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National Center for Health Statistics (US) . Health, United States, 2008: With Special Feature on the Health of Young Adults. Hyattsville (MD): National Center for Health Statistics (US); 2009 Mar.

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Health, United States, 2008: With Special Feature on the Health of Young Adults.

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Executive Summary and Highlights

Executive Summary

Health, United States, 2008, is the 32nd annual report on the health status of the Nation prepared by the Secretary of the Department of Health and Human Services for the President and Congress. In a chartbook and 151 detailed tables, it provides an annual picture of the health of the entire Nation. Trends are presented on health status and health care utilization, resources, and expenditures. This year’s report includes a special feature on young adults, age 18 to 29 years. As young people in this age group reach legal adulthood, they make many life choices, including decisions about education, marriage, childbearing, and health behaviors such as tobacco and alcohol use, which will affect both their future economic and health status as well as affect the well-being of their families.

For those entrusted with safeguarding the Nation’s health, monitoring the health of the American people is an essential step in making sound health policy and setting research and program priorities. Health measures provide essential information for assessing how the Nation’s resources should be directed to improve the population’s health. Examination of emerging trends identifies diseases, conditions, and risk factors that warrant study and intervention. Health, United States presents trends and current information on measures and determinants of the Nation’s health. It also identifies variation in health, health behaviors, and health care among people by race and ethnicity, gender, education and income level, and geographic location. Given the increasing diversity of the Nation and the continuing changes in the health care infrastructure, this is a challenging and critically important task.

The Nation and its Health

The Nation is growing more diverse and the related health and health care needs of its population are changing. The percentage of the population that is of Hispanic or Asian origin has more than doubled since 1980 (data table for Figure 2). Between 1970 and 2004, the percentage of the U.S. population that was foreign-born also more than doubled (1).

Birth rates have decreased since the 1960s, and have remained relatively stable since 1995 (Table 4). Between 2005 and 2006 (preliminary data), the birth rate for teenagers 15–19 years rose 3%, from 40.5 live births per 1,000 females to 41.9 (2). This follows a 14–year downward trend in which the teen birth rate fell by 34% from its all-time peak of 61.8 births per 1,000 in 1991 (2). Teenage pregnancy increases the risk of adverse birth outcomes independently of important known risk factors (3). The 2006 (preliminary data) birth rate for unmarried women reached a record high of 50.6 births per 1,000 unmarried women age 15–44 years, up 7% from 2005. In 2006, 39% of all births were to unmarried women (preliminary data, 2). Women who have nonmarital births have, on average, lower educational attainment and lower income, are less likely to work full-time, and are more likely to receive public assistance (4,5).

In 2006, American men could expect to live 3.6 years longer, and women 1.9 years longer, than they did in 1990 (preliminary data, Table 26, and Figure 14). Mortality from heart disease, stroke, and cancer has continued to decline in recent years (Figure 16). Infant mortality, one major component of overall life expectancy, declined (Table 21 and Figure 15) through 2001 and has changed little since then.

In 2005, however, at least 29 other (selected) countries had infant mortality rates lower than those in the United States, compared with only 11 of the same comparison countries in 1960; and life expectancy for both men and women is higher in many other developed countries than in the United States (Tables 24 and 25). In 2004, the United States ranked 23rd in life expectancy at birth for men and 25th for women; the United States ranked 9th for men and women in life expectancy at 65 years of age (Table 25).

Longer life spans are generally considered desirable, particularly when healthy years of life are increased. However, with an aging population and longer life expectancy comes increasing total prevalence of chronic diseases and conditions associated with aging, such as disability and limitation of activity. The percentage of the population 75 years of age and over was 6% in 2006 and is projected to double by 2050 (Figure 1). In 2006, 42% of those age 75 years and over living in the community reported having a limitation in their usual activity due to a chronic condition, compared with 13% of people 45–54 years of age (Table 58).

Chronic diseases such as hypertension and diabetes are associated with aging, as is end-stage renal disease. Sixty-five percent of men and 80% of women age 75 years and over either had high blood pressure or were taking antihypertensive medication in 2003–2006, compared with about 36% of adults age 45–54 years (Table 71). The proportion of the population with high serum cholesterol levels has been dropping, in large part due to increased use of cholesterol-lowering drugs (Tables 72 and 97). In 2003–2006, 16% of adults had high serum cholesterol. Women age 55 and over were substantially more likely to have high cholesterol than their male counterparts (Table 72). The incidence and prevalence of end-stage renal disease has increased since 1980 (Table 55). Nearly one-quarter of older adults (age 60 and over) had diabetes (either physician diagnosed or undiagnosed) in 2003–2006 (Table 54).

The number of new cases of many infectious diseases such as hepatitis types A, B, and C, childhood diseases such as measles and rubella, and invasive pneumococcal disease has been greatly reduced through vaccination and other prevention initiatives (Table 50 and Figure 9). However, incidence rates of some communicable diseases including pertussis (for which an effective vaccination exists) and Chlamydia have increased in recent years (Table 50). In addition, newly recognized infectious agents have emerged and caused substantial public health concern and investment, including SARS, H5N1 Avian Influenza, and some particularly virulent or drug-resistant strains such as Methicillin-Resistant Staphylococcus aureus (MRSA) (6). Pneumonia hospitalizations have increased, notably among persons 85 years of age and over (Figure 25). Influenza and pneumonia remain major causes of death, particularly among persons 65 years of age and over, and HIV/AIDS continues to spread (Table 31).

Of concern for all Americans is the high prevalence of people with risk factors such as obesity and insufficient exercise, which are associated with chronic diseases such as heart disease, diabetes, and hypertension. Obesity rates do not appear to be increasing as rapidly as they did in past decades, but remain at unacceptable levels with over one-third of adults age 20 and over considered to be obese in 2005–2006 (Tables 70, 75, and Figure 7). The percentage of adults 18 years of age and over who engaged in regular leisure-time physical activity (about one-third of adults in 2005–2006) and strength training (about one-fifth of adults in 2005–2006) remains low (Figure 8).

