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National Center for Health Statistics (US) . Health, United States, 2007: With Chartbook on Trends in the Health of Americans. Hyattsville (MD): National Center for Health Statistics (US); 2007 Nov.

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Health, United States, 2007: With Chartbook on Trends in the Health of Americans.

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Chartbook on Trends in the Health of Americans

Population

Age

The population age 65 and over is increasing at a faster rate than the total population.

From 1950 to 2005, the total resident population of the United States increased from 151 million to 296 million, representing an average annual growth rate of 1.2% (Figure 1). During the same period, the population 65 years of age and over grew, on average, 2.0% per year, increasing from 12 to 37 million persons. The population 75 years of age and over grew the fastest (on average, 2.8% per year), increasing from 4 to 18 million persons.

Figure 1. Total population and older population: United States, 1950–2050.

Figure 1

Total population and older population: United States, 1950–2050. Click here for spreadsheet version Click here for PowerPoint NOTE: See data table for Figure 1 for data points graphed and additional notes.

Projections indicate that the rate of growth for the total population from now until 2050 will be slower, but older age groups will continue to grow more rapidly than the total population (1). By 2029, all of the baby boomers (those born in the post World War II period 1946–1964) will be age 65 years and over. As a result, the population age 65–74 years will increase from 6% to 10% of the total population between 2005 and 2030 (data table for Figure 1). As the baby boomers age, the population 75 years of age and over will rise from 6% to 9% of the population by 2030 and continue to grow to 12% in 2050. By 2040, the population age 75 years and over will exceed the population 65–74 years of age.

Reference

1.
Day JC. National population projections. 2001. U.S. Census Bureau. Available from: www​.census.gov/population​/www/pop-profile/natproj.html.

Foreign-Born Population

The proportion of the United States' population that is foreign-born more than doubled between 1970 and 2004.

According to the U.S. Census Bureau, foreign-born persons are defined as those who were not U.S. citizens at birth and include immigrants (legal permanent residents), temporary migrants (e.g., students, visiting scientists), humanitarian migrants (refugees), and unauthorized migrants (people illegally residing in the United States). Persons born abroad of U.S. citizen parents or born in Puerto Rico or other U.S. island areas are not considered foreign-born. Foreign-born persons may be United States citizens by naturalization or they may be noncitizens of the United States (1). Foreign-born noncitizens may be either legal or illegal U.S. residents.

In 2004, there were 34.2 million foreign-born people, representing nearly 12% of the civilian noninstitutionalized population of the United States (data table for Figure 2). Between 1970 and 2004, the percentage of the U.S. population that was foreign-born more than doubled (Figure 2).

Figure 2. Foreign-born population, by citizenship: United States, 1970–2004.

Figure 2

Foreign-born population, by citizenship: United States, 1970–2004. Click here for spreadsheet version Click here for PowerPoint NOTES: Data are for the U.S. resident population (1970, 1980, and 1990). Starting (more...)

The proportion of foreign-born noncitizens living in the United States is growing more rapidly than that of naturalized citizens. In 2004, the number of foreign-born noncitizens reached 21.1 million, representing 7.3% of the U.S. civilian noninstitutionalized population. Noncitizen foreign-born persons are disproportionately low-income and uninsured (2). They are also more likely than naturalized citizens to face other barriers to accessing health care including ineligibility for many government-sponsored programs and difficulty in finding providers who speak their language and provide culturally-sensitive care (3).

References

1.
U.S. Census Bureau. 2000 census of population and housing, demographic profile. Available from: factfinder.census.gov/home/saff/main.html?_lang=en.
2.
Kaiser Commission on Medicaid and the Uninsured. Immigrants' health care: Coverage and access. Washington, DC: Kaiser Family Foundation, August, 2003.
3.
Ku L, Matani S. Left out: Immigrants' access to health care and insurance. Health Affairs. 2001;20(1):247–56. [PubMed: 11194848]

Race and Ethnicity

The percentage of Americans who identify themselves as Hispanic or Asian continues to increase.

Changes in the racial and ethnic composition of the population have important consequences for the Nation's health because many measures of disease and disability differ significantly by race and ethnicity. One of the overarching goals of U.S. public health policy is elimination of racial and ethnic disparities in health.

Diversity has long been a characteristic of the U.S. population, but the racial and ethnic composition of the Nation has changed over time. In 2006, about 30% of adults and over 40% of children were members of racial or ethnic minority populations (data table for Figure 3). Moreover, the percentage of the population that is of Hispanic origin or Asian has more than doubled in recent decades (data table for Figure 3).

Figure 3. Population in selected race and Hispanic origin groups, by age: United States, 1980–2006.

Figure 3

Population in selected race and Hispanic origin groups, by age: United States, 1980–2006. Click here for spreadsheet version Click here for PowerPoint 1Not Hispanic.

In the 1980 and 1990 decennial censuses, Americans could choose only one racial category to describe their race (1). Beginning with the 2000 census, the question on race was modified to allow the choice of more than one racial category. Although, overall, a small percentage of persons of non-Hispanic origin selected two or more races in 2006, the percentage of children described as being of more than one race was more than twice as high as the percentage of adults (Figure 3). The number of American adults identifying themselves or their children as multiracial is expected to increase in the future (2).

The percentage of persons reporting two or more races varies considerably among racial groups. For example, the percentage of persons reporting a specified race in combination with one or more additional racial groups was 1.7% for white persons and 35.5% for American Indian or Alaska Native persons in 2006 (3).

References

1.
Grieco EM, Cassidy RC. Overview of race and Hispanic origin. Census 2000 brief. U.S. Census Bureau. March 2001.
2.
Waters MC. Immigration, intermarriage, and the challenges of measuring racial/ethnic identities. Am J Public Health. 2000;90(11):1735–7. [PMC free article: PMC1446407] [PubMed: 11076242]
3.
U.S. Census Bureau. Monthly postcensal resident population, by single year of age, sex, race, and Hispanic origin. Available from: www​.census.gov/popest​/national/asrh/2005_nat_res.html. (Data for July 1, 2006.)

Poverty

The poverty rate continues to be highest among children under 18 years of age.

Children and adults in families with income below or near the federal poverty level have worse health than those with higher income (see Appendix II, Poverty, for a definition of the federal poverty level). Although in some cases illness can lead to poverty, more often poverty causes poor health by its connection with inadequate nutrition, substandard housing, exposure to environmental hazards, unhealthy lifestyles, and decreased access to and use of health care services (1).

In 2005, the overall percentage of the U.S. population living in poverty was 12.6%, up from 11.3% in 2000 (2). The poverty rate increased for people 65 years of age and over from 2004 to 2005, but declined slightly for other ages (data table for Figure 4).

Figure 4. Poverty by age: United States, 1966–2005.

Figure 4

Poverty by age: United States, 1966–2005. Click here for spreadsheet version Click here for PowerPoint NOTES: Data shown are the percentage of persons with family income below the poverty level. See data table (more...)

Starting in 1974, children have been more likely than either working-age or older adults to be living in poverty (Figure 4). In 2005, 13 million children (17.6%) lived in poverty and another 15.6 million children (21.3%) were classified as near-poor with family income of 100% to less than 200% of the poverty level (data table for Figure 5).

Figure 5. Low income by age, race, and Hispanic origin: United States, 2005.

Figure 5

Low income by age, race, and Hispanic origin: United States, 2005. Click here for spreadsheet version Click here for PowerPoint NOTES: Percent of poverty level is based on family income and family size and composition (more...)

Prior to 1974, persons 65 years of age and over were more likely to live in poverty than people of other ages. With the increased benefits provided by government social insurance programs such as Social Security, the poverty rate of older adults declined rapidly until 1974 and continued a gradual decline to a low of 9.7% in 1999 (3). In 2005, 3.6 million persons age 65 years and over or 10.1% of older adults lived in poverty. An additional 9.5 million (26.7%) were near-poor (data table for Figure 5).

At all ages, a higher percentage of Hispanic and black persons than non-Hispanic white persons were poor (Figure 5). In 2005, 28%–35% of Hispanic and black children were poor compared with 10%–11% of non-Hispanic white and Asian children. Similarly, among persons 65 years of age and over, almost one-fifth of Hispanic and one-quarter of black persons were poor, compared with 8% of non-Hispanic white persons and 13% of Asians. In 2003–2005, one-quarter of American Indian or Alaska Native persons lived in poverty (estimate based on 3 years of data) (2).

References

1.
Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Socioeconomic Status and Health Chartbook. Health, United States, 1998. Hyattsville, MD: National Center for Health Statistics. 1998.
2.
DeNavas-Walt C, Proctor B, Hill LC. Income, poverty, and health insurance coverage in the United States: 2005. Current population reports, series P-60 no 231. Washington, DC: U.S. Government Printing Office. 2006. Available from: www​.census.gov/prod/2006pubs​/p60–231.pdf.
3.
Clark RL, Quinn JF.The economic status of the elderly. Medicare Brief. 1999. pp. 1–12. [PubMed: 10915459]

Health Care Expenditures

Personal Health Care Expenditures

In 2005, the largest shares of personal health care expenditures were paid by private health insurance and the federal government.

In 2005, the United States spent 16% (up from 14% in 2000) of its Gross Domestic Product (GDP) on health care, a greater share than any other developed country for which data are collected by the Organisation of Economic Co-operation and Development (Tables 120 and 121).

In 2005, the United States spent $2 trillion on health care, an average of $6,700 per person (Table 121). Personal health care expenditures, a component of national health expenditures that includes spending for hospital care, physician services, prescription drugs, nursing home care, dental care, and other types of medical care accounted for 84% of national health expenditures in 2005. The remaining 16% was spent on administration, government public health activities, research, and structures and equipment (Table 124) (1).

Overall, private health insurance paid for 36% of total personal health expenditures in 2005, the federal government 34%, state and local government 11%, and out-of-pocket payments accounted for 15% (Figure 6). The share of total expenditures paid out-of-pocket has declined from 27% in 1980 to 15% in 2005 (Table 125). This decline resulted from an expansion of benefits in both private health insurance plans and in government programs. Despite the decline in the share of health care expenditures paid out-of-pocket, the growth in health care costs over recent years means that consumers may still have significant out-of-pocket expenditures for their health care.

Figure 6. Personal health care expenditures, by source of funds and type of expenditures: United States, 2005.

Figure 6

Personal health care expenditures, by source of funds and type of expenditures: United States, 2005. Click here for spreadsheet version Click here for PowerPoint NOTE: See data table for Figure 6 for data points (more...)

In 2005, 37% of personal health care expenditures were for hospital care, 25% for physician care, 12% for prescription drugs, 7% for nursing home care, and the remaining 18% for other personal health care, including visits to nonphysician medical providers, medical supplies, and other health services (Figure 6). The share of total personal health care expenditures devoted to hospital care has declined from 40% in 1980 to 31% in 2005 and the prescription drug expenditure share has doubled from 5% to 10% over the same period, reflecting the shift in health care from inpatient to ambulatory care settings and the increasing contribution of prescription drugs to health care services and spending (Table 124).

Reference

1.
Smith C, Cowan C, Heffler S, Catlin A. National health spending in 2005: the slowdown continues. Health Aff (Millwood) 2007;26(1):142–153. [PubMed: 17211023]

Expenditures for Mental Health Services and Substance Abuse Treatment

Medicaid and private insurance pay the largest shares of mental health expenditures, whereas the largest share of substance abuse expenditures come from other state and local government funds (excluding Medicaid expenditures).

Mental health treatment has often been considered the stepchild of the medical care system with patients reluctant to use these services and insurers reluctant to pay for them. Estimates from a survey covering the years 2001 to 2003 found that about 30% of people 18–54 years of age suffered from a mental disorder during the year, yet only one-third of them received treatment (1).

A recent report estimated mental health services and substance abuse treatment (MHSA) expenditures from 1986 to 2003 (2). Combined expenditures for these services accounted for 7.5% of national health expenditures ($121 billion) in 2003. The MHSA expenditures have grown at a slower rate than overall health expenditures since 1986 (2), despite an increase in the number of people treated (1). Inflation-adjusted expenditures on mental health services doubled between 1986 and 2003, while expenditures on substance abuse treatment increased by one-half during this same period (data tables for Figures 7 and 8). From 1986 to 2003 national health expenditures increased by nearly two and one-half times (3).

Figure 7. National expenditures for mental health services, by source of funds: United States, 1986–2003.

Figure 7

National expenditures for mental health services, by source of funds: United States, 1986–2003. Click here for spreadsheet version Click here for PowerPoint NOTES: Estimates have been inflation-adjusted (more...)

Figure 8. National expenditures for substance abuse treatment, by source of funds: United States, 1986–2003.

Figure 8

National expenditures for substance abuse treatment, by source of funds: United States, 1986–2003. Click here for spreadsheet version Click here for PowerPoint NOTES: Estimates have been inflation-adjusted (more...)

The relative importance of sources of funds differed between mental health services and substance abuse treatment. By 2003, Medicaid accounted for the largest share of mental health services expenditures (26%), up from 16% in 1986 (Figure 7). Starting in 1998, Medicaid surpassed other state and local government funding as the largest payer for mental health services. Other state and local government payments cover mental health programs run by state, county, and municipal governments. Since 2001, private health insurance has been second behind Medicaid in paying for mental health services, followed by other state and local government expenditures, out-of-pocket payments, and Medicare.

