The study correlated 2,745 pre-pandemic county-level variables against age-standardised excess deaths in US counties for each year from 2020 to 2024. Variables covered demography, race/ethnicity, income, insurance, education, employment, housing and health system supply, with counties weighted by population. The strongest correlates were college attainment (-0.54) and uninsurance among adults aged 40-64 (+0.53). Only 7% of health system variables correlated above 0.30 with excess deaths, as compared to 31% of socioeconomic and demographic variables.
Why it is interesting: Past analyses typically considered few factors; this study screens 2,745 county variables at once. It separates the socioeconomic gradient from health-care supply, and shows the association was concentrated in 2020 and 2021.
Abstract — the authors' own words, CC BY
Socioeconomic, demographic, and health system structures may have shaped COVID-19 pandemic impact across populations, but past analyses typically examined few factors. We systematically examined correlates of COVID-era excess mortality, considering 2,745 county-level variables of demography, race/ethnicity, income, insurance, education, employment, housing, and health system. Pearson correlation coefficients (CCs) were obtained for the most recent available pre-pandemic value against age-standardized county excess-death for each year during 2020-2024. Counties were population-weighted. Variables were grouped by meaning into 11 semantic super-clusters. Overall, 17.3% of variables reached at least a moderate correlation level (|CC| > 0.30) and 2.8% reached strong correlations (|CC| > 0.45). Strongest correlations were seen for college attainment (CC -0.54), uninsurance among adults 40-64 (+0.53), and high income (-0.53). At least moderate correlations were seen for 9.1% of variables in 2020 and 8.5% in 2021, but only 1.8%, 0%, and 1.3% in 2022, 2023, and 2024, respectively. Similar patterns of concentration of moderate correlations in the first two pandemic years appeared in both elderly and non-elderly populations. Of 472 variables with |CC| > 0.30, 362/395 moderate-band and 77/77 strong-band variables belonged to demography and socioeconomic super-clusters. Only 7% of health system variables reached |CC| > 0.30, versus 31% of socioeconomic and demographic variables. Using the most recent available value until 2023 or 2015, different population weighting, and Spearman correlations yielded similar results. Overall, these ecological analyses suggest strong relationships of socioeconomic structure and demographics rather than health-care resources/supply with excess mortality across US counties especially during 2020-2021.
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