Unintentional injuries remain in the top ten leading causes of death for all age groups, and are the number one cause of death for persons 1–44 years of age (Tables 30 and 31). However, deaths from unintentional injuries have declined since 1970, which is in part associated with increased use of seat belts, helmets, and other public health injury-prevention initiatives (7, Table 28). Among young adults 18–29 years of age, the percentage of motor-vehicle fatalities that were alcohol related declined from 72% in 1982 to 51% in 2006 (8).

Health Care Resources

Health care technologies, facilities, equipment, and provider specialties have changed over recent decades. Until the mid-20th century, general hospitals and primary care physicians were the major providers of health care. There are now more specialized health care facilities, including imaging centers, outpatient surgical centers, and dialysis centers, as well as physician specialties and subspecialties (Tables 110 and 121). More procedures are being furnished on an outpatient basis and the average length of inpatient hospital stays has shortened since 1995, especially among persons 65 years of age and over (Tables 102 and 106). The supply of assisted living facilities is increasing rapidly, whereas the number of nursing homes has declined slightly since the year 2000 (9, Table 120). The number of physicians per capita has been increasing, but they are not distributed equally across the Nation (Table 109). The supply of allied health professionals is shifting. The numbers of massage therapists, dental hygienists and dental assistants, diagnostic medical sonographers, medical equipment preparers, medical assistants, pharmacy technicians, and occupational therapist assistants have increased 5% or more per year, on average, between 1999 and 2006, whereas the numbers of respiratory therapy technicians and recreational therapists have declined by 3% or more per year, on average, over the same period (Table 112). Projections indicate that there may be a continuing shortage of nurses, pharmacists, and other health professionals needed to care for our aging population (10,11).

Expenditures and Health Insurance

The United States spends more on health per capita than any other country, and health spending continues to increase (Table 123). In 2006, national health care expenditures in the United States totaled $2.1 trillion, a 6.7% increase from 2005 (Table 124). Hospital spending, which accounts for 31% of national health expenditures, increased by 7% in 2006 (Table 127). Spending for prescription drugs accounted for 10% of national health expenditures in 2006. This spending increased 8.5% in 2006, up from 5.8% in 2005, accelerating for the first time in 6 years (Table 127).

Overall, private health insurance paid 36% of total personal health care expenditures in 2006, the federal government 35%, state and local governments 10%, and out-of-pocket payments 15% (data table for Figure 19). Personal health care expenditures differ by state of residence as well as by age, sex, and other sociodemographic characteristics. In 2004, the latest year for which estimates are available for 50 states and the District of Columbia, the highest per capita spending was in the District of Columbia ($8,295), followed by, Massachusetts, Maine, New York, and Alaska. The lowest per capita spending was in Utah ($3,972), followed by Arizona, Idaho, New Mexico, and Nevada (Table 148 and Figure 20). State expenditures per resident are associated with differences in payer mix, provider supply, demographic and sociodemographic distributions, and policy factors such as Medicaid spending and state payment policies (12).

Use of and Access to Health Care Services

Americans consume vast amounts of health care services, as indicated by the large amount they spend on personal health care services. In 2006, there were 1.1 billion visits to physician offices, hospital outpatient departments and emergency departments (Table 94). In 2006, about two-thirds of people age 2 years and over had a dental visit in the past year (Table 96) and 83% of all people had at least one visit to a doctor’s office, emergency department, or a home visit in the past year (Table 83). About 7% of persons 1 year of age or over, had at least one hospital stay in the past year, and 21% of persons age 75 and over had a hospitalization in the past year (Table 101). In 2001–2004, about one-half (47%) of Americans had at least one drug prescribed in the past month and one-fifth (20%) had three or more drugs prescribed (Table 98). Sixty percent of people age 65 and over had three or more drugs prescribed in the past month.

Although Americans are increasingly using many types of clinical preventive services, utilization remains below recommended levels for some services. In 2006, 77% of children age 19–35 months received a combined vaccination series protecting them against several childhood infectious diseases, an increase from 66% in 2002 (Table 85). The percentage of mothers receiving prenatal care in the first trimester of pregnancy remained unchanged from 2004 to 2005 at 84% for the 37 states, the District of Columbia, and New York City for which comparable trend data were available (Table 7). In 2003–2004, 61% of the population age 2 years and older reported having a dental cleaning in the past year (Figure 23). Children 2–17 years of age were more likely than adults to have their teeth cleaned in the past year (79% compared with 51%–65%) (Figure 23).

Whereas most Americans have access to the health care services they need, in 2006, 8% of adults 18–64 years of age reported that they did not get needed medical care, 10% reported they received delayed medical care, and 9% reported they did not get needed prescription drugs during the past 12 months, due to the cost (Table 80). Access to health care is strongly associated with health insurance coverage. People with no health insurance are less likely to receive some needed health services than people with insurance (Table 80 and Figure 39). An estimated 44 million people or 17% of Americans under 65 years of age did not have health insurance coverage at the time they were interviewed in 2006 (Table 140).

Disparities in Health and Health Care by Income and Racial and Ethnic Group

Health, United States, 2008, identifies major disparities in health and health care by socioeconomic status, race, ethnicity, and insurance status. Many aspects of the health of the Nation have improved, but the health of some income, and racial and ethnic groups has improved less than others and for some groups, the gap has widened.

Persons living in poverty are considerably less likely to have used many types of health care than those with income of 200% of the poverty line or higher (Tables 82, 83, and 96). People with a family income of at least 200% of poverty were substantially more likely to have had a dental visit for cleaning in the past year than people living below 200% of poverty (68% compared with 47%–50% in 2003–2004) (data table for Figure 23). Children living below the poverty threshold remain less likely than children living at or above poverty to have received the combined vaccination series (73% compared with 78% in 2006) (Table 85).

Significant racial and ethnic disparities exist across a wide range of health and utilization measures. The gap in life expectancy between the black and white populations has narrowed, but persists (Table 26 and Figure 14). Obesity, a major risk factor for many chronic diseases, varies by race and ethnicity—53% of non-Hispanic black women age 20 years and over were obese in 2003–2006, compared with 42% of women of Mexican origin and 32% of non-Hispanic white women (Table 75, age-adjusted). Differences in health status by race and Hispanic origin documented in this report may be explained by factors including socioeconomic status, health practices, psychosocial stress and resources, environmental exposures, discrimination, and access to health care (13). Socioeconomic and cultural differences among racial and ethnic groups in the United States will likely also influence future patterns of disease, disability, and health care use.