In contrast, other state and local government funds have paid the largest share of substance abuse treatment expenditures since 1987, and that share has grown steadily. In 2003, other state and local government payments (not including the state share of Medicaid expenditures) accounted for 40% of substance abuse treatment expenditures, up from 29% in 1986 (Figure 8). The share of private health insurance declined from 30% to 10% during this time while the share of Medicaid and other federal government funding increased. Total public expenditures (other state and local government, Medicaid, Medicare, and other federal sources) for substance abuse treatment increased from 50% of total expenditures in 1986 to 77% in 2003.

Changes in the funding of mental health services and substance abuse treatment resulted from many factors including population growth; increased societal acceptance of mental health treatment; more effective psychotropic drugs prescribed more often in primary care settings; the emergence of managed health care; expansions in populations served by public programs such as Medicaid and Social Security Disability Insurance; and cost containment measures (2).

References

1.
Kessler RC, Demler O, Frank RG, Olfson M, Pincus HA, Walters EE. et al. Prevalence and treatment of mental disorders, 1990 to 2003. N Engl J Med. 2005;352(24):3095–105. [PMC free article: PMC2847367] [PubMed: 15958807]
2.
Mark TL, Levit KL, Coffey RM, McKusick DR, Harwood H, King E, et al. National expenditures for mental health services and substance abuse treatment, 1993–2003. SAMHSA pub. no. SMA 07–4227. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2007.
3.
Calculated using the gross domestic product implicit price deflator from Table 126 and national health expenditure estimates from the Centers for Medicare & Medicaid Services. Available from: www​.cms.gov/NationalHealthExpendData​/downloads/nhegdp05.zip.

Health Risk Factors

Cigarette Smoking

Fewer Americans are smoking cigarettes, but nearly one-fifth of women and one-quarter of men and high school students still are current cigarette smokers, as are 10% of pregnant women.

Smoking is associated with a significantly increased risk of heart disease, stroke, lung and other types of cancer, and chronic lung diseases (1). Decreasing cigarette smoking among adolescents and adults is a major public health objective for the Nation. Preventing smoking among teenagers and young adults is critical because smoking usually begins in adolescence (2). Smoking during pregnancy contributes to elevated risk of miscarriage, premature delivery, and having a low birthweight infant (3).

Following the first Surgeon General's Report on smoking in 1964, cigarette smoking declined sharply for men and at a slower pace for women (Figure 9). The percentage of men and women who smoke declined more slowly between 1990 and 2004, and in 2005 the proportion did not change (4). In 2005, 23% of men and 18% of women were smokers. Cigarette smoking by adults continues to be strongly associated with educational attainment. Adults with less than a high school education were three times as likely to smoke as those with a bachelor's degree or more education (Table 64).

Figure 9. Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965–2005.

Figure 9

Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965–2005. Click here for spreadsheet version Click here for PowerPoint NOTES: Estimates for men and (more...)

Cigarette smoking among high school students in grades 9–12 decreased between 1997 and 2003 after increasing in the early 1990s. In 2005, 23% of high school students had smoked cigarettes in the past month, 14% had smoked cigars, and 8% had used smokeless tobacco (5).

Among mothers with a live birth, the percentage reporting on the birth certificate that they smoked cigarettes during pregnancy declined between 1989 and 2004 from 20% to 10%. Maternal smoking has declined for all racial and ethnic groups, but differences among these groups persist (Table 12).

References

1.
U.S. Department of Health and Human Services. The health consequences of smoking: A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention; 2004. Available from: www​.cdc.gov/tobacco/sgr/sgr_2004/index​.htm.
2.
U.S. Department of Health and Human Services. Preventing tobacco use among young people: A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention; 1994. Available from: www​.cdc.gov/tobacco/sgr/sgr_1994/.
3.
Mathews TJ. Smoking during pregnancy in the 1990s. National vital statistics reports 2001; vol 49 no 7. Hyattsville, MD: National Center for Health Statistics. 2001. Available from: www​.cdc.gov/nchs/data​/nvsr/nvsr49/nvsr49_07.pdf. [PubMed: 11561426]
4.
CDC. Tobacco use among adults—United States, 2005. MMWR 2006;55(42):1145–48. Available from: www​.cdc.gov/mmwr/preview​/mmwrhtml/mm5542a1.htm. [PubMed: 17065979]
5.
CDC. Youth Risk Behavior Surveillance—United States, 2005. MMWR 2006;55(SS-5):1–33. Available from: www​.cdc.gov/mmwr/PDF/ss/ss5505.pdf.

Blood Cotinine Levels in Children

Children living below or near the poverty level are more likely to have high blood cotinine levels than children living in higher income families.

Secondhand tobacco smoke exposure or environmental tobacco smoke (ETS) is an important and preventable cause of morbidity among children. Children exposed to ETS are at an increased risk for acute lower respiratory tract infections, asthma induction and exacerbation, and middle-ear infections (1). The primary source of children's exposure to ETS is in the home (2). In 1992, the Environmental Protection Agency classified ETS as a Group A carcinogen known to cause cancer in humans (1).

Cotinine, a breakdown product of nicotine, is a marker for exposure to secondhand smoke (3,4). Heavy exposure to ETS usually produces blood cotinine levels above 1.0 ng/ml (defined as high cotinine level in this analysis) (5). Higher cotinine levels are associated with an increased prevalence of respiratory health problems such as wheezing apart from colds among all children and asthma for younger children 4–6 years of age (6).

The percentage of children 4–17 years of age with any detectable blood cotinine levels (at or above 0.05 ng/ml) decreased from 84% in 1988–1994 to 57% in 2001–2004 (Figure 10). High cotinine levels (more than 1.0 ng/ml) among children 4–17 years of age decreased from 23% in 1988–1994 to 17% in 2001–2004.

Figure 10. Blood cotinine levels among children 4–17 years of age, by percent of poverty level: United States, 1988–1994 and 2001–2004.

Figure 10

Blood cotinine levels among children 4–17 years of age, by percent of poverty level: United States, 1988–1994 and 2001–2004. Click here for spreadsheet version Click here for PowerPoint (more...)

Children living below or near the poverty level are more likely to have high blood cotinine levels than children living in higher income families. In 2001–2004, children living below 200% of poverty were more than twice as likely to have had a high blood cotinine level as children living in higher income families (22%–28% compared with 10%) (Figure 10). Some studies indicate that factors such as less spacious housing, including fewer rooms in the home, and low parental education are among the many predictors of high cotinine levels in children (6,7). Such factors are more common in lower-income households.

High blood cotinine level varies by race and ethnicity. In 2001–2004, children of Mexican origin had the lowest rate of high blood cotinine levels at 5%, compared with non-Hispanic black children (22%) and non-Hispanic white children (19%) (data table for Figure 10).

References

1.
U.S. Environmental Protection Agency. Respiratory health effects of passive smoking: Lung cancer and other disorders. Washington, DC: U.S. Environmental Protection Agency, 1992; pub. no. EPA/600/6–90/006F.
2.
CDC. State-specific prevalence of cigarette smoking among adults, and children's and adolescents' exposure to environmental tobacco smoke—United States, 1996. MMWR. 1997;46(44):1038–43. [PubMed: 9370224]
3.
U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general. Atlanta, GA. 2006.
4.
Federal Interagency Forum on Child and Family Statistics. America's children: Key national indicators of well-being, 2005. Washington, DC: U.S. Government Printing Office. 2005.
5.
Centers for Disease Control and Prevention. Third national report on human exposure to environmental chemicals. 2005. Available from: www​.cdc.gov.exposurereport/report.htm.
6.
Mannino DM, Moorman JE, Kingsley B. et al. Health effects related to environmental tobacco smoke exposure in children in the United States: Data from the Third National Health and Nutrition Examination Survey. Arch Pediatr Adolesc Med. 2001;155:36–41. [PubMed: 11177060]
7.
Wilson SE, Kahn RS, Khoury J. et al. Racial differences in exposure to environmental tobacco smoke among children. Environmental Health Perspectives. 2005;113(3):362–7. [PMC free article: PMC1253766] [PubMed: 15743729]

Alcohol-Related Emergency Department Visits: Adolescents and Young Adults

During 2002–2004, there were on average each year, more than 230,000 alcohol-related emergency department visits among underage adolescents 14–20 years of age.

Alcohol is the most widely used drug among youth (1). Alcohol use causes serious and potentially life-threatening problems for adolescents and young adults. Research indicates that drinking is associated with risk-taking and sensation-seeking behavior, and alcohol has disinhibiting effects that may increase the likelihood of unsafe activities. In 1984, the Uniform Drinking Age Act was enacted that mandated reduced federal transportation funds to those states that did not raise the minimum legal drinking age to 21, and by 1988 all states had increased the legal drinking age to 21 years (2). In 2007, the U.S. Surgeon General's Office issued a Call to Action against underage drinking, which has remained at consistently high levels (3). Currently, there are approximately 11 million underage drinkers in the U.S.

The National Hospital Ambulatory Medical Care Survey (NHAMCS) collects data on visits to hospital emergency departments (ED). In this analysis, an emergency department visit was considered alcohol-related based on a review of the ED record including the patient's reasons for the ED visit, and the diagnoses and the injury codes recorded (see Technical Notes for detailed information related to the definition of an alcohol-related visit). Because alcohol can be a contributing or underlying cause of ED visits, different algorithms for identifying alcohol-related ED visits exist (4). Our analysis uses a conservative approach to identify alcohol-related ED visits.

During 2002–2004, there were, on average each year, more than 230,000 alcohol-related ED visits among underage adolescents 14–20 years of age (data table for Figure 11). Alcohol-related ED visits among underage adolescents accounted for 2% of all ED visits for this age group (5).

Figure 11. Alcohol-related emergency department (ED) visit rates among persons 14–28 years of age, by age and sex: United States, 2002–2004.

Figure 11

Alcohol-related emergency department (ED) visit rates among persons 14–28 years of age, by age and sex: United States, 2002–2004. Click here for spreadsheet version Click here for PowerPoint * (more...)

Alcohol-related ED visit rates differed by sex and age, for both underage and legal drinkers (Figure 11). Visit rates among males were higher than among their female counterparts in every age group except for adolescents 18–20 years of age. Alcohol-related ED visit rates increased with age from early to late adolescence and then remained at that level through young adulthood (data table for Figure 11). In 2002–2004, rates for older male adolescents 18–20 years of age were more than twice those of male adolescents 14–17 years of age and rates for older female adolescents were more than three times those of younger female adolescents. Alcohol-related ED visit rates did not differ significantly between young adults who had reached legal drinking age and late adolescent drinkers 18–20 years of age.

Most (89%) alcohol-related ED visits resulted in patients being treated and released from the ED, 5% were admitted to inpatient units, and a small number of patients were transferred to other health facilities, left before being seen, or left against medical advice (5).

References

1.
Substance Abuse and Mental Health Services Administration. Consequences of underage alcohol use. Available from: ncadi.samhsa.gov/govpubs/rpo992/.
2.
French MT, Maclean JC. Underage alcohol use, delinquency, and criminal activity. Health Economics. 2006;15:1261–81. [PubMed: 16786500]
3.
U.S. Department of Health and Human Services. The Surgeon General's call to prevent and reduce underage drinking. U.S. Department of Health and Human Services, Office of the Surgeon General, 2007. Available from: www​.surgeongeneral.gov​/topics/underagedrinking/calltoaction​.pdf.
4.
McDonald AJ, Wang N, Camargo CA. U.S. emergency department visits for alcohol-related diseases and injuries between 1992 and 2000. Arch Int Med. 2004;164:531–7. [PubMed: 15006830]
5.
National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, unpublished analysis.

Frequency of Restaurant Meals

Over one-half of Americans reported eating an average of one to three restaurant meals weekly.

Between 1972 and 2004, the number of food service establishments in the United States nearly doubled from 491,000 to 878,000 (1). In 2004, spending on food away from home, including restaurant meals, catered affairs, and food on out-of-town trips accounted for 42% of average annual food expenditures compared with 26% in 1970 (2,3).

Although away-from-home meals can be healthy, research has shown that, on average, they are higher in overall calories, fat, saturated fat, and sodium content than foods eaten at home (3,4). Restaurant meal portion sizes tend to be larger than at home portion sizes and have been increasing over the past 30 years (5).

In 1999–2004, frequency of restaurant meal consumption varied by age (Figure 12). Restaurant meals included meals eaten at eat-in restaurants, carryout restaurants, and restaurants that deliver food (see Technical Notes). Adults 65 years and older were least likely to consume restaurant meals, whereas 18–24 year olds were most likely (data table for Figure 12). Although children 1–12 years of age had the lowest percentage of eating four or more restaurant meals a week (9%), this group had one of the highest percentages of eating one to three restaurant meals a week (63%). Restaurant meal consumption was consistently higher among males and among individuals with family income above 200% of the poverty level (6).

Figure 12. Weekly restaurant meal consumption among people 1 year of age and over, by age: United States, 1999–2004.

Figure 12

Weekly restaurant meal consumption among people 1 year of age and over, by age: United States, 1999–2004. Click here for spreadsheet version Click here for PowerPoint NOTES: Data for children 115 years (more...)

