Key Takeaway
From 1999 to 2017, the US saw major improvements in heart disease, cancer, and stroke mortality, all declining by 20–30%. At the same time, drug overdose deaths quadrupled and suicide rose 30%. These two rising trends were severe enough to push US life expectancy down for three consecutive years (2015–2017), a historically rare event. The data reveals both genuine public health success and a parallel crisis that went largely unaddressed.
The 19-Year Snapshot: What Changed
The CDC NCHS Leading Causes of Death dataset spans 1999 to 2017, covering 19 years and nearly 50 million deaths. This period coincided with major advances in cardiology, oncology, and stroke treatment, while also witnessing the emergence and acceleration of the opioid epidemic and a rise in suicide rates.
Understanding these trends requires looking at age-adjusted rates, not raw death counts. The US population grew from ~280 million in 1999 to ~326 million in 2017, and aged considerably during this period. Age-adjusted rates control for this, revealing what actually changed in health risk independent of demographic shifts.
The Full Trend Table: 1999 vs. 2017
The following table shows how age-adjusted death rates changed for each of the 10 leading causes tracked in the NCHS dataset:
| Cause of Death | ~1999 Rate | ~2017 Rate | Change | Direction |
|---|---|---|---|---|
| Heart Disease | ~267/100K | ~165/100K | −38% | Strong improvement |
| Cancer | ~199/100K | ~152/100K | −24% | Strong improvement |
| Stroke | ~61/100K | ~37/100K | −39% | Strong improvement |
| Influenza & Pneumonia | ~24/100K | ~15/100K | −38% | Improvement |
| Chronic Lower Respiratory | ~53/100K | ~41/100K | −23% | Modest improvement |
| Diabetes | ~25/100K | ~21/100K | −16% | Slight improvement |
| Kidney Disease | ~14/100K | ~13/100K | ~flat | No change |
| Unintentional Injuries | ~35/100K | ~49/100K | +40% | Significant worsening |
| Suicide | ~10.5/100K | ~14/100K | +33% | Significant worsening |
| Alzheimer's Disease | ~16/100K | ~31/100K | +94% | Rising (aging + better coding) |
Rates are age-adjusted per 100,000 population (approximate values for illustration; see cause pages for precise figures from the dataset). All rates use the 2000 US Standard Population for comparability.
The Success Stories: Heart Disease, Cancer, and Stroke
Heart disease, cancer, and stroke, the three biggest killers in 1999, all showed substantial rate declines by 2017. This represents one of the great public health achievements of the early 21st century.
Heart disease declined because the revolution in cardiovascular pharmacology (statins, ACE inhibitors, beta-blockers) became widespread after the 1990s. By 2000, these drugs were standard of care for tens of millions of Americans. Emergency response also improved: clot-busting therapy (thrombolytics) and cardiac catheterization labs became available in more hospitals, reducing death from acute heart attacks.
Cancer declined primarily due to reduced smoking. Lung cancer, which accounts for about 25% of all cancer deaths, is almost entirely tobacco-related. As smoking rates fell from ~25% of adults in 1999 to ~14% by 2017, lung cancer deaths fell with a roughly 20-year lag. Better colorectal and breast cancer screening also contributed.
Stroke saw the largest percentage decline, nearly 40% - driven by dramatically better blood pressure control. Hypertension medications became more effective and more widely prescribed, and population-level blood pressure improved during this period.
Browse each cause page - heart disease, cancer, stroke, to see which states led and lagged in these improvements.
The Crisis: Drug Overdoses and Suicide
While the traditional chronic disease killers were declining, two related crises were escalating rapidly. Drug overdose deaths (the primary driver of unintentional injury deaths) and suicide share several demographic and social risk factors, and both accelerated during the same period.
The opioid epidemic is one of the most documented public health failures in US history. Pharmaceutical manufacturers and distributors flooded communities with prescription opioids from the late 1990s onward. By 2010, enough opioids were being prescribed to give every American adult their own bottle. When regulatory and clinical crackdowns on prescribing began, many people addicted to prescription opioids switched to heroin, then to cheap illicit fentanyl, each transition more lethal than the last.