In 2006, among persons under 65 years of age, those of Hispanic origin and American Indians and Alaska Natives were more likely to be uninsured at a point in time than were those in other racial and ethnic groups (Table 140). More than two-fifths of people of Mexican origin were uninsured for at least part of the 12 months prior to interview (Figure 18).

Use of preventive care also varies by race and ethnicity. Since 1998, mammography levels have been lower among Hispanic and Asian women compared with non-Hispanic white and black women (Table 89). In 2005, the percentage of mothers with early prenatal care was lowest among American Indian or Alaska Native mothers and was highest among non-Hispanic white mothers (Table 7).

Special Feature: Young Adults Age 18–29 Years

The period starting with age 18 and spanning the 20s is often considered the transition to adulthood, when young people obtain legal and emotional independence, invest in education, begin working to obtain financial independence, and choose to marry or to have children (14,15). This transition is also the period when financial and other support services previously provided by parents, social and government programs, and school health and education programs are decreased or terminated, often abruptly. Young adults may lose their insurance eligibility under their parents’ plan or their qualification for the State Children’s Health Insurance Program (SCHIP). As parental and other adult oversight decreases, young people assume increasing responsibility for decisions that will directly affect their current and future health status—e.g., alcohol, cigarette, and illicit drug use or nonuse; sexual activity; childbearing; exercise; eating habits—as well as decisions that will indirectly affect their future health such as investment in education, employment, or other activities that help determine future income and lifestyle as well as affect the well-being of their families.

Young adults today have more choices (or more perceived choices) about the course to pursue after age 17 than in past generations. They increasingly complete high school and go to college or other post-high-school educational programs. Young adults are also likely to work for pay (Figures 27 and 28). Marriage rates are decreasing and age at first marriage is increasing (16). Birth rates for unmarried black women ages 18–19 and 20–24 years of age have decreased over the past decade and a half, while rates have increased among unmarried non-Hispanic white women age 25–29 over the same time frame (Figure 30). Educational enrollment and attainment of young adults is higher than in past years (Figure 28), which should in theory increase their income. However, disparities in income by race, gender, and ethnicity remain (data table for Figure 29).

Even with public and school education campaigns emphasizing the consequences of smoking and alcohol abuse, trends in cigarette smoking and alcohol consumption among young adults 18–29 years of age have changed little over the past decade. More than one-quarter of young adult men and one-fifth of young women were current smokers (2006 data), and nearly one-quarter of young men and 9% of young women 18–29 years of age reported 5 or more drinks in a day on at least 12 days in the past year (Figure 31). More than one-fifth of 18–20 year olds, and 14% of 26–29 year olds, reported using illicit drugs in the past month; and 19% of 18–20 year olds reported using marijuana or hashish in the past month (Figure 32). Obesity rates of young adults have tripled between 1971–1974 and 2005–2006 (Figure 7); in 2005–2006 about one-quarter of young adults were obese. Participation in regular leisure-time exercise among young adults, although higher than among older adults, is below recommended levels (Figure 8), and has been stable since 1999–2000.

Young adults are sometimes called the “young invincibles,” but they are not immune to death, illness, or injury. In 2005, there were more than 47,000 deaths among young adults 18–29 years of age with three-quarters of them occurring among young men (data table for Figure 37). Unintentional injuries are by far the leading cause of death in this age group, with other leading causes including homicide, suicide, cancer, and heart disease (Figure 37). Young adults also have among the highest rate of emergency department visits for all adult age groups (17,18) and the highest rate of injury-related emergency department visits (see related Table 93 and Figure 41). Regardless of the extent of physical injuries, suicidal behavior and interpersonal violence, including physical and sexual violence perpetrated by intimate partners, acquaintances, or strangers, can have substantial immediate and long-term emotional, social, and financial consequences for victims and their families (19).

Young adults are also not immune to chronic health problems. Fifteen percent of young adults in 2004–2006 reported ever being diagnosed with one of the following chronic health conditions: arthritis (3.9%), current asthma (7.2%), diabetes (1.1%), cancer (1.1%), heart disease (0.4%), and hypertension (3.3%) (data table for Figure 35). In 1999–2004, almost 9% of young adults 20–29 years of age had major depression, generalized anxiety disorder, or panic disorder in the past 12 months. (Figure 36).

In addition to the need for medical care for chronic and acute conditions, young adults have a need for preventive care such as routine dental check-ups and cleanings and periodic eye examinations, and may require other preventive services or screening tests based on their health status (20–23). Young adult women often need health services for reproductive-associated reasons and contraception.

However, young adults, and young men in particular, are more likely to lack health insurance than any other age group (Table 140). In 2006, 15% of young adults reported that they did not receive needed dental care in the past year due to cost and about 9%–10% did not receive needed medical care and prescription medicines (data table for Figure 39).

Young adulthood is a critical period in forming adult patterns relating to health habits and behaviors that can have major effects later in life. Targeting this age group with health information is vital. But as young adults undergo transitions and strive to achieve financial and emotional independence during this critical period, reaching out to them to provide education about both the short- and long-term consequences of the health-related decisions they are making can be challenging because young adults are diverse and unpredictable with respect to geographic location, school enrollment, and workforce patterns. In addition, young adults use a wide variety of new technologies for receiving health information and communicating with each other.

To improve the health of all Americans, it is critical to keep collecting data about all components of health, documenting trends in access to and utilization of health care services, and disseminating reliable and accurate information about the health of our population. Equally important is gaining an understanding of the health care needs and utilization patterns of population subgroups, such as young adults. Such insight will enable policymakers to monitor future trends, target resources most effectively, and set program priorities. The following highlights from Health, United States, 2008 summarize the latest findings gathered from the public and private health care sectors to help the Department of Health and Human Services, the President, and the Congress in carrying out their mission of monitoring and improving the health of the Nation.

