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National Center for Health Statistics (US) . Health, United States, 2006: With Chartbook on Trends in the Health of Americans. Hyattsville (MD): National Center for Health Statistics (US); 2006 Nov.

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Health, United States, 2006: With Chartbook on Trends in the Health of Americans.

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Executive Summary

Health, United States, 2006, is the 30th annual report on the health status of the Nation prepared by the Secretary of the Department of Health and Human Services for the President and Congress. In a chartbook and 147 detailed tables, it provides an annual picture of health for the entire Nation. Trends are presented on health status and health care utilization, resources, and expenditures.

For those entrusted with safeguarding the Nation's health, monitoring the health of the American people is an essential step in making sound health policy and setting priorities for research and programs. Measures of the population's health provide essential information for assessing how the Nation's resources should be directed to improve the health of the population. Examination of emerging trends identifies diseases, conditions, and risk factors that warrant study and intervention. Health, United States presents trends and current information on measures and determinants of the Nation's health. It also identifies differences in health and health care among people of differing races and ethnicities, genders, education and income levels, and geographic locations, and it shows whether these differences are narrowing or increasing. Given the increasing diversity of the Nation and the continuing changes in the health care infrastructure, this is a challenging task, but it is a critically important undertaking.

Overall Health of the Nation

The health of the Nation continues to improve overall in many respects, in part because of the significant resources devoted to public health programs, research, health care, and health education. Life expectancy in the United States continues a long-term upward trend, although the most dramatic increases were in the early part of the 20th century. Over the past century, many diseases have been controlled or their morbidity and mortality substantially reduced. Notable achievements in public health have included the control of infectious diseases such as typhoid and cholera through decontamination of water; implementation of widespread vaccination programs to contain polio, diphtheria, pertussis, and measles; fluoridation of water to drastically reduce the prevalence of dental caries; and improvements in motor vehicle safety through vehicle redesign and efforts to increase usage of seatbelts and motorcycle helmets (1). A sharp decline in deaths from cardiovascular disease is a major public health achievement that resulted in large part from public education campaigns emphasizing a healthy lifestyle and increased use of cholesterol and hypertension-lowering medications (2). Advances in medical technology, including diagnostic imaging technologies, procedures, and new prescription drugs have extended and improved the quality of countless lives.

Yet, even as progress is made in improving life expectancy, increased longevity is accompanied by increased prevalence of chronic conditions and their associated pain and disability. In recent years, progress in some arenas—declines in infant and cause-specific mortality, morbidity from chronic conditions, reduction in prevalence of risk factors including smoking and lack of exercise—has not been as rapid as in earlier years or trends have been moving in the wrong direction. Moreover, improvements have not been equally distributed by income, race, ethnicity, education, and geography.

Health Status and Its Determinants

In 2003, American men could expect to live 3 years longer, and women more than 1 year longer, than they did in 1990 (Table 27 and Figure 24). Mortality from heart disease, stroke, and cancer continued to decline in recent years (Table 29 and Figure 27). With longer life expectancy, however, comes increasing prevalence of chronic diseases and conditions that are associated with aging. Some diseases, including diabetes and hypertension, produce cumulative damage if not properly treated, while others, such as emphysema and some types of cancer, develop slowly or after long periods of environmental exposure. In 2001–2004, 10% of persons 20 years of age and over and more than one-fifth of adults 60 years and over had diabetes, including those with diabetes previously diagnosed by a physician and those with undiagnosed diabetes determined by results of a fasting blood sugar test (Table 55). About 30% of adults age 20 and over had elevated blood pressure or reported they were taking medications for high blood pressure in 2001–2004, and 17% had high serum cholesterol (Tables 69 and 70). The percentage of the population reporting fair or poor health status, or a limitation of their usual activity due to any chronic condition, increases sharply with age (Tables 58 and 60). In 2004, 32% of those 75 years of age and over reported fair or poor health compared with 22% of people age 65–74 and 6% of young adults age 25–44 years.

Of particular concern in recent years has been the increase in overweight and obesity, which are risk factors for many chronic diseases and disabilities including heart disease, hypertension, and back pain. The rising number of children and adults who are overweight, and the large percentage of Americans who are not physically active (Figures 12, 13, and Tables 7274) raise additional concerns about Americans' future health (3).

Decreased cigarette smoking among adults is a prime example of a trend that has contributed to overall declines in mortality. However, the rapid drop in cigarette smoking in the two decades following the first Surgeon General's Report in 1964 has slowed in recent years. About one-quarter of men and one-fifth of women were current smokers in 2004 (Figure 10 and Table 63). The percentage of the population with high serum cholesterol has also been decreasing, in part due to the increased use of new cholesterol-lowering medications (Table 70) (4).