The frequent consumption of restaurant meals, coupled with the overall poor nutritional profile of these foods, has coincided with the significant increase in the percentage of Americans who are obese (Figure 13). Several factors contribute to the frequent consumption of restaurant meals including the high percentage of women employed outside the home, smaller households, and the increased supply of restaurants, including the proliferation of relatively inexpensive fast-food restaurants (3,4).

Figure 13. Overweight and obesity, by age: United States, 1960–2004.

Figure 13

Overweight and obesity, by age: United States, 1960–2004. Click here for spreadsheet version Click here for PowerPoint NOTES: Estimates for adults are age-adjusted. For adults: overweight including obese is defined (more...)

References

1.
The Keystone Center. The Keystone Forum on away-from-home foods: Opportunities for preventing weight gain and obesity. Final Report. May, 2006.
2.
U.S. Department of Labor, U.S. Bureau of Labor Statistics. Consumer expenditures in 2004. Report 992, April 2006.
3.
Lin BH, Guthrie J, Frazao E. Away-from-home foods increasingly important to quality of American diet. Economic Research Service, U.S. Department of Agriculture, Agriculture Information Bulletin No. 749; 1999.
4.
Kant AK, Graubard BI. Eating out in America, 1987–2000: Trends and nutritional correlates. Preventive Medicine. 2004;38:243–9. [PubMed: 14715218]
5.
Young LR, Nestle M. The contribution of expanding portion sizes to the U.S. obesity epidemic. Am J Public Health. 2002;92:246–9. [PMC free article: PMC1447051] [PubMed: 11818300]
6.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, unpublished analysis.

Overweight and Obesity

Two-thirds of American adults are overweight and one-third are obese.

Surplus body weight is associated with excess morbidity and mortality (1). Among adults, overweight and obesity are associated with an elevated risk of heart disease, diabetes, and some types of cancer. Overweight and obesity also increase the severity of disease associated with hypertension, arthritis, and other musculoskeletal problems (2). Additionally, overweight has serious health consequences among younger persons. Among children and adolescents, overweight is associated with an increased risk of high cholesterol, liver abnormalities, diabetes, and becoming an overweight adult (3). Diet, physical inactivity, genetic factors, environment, and health conditions all contribute to overweight in children and adults. The potential health benefits from reduction in the prevalence of overweight and obesity are of significant public health importance.

The prevalence of overweight and obesity changed little between the early 1960s and 1976–1980 (Figure 13). Findings from the 1988–1994 and 1999–2004 National Health and Nutrition Examination Surveys, however, showed substantial increases in overweight among adults. The upward trend in overweight since 1980 reflects primarily an increase in the percentage of adults 20–74 years of age who are obese. In 2003–2004, 67% of adults in that age group were overweight (includes obese); 34% of adults 20–74 years of age were obese (age-adjusted). Since 1960–1962, the percentage of adults who were overweight but not obese has remained steady at 32%–34% (age-adjusted).

The percentage of children (6–11 years of age) and adolescents (12–19 years of age) who are overweight has risen since 1976–1980. In 2003–2004, 17%–19% of children and adolescents were overweight. The percentage of preschool-age children (2–5 years of age) who are overweight almost doubled from 1988–1994 (7%) to 2003–2004 (14%).

The prevalence of obesity varies among adults by sex, race, and ethnicity (Table 74). In 2001–2004, 30% of men and 34% of women 20–74 years of age were obese (age-adjusted). The prevalence of obesity among women differed significantly by racial and ethnic group (among the groups presented). In 2001–2004, one-half of non-Hispanic black women were obese compared with nearly one-third of non-Hispanic white women. In contrast, the prevalence of obesity among men was similar by race and ethnicity.

References

1.
National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. NIH pub. no. 98–4083. 1998. Available from: www​.nhlbi.nih.gov/guidelines​/obesity/ob_gdlns.htm. [PubMed: 9813653]
2.
U.S. Department of Health and Human Services. The Surgeon General's call to action to prevent and decrease overweight and obesity. Rockville, MD: U.S. Department of Health and Human Services; 2001. Available from: www​.surgeongeneral.gov/topics/obesity/.
3.
Dietz WH. Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics. 1998;101(3 Pt 2):518–25. [PubMed: 12224658]

Morbidity and Limitation of Activity

Limitation of Activity Due to Chronic Conditions: Children

Conditions associated with learning, emotional, and behavioral problems are leading causes of activity limitation among children.

Limitation of activity due to chronic physical, mental, or emotional conditions is a broad measure of health and functioning that gauges a child's ability to engage in major age-appropriate activities and is related to a child's need for special educational and medical services. The National Health Interview Survey identifies children with activity limitation through questions about specific limitations in activities such as play, self-care, walking, memory, and other activities, and the current use of special education or early intervention services. Estimates of the number of children with an activity limitation may differ depending on the type of limitations included and the methods used to identify them (1).

Between 1997 and 2005, the percentage of children with activity limitation was 7% (Table 58). In 2004–2005, the percentage of school-age children with activity limitation (8%) was double the percentage of preschoolers with activity limitation (4%) primarily due to the large number of school-age children who were identified as limited solely by their participation in special education (2).

In 2004–2005, chronic health conditions causing activity limitation in children varied by age (Figure 14). Speech problems, mental retardation, and asthma were the leading causes of activity limitation among preschool children. Learning disability and Attention Deficit/Hyperactivity Disorder (ADHD or ADD) were reported as leading causes of activity limitation among all school-age children. Among younger school-age children, speech problems were also a leading cause of activity limitation, and among older school-age children, other mental, emotional, and behavioral problems were an additional important cause.

Figure 14. Limitation of activity caused by selected chronic health conditions among children, by age: United States, 2004–2005.

Figure 14

Limitation of activity caused by selected chronic health conditions among children, by age: United States, 2004–2005. Click here for spreadsheet version Click here for PowerPoint * Estimates are considered (more...)

References

1.
Newacheck PW, Strickland B, Shonkoff JP. et al. An epidemiologic profile of children with special health care needs. Pediatrics. 1998;102(1):117–23. [PubMed: 9651423]
2.
Federal Interagency Forum on Child and Family Statistics. America's children: Key national indicators of well-being, 2007. Washington, DC: U.S. Government Printing Office; 2007. Available from: www​.childstats.gov/.

Limitation of Activity Due to Chronic Conditions: Working-Age and Older Adults

Arthritis and other musculoskeletal conditions are the most frequently reported cause of activity limitation among both working-age and older adults.

Chronic physical, mental, and emotional conditions can limit the ability of adults to perform important activities such as working and doing everyday household chores. With advancing age, an increasing percentage of adults experience limitation of activity. Estimates of the number of working-age and older adults with limitation of activity are important for determining current and future types of health care needs and associated costs (1).

Between 1997 and 2005, the percentage of noninstitutionalized working-age adults 18–64 years of age reporting an activity limitation caused by a chronic health condition remained relatively stable (Table 58). In 2004–2005, the percentage of working-age adults who reported limitations ranged from 6% at age 18–44 years to 20% at age 55–64 years (2). Arthritis and other musculoskeletal conditions were the most frequently mentioned conditions causing limitation among working-age adults of all ages in 2004–2005 (Figure 15). Among adults 18–44 years of age, mental illness was the second leading cause of activity limitation followed by fractures or joint injury. Among adults 45–64 years of age, heart and circulatory conditions were the second leading cause of limitation. Other frequently mentioned conditions included mental illness and diabetes.

Figure 15. Limitation of activity caused by selected chronic health conditions among working-age adults, by age: United States, 2004–2005.

Figure 15

Limitation of activity caused by selected chronic health conditions among working-age adults, by age: United States, 2004–2005. Click here for spreadsheet version Click here for PowerPoint NOTES: Data (more...)

Between 1997 and 1999, the percentage of noninstitutionalized adults 65 years and over with limitation of activity declined and has remained relatively stable since 1999. (Table 58). In 2004–2005, the percentage of older adults with limitation of activity ranged from 25% of 65–74 year olds to 60% of adults 85 years old and over (2). Arthritis and other musculoskeletal conditions were the most frequently mentioned chronic conditions causing limitation of activity (Figure 16). Heart and circulatory conditions were the second leading cause of activity limitation. Among noninstitutionalized adults 85 years and over, senility or dementia, vision conditions, and hearing problems were frequently mentioned causes of activity limitation.

Figure 16. Limitation of activity caused by selected chronic health conditions among older adults, by age: United States, 2004–2005.

Figure 16

Limitation of activity caused by selected chronic health conditions among older adults, by age: United States, 2004–2005. Click here for spreadsheet version Click here for PowerPoint NOTES: Data are for (more...)

References

1.
Guralnik JM, Fried LP, Salive ME. Disability as a public health outcome in the aging population. Annu Rev Public Health. 1996;17:25–46. [PubMed: 8724214]
2.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, unpublished analysis.

Three or More Chronic Conditions

Poverty is strongly associated with having three or more chronic conditions, especially among adults 45–64 years of age.

Many studies of adult health have shown a strong association between poverty and a wide array of chronic health conditions (1). Given the association between poverty and the risk factors for many chronic health conditions, it is not surprising that low-income adults more often report multiple serious health conditions than those with higher income. The relationship between poverty and serious health problems reflects both the effect of low income on health and the effect of poor health on the ability to earn a living (1,2).

Data from the National Health Interview Survey were used to assess chronic health conditions of adults age 45 years and over living in the community. Adults were identified as having three or more chronic conditions if they reported ever being told by a physician or other health professional that they had three or more of the following conditions: hypertension, heart disease, stroke, emphysema, diabetes, cancer, or arthritis. Among adults ever diagnosed with asthma, only those who reported currently having asthma were considered to have a chronic condition.

In 2005, the percentage of adults with three or more chronic conditions increased with age from 7% of adults 45–54 years of age to 37% of adults 75 years of age and over. Among adults 45–64 years of age, the prevalence of three or more chronic conditions was strongly related to family income. Among adults 45–54 and 55–64 years of age, the percentage with three or more chronic conditions in the lowest family income group (below 100% of the poverty level) was two to three times the level in the highest family income category (400% or more of the poverty level) (Figure 17). Among middle-age poor adults, the level of multiple chronic conditions was similar to that for much older adults with high family income. In 2005, 30% of adults 55–64 years of age in the lowest income group and 31% of adults 75 years of age and over in the highest income group had three or more chronic conditions.

Figure 17. Three or more chronic conditions among adults 45 years of age and over, by age and percent of poverty level: United States, 2005.

Figure 17

Three or more chronic conditions among adults 45 years of age and over, by age and percent of poverty level: United States, 2005. Click here for spreadsheet version Click here for PowerPoint NOTES: Adults who (more...)

References

1.
Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Socioeconomic Status and Health Chartbook. Health, United States, 1998. Hyattsville, MD: National Center for Health Statistics. 1998. Available from: www​.cdc.gov/nchs/hus.htm.
2.
Freidland RB. Multiple chronic conditions. Data Profiles, Challenges for the 21st Century: Chronic and Disabling Conditions: Number 12. Georgetown University Center on an Aging Society. November 2003.

Mortality

Life Expectancy

The gap in life expectancy at birth between white persons and black persons persists, but has narrowed since 1990.

Life expectancy is a measure often used to gauge the overall health of a population. As a summary measure of mortality, life expectancy represents the average number of years of life that could be expected if current death rates were to remain constant. Shifts in life expectancy are often used to describe trends in mortality. Life expectancy at birth is strongly influenced by infant and child mortality. Life expectancy later in life reflects death rates at or above a given age and is independent of the effect of mortality at younger ages (1).

From 1900 through 2004, life expectancy at birth increased from 46 to 75 years for men and from 48 to 80 years for women (Table 27). Life expectancy at age 65 also increased during this period. Among men, life expectancy at age 65 rose from 12 to 17 years and among women from 12 to 20 years. In contrast to life expectancy at birth, which increased sharply early in the 20th century, life expectancy at age 65 improved primarily after midcentury. Improved access to health care, advances in medicine, healthier lifestyles, and better health before age 65 are factors underlying decreased death rates among older Americans (2).

In 2004, life expectancy at birth was 76 years for white males compared with 70 years for black males and 81 years for white females compared with 76 years for black females (data table for Figure 18). Life expectancy at birth increased more for the black than for the white population between 1990 and 2004 (Figure 18). During this period, the gap in life expectancy between white males and black males narrowed from 8 years to 6 years (data table for Figure 18). During the same period, the gap in life expectancy between white females and black females decreased from 6 years to 5 years.

Figure 18. Life expectancy at birth and at 65 years of age, by race and sex: United States, 1970–2004.

Figure 18

Life expectancy at birth and at 65 years of age, by race and sex: United States, 1970–2004. Click here for spreadsheet version Click here for PowerPoint NOTES: Life expectancies prior to 1997 are from (more...)

The gap in life expectancy between white and black people at age 65 is narrower than at birth. Between 1990 and 2004, the difference in life expectancy at age 65 between white males and black males remained stable at 2 years. In 2004, life expectancy at age 65 was 17 years for white males and 15 years for black males. The difference in life expectancy between white and black females has also been stable in recent years; in 2004, at age 65, white females and black females could expect to live an additional 20 and 19 years, respectively.

References

1.
Arriaga EE. Measuring and explaining the change in life expectancies. Demography. 1984;21(1):83–96. [PubMed: 6714492]
2.
Fried LP. Epidemiology of aging. Epidemiol Rev. 2000;22(1):95–106. [PubMed: 10939013]

Infant Mortality

Both neonatal and postneonatal mortality rates have declined substantially since 1950.