References

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Highlights

Health, United States, 2008, is the 32nd report on the health status of the Nation. The report contains a chartbook and 151 trend tables presenting current and historic information on the health of the U.S. population. The trend tables are organized around four major subject areas: health status and determinants, health care utilization, health care resources, and health care expenditures and payors. The 2008 chartbook focuses on selected determinants and measures of health and includes a special feature on young adults 18–29 years of age.

Life Expectancy and Mortality

As overall death rates have declined, racial and ethnic disparities in mortality have persisted, but the gap in life expectancy between the black and white populations has narrowed. Life expectancy at birth in the United States lags behind that in most other industrialized countries. Life expectancy and infant mortality are often used to gauge the overall health of a population. Life expectancy shows a long-term upward trend and infant mortality shows a long-term downward trend.

In 2006, life expectancy at birth for the total population reached a record high of 78.1 years, up from 75.4 years in 1990 (preliminary data and Table 26).

Between 1990 and 2006, life expectancy at birth increased 3.6 years for males and 1.9 years for females. The gap in life expectancy between males and females narrowed from 7.0 years in 1990 to 5.3 years in 2006 (preliminary data and Table 26).

Between 1990 and 2006, life expectancy at birth increased more for the black than for the white population, thereby narrowing the gap in life expectancy between these two racial groups. In 1990, life expectancy at birth for the white population was 7.0 years longer than for the black population. By 2006, the difference had narrowed to 4.9 years (preliminary data, Figure 14, and Table 26).

Among the 37 countries and territories that submitted data to the Organisation for Economic Co-operation and Development (OECD) in 2004, Hong Kong had the highest life expectancy at birth for men (79.0 years) and Japan for females (85.6 years). The Russian Federation had the lowest life expectancy at birth for both males (59.1 years) and females (72.4 years). In 2004, the U.S. ranked 23rd in life expectancy at birth for males and 25th for females (Table 25).

Overall mortality was 28% higher for black Americans than for white Americans in 2006 compared with 37% higher in 1990 (preliminary data). In 2005, age-adjusted death rates for the black population exceeded those for the white population by 46% for stroke (cerebrovascular disease), 31% for heart disease, 22% for cancer (malignant neoplasms), 108% for diabetes, and 782% for HIV disease (Table 28).

In 2006, the infant mortality rate was 6.71 infant deaths per 1,000 live births, 27% lower than in 1990 (preliminary data and Figure 15).

Large disparities in infant mortality rates among racial and ethnic groups continue to exist. In 2005, infant mortality rates were highest for infants of non-Hispanic black mothers (13.6 deaths per 1,000 live births), American Indian mothers (8.1 per 1,000) and Puerto Rican mothers (8.3 per 1,000); and lowest for infants of Cuban (4.4 per 1,000), Central and South American (4.7 per 1,000 live births) and Asian or Pacific Islander mothers (4.9 per 1,000) (Table 18).

The leading cause of death differs by age group. In 2006, the leading cause of death was congenital malformations for infants, unintentional injuries for people age 1–44 years, cancer for adults age 45–64 years, and heart disease for adults age 65 years and over (preliminary data and Table 31).

Age-adjusted mortality from heart disease, the leading cause of death overall, declined 38% between 1990 and 2006, continuing a long-term downward trend (preliminary data, Figure 16, and Table 35).

Age-adjusted mortality from cancer (malignant neoplasms), the second leading cause of death overall, decreased 16% between 1990 and 2006 (preliminary data, Figure 16, and Table 37).

The age-adjusted death rate for motor vehicle-related injuries has remained stable since the early 1990s following a period of decline. Death rates for motor vehicle-related injuries are higher at age 15–24 years and 75 years and over than at other ages (Table 43).

The age-adjusted death rate for HIV disease has declined slowly since 1999, after a sharp decrease during the late 1990s. The death rate for HIV disease is higher at age 35–54 years than at other ages (Table 41).

The homicide rate for black males 15–24 years of age decreased sharply from the early to the late 1990s and has remained relatively stable since then. Homicide continues to be the leading cause of death for young black males 15–34 years of age (Table 44).

The suicide rate for non-Hispanic white men 65 years of age and over is higher than in other groups. In 2005, the suicide rate for older non-Hispanic white men was about 2 to 3 times the rate for older men in other race or ethnicity groups and nearly 8 times the rate for older non-Hispanic white women (Table 45).

Health Behaviors and Risk Factors

Health behaviors affect health status. Pregnant teenagers are less likely to receive early prenatal care and more likely to drop out of school and to live in poverty than are older pregnant women. Heavy and chronic use of alcohol and use of illicit drugs increase the risk of disease and injuries. Cigarette smoking increases the risk of lung cancer, heart disease, emphysema, and other diseases. Obesity increases the risk of heart disease, diabetes, and stroke. Regular physical activity reduces the risk of disease and enhances mental and physical functioning.

Between 2005 and 2006, the birth rate for teenagers 15–19 years of age rose 3%, from 40.5 to 41.9 live births per 1,000 females age 15–19 years (preliminary data). This follows a 14–year downward trend in which the teen birth rate fell by 34% from its recent peak of 61.8 births per 1,000 in 1991 (Table 4).

In 2006 (preliminary data), the birth rate for unmarried women reached a record high of 50.6 births per 1,000 unmarried women age 15–44 years, up 7% from 2005. In 2006, 38.5% of all births were to unmarried women. The increases in 2006 in the rate and proportion of births to unmarried women were the largest single-year increases reported in these measures since 1988–1989 (Table 10).

Low birthweight is associated with elevated risk of death and disability in infants. In 2006 (preliminary data), the low birthweight rate (less than 2,500 grams, or 5.5 pounds, at birth) increased slightly to 8.3% from 8.2% in 2005. The 2006 rate is 19% higher than that for 1990 (7%) (Table 12).

Between 1988–1994 and 2005–2006, the prevalence of overweight among preschool-age children 2–5 years of age increased by more than 50%, from about 7% to 11% (Table 70).

The prevalence of overweight among school-age children increased between 1988–1994 and 2005–2006. Among children 6–11 years of age, the prevalence of overweight increased from 11% to 15% and among adolescents 12–19 years of age grew from 11% to 18% (Tables 70 and 76).