Prevalence of some risky behaviors among children and young adults remains at unacceptable levels. In 2005, 30% of high school students in grades 11–12 reported binge drinking, and 22% had used marijuana in the past 30 days. Marijuana use increased from 12% to 20% between 1991 and 2003 among students in grades 9–10 (Figure 11). The percentage of high school students who seriously considered suicide has declined since 1991, but the percentage who attempted suicide has remained stable (7%–9%) (Table 62).

Health Care Utilization and Resources

People use health care services for many reasons: to treat illnesses, injuries, and health conditions; to prevent or delay future health care problems; to reduce pain and increase quality of life; and to obtain information about their health status and prognoses. The study of trends in health care utilization provides important information on these phenomena and spotlights areas that warrant further study. Utilization trends may also be used to project future health care needs and expenditures, as well as training and supply needs.

Americans are increasingly using many types of preventive or early-detection health services. In 2004, 83% of children 19–35 months of age had received a combined vaccination series protecting them against several childhood infectious diseases, and the percentage of children receiving varicella (chickenpox) vaccine has increased sharply since it was first recommended in 1996 (Table 81). The percentage of women receiving Pap smears and mammograms has increased since 1987 but has leveled off in recent years (Tables 84 and 85).

Rates of ambulatory care visits to office-based physicians and hospital outpatient departments have remained steady since the mid-1990s at 3 to 4 visits per person (data table for Figure 22 and Table 89). Admissions to hospitals and length of stay declined substantially in the 1980s and 1990s, but these declines appear to have leveled off (Tables 9698). Hospital inpatient care is becoming more intensive and complex, with more procedures such as insertion of coronary artery stents, and hip and knee replacements being performed, particularly on older persons (Table 99). Hospitalizations for procedures that can be performed on an outpatient basis, such as hernia repairs and knee arthroscopies have declined sharply in inpatient settings, and imaging procedures such as diagnostic ultrasound and computerized axial tomography are increasingly performed on an outpatient basis.

The numbers of hospitals and hospital beds continue to decrease. Occupancy rates declined from 1975 to 1990 and have been stable since then (Table 112). The number of physicians in the United States has been increasing along with the overall population, but physicians are not distributed equally across the Nation (Table 104). New and different types of health practitioners and healthcare support occupations continue to evolve. The numbers of dental hygienists and dental assistants, pharmacy technicians, diagnostic medical sonographers, massage therapists, medical assistants, and medical equipment preparers have increased, on average, by 5% or more per year since 1999, while the numbers of audiologists, respiratory therapy technicians, recreational therapists, and occupational therapist aides have all declined, on average, by 5% or more per year (Table 108). Projections indicate that there may be an increasing shortage of nurses and pharmacists, as well as other health professionals, needed to care for our aging population (5,6).

Expenditures and Health Insurance

The United States spends more on health per capita than any other country, and health spending continues to increase rapidly. Much of this spending is for care that controls or reduces the impact of chronic diseases and conditions affecting an aging population. In 2004, national health care expenditures in the United States totaled $1.9 trillion, a 7.9% increase from 2003 (Table 120). Hospital spending, which accounts for 30% of total national health expenditures, increased by 8.6% in 2004 (Table 123). Spending for prescription drugs increased 8.2% in 2004, compared with an average annual growth of 13% from 2000 to 2003. Spending for prescription drugs accounted for 10% of national health expenditures in 2004.

Overall, private health insurance paid for 36% of total personal health care expenditures in 2004, the federal government 34%, state and local government 11%, and out-of-pocket payments paid for 15% (Figure 9). The percentage of the population under 65 years of age with no health insurance coverage at the time they were interviewed fluctuated around 16%–18% between 1994 and 2004 (Figure 6 and Table 135).

Many people under age 65, particularly those with low incomes, do not have health insurance coverage consistently throughout the year. In 2004, about 20% of people under age 65 reported that they had been uninsured for at least part of the 12 months prior to their interview (Figure 7). In 2004, only 2% of people under age 65 who were insured continuously for all 12 months before their interview reported that they did not receive needed medical care due to cost, compared with about 20% of people who were uninsured for at least part of the 12 months before their interview (Table 78).

Disparities in Risk Factors, Access, and Utilization

Efforts to improve Americans' health in the 21st century will be shaped by important changes in demographics. Ours is a Nation that is growing older and becoming more racially and ethnically diverse. In 2005, nearly one-third of adults and about two-fifths of children were identified as black, Hispanic, Asian, American Indian or Alaska Native. In 2005, 14% of Americans identified themselves as Hispanic, 12% as black, and 4% as Asian (Figure 3).

Residents of institutions such as nursing homes, military barracks, and prisons have specialized health care needs and these populations are not generally included in many of the surveys that assess our Nation's health. Among men age 20–34 years, 11%–13% of non-Hispanic black men, 3%–4% of Hispanic men, and about 2% of white non-Hispanic men resided in local jails or state or federal prisons on June 30, 2004 (Table 2).

