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...from the attached paper...
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Since the identification of SARS-CoV-2 in December 2019, the virus has exacted a devastating toll on global health. In the United States (US), the COVID-19 pandemic has caused more than 33 million confirmed infections and over 600,000 reported deaths as of July 1, 2021. However, recent estimates of undiagnosed infections [1] and under-reported deaths [2], [3], [4] demonstrate that the true burden of COVID-19 in the US, and likely in other countries, has not been fully captured.

In The Lancet Regional Health – Americas, Iuliano et al [4] used an excess-mortality Poisson regression model to estimate the number of deaths attributable to COVID-19 in the US from March 2020 to May 2021. By adjusting all-cause death counts for incomplete reporting, Iuliano et al [4] fitted their age-stratified model to each American state. All-cause excess mortality includes deaths both from the virus itself and those that arise from the externalities of the pandemic. The excess deaths metric thereby includes deaths for which COVID-19 was not necessarily the proximate cause, but where an overtaxed healthcare system led to failures in addressing other causes of mortality.

Nationally, Iuliano et al [4] estimated a 24% rate in under-reporting, meaning that over 180,000 additional deaths were either directly or indirectly attributable to COVID-19 beyond the 582,135 that were reported on death certificates by May 2021. The majority of unrecognized deaths were estimated to have occurred during the early months of pandemic spread when the healthcare system was overwhelmed and testing inadequate.
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Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC8354557/#:~:text=Nationally%2C%20Iuliano%20et%20al%20%5B4,death%20certificates%20by%20May%202021.