Between 1991 and 2007, the percentage of high school students who reported attempting suicide (7%–9%) and whose suicide attempts required medical attention (2%–3%) remained fairly constant. Girls were more likely than boys to consider or attempt suicide. However, in 2005 adolescent boys (15–19 years of age) were four times as likely to die from suicide as were adolescent girls, in part reflecting their choice of more lethal methods, such as firearms (Tables 45 and 62).

In 2006, 6% of people age 12 years and over reported marijuana use in the past month, and 3% reported nonmedical use of prescription drugs. Use of illicit drugs was highest among young adults age 18–25 years (Table 66 and Figure 32).

In 2006, 20% of adults age 18 years and over reported drinking five or more drinks on at least one day in the past year and 9% reported five or more drinks on at least 12 days in the past year. (Table 69).

Between 2003 and 2007, the percentage of high school students who reported smoking cigarettes in the past month remained stable at 20%–23%, after declining from 36% in 1997 (Figure 6).

In 2006, 21% of U.S. adults were current cigarette smokers, the same percentage as in the previous two years, suggesting that the decline in cigarette smoking prevalence is stalling. Men were more likely to be current cigarette smokers than women (24% compared with 18%) (Figure 6 and Table 63).

American adults have made no substantial progress toward achieving recommended levels of physical activity or strength training. Between 1995–1996 and 2005–2006, the percentage of adults 18 years of age and over engaged in regular leisure-time physical activity or strength training activities remained level (Figure 8 and Table 74).

Among adults 20–74 years of age, obesity rates have more than doubled since 1960–1962. From 1960–1962 to 2003–2006, the percentage of adults who were obese has increased from 13% to 34% (age-adjusted) (Table 75).

Health Status and Health Conditions

Measures of health status presented in this report include respondent-assessed health status, limitation in activity caused by chronic conditions, and serious psychological distress. Measures of morbidity include the incidence and prevalence of selected specific diseases and conditions.

In 2006, the percentage of noninstitutionalized adults reporting their health as fair or poor ranged from 6% of those age 18–44 years to 28% of those age 75 years and over. The proportion with fair or poor health was higher among non-Hispanic black and Hispanic persons compared with non-Hispanic white persons (Table 60).

In 2005–2006, 3% of the noninstitutionalized population 18 years of age and over reported having serious psychological distress. Adults living below the poverty level were more than four times as likely to report serious psychological distress as adults in families with an income at least twice the poverty level (8% compared with 2%, age-adjusted) (Table 61).

In 2006, 6% of noninstitutionalized adults 65 years of age and over reported a limitation in activities of daily living (ADLs) and 11% reported a limitation in instrumental activities of daily living (IADLs). Among older adults, those living in poverty were more than twice as likely to report an ADL or IADL limitation as those with a family income above twice the poverty level (age-adjusted estimates) (Table 58).

In 2006, 22% of adults 75 years of age and over had trouble seeing even with glasses or contacts and 16% had a lot of trouble hearing or were deaf (Table 59).

In 2006, activity limitation caused by chronic health conditions was reported for 7% of children under the age of 18 years. Among school-age children (5–17 years of age), speech problems, learning disabilities, and attention-deficit/hyperactivity disorder (ADHD or ADD) were the most frequently reported causes of activity limitation (Figure 11 and Table 58).

Between 1996–1998 and 2004–2006, physician office and hospital outpatient department visits for attention-deficit/hyperactivity disorder among children 4–17 years almost doubled. Among boys, visits increased from 8 to 14 visits per 100 children. The visit rate among boys was three times the visit rate among girls in 2004–2006 (Figure 21).

Arthritis and other musculoskeletal conditions were the leading causes of activity limitation among working-age adults 18–64 years of age in 2005–2006. Mental illness was the second most frequently mentioned condition causing activity limitation among adults 18–44 years of age and the third most frequently mentioned among adults 45–54 years of age (Figure 12).

The prevalence of hypertension, defined as elevated blood pressure or taking antihypertensive medication, increases with age. In 2003–2006, 36% of men and women age 45–54 years had hypertension, compared with 65% of men and 80% of women age 75 years and over (Table 71).

Between 1988–1994 and 2003–2006, the percentage of both men and women 55 years and over with a high total serum cholesterol level (greater than or equal to 240 mg/dL) declined. However, older women were more likely to have high serum cholesterol than older men. In 2003–2006, 24% of women age 65–74 years had high serum cholesterol, compared with 11% of men of the same age (Table 72).

In 2003–2006, the prevalence of diabetes (including both diagnosed and undiagnosed) among adults increased by more than 23% from 1988–1994 (8%) to 2003–2006 (10%). The prevalence increased by slightly more than one-quarter among men to 11% and almost one-fifth among women to 9% (percents are age-adjusted) (Table 54).

Between 1980 and 2005 the incidence of end-stage renal disease increased 4.6 fold to 350 new cases per million people. In 2005, nearly 480 thousand Americans were living with end-stage renal disease (Table 55).

In 2004–2006, current asthma prevalence was 9% among women compared with 5% among men. Eleven percent of adults living below poverty had asthma compared with 6% of those with a family income of 200% or more of the poverty level (Figure 10).

From 1990 to 2005, the annual percent change in new cases of lung and bronchus cancer declined 2% among males and remained unchanged among females. Cancer of the lung and bronchus is the second most common site of newly diagnosed cancer among males and females (age-adjusted rates; Table 52).

Between 1988–1994 and 2001–2004, approximately one-quarter of adults 20–64 years of age had untreated dental caries, down from nearly one-half in 1971–1974 (Table 77).

In 2006, approximately 2.1 million workplace injuries and illnesses in the private sector involved days away from work, job transfer, or restricted duties at work for a rate of 2.3 cases per 100 full-time workers (FTW). The transportation and warehousing industry reported the highest injury and illness rate, with 4.3 cases per 100 FTW. The next highest rates were reported by the manufacturing industry (3.3 per 100 FTW), and the construction industry and the agriculture, forestry, fishing, and hunting industry (3.2 per 100 FTW) (Table 49).