The infant mortality rate, the risk of death during the first year of life, is related to the underlying health of the mother, public health practices, socioeconomic conditions, and availability and use of appropriate health care for infants and pregnant women. Disorders related to short gestation and low birthweight, and congenital malformations are the leading causes of death during the neonatal period (less than 28 days of life). Sudden Infant Death Syndrome (SIDS) and congenital malformations rank as the leading causes of infant deaths during the postneonatal period (28 days through 11 months of life) (1).

After decades of decline, there has been little progress in lowering the U.S. infant mortality rate from 2000–2004. In 2004, the infant mortality rate was 6.8 infant deaths per 1,000 live births, compared with 6.9 in 2000. The 2004 infant mortality rate was 77% lower than in 1950, due primarily to annual declines in the infant mortality rate from 1960–2000 (Figure 19).

Figure 19. Infant, neonatal, and postneonatal mortality rates: United States, 1950–2004.

Figure 19

Infant, neonatal, and postneonatal mortality rates: United States, 1950–2004. Click here for spreadsheet version Click here for PowerPoint NOTES: Infant is defined as under 1 year of age, neonatal as under (more...)

Infant mortality rates have declined for most racial and ethnic groups, but large disparities among the groups remain (Table 19). During 2001–2003, the infant mortality rate was highest for infants of non-Hispanic black mothers. Infant mortality rates were also high among infants of American Indian or Alaska Native mothers and Puerto Rican mothers. Infants of mothers of Cuban origin had the lowest infant mortality rates.

Reference

1.
Heron MP, Smith BL. Deaths: Leading causes for 2003. National vital statistics reports; vol 55 no 10. Hyattsville, MD: National Center for Health Statistics. 2007. Available from: www​.cdc.gov/nchs/data​/nvsr/nvsr55/nvsr55_10.pdf.

Leading Causes of Death for All Ages

Mortality from heart disease, stroke, and unintentional injuries is substantially lower than in 1950.

In 2004, a total of 2.4 million deaths were reported in the United States (Table 31). The overall age-adjusted death rate was 45% lower in 2004 than in 1950. The reduction in overall mortality during the last half of the twentieth century was driven mostly by declines in mortality for such leading causes of death as heart disease, stroke, and unintentional injuries (Figure 20).

Figure 20. Death rates for leading causes of death for all ages: United States, 1950–2004.

Figure 20

Death rates for leading causes of death for all ages: United States, 1950–2004. Click here for spreadsheet version Click here for PowerPoint NOTES: Estimates are age-adjusted. Causes of death shown are (more...)

In 2004, the age-adjusted death rate for heart disease, the leading cause of death, was 63% lower than the rate in 1950 (Table 36). The age-adjusted death rate for stroke, the third leading cause of death, declined 72% since 1950 (Table 37). Heart disease and stroke mortality are associated with risk factors such as high cholesterol, high blood pressure, smoking, and dietary factors. Other important factors include socioeconomic status, obesity, and physical inactivity. Factors contributing to the decline in heart disease and stroke mortality include better control of risk factors, improved access to early detection, and better treatment and care, including new drugs and expanded uses for existing drugs (1).

Overall age-adjusted death rates for cancer, the second leading cause of death, rose between 1960 and 1990 and then reversed direction (Table 38). Between 1990 and 2004 overall death rates for cancer declined 14%. The trend in the overall cancer death rate reflects the trend in the death rate for lung cancer (Table 39). Since 1970, the death rate for lung cancer for the total population has been higher than the death rate for any other cancer site.

Chronic lower respiratory diseases (CLRD) were the fourth leading cause of death in 2004. The age-adjusted death rate for CLRD in 2004 was 45% higher than the rate in 1980. CLRD mortality increased during the period 1980 to 1999. Since 1999, CLRD mortality has decreased 9% (Table 41).

The fifth leading cause of death in 2004 was unintentional injuries. Age-adjusted death rates for unintentional injuries declined during the period 1950–1992 (Table 29). Since 1992, the unintentional injury mortality rate has gradually increased. Despite recent increases, the death rate for unintentional injuries in 2004 was still 52% lower than the rate in 1950.

Reference

1.
CDC. Achievements in public health, 1990–1999: Decline in deaths from heart disease and stroke—United States, 1990–1999. MMWR 1999;48(30):649–56. Available from: www​.cdc.gov/mmwr/preview​/mmwrhtml/mm4830a1.htm.

Special Feature: Access to Health Care

Introduction

In 2005, almost 20% of adults reported they did not receive needed health-related services in the past 12 months because they could not afford them.

The American health care delivery system is evolving, and as it changes, so do the types of services that are available. New technological advances can prevent, treat, or ameliorate conditions and diseases that were once thought untreatable. Yet many people who could benefit from these services do not receive them. Identifying which Americans do not receive potentially beneficial services, and the reasons underlying suboptimal use of services, is essential to identifying solutions that can improve access to health care. Providing needed preventive, curative, rehabilitative, and palliative health care services to people in need benefits not only the individuals but also their communities, in terms of having a healthier population, increasing productivity, and reducing spending for expensive types of care such as emergency department care or care for persons who are needlessly ill or disabled (1).

This Special Feature examines access to health care in the United States for the noninstitutionalized population. A 1993 Institute of Medicine panel defined health care access as "the timely use of personal health services to achieve the best possible health outcomes" (2). Due to the difficulty of directly measuring need for services, appropriate timeliness of services, and health outcomes, access is usually studied indirectly by examining whether rates of service use are at recommended or expected levels, or whether population groups differ in use of services. Lower rates of service use among a group may reflect a barrier to access but must be further studied to determine if there is differing need for services among the groups, and whether services are underutilized in the lower-use group or overutilized in the higher-use group. However, having equal access to health care services does not guarantee that needed services are received or that outcomes are optimal. Not everyone who has access to services receives them when needed, and people who live in areas with few services may still obtain them (2). Additionally, the relationship between health care and outcomes is influenced by a myriad of factors other than access, including propensity to seek care, health status, compliance with medical advice, and quality of services provided.

Health insurance coverage is also used as a proxy measure of access to health care because the lack of any health insurance coverage has been established as a major barrier to receiving most health care services. However, insurance alone is not sufficient to ensure access to all health care services. Few insurance policies cover all needed or desired services, and many policies exclude coverage for pre-existing conditions (2). Cost-sharing varies widely across insurance policies, so that even people with insurance may have to pay substantial copayments, deductibles, and other out-of-pocket expenses. Generosity of coverage, especially for long-term care, medical supplies, psychotherapy, or dental, vision, home health, or rehabilitative services varies considerably among private health insurance policies. States also vary in the extent to which they cover these types of services in their Medicaid and State Children's Health Insurance Program (SCHIP) programs. The Medicare program does not cover several health services, including general physical, vision, or hearing exams; long-term custodial care; dental care; and the cost of eyeglasses or hearing aids, and it requires a deductible and copayment for most services. The majority of Medicare enrollees have supplemental insurance to cover some costs for services not covered by Medicare (Table 140).

The burden of out-of-pocket health care expenses is greatest for poor and uninsured people (3). But some higher-income families with health insurance who have catastrophic illnesses or high out-of-pocket expenditures for noncovered services may devote a substantial portion of their income to medical care, or to health insurance premiums, or both (2, Figure 31). Health insurance premiums alone can be a burden on family income. Even with employer subsidies for their workers' health insurance, worker contributions averaged $627 for a single-person plan and $2,973 for a family plan in 2006; employers paid an average of $3,615 per worker for single plans and $8,508 for family coverage (4). Individual insurance policies paid entirely by the beneficiary can cost substantially more—particularly for people with pre-existing conditions—and can account for a large share of disposable income in poorer families (5).

The majority of Americans do not report having problems accessing health care services due to cost. In 2005, 19% of adults 18 years of age and over—more than 40 million people—reported they did not receive one or more of the following health-related services in the past year because they could not afford them: medical care, prescription medicines, mental health care, dental care, or eyeglasses (see Technical Notes for the survey questions). About 12% of adults reported they did not receive needed dental care and 7% did not purchase needed eyeglasses due to cost (data table for Figure 21). About 7% of adults (representing about 15 million people) reported they did not receive needed medical care in 2005 because they could not afford it. The percentage of adults who did not receive prescription drugs because they could not afford them increased from 6% in 1997 to 9% in 2005 (6). Fewer problems in obtaining needed services were reported for children and adults age 65 years and over than working-age adults 18–64 years of age (Table 79, Figure 21).

Figure 21. Adults 18 years of age and over reporting they did not receive needed health-related services in the past 12 months because they could not afford them, by age and type of service: United States, 2005.

Figure 21

Adults 18 years of age and over reporting they did not receive needed health-related services in the past 12 months because they could not afford them, by age and type of service: United States, 2005. Click here for spreadsheet (more...)

This Special Feature explores several dimensions of access to care, including supply of medical care providers and services (distribution of primary care physicians and obstetricians or gynecologists by county, and supply relative to demand for transplantable kidneys), nonfinancial barriers to care (lack of usual source of care and delayed care due to lack of transportation), and financial barriers to care (insurance and the burden of health care expenditures by family income). It also presents data on utilization of selected services—dental care, colorectal scope procedures, and antidepressant drugs—to highlight differences in use rates by population groups. Population groups with lower use rates may have some barriers to accessing these services. Taken together, these charts present some major issues related to access to health care in our Nation.

References

1.
Institute of Medicine (U.S.). Coverage matters: Insurance and health care. Washington, DC: National Academy Press; 2001. Available from: books.nap.edu/html/coverage_matters/index.html.
2.
Institute of Medicine (U.S.). Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Washington, DC: National Academy Press; 1993.
3.
Banthin JS, Bernard DM. Changes in financial burdens for health care: National estimates for the population younger than 65 years, 1996 to 2003. JAMA. 2006;296(22):2712–9. [PubMed: 17164457]
4.
The Kaiser Family Foundation and Health Research and Educational Trust. Employer health benefits: 2006 summary of findings. Available from: www​.kff.org/insurance/7527/upload/7528​.pdf.
5.
Pauly MV, Nichols LM. The nongroup health insurance market: Short on facts, long on opinions and policy disputes. Health Aff (Millwood) 2002 Jul–Dec;(suppl web exclusives):w325–44. [PubMed: 12703588]
6.
National Center for Health Statistics, National Health Interview Survey, unpublished analysis.

Physician Supply

The supply of physicians varies by metropolitan status and geography, and nearly one-half of U.S. counties had no obstetricians or gynecologists in 2004.

A shortage of physicians in a geographic area can increase travel time to see a physician and serve as a deterrent to timely and appropriate health care. Scarcity of physicians can also lead to higher caseloads for physicians and consequently, increased time to getting an appointment, as well as increased waiting time for receiving care.

The supply of patient care physicians in the United States has increased by 50% since 1980 (1). In 2004, there were 24 active, nonfederal, patient care physicians per 10,000 population in the United States (data table for Figure 22) compared to 16 per 10,000 population in 1980 (1). However, the supply of physicians varied substantially across the country (Figure 22, see Technical Notes). Only 11% of counties had a ratio of physicians to population above the national ratio, while 4% of counties had no physicians and an additional 7% met the criteria to be designated as health professional shortage areas (HPSA). HPSAs are defined by the Health Resources and Services Administration as a geographic area with less than 2.86 primary care physicians per 10,000 population (2).

Figure 22. Patient care physicians per 10,000 population, by county: United States, 2004.

Figure 22

Patient care physicians per 10,000 population, by county: United States, 2004. Click here for spreadsheet version Click here for PowerPoint NOTES: Data are for active, nonfederal, patient care physicians. Doctors of medicine (more...)

In 2004, about 50 million people or 17% of the U.S. population lived in nonmetropolitan counties (see Appendix II, Metropolitan statistical area). Of the 707,380 active, nonfederal, patient care physicians, only 9% were located in nonmetropolitan counties. More than 90% of the 134 U.S. counties with no physicians were nonmetropolitan. Most of the counties with no physicians are located in the Plains states and parts of the Southwest (Figure 22).

Obstetricians or gynecologists (obgyns) are physician specialists who provide medical and surgical care to women and have expertise in pregnancy, childbirth, and disorders of the female reproductive system. Between 1980 and 2004, the national supply of nonfederal, patient care, obgyns (doctors of medicine only, see data table for Figure 23) increased from about 2.5 to 3.0 obgyns per 10,000 females age 15 years and over (1). However, in 2004, nearly 50% of U.S. counties had no obgyns providing direct patient care, and 85% of counties fell below the national ratio indicating that, as with patient care physicians, the nationwide ratio is being driven by the counties that have high concentrations of obgyns (Figure 23). Relative to population, nonmetropolitan counties had less than one-half the number of obgyns compared with metropolitan counties (1.4 obgyns versus 3.3 per 10,000 females 15 years of age and over) (data table for Figure 23). Ninety-three percent of counties that had no obgyns also had no certified nurse midwives in 2003 (1).

Figure 23. Obstetricians or gynecologists per 10,000 females age 15 years and over, by county: United States, 2004.

Figure 23

Obstetricians or gynecologists per 10,000 females age 15 years and over, by county: United States, 2004. Click here for spreadsheet version Click here for PowerPoint NOTES: Data are for active, nonfederal, patient (more...)