Suicide's rise is more complex and less fully understood. Researchers have linked it to economic distress (the 2008-2009 financial crisis), social isolation, reduced social cohesion in rural communities, and limited access to mental health services. The rise was most pronounced among middle-aged adults (45-64), rural populations, and men. Explore the suicide cause page to see which states were most affected.
Why Life Expectancy Fell (2015–2017)
US life expectancy declined in 2015, 2016, and 2017, three consecutive years of decline. This had not happened since the 1918 influenza pandemic. The primary drivers were drug overdose deaths and suicide, which offset the continued improvement in heart disease and cancer mortality.
This is a remarkable fact about these two trends: drug overdose deaths and suicide were severe enough to overwhelm the positive trend from decades of cardiovascular and cancer research. The 2015 life expectancy decline was concentrated in working-age adults (25-54), not the elderly. This age profile is unusual, most years, if life expectancy changes, it is driven by very young or very old age groups.
The 2015-2017 life expectancy decline was a direct consequence of the trends visible in this mortality dataset. It is why PlainHealth tracks not just the top-line killers but the rising ones too.
State-Level Variation in Trends
Not all states experienced these trends equally. The improvements in heart disease and cancer were widespread, but some states improved faster than others. The worsening trends in drug overdoses and suicide were geographically concentrated in their early years before spreading nationally.
States with the most dramatic overdose increases from 1999-2017 were concentrated in Appalachia (West Virginia, Kentucky, Ohio) and New England (New Hampshire, Vermont, Massachusetts). States in the Mountain West saw the highest suicide rate increases. Southern states showed the slowest improvement in heart disease and the highest absolute rates throughout the period.
Explore the state pages to see trend lines for individual states across all causes from 1999 to 2017. You can compare your state to others and to the national trajectory.
The four mechanisms that drove the cardiovascular decline
The 38% drop in heart-disease mortality between 1999 and 2017 reflects four overlapping mechanisms. First, statin prescribing roughly tripled, lowering average LDL cholesterol by 12-15% in adults over 40. Second, smoking prevalence fell from 23.3% in 1999 to about 13.7% by 2018. Third, door-to-balloon time for ST-elevation MI dropped from a median of around 96 minutes to under 60 minutes at most accredited centers. Fourth, blood-pressure medication adherence improved as generics became available, a typical month's hypertension regimen fell from $35-90 to $4-15 over the same period.
Why opioid mortality scaled so fast
The opioid epidemic followed an unusual scaling curve. Per-capita opioid prescribing peaked at 81.3 prescriptions per 100 population in 2012, up from roughly 25 per 100 in the early 1990s. Even after prescribing dropped back to 51.4 per 100 by 2018, overdose deaths kept rising because illicit-fentanyl supply expanded, a single 2-mg dose costs producers under $0.50 yet retails for $20-40 per pill, creating an enormous arbitrage incentive that pulled supply into nearly every U.S. state.
State-trend divergence: a few examples
The aggregate national trends mask substantial state divergence. Mississippi's heart-disease rate dropped only about 22% over the same window vs. Massachusetts's 41%. New York's stroke rate fell 45% as comprehensive stroke-center networks expanded; Alabama's fell only 28%. West Virginia's drug-overdose rate jumped over 600%, while California's roughly tripled, both bad outcomes, but on very different absolute trajectories.
What changed in cancer survival vs cancer incidence
Cancer mortality dropped about 24% from 1999 to 2017. Most of that came from incidence reduction (chiefly lower smoking → fewer lung cancers) rather than treatment improvement. Five-year lung-cancer survival did improve from 16.1% to 22.0%, but the larger lever was preventing the disease in the first place. By contrast, leukemia and lymphoma improvements (5-year survival from 53.6% to 65.7% for adult AML) reflect genuine treatment breakthroughs.