In 2006, there were nearly thirty-seven thousand new AIDS cases reported. Males 13 years of age and older accounted for 73% of all new cases. Black males made up 31% of all cases and black females accounted for 17% of all cases (Table 51).

Incidence rates for some infectious diseases have increased since 1990. From 1990 to 2006, the incidence rate for chlamydia increased from 160 to 348 cases per 100,000 population and the incidence rate for pertussis increased from 1.8 to 5.3 cases per 100,000 population. During this time period, the incidence for most vaccine-preventable diseases (e.g. measles) as well as other diseases (e.g. gonorrhea and syphilis) declined (Table 50).

In 2006, incident cases of acute viral hepatitis A and B were at historically low levels (Figure 9). Hepatitis A incidence rates declined from 12.0 cases per 100,000 population in 1995, when hepatitis A vaccine became available, to 1.2 cases per 100,000 population in 2006. Incident cases of acute hepatitis B declined from 9.6 per 100,000 population in 1982, the year hepatitis B vaccine was approved, to 1.6 cases per 100,000 in 2006. Incidence of acute hepatitis C declined from 2.4 to 0.3 cases per 100,000 population from 1992 to 2006 (Figure 9).

Health Care Expenditures and Payors

The United States spends more on health per capita than any other country, and U.S. health spending continues to increase. Spending increases are due to increased intensity and cost of services, and a higher volume of services needed to treat an aging population. Major payors for health care include private health insurers and public programs such as Medicaid and Medicare. Medicaid is jointly funded by the federal and state governments to provide health care for certain groups of low-income persons. Medicare is funded by the federal government and covers the health care of most persons 65 years of age and over and disabled persons.

The United States spends a larger share of its gross domestic product (GDP) on health than does any other major industrialized country. In 2005, the United States devoted 15% of its GDP to health compared with 12% in Switzerland, the country with the next highest share (Table 123).

In 2006, national health care expenditures in the United States totaled $2.1 trillion, a 6.7% increase from 2005. The average per capita expenditure on health in the United States was $7,026 in 2006 (Table 124).

Prescription drug expenditures increased 9% between 2005 and 2006 compared with a 6% increase between 2004 and 2005 (Table 127).

Expenditures for hospital care accounted for 31% of all national health expenditures in 2006. Physician and clinical services accounted for 21% of the total in 2006, prescription drugs for 10%, and nursing home care for 6% (Table 127).

In 2006, 35% of personal health care expenditures were paid by the federal government and 10% by state and local government; private health insurance paid 36% and consumers paid 15% out-of-pocket (Figure 19 and Table 128).

In 2007, the Medicare program had about 44 million enrollees and expenditures of $432 billion, up from $408 billion the previous year. Expenditures for the new Medicare drug program (Part D), introduced in 2006, were $50 billion in 2007 (preliminary data) (Table 142).

Of the 36 million Medicare enrollees in the fee-for-service program in 2006, 12% were 85 years of age and over and 17% were under 65 years of age (Table 143).

In 2005, children under 21 years of age accounted for 47% of Medicaid recipients but only 17% of expenditures. Aged, and blind and disabled persons accounted for 22% of recipients and 66% of expenditures (Table 145).

In 2004, per capita personal health care expenditures varied widely by state of residence. The states with the highest spending per resident were concentrated in the New England and Mideast regions and the states with the lowest spending were concentrated in the Southwest, Rocky Mountains, and Far West regions of the country (Figure 20 and Table 148).

Health Care System Influences, Personnel, and Resources

Major changes continue to occur in the delivery of health care in the United States, driven in part by changes in payment policies intended to rein in rising costs and by advances in technology that have allowed more complex treatments to be performed on an outpatient basis. The ratio of physicians per population continues to increase slowly, but the supply is not equally distributed across the country. The supply of other practitioners, including pharmacists and nurses, may not be increasing as rapidly as needed to keep pace with our aging population.

Between 1999 and 2006, the number of massage therapists, dental hygienists and assistants, diagnostic medical sonographers, medical equipment preparers, medical assistants, and pharmacy technicians increased by 5%–10% annually. During this period, the hourly wages of radiation therapists, nuclear medicine technologists, pharmacists, and physician assistants increased more than wages in other health occupations (Table 112).

In 2006, 63% of surgeries in community hospitals were performed on an outpatient basis compared with 51% in 1990 and 16% in 1980 (Table 106).

Between 1990 and 2006, the number of community hospital beds declined 13%, from about 927 to 803 thousand. Since 1990, the community hospital occupancy rate has remained steady at 63%–67% (Table 116).

Between 1990 and 2004, the overall rate of inpatient mental health beds per 100,000 civilian population in the United States declined by 45%. In state and county mental hospitals, the number of mental health beds per 100,000 population declined by 53%, in private psychiatric hospitals the decline was 48%, and in nonfederal general hospital psychiatric services the decline was 34% (Table 117).

In 2007, there were about 1.7 million nursing home beds in about 16,000 certified nursing homes. Between 1995 and 2007, nursing home bed occupancy was relatively stable at 83%–85%. Occupancy rates were 90% or higher in 17 states and the District of Columbia in 2007 (Table 120).

Utilization of Health Care Services

Factors associated with the utilization of health care services include health behaviors, health status, health insurance coverage, health care resources, family income and other demographic variables. Use of inpatient hospital care remained relatively stable over the past decade, use of physician services and hospital outpatient care increased slowly, and use of prescription drugs increased more rapidly.

In 2006, there were about 1.1 billion visits to physicians’ offices, hospital outpatient departments, and hospital emergency departments. There were 902 million to physicians’ offices, 102 million visits to hospital outpatient departments, and 119 million visits to hospital emergency departments (Table 94).

Between 1995 and 2006 the rate of visits to office-based physicians increased from 266 to 307 per 100 persons. During the same period, the hospital outpatient department visit rate increased from 26 to 35 visits per 100 persons. Since 2000, the hospital emergency department visit rate has remained stable at about 40 visits per 100 population after a slight increase from 37 visits per 100 population in 1995 (Table 94).