References

1.
Health Resources and Services Administration, 2005 Area Resource File, unpublished analysis.
2.
Health Resources and Service Administration, Bureau of Health Professionals. Available from: bhpr.hrsa.gov/shortage/.

Kidney Transplants

The supply of donated kidneys available for people with end-stage renal disease is not keeping up with demand.

End-stage renal disease (ESRD) is defined as a permanent loss of the kidneys' ability to filter wastes from the circulatory system. Its prevalence and treatment costs have increased substantially over the past few decades. In 2004, Medicare's End-Stage Renal Disease program paid almost $19 billion, and other sources paid more than $10 billion, for ESRD care (1). ESRD can result from a number of medical conditions, but the most common causes are diabetic nephropathy, systemic arterial hypertension, glomerulonephritis, and polycystic kidney disease. Once kidney function declines to less than 12%–15%, patient survival is dependent on renal replacement therapy—either ongoing dialysis treatments or kidney transplant. For eligible candidates, transplant and subsequent anti-rejection therapy is preferable because it eliminates the need for dialysis, reduces mortality, improves quality of life, and is less costly than dialysis (2).

With the aging of the population and increases in diabetes prevalence, the prevalence of ESRD and the subsequent need for kidney transplantation is expected to continue to increase. Black people are significantly more likely to develop ESRD than white people. Diabetes and hypertension prevalence rates are higher in black than in white populations. The progression of these diseases differs between the black and white populations, producing earlier onset of ESRD in black people. However, the causes of higher rates of ESRD in black people have not yet been fully explained (3).

The U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients contain data regarding every organ donation and transplant event occurring in the United States since 1987. This database shows that the number of new registrations on the kidney transplant waiting list increased more than 300% between 1988 and 2006, and 67% between 1996 and 2006 (data table for Figure 24). Non-Hispanic black people made up 33% of the active waiting list (patients eligible for an immediate transplantation) in 2006, more than three times their proportion of the United States population (13%, Table 1). The percentage of non-Hispanic black people on the waiting list remained relatively stable over the past decade, whereas the percentage of non-Hispanic white people declined, and the percentages of Hispanic and non-Hispanic Asian people increased. In 2006, there were 19,247 non-Hispanic white and 16,452 non-Hispanic black patients on the active kidney transplant waiting list (Figure 24).

Figure 24. Active kidney transplant waiting list patients at end of year, by race and Hispanic origin: United States, 1988, 1996, and 2006.

Figure 24

Active kidney transplant waiting list patients at end of year, by race and Hispanic origin: United States, 1988, 1996, and 2006. Click here for spreadsheet version Click here for PowerPoint NOTES: Race and ethnicity (more...)

Although the majority of the costs of kidney transplantation are paid by Medicare's End-Stage Renal Disease program or by private insurance, the ability to pay for transplantation does not ensure access to a kidney. The supply of available and donor-recipient compatible kidneys has not kept pace with demand, and the percentage of patients who remain on the active waiting list for multiple years is increasing in large part because of lack of availability of organs. At the end of 2006, 23% of all active waiting list patients had been waiting for three years or more for their transplant (4).

Between 1988 and 2004, the percentage of patients transplanted within two years of being added to the active waiting list declined 56% for non-Hispanic white patients, about 65% for non-Hispanic black or non-Hispanic Asian patients, and 69% for Hispanic patients (data table for Figure 25). In 2004, non-Hispanic white patients were more likely to receive a transplant within two years than non-Hispanic black, non-Hispanic Asian or Hispanic patients (30% compared to 20%–21%) (Figure 25). Racial disparities in rates of organ donation and renal transplantation may be influenced by genetic and biological factors, the request and consent procedures of organ procurement organizations, patient registration practices for a center or region, organ acceptance practices at each transplant center, geographic location, socioeconomic status, cultural attitudes and beliefs about organ donation, rates of organ donation within each local area, and the donor pool (5,6).

Figure 25. Active waiting list patients who received a kidney transplant within 2 years, by race and Hispanic origin: United States, 1988, 1996, and 2004.

Figure 25

Active waiting list patients who received a kidney transplant within 2 years, by race and Hispanic origin: United States, 1988, 1996, and 2004. Click here for spreadsheet version Click here for PowerPoint NOTES: (more...)

References

1.
U.S. Renal Data System, USRDS 2006 annual data report: Atlas of end-stage renal disease in the United States. 2006. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD. Available from: www​.usrds.org/.
2.
Wolfe RA, Ashby VB, Milford EL. et al. Comparison of mortality in patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341:1725–30. [PubMed: 10580071]
3.
Young CJ, Kew C. Health disparities in transplantation: Focus on complexity and challenge of renal transplantation in African Americans. Med Clin N Am. 2005;89:1003–31. [PubMed: 16129109]
4.
U.S. Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation, Rockville, MD; United Network for Organ Sharing, Richmond, VA. Unpublished data from the Organ Procurement and Transplantation Network as of March 9, 2007.
5.
Sanfilippo FP, Vaughn WK, Peters TG. et al. Factors affecting the waiting time of cadaveric kidney transplant candidates in the United States. JAMA. 1992;267:247–52. [PubMed: 1727521]
6.
Healthy People 2010: Objectives for improving health. Volume 1 (Part A, chapter 4). 2000. Available from: www​.healthypeople.gov​/Document/RTF/Volume1/04CKD.rtf.

No Usual Source of Medical Care

Between 5% and 6% of adults 45–64 years of age with diagnosed hypertension, serious heart conditions, or diabetes report not having a usual source of medical care.

Not having a medical home or usual source of health care may be a barrier to accessing health care. Lacking a usual source of care is associated with poorer control of chronic conditions such as hypertension and lower receipt of preventive services (1,2). Lack of a usual source of care is most common among young adults 18–44 years of age (Table 78). However, about 10% of adults 45–64 years of age—a time in life when chronic illnesses become more common—did not have a usual source of health care in 2004–2005. The proportion of adults 45–64 years of age without a usual source of care has been stable over the past decade.

In 2004–2005, adults 45–64 years of age who did not report diagnosed chronic conditions were nearly three times as likely to lack a usual source of care as adults who reported hypertension, a serious heart condition, or diabetes (Figure 26, see Technical Notes for definitions of categories). Among those not reporting chronic conditions, Hispanic adults were considerably more likely than others to lack a usual source of care.

Figure 26. No usual source of care among adults 45–64 years of age, by selected diagnosed chronic conditions and race and Hispanic origin: United States, 2004–2005.

Figure 26

No usual source of care among adults 45–64 years of age, by selected diagnosed chronic conditions and race and Hispanic origin: United States, 2004–2005. Click here for spreadsheet version Click here for (more...)

About 5%–6% of adults 45–64 years of age with diagnosed hypertension, serious heart disease, and diabetes reported not having a usual source of care. Among midlife adults with diagnosed hypertension, Hispanic and non-Hispanic black adults were more likely than non-Hispanic white adults to lack a usual source of care. For midlife adults with diagnosed diabetes, Hispanic adults were at least twice as likely to lack a usual source of care as other racial or ethnic groups.

References

1.
Jiang H, Muntner P, Chen J, Roccella EJ, Streiffer RH, Whelton PK. Factors associated with hypertension control in the general population of the United States. Arch Intern Med 2002;162:1051–8. Available from: archinte.ama-assn.org/cgi/content/abstract/162/9/1051. [PubMed: 11996617]
2.
Corbie-Smith G, Flagg EW, Doyle JP, O'Brien MA. Influence of usual source of care on differences by race/ethnicity in receipt of preventive services. J Gen Intern Med. 2002;17(6):458–64. [PMC free article: PMC1495054] [PubMed: 12133161]

Delayed Medical Care Due to Lack of Transportation

Poor adults are more likely than those with higher incomes to delay medical care due to lack of transportation, with poor women age 45–64 years most likely to report this problem.

Missing routine or preventive medical care can lead to the need for emergency care or even to preventable hospitalizations. Lack of access to transportation due to not owning a vehicle, not having a vehicle available via a friend or family member, or not having access to public transportation can lead to difficulty in seeking medical care.

According to the 2001 National Household Transportation Survey, 27% of households with income below $20,000 did not own a vehicle, compared with 5% among households earning $20,000 to $39,999 and 8% of all U.S. households (1). Although public transit is an option, cost can be prohibitive and routes may not correspond with the location of medical facilities. In many communities, various forms of paratransit, alternative modes of flexible passenger transportation that do not follow fixed routes or schedules such as van services and demand-responsive buses, are available for medically-related trips (2). However, publicly funded transportation programs are usually targeted to specific vulnerable groups, such as Medicaid enrollees, persons with disabilities, or older persons.

In 2004–2005, adults living in families with income below 100% of the poverty level reported delaying care due to lack of transportation at 10 times the rate of adults with family incomes of 200% or more of the poverty level (data table for Figure 27; see Technical Notes for exact question wording). Among those with family income below 100% of the poverty level, adults 45–64 years of age reported the highest rates of delaying medical care due to lack of transportation (Figure 27). The problem was most commonly reported among poor women age 45–64 years, with almost 10% reporting that they delayed obtaining medical care due to lack of transportation.

Figure 27. Delayed medical care in the past 12 months due to lack of transportation among adults 18 years of age and over, by sex, percent of poverty level, and age: United States, 2004–2005.

Figure 27

Delayed medical care in the past 12 months due to lack of transportation among adults 18 years of age and over, by sex, percent of poverty level, and age: United States, 2004–2005. Click here for spreadsheet version (more...)

References

1.
Pucher J, Renne JL. Socioeconomics of urban travel: Evidence from the 2001 NHTS. Transportation Quarterly. 2003;75:49–77.
2.
Transit Cooperative Research Board. Cost-benefit analysis of providing non-emergency medical transportation. 2005. Available from: onlinepubs.trb.org/onlinepubs/tcrp/tcrp_webdoc_29.pdf.

Health Insurance at the Time of Interview

Between 1999 and 2005, the percentage of people under age 65 with private health insurance declined while public coverage programs expanded leaving the uninsured rate unchanged.

Health insurance coverage is an important determinant of access to health care (1). Uninsured children and adults under 65 years of age are substantially less likely to have a usual source of health care or a recent health care visit than their insured counterparts (Tables 77, 78, 79, 81). Uninsured people are more likely to forego needed health care because they cannot afford it (Table 79). The major source of coverage for persons under 65 years of age is private employer-sponsored group health insurance. Private health insurance may also be purchased on an individual basis, but is generally more costly and tends to provide less adequate coverage than group insurance. Public programs such as Medicaid and the State Children's Health Insurance Program (SCHIP) provide coverage for many low-income children and adults. Almost all adults age 65 and over are covered by the Medicare program, resulting in very few older adults without health insurance. Medicare enrollees may have additional private or public coverage to supplement their Medicare benefit package.

Between 1984 and 1994, private coverage declined among people under 65 years of age while Medicaid coverage and the percentage with no health insurance increased (Figure 28, Appendix II, Health insurance coverage). After rising to 73% in 1999, the percentage with private health insurance has declined each year, reaching 68% in 2005. This decrease has been offset by an increase in the percentage with Medicaid or SCHIP, resulting in little change in the percentage uninsured.

Figure 28. Health insurance coverage at the time of interview among persons under 65 years of age: United States, 1984–2005.

Figure 28

Health insurance coverage at the time of interview among persons under 65 years of age: United States, 1984–2005. Click here for spreadsheet version Click here for PowerPoint NOTE: See data table for Figure (more...)

In recent years, 16%–17% of people under 65 years had no health insurance at the time of their interview. In 2005, cost was cited by more than one-half of these uninsured as the reason for their lack of coverage (2). Other reasons given were having lost a job or a change in employment (24%), Medicaid benefits stopped (10%), and ineligibility for family insurance coverage due to age or leaving school (8%).

References

1.
Institute of Medicine. Committee on the consequences of uninsurance. Series of reports: Coverage matters: Insurance and health care; Care without coverage; Health insurance is a family matter; A shared destiny: Community effects of uninsurance; Hidden costs, value lost: Uninsurance in America. Washington, DC: National Academy Press. 2001–2003.
2.
Adams PF, Dey AN, Vickerie JL. Summary health statistics for the U.S. population: National Health Interview Survey, 2005. National Center for Health Statistics. Vital Health Stat 2007;10(233). Available from: www​.cdc.gov/nchs/data​/series/sr_10/sr10_233.pdf. [PubMed: 17315515]

Length of Time Without Health Insurance

Persons of Mexican origin are more likely than those in other race or ethnic groups to be uninsured for more than 12 months.

Many people under age 65, particularly those with low incomes, do not have health insurance coverage consistently throughout the year. Reasons for discontinuities in coverage may include loss or change of employment and financial reversals, divorce, births and other changes in life circumstances, and migration between states. Respondents to the National Health Interview Survey (NHIS) were asked whether they had health insurance at the time of their interview and the type of coverage (see Appendix II, Health insurance coverage). Those covered by health insurance at the time of interview were asked whether there was any time during the 12 months prior to the interview when they did not have health insurance. People who were uninsured at the time of interview were asked how long it had been since they last had health coverage. These questions provide estimates of the percentage of persons without coverage at a point-in-time (Figure 28), as well as estimates of the percentage without coverage for different lengths of time (Figure 29).