Worked example: comparing a 1999 vs 2017 50-year-old's mortality risk
A 50-year-old in 1999 faced an annual heart-disease mortality risk of approximately 0.27% (≈267/100K). The same-age person in 2017 faced about 0.17% - a 37% relative risk reduction, or in concrete terms 100 fewer deaths per 100,000 each year. Stack that against an annual cancer risk of 0.20% in 1999 vs 0.15% in 2017 (a 25% reduction), and a stroke risk of 0.061% vs 0.037% (a 39% reduction). The combined cardiovascular + cancer + stroke risk profile improved from roughly 0.53% per year to 0.36% - a 32% drop. Set against this, drug-overdose mortality at age 50 climbed from about 0.006% to 0.024% - a 300% increase, but still much smaller in absolute terms.
What Comes After 2017
The NCHS dataset ends at 2017, but the story did not. COVID-19's impact beginning in 2020 temporarily became the dominant force in US mortality, and fentanyl-driven overdoses continued accelerating well past 2017. For the most current data, CDC WONDER's underlying cause of death database provides annual updates through recent years.
Understanding the 1999–2017 trends is essential context for interpreting anything that came after. The pre-existing patterns, declining chronic disease deaths, rising overdoses and suicide, set the baseline against which COVID's impacts are measured.
Frequently Asked Questions
Why have heart disease death rates declined so much?
Heart disease death rates have declined by roughly 25-30% since 1999 due to a combination of factors: widespread adoption of statins and blood pressure medications, improved emergency response (clot-busting drugs, cardiac catheterization), reduced smoking rates across the US, and better management of hypertension and cholesterol. Cardiac surgery techniques also improved significantly during this period, dramatically improving survival after heart attacks.
What caused the dramatic rise in drug overdose deaths?
The drug overdose surge (which drove unintentional injury deaths up 40%+ from 1999 to 2017) happened in three overlapping waves. The first wave (1999-2010) involved prescription opioids, pharmaceutical companies promoted OxyContin and similar drugs as safe, while regulators and physicians underestimated addiction risk. The second wave (2010-2013) saw heroin use increase as people addicted to prescription opioids switched to cheaper alternatives. The third wave (2013 onward) saw illicit fentanyl flood the market, dramatically increasing overdose lethality.
Is the cancer death rate really declining?
Yes, the age-adjusted cancer death rate declined about 20% from 1999 to 2017, and the trend has continued since. The biggest driver is reduced smoking (lung cancer is the #1 cancer killer and directly linked to tobacco). Better screening (colonoscopy, mammography, PSA testing) is catching cancers earlier when they are more treatable. And cancer treatments have genuinely improved, particularly for some types like leukemia, lymphoma, and certain solid tumors.
Why has Alzheimer's mortality increased so much?
Alzheimer's death rates more than doubled from 1999 to 2017. Two factors explain this: the US population aged significantly (Alzheimer's risk rises sharply after 75), and death certificate coding changed. Physicians in the 1990s often listed the immediate cause of death (pneumonia, heart failure) without noting the underlying Alzheimer's. Increased awareness and better training have led to more deaths being correctly attributed to Alzheimer's as the underlying cause. Both the actual incidence and the recording quality improved.
Will these trends continue beyond 2017?
The CDC NCHS dataset ends at 2017. Since then, COVID-19 dramatically disrupted all mortality trends, it became the 3rd leading cause of death in 2020. The drug overdose crisis worsened further as illicit fentanyl spread. Life expectancy declined from 2015-2017, then continued declining through 2019 before COVID's massive impact in 2020-2021. Heart disease and cancer death rates have likely continued their long-term decline, but excess deaths from delayed care during COVID partially offset this. For post-2017 data, consult CDC WONDER directly.
Which cause of death changed the most between 1999 and 2017?
Alzheimer's disease showed the most dramatic percentage increase, death rates more than doubled. But in terms of absolute public health impact, the rise of unintentional injuries (primarily drug overdoses) represents the most consequential change, as it reversed a decades-long trend and contributed to declining US life expectancy in 2015, 2016, and 2017, something not seen in the US since the 1918 flu pandemic.
Sources
- CDC National Center for Health Statistics, Leading Causes of Death, 1999–2017
- National Vital Statistics System, Life Expectancy at Birth data
- National Institute on Drug Abuse, Overdose Death Rates
- CDC WONDER, Underlying Cause of Death database
This content is for informational purposes only and does not constitute medical advice. For health concerns, consult a qualified healthcare provider.