In 2006, 43% of doctor visits were to specialty care physicians, up from 34% in 1980. During this period, the proportion of office-based doctor visits to general and family practice physicians decreased from 34% to 23% (Table 95).

In 2005–2006, 6% of children under 6 years of age and 14% of children 6–17 years of age did not have a health care visit to a doctor’s office or a clinic in the past year (Table 82).

In 2006, 21% of children under age 18 years had at least one emergency department visit in the past year and 8% had two or more visits. Emergency department utilization was higher among children under 6 years of age than for older children (28% compared with 18% of older children) (Table 91).

In 2006, 20% of adults 18 years of age and over had at least one emergency department visit in the past year and 7% had two or more visits. Emergency department utilization was higher among persons with family income below 200% of poverty than for higher income persons (24%–28% compared with 18%) (Table 92).

In 2006, visit rates to physician offices and hospital outpatient departments among persons 18–44 years of age were more than twice as high for women as for men, largely due to medical care associated with female reproduction (Table 94).

Between 1997 and 2006, about two-thirds of persons 2 years of age and over had seen a dentist in the past year. Dental visit rates were higher among children 2–17 years of age than among adults, with three-quarters of children having had a recent dental visit in 2006 (Table 96).

In 2003–2004, 61% of persons 2 years of age and over reported having a dental visit for teeth cleaning by a dentist or dental hygienist in the past year. Females were more likely than males to have had their teeth cleaned by a dental professional (65% compared with 57%). Children 2–17 years of age were more likely than adults 18 years and older to have had their teeth cleaned by a dental professional in the past year (Figure 23).

Between 1995 and 2006, nonfederal short-stay hospital discharge rates remained stable after declining sharply during the 1980s. During this period, average length of stay declined by about one-half a day to 4.8 days in 2006 (Table 102).

Between 1979–1980 and 2005–2006, rates of hospitalizations with any-listed pneumonia diagnosis nearly doubled among persons 65 years and over (Figure 25).

In 2005, the cesarean rate increased to 30.3 per 100 live births. The rate of cesarean delivery (c-section) has increased steadily since 1996; and in 2005, the rate reached the highest level ever recorded in the United States. Cesarean delivery rates increase with increasing maternal age (Figure 26).

The percentage of the population with at least one prescription drug during the previous month increased from 39% in 1988–1994 to 47% in 2001–2004. During the same period, the percentage taking three or more prescription drugs increased from 12% to 20% (Table 98).

In 2001–2004, the percentage of adults who reported using prescription drugs in the prior month increased from 38% of those 18–44 years of age to 66% at 45–64 years of age and 87% at 65 years of age and over. In each age group women were more likely than men to use prescription drugs (Table 98).

In 2001–2004, 53% of adults 20 years of age and over reporting taking a dietary supplement in the past month. The use of dietary supplements is higher among women (59%) than men (47%) and reported use increases with age (percents are age-adjusted) (Table 99).

In 1973–1974, the nursing home resident rate for the white population 65 years of age and over was more than twice that for the black population (61 compared with 28 per 1,000 population; age-adjusted). By 2004, the resident rate for the black population (50) exceeded that for the white population (34) (Table 107).

In 2006, 77% of children 19–35 months of age received the combined vaccination series of four doses of DTaP (diphtheria-tetanus-acellular pertussis) vaccine, three doses of polio vaccine, one dose of measles containing vaccine, three doses of Hib (Haemophilus influenzae type b) vaccine, three doses of hepatitis B vaccine, and one dose of varicella vaccine. Children living below the poverty threshold were less likely than were children living at or above poverty to have received the combined vaccination series (73% compared with 78%) (Table 85).

Between 1987 and 2005, the percentage of women 18–44 years of age who had a Pap smear in the past 3 years remained level at 83%–87%. In 2005, Pap smear use was higher among insured women 18–64 years of age than uninsured women (86% compared with 68%) (Table 90).

The percentage of mothers receiving prenatal care in the first trimester of pregnancy remained unchanged from 2004 to 2005 at 84% for the 37 states, DC, and New York City for which comparable trend data were available. In 2005, the percentage of mothers with early prenatal care varied substantially by race and ethnicity, from 70% for American Indian or Alaska Native mothers to 89% for non-Hispanic white mothers (Table 7).

Between 1989 and 2006, the percentage of noninstitutionalized adults 65 years of age and over who received an influenza vaccination in the past year more than doubled (30% to 64%). In 2006, 60% of those 65–74 years of age and 69% of those 75 years of age and over had an influenza vaccination in the past year (Table 87).

Between 1989 and 2006, the percentage of noninstitutionalized adults 65 years of age and over who ever received a pneumococcal vaccination quadrupled (14% to 57%). In 2006, 52% of those 65–74 years of age and 63% of those 75 years of age and over ever had a pneumococcal vaccination (Figure 24 and Table 88).

The percentage of adults 18–64 years of age who reported not getting needed medical care due to the cost increased from 6% to 8% between 1997 and 2006. Similarly, the percentage not getting needed prescription drugs increased from 6% to 9%. Ten percent of adults 18–64 years reported delaying medical care due to cost in 1997 and 2006 (Table 80).

In 2006, 19% of people under age 65 years of age who were uninsured for all or part of the preceding year did not receive needed medical care in the past 12 months due to the cost, compared with 3% of people covered by health insurance for the full year. Twenty-three percent of people under age 65 years who were uninsured for the entire preceding year did not receive needed medical care (Table 80).

On January 1, 2006, Medicare Part D, which provides coverage for prescription medications for Medicare beneficiaries, went into effect. The percentage of adults 65 years and over with income below the poverty level who did not get the prescription drugs they needed due to cost declined from 12% in 2005 to 8% in 2006 (Table 80).

Lack of Health Insurance

Lack of health insurance coverage is a major barrier to obtaining most health care services. Out-of-pocket health care expenses may deter people from seeking health care services. People without health insurance are likely to face the highest costs, but the insured may also face substantial copayments, deductibles, and other out-of-pocket health care expenses.

In 2006, the percentage of the population under 65 years of age with no health insurance coverage (public or private) at a point in time was 17%. Between 1995 and 2006, this percentage fluctuated between 16% and 18% (Figure 17 and Table 140).