Figure 29. Uninsured for at least part of the 12 months prior to interview among persons under 65 years of age, by length of time uninsured and selected characteristics: United States, 2005.

Figure 29

Uninsured for at least part of the 12 months prior to interview among persons under 65 years of age, by length of time uninsured and selected characteristics: United States, 2005. Click here for spreadsheet version Click (more...)

In 2005, 20% of people under 65 years of age reported being uninsured for at least part of the 12 months prior to interview. Among those who reported any time without insurance coverage during the 12 months prior to interview, the majority reported being uninsured for more than 12 months. About 11% of persons under 65 years reported being uninsured for more than 12 months, 8% reported being uninsured for any period up to 12 months, and 1% reported being uninsured and had missing data for the length of time they were uninsured (data table for Figure 29).

Children under 18 years of age were less likely to be uninsured than adults were because low income children are eligible for public programs such as SCHIP designed specifically for them. The percentage of adults under 65 years of age without health insurance coverage decreased with age (Figure 29). In 2005, adults 18–24 years of age were more likely than adults age 55–64 years to lack coverage for at least part of the 12 months prior to interview (35% compared with 13%). About 20% of persons 18–24 years of age lacked coverage for more than 12 months.

More than one-third of people with low family income (less than twice the poverty level) had no health insurance coverage for at least part of the 12 months prior to interview compared with 13 percent of those with higher family income. More than one-fifth of people in these lower income families were uninsured for more than 12 months, compared with only 6% of people in higher income families. Persons of Mexican origin were more likely than those in any other race or ethnic group to be uninsured for at least part of the 12 months prior to interview. In 2005, 40% of Mexican-origin persons lacked coverage for at least part of the 12 months prior to interview with 29% lacking coverage for more than 12 months.

Profile of the Uninsured Population

Two-thirds of uninsured adults are currently working for pay.

People without health insurance coverage are more likely than their insured counterparts to forego needed medical care or prescription drugs (Table 79) and not to have a usual source of health care (Tables 77 and 78). They are also three times as likely to have not had a doctor's visit in the past year (Table 82). In 2005, 42.1 million persons under 65 years of age were uninsured on the day of their interview accounting for 16% of the nonelderly population (Table 139, see Appendix II, Health insurance coverage).

About two-thirds of uninsured adults were working for pay in the week prior to their interview in 2005 (data table for Figure 30). Employment is the major source of private health insurance coverage (Table 137). However, many uninsured people work for firms that do not offer coverage, are not eligible for coverage, or decline offers of health insurance for financial or other reasons (1). Since 2000, the percentage of private firms offering private health insurance benefits has declined. Small firms, those with a large percentage of low-income earners, and those with a high percentage of part-time workers were less likely to offer their employees health insurance coverage (2).

Figure 30. The uninsured population under 65 years of age, by selected characteristics: United States, 2005.

Figure 30

The uninsured population under 65 years of age, by selected characteristics: United States, 2005. Click here for spreadsheet version Click here for PowerPoint *Marital status is for adults 18–64 years (more...)

In 2005, the majority of the uninsured population was comprised of young adults 18–44 years of age who accounted for more than 60% of the uninsured population (Figure 30). More than one-fifth of the uninsured were 45–64 years of age, a time in life when chronic illness becomes more prevalent (Tables 55, 70, 71). Children comprised 16% of the uninsured.

The uninsured population was about equally divided between non-Hispanic white people and people of other races and ethnicities. People of Hispanic origin accounted for nearly one-third of the uninsured population, and 14% of the uninsured population were non-Hispanic black (data table for Figure 30).

Although Medicaid and the State Children's Health Insurance Program cover some poor and near poor people, private health insurance can be expensive, particularly when it is not subsidized by employers (1,3). Low-income families may have difficulty affording health insurance, but not all uninsured people have low family income. In 2005, more than 40% of uninsured people had a family income of at least 200% of the poverty level (data table for Figure 30).

About 60% of the uninsured population was unmarried (data table for Figure 30). Married people have the advantage of two potential sources of health insurance coverage.

References

1.
Department of Health and Human Services. Office of the Assistant Secretary for Planning and Evaluation. Overview of the uninsured in the United States: An analysis of the 2005 Current Population Survey. 2005. Available from: aspe.hhs.gov/health/reports/05/uninsured-cps/index.htm#work.
2.
The Kaiser Family Foundation and Health Research and Educational Trust. Employer Health Benefits: 2006 Annual Survey. Available from: www​.kff.org/insurance/7527/index.cfm.
3.
Banthin JS, Bernard DM. Changes in financial burdens for health care: National estimates for the population younger than 65 years, 1996 to 2003. JAMA. 2006;296:2712–9. [PubMed: 17164457]

Burden of Out-of-Pocket Expenditures

More than one-quarter of people under 65 years of age living in poverty are paying more than 10% of their after-tax family income on out-of-pocket medical expenses, including health insurance premiums.

Although health insurance substantially reduces the amount enrolled people pay for their medical care, out-of-pocket expenditures for non-covered services, copayments, deductibles, and caps on total amounts paid by insurance may impose a considerable financial burden even for insured people (1). In 2004, an estimated 15% of all aggregate personal health care expenditures—more than $236 billion dollars—were paid out-of-pocket (Table 125). Annual premiums for private health insurance can be expensive, and for people with employer-sponsored coverage, worker contributions averaged $627 for a single-person plan and $2,973 for a family plan in 2006 (2). Individual policies (nonemployer-sponsored, nongroup) paid entirely by the beneficiary often cost substantially more than group policies (3). Low-income and uninsured people are at a greater risk of a high burden of out-of-pocket expenditures, but insured wealthier people can also pay considerable amounts for their health care if they experience catastrophic illness or chronic disabling conditions (4).

The Medical Expenditure Panel Survey (MEPS) collects information on costs for health insurance premiums, utilization of medical care services, and expenses and source of payment for medical care services (See Technical Notes). It also collects detailed family income data. Figure 31 presents the percentage of people under 65 years of age who lived in families that spent more than 10% of their after-tax family income (disposable income) on out-of-pocket medical costs, including any costs for health insurance premiums, by family poverty level.

Figure 31. Persons under 65 years of age who spent more than 10% of after-tax family income on out-of-pocket medical expenditures, by percent of poverty level: United States, 1996 and 2004.

Figure 31

Persons under 65 years of age who spent more than 10% of after-tax family income on out-of-pocket medical expenditures, by percent of poverty level: United States, 1996 and 2004. Click here for spreadsheet version Click (more...)

The financial burden of out-of-pocket health care costs is greatest for the poor. More than one-quarter of people under age 65 with family income below the poverty line paid more than 10% of their after-tax family income on out-of-pocket health care expenditures in both 1996 and 2004 (Figure 31). Almost one-quarter of people living in families with income of 100%–less than 200% of the poverty level paid more than 10% of their disposable income for health care costs in both these years (24% in 1996 and 22% in 2004), as did 16%–17% of people with family income of 200%–less than 400% of the poverty level. Among people in the highest income group (more than 400% of the poverty level), 10% paid more than 10% of their after-tax family income on out-of-pocket health care and premiums in 2004, an increase from 7% of this income group in 1996.

Health insurance can be expensive and financially burdensome to families, particularly nongroup, individually purchased policies. In 2003, persons with nongroup plans were nearly three times as likely to spend more than 10% of their disposable income on health care, including health insurance premiums as individuals in any other insurance category, including the uninsured (1).

References

1.
Banthin JS, Bernard DM. Changes in financial burdens for health care: National estimates for the population younger than 65 years, 1996 to 2003. JAMA. 2006;296:2712–9. [PubMed: 17164457]
2.
The Kaiser Family Foundation and Health Research and Educational Trust. Employer health benefits: 2006 summary of findings. Available from: www​.kff.org/insurance/7527/upload/7528​.pdf.
3.
Pauly MV, Nichols LM. The nongroup health insurance market: Short on facts, long on opinions and policy disputes. Health Aff (Millwood) 2002 Jul-Dec;(suppl web exclusives):w325–44. [PubMed: 12703588]
4.
Hoffman C, Rowland D, Hamel E. Medical debt and access to health care. Kaiser Commission on Medicaid and the Uninsured, September 2005. Available from: kff.org/uninsured/7403.cfm.

Undiagnosed Medical Conditions

The percentage of adults 20–64 years of age who have undiagnosed high cholesterol or elevated blood pressure does not differ significantly by health insurance coverage.

Appropriate ongoing health care is necessary to prevent, reduce, or delay morbidity and disability, and to delay premature death from chronic conditions. In order to obtain appropriate health care and make any needed lifestyle adjustments, people must first be diagnosed with the medical condition. Uninsured people are less likely to have a usual source of care, have fewer ambulatory care visits per year, but are as likely to use emergency departments as insured persons (Tables 78, 82, and 90). This differential pattern of health care use may increase the likelihood that uninsured persons have undiagnosed medical conditions.

High cholesterol and elevated blood pressure are common, serious, treatable medical conditions. Both conditions are risk factors for heart disease, the leading cause of death (Table 31; 1). Elevated blood pressure is also a risk factor for stroke, the third leading cause of death (2).

In the National Health and Nutrition Examination Survey, respondents were asked about the presence of chronic health conditions, including whether a physician or other health professional had ever told them they had high cholesterol or high blood pressure. They were also asked about health insurance coverage at the time of their interview. Following their interview, respondents were examined at the mobile examination center (MEC); the examination included laboratory and other tests. The presence of high cholesterol was defined as a total cholesterol reading of 240 mg/dL or higher (6.20 mmol/L) and elevated blood pressure as an average systolic blood pressure of 140 mm Hg or higher, or an average diastolic reading of 90 mm Hg or higher. Persons were considered undiagnosed if they failed to report in the interview that the medical condition had been previously diagnosed but the condition was detected as a result of the examination at the MEC. Because nearly all persons 65 years of age and over are insured, this analysis was limited to adults 20–64 years of age. For more information, see the Technical Notes.

Overall, 10% of adults 20–64 years of age had undiagnosed high cholesterol and 8% had undiagnosed elevated blood pressure in 1999–2004 (data table for Figure 32). Adults 45–64 years of age were more likely to have undiagnosed conditions than those 20–44 years of age. In particular, they were more than three times as likely as adults 20–44 years of age to have undiagnosed elevated blood pressure.

Figure 32. Adults 20–64 years of age with undiagnosed high cholesterol or elevated blood pressure, by health insurance status and age: United States, 1999–2004.

Figure 32

Adults 20–64 years of age with undiagnosed high cholesterol or elevated blood pressure, by health insurance status and age: United States, 1999–2004. Click here for spreadsheet version Click here for (more...)

Although it appears from Figure 32 that uninsured adults were more likely than insured adults to have undiagnosed high cholesterol or elevated blood pressure based on data from 1999–2004, these differences were not statistically significant. The percentage with undiagnosed conditions did not differ by insurance status for adults 20–44 years of age or those 45–64 years of age. These chronic conditions could have been diagnosed when they were previously insured or during the use of free or subsidized care, or care paid for out-of-pocket or during the use of emergency health care services.

References

1.
Centers for Disease Control and Prevention. Heart disease risk factors. Available from: www​.cdc.gov/heartdisease/risk_factors​.htm.
2.
American Heart Association. Stroke risk factors. Available from: www​.americanheart.org/presenter​.jhtml?identifier=4716.

Foregone Medical Care Due to Cost by Length of Time Without Health Insurance

Persons with some period during the previous 12 months without health insurance are more likely to forego needed medical care due to cost than those who had coverage the whole 12 months.

Because health care can be expensive, people without health insurance may not receive needed medical care because of the cost. Even people with health insurance may find that deductibles, copayments, and coinsurance place some medical care out of their financial reach. As shown in Figure 29, many people under age 65, particularly those with low incomes, do not have health insurance coverage consistently throughout the year. Nearly all persons 65 years of age and older are covered continuously by Medicare, the federal health program for the elderly, and are therefore excluded from Figure 33.

Figure 33. Persons under 65 years of age who did not get needed medical care in the past year due to cost, by duration of health insurance coverage and percent of poverty level: United States, 2005.

Figure 33

Persons under 65 years of age who did not get needed medical care in the past year due to cost, by duration of health insurance coverage and percent of poverty level: United States, 2005. Click here for spreadsheet version (more...)

In 2005, health insurance was a major determinant of whether people were likely to forego needed health care because of the cost (see Technical Notes). People under 65 years who had been uninsured for more than 12 months or who had been uninsured for any time up to 12 months prior to their survey interview were much more likely to have foregone needed medical care because of the cost than were those who had been insured continuously the whole 12 months (Figure 33). There was little difference between people uninsured for any part of the year and those who were continuously uninsured for more than a year in their likelihood of foregoing medical care.

Children under 18 years of age were less likely to have foregone needed medical care because of cost than were adults 18–64 years of age (Figure 33). Children are less likely than adults to have chronic conditions, which often require higher-cost medical care. In 2004, annual expenses for health care for children averaged $1144 compared with $3053 for adults 18–64 years of age (calculated from Table 128). In addition, because decisions concerning children's medical care are usually made by their parents, these data suggest that adults may be more likely to forego needed medical care for themselves than for their children.