Health, United States, 2006, identifies major disparities in health and health care by socioeconomic status, race, ethnicity, and insurance status. Persons living in poverty are considerably more likely to be in fair or poor health and to have disabling conditions, and less likely to have used many types of health care than those with incomes of 200% of the poverty line or higher (Tables 58, 60, and 7880). In 2004, adults living in poverty were almost twice as likely to report having trouble seeing—even with eyeglasses or contact lenses—as higher income persons (Table 59). Adults 45–64 years of age living below the federal poverty line were two to three times as likely to have three or more chronic conditions as those with incomes of 200% of the poverty line or higher (Figure 15).

Significant racial and ethnic disparities remain across a wide range of health measures. The gap in life expectancy between the black and white populations has narrowed, but persists (Table 27). Disparities in risk factors, access to health care, and morbidity also remain. Hispanic and American Indian persons under 65 years are more likely to be uninsured than those in other racial and ethnic groups (Table 135). Obesity, a major risk factor for many chronic diseases, varies by race and ethnicity—51% of black non-Hispanic women age 20 and over were obese in 2001–2004, compared with 39% of women of Mexican origin and 31% of non-Hispanic white women (Table 73, age adjusted). In 2003–2004, about two-thirds of non-Hispanic white older adults and about one-half of Hispanic and non-Hispanic black older adults received influenza vaccinations in the past year (Figure 20). In 1999–2002, Mexican-origin children 6–17 years of age were almost twice as likely to have untreated caries as were non-Hispanic white school-age children (Figure 14 and Table 75).

Many aspects of the health of the Nation have improved, but the health of some racial and ethnic groups has improved less than others. The large differences in health status by race and Hispanic origin documented in this report may be explained by factors including socioeconomic status, health practices, psychosocial stress and resources, environmental exposures, discrimination, and access to health care (7). Socioeconomic and cultural differences among racial and ethnic groups in the United States will likely continue to influence future patterns of disease, disability, and health care use.

Special Feature: Pain

Pain is a major determinant of quality of life, and affects physical and mental functioning. In addition to the direct costs of treating pain—including health care for diagnosis and treatment, drugs, therapies, and other medical costs—it results in lost work time and reduced productivity and concentration at work, or while conducting other activities (8,9). Although pain serves the important function of identifying tissue damage or inflammation, when the damage has healed and the pain remains, identifying either the cause of the remaining pain, or how to treat it, can be frustrating, time-consuming, and expensive.

In 1999–2002, more than one-quarter of Americans (26%) age 20 and over reported that they had a problem with pain—of any sort—that persisted for more than 24 hours in duration at some time during the month preceding their interview (Figure 28). Almost 60% of adults 65 years of age and over who reported pain indicated that it lasted for 1 year or more, compared with 37% of younger adults age 20–44 years who reported pain (Figure 29). In general, women reported pain more than men, and non-Hispanic white adults reported pain more than people of other races and ethnicities. Lower-income adults also reported pain more than higher-income adults (Figures 28, 31, and 32). Prevalence of joint pain increased with age with about one-fifth of adults age 18–44 years, and one-half of people age 65 and over, reporting any joint pain in the last 30 days (Figure 32). Severe headaches or migraines were twice as common among adult women as men (21% compared with 10%), and are most common among women in their reproductive years (Table 56).

A considerable amount of health care resources is devoted to treating pain, and the amount has been increasing. For example, rates of hospitalizations with procedures to replace painful hips and knees have increased substantially in the last decade (Figure 35). In 2002–2003, ambulatory medical care or prescribed medicine expenses for headaches averaged $566 per person for headache-related care among noninstitutionalized adults who reported a headache expense, representing more than $4 billion in total expenses—not including self-treatment, over-the-counter drugs, and inpatient hospital expenses for this condition (Figure 36). The percentage of people using prescription narcotic drugs in the past month increased by 30% between 1988–1994 and 1999–2002, largely due to increased use among non-Hispanic white women and women age 45 years and over (Figure 34 and data table for Figure 34). Yet, even with greater use of pain relieving medications, surgical interventions, and other treatments, in 1999–2002 more than 10% of Americans age 20 and over reported pain that had lasted for more than 1 year (data tables for Figures 28 and Figure 29).

To improve the health of all Americans and to enable policymakers to chart future trends, target resources most effectively, and set program and policy priorities, it is critical that the Nation keep collecting and disseminating reliable and accurate information about all components of health, including current health status, the determinants of health, resources, and outcomes. The following highlights from Health, United States, 2006 With Chartbook on Trends in the Health of Americans summarize the latest findings gathered from across the public and private health care sectors to help the Department of Health and Human Services, the President, and the Congress in carrying out this essential mission.

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