Among the under 65 population, those with a family income less than 200% of the poverty level were more than twice as likely to be uninsured at a point in time than persons in higher income families (Table 140).

In 2006, 10% of children under 18 years of age were uninsured at a point in time. Between 2000 and 2006, among children in families with income just above the poverty level (100%–150% of poverty), the percentage uninsured dropped from 25% to 17%, while the percentage with Medicaid or State Children’s Health Insurance Program (SCHIP) coverage increased from 35% to 52% (Tables 139 and 140).

In 2006, among persons under 65 years of age, more than one-third of Hispanic persons and American Indians and Alaska Natives persons were uninsured at a point in time compared with less than one-fifth of those in other racial and ethnic groups (Table 140).

Many people under 65 years of age, particularly those with a low family income, do not have health insurance coverage consistently throughout the year. In 2006, one-fifth of people under 65 years of age were uninsured for at least part of the 12 months prior to interview (Figure 18).

In 2006, two-fifths of people of Mexican origin were uninsured for at least part of the 12 months prior to interview compared with one-sixth of non-Hispanic white people (Figure 18).

Special Feature: Young Adults Age 18–29 Years

Young adults 18–29 years of age are facing a time of transition in their lives with many educational, occupational, and personal life style choices to be made that can have repercussions on their health both in the short and long term. Although most are healthy, they have the same need for many preventive services as other age groups, and may have injuries or conditions that require medical care. Many in this age group also have low income and lack health insurance coverage.

Between 1980 and 2005, the percentage of adults 18–24 years of age enrolled in school rose from 46% to 68% among 18–19 year olds, from 31% to 49% among 20–21 year olds, and from 16% to 27% among 22–24 years olds (Figure 28).

Among young adults 18–29 years of age, obesity rates have tripled since 1971–1974. In 1971–1974, 8% of young adults were obese; in 2005–2006, the percentage of young adults who were obese had grown to 24% (Figure 7).

In 2005–2006, 39% of young men 18–29 years of age and 32% of young women engaged in regular leisure-time physical activity. One-third of young men and nearly one-fifth of young women reported strength training activities at least twice a week (Figure 8).

In 2006, young men were more likely to smoke cigarettes than young women (29% compared with 21%). Between 1997 and 2006, the percentage of women 18–29 years of age who currently smoked cigarettes declined nearly 20% but current smoking did not decline significantly among young men (Figure 31).

In 2006, about one-quarter of young men 18–29 years of age reported drinking 5 or more drinks in a day on at least 12 days in the past year, compared with 9% of young women (Figure 31).

In 2006, almost 40% of young people age 18–20, about one-third of 21–25 year olds, and one-quarter of 26–29 year olds reported using an illicit drug in the past year. Marijuana or hashish were the most commonly reported drugs (32% of 18–20 year olds), followed by nonmedical use of prescription drugs (reported by 17% of 18–20 year olds) (Figure 32).

In 2002, 21% of women 18–44 years of age reported having been forced to have sexual intercourse when they were under 30 years of age. Types of force reported included being physically held down, physically hurt or physically threatened, or being forced nonphysically by being given alcohol or drugs or pressured by words or actions (Figure 34).

In 2003–2004, 45% of women 20–24 years of age and 27% of women 25–29 years of age were positive for human papillomavirus (HPV). Women 20–29 years of age with family income below 100% of the poverty level had a higher prevalence of HPV (46%) than women with higher family income (31%) (Figure 33).

In 2004–2006, 18% of young women and 12% of young men reported being told by a physician that they had at least one of six specified health conditions and 4%–5% of young women and men reported overall fair or poor health, or an activity limitation due to a chronic health condition (Figure 35).

In 1999–2004, almost 9% of young adults 20–29 years of age had major depression, generalized anxiety disorder, or panic disorder in the past 12 months. Almost 7% of young adults had a diagnosis of major depression in the past year. Young women (11%) were almost twice as likely as young men (6%) to have major depression, generalized anxiety disorder, or a panic disorder in the past 12 months (Figure 36).

In 2005, unintentional injuries (“accidents”), homicide, and suicide accounted for 70% of deaths among young adults 18–29 years of age. Three-quarters of the 47 thousand deaths in this age group occurred among young men (Figure 37).

Young adults have the highest rate of injury-related emergency department visits of all age groups (Table 93). The three most common mechanisms of injury for young adults age 18–29 years with injury-related emergency department (ED) visits in 2005–2006 were motor vehicle traffic accidents (252 ED visits per 10,000 population), being struck by or against objects or persons (215 ED visits per 10,000 population), and falls (209 ED visits per 10,000 population) (Figure 41).

In 2006, 84% of young women reported a doctor visit in the past 12 months, compared with 57% of young men. Young women were almost four times as likely to report a hospital stay in the past year (11%) as young men (3%) and twice as likely to report taking a prescription drug in the past month (39% compared with 19% in 1999–2004) (Figure 40).

In 2003–2004, 51% of young adults 18–29 years of age reported having their teeth cleaned by a dental professional in the past year, similar to adults 30–64 years of age. Young adults were less likely to have a dental visit for teeth cleaning than those 2–17 years of age (79%) or older adults 65–74 years of age and 75 years and over (63%–65%) (Figure 23).

In 2006, both young men and women age 18–29 years were equally likely to be covered by private health insurance. Young women were more likely to be covered by Medicaid than young men, and young men were more likely to be uninsured than young women (34% compared with 25%) (Figure 38).

In 2006, young adults age 20–24 years were more likely to be uninsured at a point in time (34%) than those age 18–19 and 25–29 years (21% and 29%), and more than twice as likely to be uninsured as those 45–64 years of age (13%) (Figure 38 and Table 140).

In 2004–2006, 17% of young adults 18–29 years of age reported that they needed and did not receive one or more of the following services in the past year because they could not afford them: medical care, prescription medicines, mental health care, or eyeglasses (Figure 39).

In 2004–2006, 15% of young adults 18–29 years of age reported that they needed and did not receive dental care in the past year because they could not afford it (Figure 39).

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