The likelihood of foregoing needed medical care because of cost also differed according to family income. In 2005, people living in families with income less than twice the poverty level were more likely to forego such care than people with higher income, irrespective of age or health insurance.

Dental Care Utilization

Poor or near-poor persons are more likely to lack a recent dental visit than higher income persons.

Lack of regular dental care can result in pain, infection, and delayed diagnosis of oral diseases including periodontal or gingival diseases and oral cancers (1). Barriers to accessing dental care include paying for care, navigating government assistance programs, finding a dentist who will accept Medicaid, locating a dentist close to home (especially true for inner-city and rural residents), getting to a dental office, and cultural or language barriers (2). For some people, lack of knowledge concerning the need for periodic oral health care is also a barrier to seeking care. Certain subpopulation groups—the poor, black persons, and persons of Mexican origin—were more likely to have untreated dental caries (Table 76). Untreated dental caries indicates that needed dental care was not received.

Accessing dental care may be more difficult than accessing medical care because a smaller percentage of Americans have dental insurance than medical coverage. In 2001, 61% of adults had any dental insurance compared with 86% of adults with any medical insurance (3). On average, Americans paid about one-half of the cost of dental care out-of-pocket in 2003 (4). More adults reported they did not get needed dental care due to the cost (12%) than did not receive needed medical care due to cost (7%) (Figure 21).

An additional factor affecting use of dental care is the absence or presence of natural teeth (5). Edentulous persons (without any natural teeth) should see a dentist periodically for maintenance of any dental prostheses and oral cancer screening. About one-quarter of persons 65 years of age and over were edentulous in 2005 (6). Edentulous persons 65 years of age and over were almost three times as likely to lack a recent dental visit as their dentate counterparts (with at least one natural tooth) (data table for Figure 34).

Figure 34. No dental visit in the past year among persons with natural teeth, by age and percent of poverty level: United States, 2005.

Figure 34

No dental visit in the past year among persons with natural teeth, by age and percent of poverty level: United States, 2005. Click here for spreadsheet version Click here for PowerPoint NOTES: Data are for all (more...)

Use of dental care varied by family income and age (Figure 34, see Technical Notes). Within each age group, persons living below 200% of the poverty level were substantially more likely to lack a dental visit within the past year than those living in families with higher income. About one-third of all children (dentate status is not assessed for children) living below 200% of the poverty level did not have a recent dental visit. About one-half of dentate adults with family income below 200% of the poverty level did not have a recent dental visit (data table for Figure 34).

References

1.
Oral Health in America: A Report of the Surgeon General. May 2000. Available from: www​.surgeongeneral.gov​/library/oralhealth.
2.
Guay AH. Access to dental care: Solving the problem for underserved populations. JADA. 2004;135:1599–605. [PubMed: 15622666]
3.
Dental, Oral and Craniofacial Data Research Center. Oral health U.S., 2002. Bethesda, MD. Available from: drc.hhs.gov/report/inside_cover.htm.
4.
Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey. Center for Financing, Access, and Cost Trends. Dental services expenditures table 2. 2003. Available from: www​.meps.ahrq.gov/mepsweb​/data_stats/summ_tables​/hc/state_expend/2003/table2.htm.
5.
Macek MD, Cohen LA, Reid BC, Manski RJ. Dental visits among older U.S. adults, 1999: The roles of dentition status and cost. JADA. 2004;135:1154–62. [PubMed: 15387055]
6.
Centers for Disease Control and Prevention, National Health Interview Survey, unpublished analysis. [PubMed: 10977762]

Colorectal Scope Procedures

The percentage of adults ever having a colorectal scope procedure remains low; racial and ethnic disparities persist even among adults with health insurance coverage.

Colorectal cancer, or cancer of the colon or rectum, is the second leading cause of cancer-related death in the United States. In 2004, about 54,000 people in the United States died from colorectal cancer (1). Reducing the number of deaths from colorectal cancer depends on detecting and removing precancerous polyps or growths as well as detecting and treating the cancer in its early stages (2). The U.S. Preventive Services Task Force (UPSTF) recommends regular screening for colorectal cancer for all adults 50 years of age and over. Recommendations call for one or more of the following tests: fecal occult blood test (FOBT) every year, flexible sigmoidoscopy every 5 years, double-contrast barium enema every 5 years, or colonoscopy every 10 years (3).

About 44% of adults 50 years of age and over reported ever having had a colonoscopy, sigmoidoscopy, or proctoscopy (scope procedure) (data table for Figure 35, Technical Notes). Uninsured adults were less than half as likely as their insured counterparts to have been screened. The average procedure cost was estimated at $800–$2,000 for colonoscopy and $150–$300 for sigmoidoscopy (4,5). The Medicare program covers much of the cost of scope procedures among adults 65 years and over, and scope procedure rates among older insured persons are higher than for younger insured adults. More than one-half (52%) of older insured adults reported ever having a scope procedure compared with about 40% of insured adults 50–64 years of age (data table for Figure 35).

Figure 35. Adults 50 years of age and over ever having a colorectal scope procedure, by selected characteristics: United States, annual average 2000, 2003, and 2005.

Figure 35

Adults 50 years of age and over ever having a colorectal scope procedure, by selected characteristics: United States, annual average 2000, 2003, and 2005. Click here for spreadsheet version Click here for PowerPoint (more...)

Although use of scope procedures has been increasing in recent years (6), racial and ethnic disparities persist even among adults who have health insurance coverage. Among insured adults 50–64 years of age, the percentage ever having a scope procedure was lower among Hispanic and non-Hispanic black adults than non-Hispanic white adults (Figure 35). Access barriers such as language, health literacy, and cultural perceptions of risk may contribute to the racial and ethnic disparities in scope procedure rates (7). The percentage ever having a scope procedure also varied by educational attainment. About 30% of insured adults age 50–64 years with less than a high school education, compared to 45% of adults with more than a high school education, reported ever having a scope procedure (Figure 35).

Population groups that were less likely to have ever had scope procedures were also less likely to have fecal occult blood tests in the past year, so it is unlikely that they are substituting more affordable annual fecal occult tests (between $10–$25) for scope procedures (5,8).

References

1.
Miniño AM, Heron M, Smith BL, Kochanek KD. Deaths: Final data for 2004. National vital statistics reports. Hyattsville, MD: National Center for Health Statistics. Forthcoming.
2.
Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Cancer—Colorectal cancer screening. 2006. Available from: www​.cdc.gov/cancer/colorectal​/basic_info/screening/.
3.
U.S. Preventive Services Task Force. Screening for colorectal cancer: Recommendations and rationale. Ann Intern Med 2002. Jul 16;137(2):129–31. Available from: www​.ahrq.gov/clinic/uspstf/uspscolo.htm. [PubMed: 12118971]
4.
Sonnenberg A, Delcò F, Inadomi JM. Cost-effectiveness of colonoscopy in screening for colorectal cancer. Ann Intern Med. 2000;133:573–84. [PubMed: 11033584]
5.
Myers D. Colon cancer screening for the uninsured. About colon cancer. Available from: coloncancer.about.com/od/screening/a/Uninsured.htm.
6.
Centers for Disease Control and Prevention. Increased use of colorectal cancer tests—United States, 2002 and 2004. MMWR 55(11);308–11. 2006. Available from: www​.cdc.gov/mmwr/preview​/mmwrhtml/mm5511a4.htm. [PubMed: 16557215]
7.
Shih YT, Zhao L, Elting LS. Does Medicare coverage of colonoscopy reduce racial/ethnic disparities in cancer screening among the elderly? Health Affairs. 2006;25(4):1153–62. [PubMed: 16835198]
8.
Centers for Disease Control and Prevention, National Health Interview Survey, unpublished analysis. [PubMed: 10977762]

Antidepressant Drugs: Adults

Non-Hispanic white women are more likely to have used antidepressant drugs in the past month than non-Hispanic black women or women of Mexican origin.

Depression and other forms of mental illness are critical public health issues in America today. In 2001–2002, an estimated 16% of noninstitutionalized adults had a major depressive disorder at some point in their lifetime, with 7% having had a major depressive episode during the 12 months prior to interview (1). The detrimental effects of depressive symptoms on quality of life and daily functioning have been estimated to equal or exceed those of heart disease and exceed those of diabetes, arthritis, and gastrointestinal disorders (2,3). Access to both accurate diagnosis and appropriate treatment of depression is necessary to combat this prevalent and debilitating disease.

Prescriptions for antidepressants have been rising, associated with the introduction in 1988 of a new class of drugs known as selective serotonin reuptake inhibitors (SSRIs) (4). Current SSRIs include the brand names Celexa®, Lexapro®, Luvox®, Paxil®, Prozac®, and Zoloft®. In addition to their use as antidepressants, SSRIs are approved and marketed for the treatment of other mental disorders including obsessive compulsive disorder, panic disorder, anxiety disorders, and premenstrual dysphoric disorder. The substantial increase in prescriptions for antidepressants also suggests widespread "off-label" (other than FDA-approved uses) use for subsyndromal mental health conditions and a variety of physical disorders (5,6).

Between 1988–1994 and 1999–2002 the percentage of adults in the civilian noninstitutionalized population who reported using an antidepressant drug during the past month more than tripled, increasing from 2.5% to 8.0% (age-adjusted; data table for Figure 36, Technical Notes). Use among women rose from 3.3% to 10.6% and use among men from 1.6% to 5.2%. In both time periods, antidepressant use by women was about twice that of men.

Figure 36. Adults 18 years of age and over reporting antidepressant drug use in the past month, by sex and race and Hispanic origin: United States, 1988–1994 and 1999–2002.

Figure 36

Adults 18 years of age and over reporting antidepressant drug use in the past month, by sex and race and Hispanic origin: United States, 1988–1994 and 1999–2002. Click here for spreadsheet version Click (more...)

In 1999–2002, the percentage of non-Hispanic white adults who reported the use of antidepressants was more than double that reported by non-Hispanic black and Mexican adults. Nearly 13% of non-Hispanic white women reported use of antidepressants in the past month, compared with about 5% of non-Hispanic black and Mexican women. In the same time period, 6% of non-Hispanic white men reported antidepressant drug use in the past month, compared with about 3% of non-Hispanic black men and less than 2% of men of Mexican origin. Disparities in the diagnosis of depression of black and Hispanic patients compared to white patients may have narrowed in recent years. However, racial or ethnic disparities in the treatment—including prescriptions for antidepressant drugs—of depression once diagnosed persist (7). Black and Hispanic patients who have been diagnosed with depression are less likely to obtain counseling and drug therapy to treat their depression than are white patients. Factors contributing to this disparity may include a belief by more African American and Hispanic persons than white persons that antidepressant therapy is unacceptable or ineffective, a preference for other types of therapy, or financial and insurance barriers to obtaining treatment (7,8).

References

1.
Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR. et al. The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R) JAMA. 2003;289(23):3095–105. [PubMed: 12813115]
2.
Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M. et al. The functioning and well-being of depressed patients: Results from the Medical Outcomes Study. JAMA. 1989;262(7):914–9. [PubMed: 2754791]
3.
Burvill PW. Recent progress in the epidemiology of major depression. Epidemiol Rev. 1995;17(1):21–31. [PubMed: 8521939]
4.
Pincus HA, Tanielian TL, Marcus SC, Olfson M, Zarin DA, Thompson J. et al. Prescribing trends in psychotropic medications: Primary care, psychiatry, and other medical specialties. JAMA. 1998;279(7):526–31. [PubMed: 9480363]
5.
Foote SM, Etheredge L. Increasing use of new prescription drugs: A case study. Health Aff. 2000;19(4):165–70. [PubMed: 10916970]
6.
Stone KJ, Viera AJ, Parman CL. Off-label applications for SSRIs. Am Fam Physician. 2003;68(3):498–504. [PubMed: 12924832]
7.
Miranda J, Cooper LA. Disparities in care for depression among primary care patients. J Gen Intern Med. 2004;19(2):120–6. [PMC free article: PMC1492138] [PubMed: 15009791]
8.
Schraufnagel TJ, Wagner AW, Miranda J, Roy-Byrne PP. Treating minority patients with depression and anxiety: What does the evidence tell us? Gen Hosp Psychiatry. 2006 Jan-Feb;28(1):27–36. [PubMed: 16377362]

Technical Notes

Data Sources and Comparability

Data for The Chartbook on Trends in the Health of Americans come from many different surveys and data systems and cover a broad range of years. Detailed descriptions of data sources are contained in Appendix I.

Data Presentation

Many measures in The Chartbook on Trends in the Health of Americans are shown for people in specific age groups because of the strong effect age has on most health outcomes. Some estimates are age-adjusted using the age distribution of the 2000 standard population, and this is noted in the data tables that accompany each Figure (see Appendix II, Age adjustment). Age-adjusted rates are computed to eliminate differences in observed rates that result from age differences in population composition. For some Figures, data years are combined to increase sample size and reliability of the estimates. Some charts present time trends and others focus on differences in estimates among population subgroups for the most recent time point available.

