable health care coverage before 65 years of age, including access to …