Graphic Presentation

Most line charts, for which only selected years of data are displayed, have dot markers on the data years. Line charts for which data are displayed for every year in the trend are shown without the use of dot markers. Figure 20 does not show dot markers, although selected years of data are graphed for years prior to 1995. Most trends are shown on a linear scale to emphasize absolute differences over time. The linear scale is the scale most frequently used and recognized, and it emphasizes the absolute changes between data points over time (1). The time trend for overall mortality measures is shown on a logarithmic (or log) scale to emphasize the rate of change and to enable measures with large differences in magnitude to be shown on the same chart. Log scales emphasize the relative or percentage change between data points. Readers are cautioned that one potential disadvantage to log scale is that the absolute magnitude of changes may appear smaller than the untransformed statistics would indicate (2). When interpreting data on a log scale, the following points should be kept in mind:

  1. 1. A sloping straight line indicates a constant rate (not amount) of increase or decrease in the values,
  2. 2. A horizontal line indicates no change,
  3. 3. The slope of the line indicates the rate of increase or decrease,
  4. 4. Parallel lines, regardless of their magnitude, depict similar rates of change (1).

Tabular Presentation

Following the Technical Notes are data tables that present the data points graphed in each Figure. Some data tables contain additional data that were not graphed because of space considerations. Standard errors for data points are provided for many measures. Additional information clarifying and qualifying the data are included in table notes and Appendix I and II references.

Survey Questions and Coding

Additional information on data used in the Chartbook and Special Feature, including exact wording of questions and coding schemes, is detailed below.

National Health Interview Survey (NHIS)

Figures 21 and 33: The following questions were about the use of health care. Do not include dental care. "DURING THE PAST 12 MONTHS, was there any time when [you/someone in the family] needed medical care, but did not get it because [you/the family] couldn't afford it?" (In Figure 21, results are presented only for sample adults to be consistent with the rest of the chart. Therefore, estimates in this Figure for not receiving needed medical care due to cost may differ slightly from those presented in Table 79.)

Figure 21: "DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn't get it because you couldn't afford it?" (asked of sample adults)

___ prescription medicines

___ mental health care or counseling

___ dental care (including checkups)

___ eyeglasses

Figure 26: Respondents were asked whether they have a place they usually go to when they are sick or need advice about their health. Persons who reported the emergency department as their usual source of care were considered to lack a usual source in this analysis. Diagnosed chronic health conditions were identified by asking if a doctor or other health professional ever told the respondent they had hypertension (told at least two times), a serious heart condition (told they had coronary heart disease, heart attack, or angina), or diabetes (excluding during pregnancy). Adults classified in this analysis as without chronic conditions did not report being diagnosed with serious heart conditions, hypertension, cancer (excluding non-melanoma skin cancer), diabetes, arthritis, emphysema, asthma, stroke, ulcer, and not told in the past year had: chronic bronchitis, liver or kidney disease. See Appendix II, Usual source of care.

Figure 27: "There are many reasons people delay getting medical care. Have you delayed getting care for any of the following reasons in the PAST 12 MONTHS?"

___ you didn't have transportation (asked of sample adults).

Figures 2830: See Appendix II, Health insurance coverage.

Figure 34: See Appendix II, Dental visit.

Figure 35: "Have you EVER HAD a sigmoidoscopy, colonoscopy, or proctoscopy? These are exams in which a health care professional inserts a tube into the rectum to look for signs of cancer or other problems." Data from 2000, 2003, and 2005 were combined to produce estimates.

National Health and Nutrition Examination Survey (NHANES)

Figure 12: "On average, how many times per week do you/does sample person eat meals that were prepared in a restaurant? Please include eat-in restaurants, carry-out restaurants and restaurants that deliver food to your house." [`Meals' mean more than a beverage or snack food like candy bars or bag of chips].

Figure 32: To determine if a respondent had undiagnosed high cholesterol or high blood pressure, information from the interview, examination, and laboratory sections of the NHANES was used. The questionnaire administered to all participants included questions about whether the respondent had been told by a health professional that he or she had certain medical conditions. The questions for high blood cholesterol and high blood pressure were: "Have you ever been told by a doctor or other health professional that your blood cholesterol level was high?" and "Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?"

Respondents answering yes were classified as diagnosed with the condition. Respondents answering no were classified as not diagnosed with the condition. Respondents without a yes or no response were excluded from the relevant analysis. For more information on the questionnaire, see www.cdc.gov/nchs/data/nhanes/nhanes_03_04/sp_bpq_c.pdf. Most respondents, regardless of their responses to the questionnaire, were examined at the mobile examination center (MEC); the examination included laboratory and other tests. The presence of high cholesterol was defined as a total cholesterol reading of 240 mg/dL or higher (6.20 mmol/L). Most participants have at least three blood pressure readings taken. High blood pressure is defined as an average systolic blood pressure of 140 mm Hg or higher, or an average diastolic reading of 90 mm Hg or higher. Blood pressure readings of zero were assumed to be in error and were not included in our calculations.

Respondents who did not have their cholesterol or blood pressure measured were excluded from the corresponding analysis. For more information on cholesterol testing, see www.cdc.gov/nchs/data/nhanes/nhanes_03_04/l13_c.pdf. For more information on blood pressure readings, see www.cdc.gov/nchs/data/nhanes/nhanes_03_04/bpx_c.pdf. Persons were considered undiagnosed if during the interview they reported that they did not have the medical condition but the condition was detected as a result of the examination at the MEC. To determine insurance coverage, respondents were asked: "Are you covered by health insurance or some other kind of health care plan?" [Include health insurance obtained through employment or purchased directly as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills.]

Respondents answering yes were classified as insured; respondents answering no were classified as uninsured. For more information on the health insurance questions, see www.cdc.gov/nchs/data/nhanes/nhanes_03_04/sp_hiq_c.pdf.

Figure 36: The questionnaire administered to all participants also included a question on whether they had taken a prescription drug in the past month. Those who answered "yes" were asked to show the interviewer the medication containers for all the prescriptions. For each drug reported, the interviewer entered the product's complete name from the container. If no container was available, the interviewer asked the participant to verbally report the name of the drug. Additionally, participants were asked how long they had been taking the drug and the main reason for use. All reported medication names were converted to their standard generic ingredient name. For multi-ingredient products, the ingredients were listed in alphabetical order (i.e., Tylenol #3 would be listed as Acetaminophen; Codeine). No trade or proprietary names were provided on the data file. Antidepressant drugs include: amitriptyline, amoxapine, bupropion, citalopram, clomipramine, desipramine, doxepin, escitalopram, fluoxetine, fluvoxamine, imipramine, isocarboxazid, maprotiline, mirtazapine, nefazodone, nortriptyline, paroxetine, phenelzine, protriptyline, sertraline, tranylcypromine, trazodone, trimipramine, and venlafaxine. More information on prescription drug data collection and coding in the NHANES is available from: www.cdc.gov/nchs/data/nhanes/frequency/rxq_rxdoc.pdf. More information on NHANES III prescription drug data collection and coding is available from: www.cdc.gov/nchs/data/nhanes/nhanes3/PUPREMED-acc.pdf. Also see Appendix I, National Health and Nutrition Examination Survey.

Medical Expenditure Panel Survey (MEPS)

Figure 31: The Medical Expenditure Panel Survey produces nationally representative estimates of health care use, expenditures, source of payment, and insurance coverage for the civilian noninstitutionalized population. For each medical care visit or prescription drug during a 1-year period, the respondent reports the condition for which the visit was made. Expenses associated with each visit or prescription drug are recorded. For information on family income measurement, see Banthin JS, Selden TM. Income measurement in the Medical Expenditure Panel Survey. Agency for Healthcare Research and Quality working paper No. 06005, July 2006. Available from://207.188.212.220/mepsweb/data_files/publications/workingpapers/wp_06005.pd. Also see Appendix I: Medical Expenditure Panel Survey.

Area Resource File

Figures 22 and 23: Data are for active, nonfederal, patient care physicians. Patient care physicians include office-based physicians, full-time hospital staff, and residents or fellows. Estimates for Figure 22 include doctors of medicine and doctors of osteopathic medicine, whereas estimates for Figure 23 only includes data for doctors of medicine (35,799 and excludes 1,502 obgyn doctors of osteopathy (D.O.) in 2004. Obgyn D.O. data were not available at the county level.) County metropolitan status was determined using the Office of Management and Budget definition. See Appendix II, Metropolitan statistical area. The highest category of physician to population on each map represents counties that have physician to population ratios greater than the national ratio. For Figure 22, the category with less than 2.86 patient care physicians per 10,000 population indicates counties that meet the Health Resources and Services Administration definition of a health professional shortage area. Available from: bhpr.hrsa.gov/shortage/.

National Hospital Ambulatory Medical Care Survey

Figure 11: An emergency department (ED) visit was considered alcohol-related if the checkbox for alcohol was indicated, the physician's diagnoses (any-listed) were alcohol-related (ICD–9–CM 291, 303, 305.0, 425.5, 535.30, 571.1–.3, 760.71, 790.3, 980, or V–113), alcohol-related external cause-of-injury codes were present (ICD–9–CM E860 or 710, an alcohol use or abuse cause-of-injury code developed by the National Center for Health Statistics), or the patient's reasons for the visit codes were alcohol-related (alcohol-related problem, including alcohol abuse, drinking problem (1145.0), alcoholism, including alcohol dependence (2320.0), or adverse effects of alcoholism, including acute intoxication, drunk, intoxication (5915.0). The checkbox for alcohol can indicate use among the patient or some other person. Among adolescents and young adults, 0.2% of ED visits were related to use among someone other than the patient.

References

1.
Page RM, Cole GE, Timmreck TC. Basic epidemiological methods and biostatistics: A practical guidebook. Sudbury, MA: Jones and Bartlett Publishers, 1995.
2.
Jekel JF, Elmore JG, Katz DL. Epidemiology biostatistics and preventive medicine. Philadelphia, PA: W.B. Saunders Company, 1996.

Data Tables for Figures 1–36

Data table for Figure 1. Total population and older population: United States, 1950–2050Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 2. Foreign-born population, by citizenship: United States, 1970–2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 3. Population in selected race and Hispanic origin groups, by age: United States, 1980–2006Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 4. Poverty by age: United States, 1966–2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 5. Low income by age, race, and Hispanic origin: United States, 2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 6. Personal health care expenditures, by source of funds and type of expenditures: United States, 2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 7. National expenditures for mental health services, by source of funds: United States, 1986–2003Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 8. National expenditures for substance abuse treatment, by source of funds: United States, 1986–2003Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 9. Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965–2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 10. Blood cotinine levels among children 4–17 years of age, by age, race and Hispanic origin, and percent of poverty level: United States, 1988–1994 and 2001–2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 11. Alcohol-related emergency department (ED) visits among persons 14–28 years of age, by age and sex: United States, 2002–2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 12. Weekly restaurant meal consumption among people 1 year of age and over, by age: United States, 1999–2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 13. Overweight and obesity, by age: United States, 1960–2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 14. Limitation of activity caused by selected chronic health conditions among children, by age: United States, 2004–2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 15. Limitation of activity caused by selected chronic health conditions among working-age adults, by age: United States, 2004–2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 16. Limitation of activity caused by selected chronic health conditions among older adults, by age: United States, 2004–2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 17. Three or more chronic conditions among adults 45 years of age and over, by age and percent of poverty level: United States, 2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 18. Life expectancy at birth and at 65 years of age, by race and sex: United States, 1970–2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 19. Infant, neonatal, and postneonatal mortality rates: United States, 1950–2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 20. Death rates for leading causes of death for all ages: United States, 1950–2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 21. Adults 18 years of age and over reporting they did not receive needed health-related services in the past 12 months because they could not afford them, by age and type of service: United States, 2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 22. Patient care physician supply and distribution among United States counties, by county metropolitan status: United States, 2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 23. Obstetrician or gynecologist supply and distribution among United States counties, by county metropolitan status: United States, 2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 24. Active kidney transplant waiting list patients at end of year, by race and Hispanic origin: United States, 1988, 1996, and 2006Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 25. Active waiting list patients who received a kidney transplant within 2 years, by race and Hispanic origin: United States, 1988, 1996, and 2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 26. No usual source of care among adults 45–64 years of age, by selected diagnosed chronic conditions and race and Hispanic origin: United States, 2004–2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 27. Delayed medical care in the past 12 months due to lack of transportation among adults 18 years of age and over, by sex, percent of poverty level, and age: United States, 2004–2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 28. Health insurance coverage at the time of interview among persons under 65 years of age: United States, 1984–2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 29. Uninsured for at least part of the 12 months prior to interview among persons under 65 years of age, by length of time uninsured and selected characteristics: United States, 2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 30. Uninsured and insured populations under 65 years of age by selected characteristics: United States, 2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 31. Persons under 65 years of age who spent more than 10% of after-tax family income on out-of-pocket medical expenditures, by percent of poverty level: United States, 1996 and 2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 32. Adults 20–64 years of age with undiagnosed high cholesterol or elevated blood pressure, by health insurance status and age: United States, 1999–2004Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 33. Persons under 65 years of age who did not get needed medical care in the past year due to cost, by duration of health insurance coverage and percent of poverty level: United States, 2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 34. No dental visit in the past year by dentition status (presence of natural teeth), age, and percent of poverty level: United States, 2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 35. Adults 50 years of age and over ever having a colorectal scope procedure, by selected characteristics: United States, annual average 2000, 2003, and 2005Click here for spreadsheet version Click here for PowerPoint

Data table for Figure 36. Adults 18 years of age and over reporting antidepressant drug use in the past month, by sex and race and Hispanic origin: United States, 1988–1994 and 1999–2002Click here for spreadsheet version Click here for PowerPoint

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