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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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Executive Summary

Health, United States, 2007, is the 31st 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 focus on access to needed or recommended health care services.

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 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.

Overall Health of the Nation

Life expectancy in the United States continues to increase. In 2004, American men could expect to live more than 3 years longer, and women more than 1 year longer, than they did in 1990 (Figure 18 and Table 27). Mortality from heart disease, stroke, and cancer has continued to decline in recent years (Figure 20 and Table 29). Infant mortality, one major determinant of overall life expectancy, declined (Figure 19 and Table 22) through 2001 and has changed little since then.

Yet, even as progress is made in improving life expectancy, increased longevity is accompanied by increased prevalence of chronic conditions and their associated pain and disability. In recent years, progress in some areas has not been as rapid as in earlier years, or trends have been moving in the wrong direction. Moreover, improvements have not been equally distributed by income, race, ethnicity, education, and geography.

Of concern for all Americans is the high prevalence of people with unhealthy lifestyles and behaviors, such as insufficient exercise and overweight, which are risk factors for many chronic diseases and disabilities including heart disease, diabetes, hypertension, and back pain. The rising number of overweight children and adults and the large percentage of those who are physically inactive (Figures 1213 and Tables 7275) raise additional concerns about Americans' future health (1).

Prevalence of risky behaviors among children and young adults remains at unacceptable levels. About 20% of adolescents age 16–17 years, and more than 40% of young adults age 18–25 years, reported binge alcohol use in 2005, and 20% of young adults age 18–25 years reported using illicit drugs in the past month (Table 66). The percentage of high school students who seriously considered suicide has declined since 1991, but the percentage who attempted suicide has remained stable (7%–9%) (Table 62).

Health Status by Sociodemographic Characteristics

Efforts to improve Americans' health in the 21st century will be influenced by important changes in demographics. Ours is a nation growing older and becoming more racially and ethnically diverse. The percentage of the population 75 years of age and over was 6% in 2005 and is projected to increase to 12% by 2050 (Figure 1). 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. In 2005, 44% 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 12% of people 45–54 years of age (Table 58). Many of the diseases associated with aging, including diabetes and hypertension, produce cumulative damage if not properly treated. Others, such as emphysema and some cancers, develop slowly or after long periods of environmental exposure. Almost 70% of men and more than 80% of women age 75 years and over had either high blood pressure or were taking antihypertension medication in 2001–2004, compared with about 35% of adults age 45–54 years (Table 70). The proportion of the population with high serum cholesterol rates has been dropping, in large part due to increased use of cholesterol-lowering drugs (Table 71). In 2001–2004, 17% of adults had either diagnosed or undiagnosed high serum cholesterol, and older women (age 55 and over) were substantially more likely to have high cholesterol than older men (Table 71). Vision and hearing also decline with age (Table 59) and many types of pain, particularly those associated with the musculoskeletal system such as joint pain, are more common at older ages (Table 57).

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. Health, United States, 2007, identifies major disparities in health and health care by socioeconomic status, race, ethnicity, and insurance status. In 2006, 15% of Americans were of Hispanic origin, 12% were African American, 4% were Asian, and about 1% were American Indian or Alaska Native or were of more than one race (Figure 3). Significant racial and ethnic disparities exist across a wide range of health measures. The gap in life expectancy between the black and white populations has narrowed, but persists (Figure 18 and Table 27). Disparities in risk factors and morbidity also exist. Obesity, a major risk factor for many chronic diseases, varies by race and ethnicity—51% of non-Hispanic black women age 20 years and over were obese in 2001–2004, compared with 39% of women of Mexican origin and 31% of non-Hispanic white women (Table 74, age-adjusted). The differences in health status by race and Hispanic origin documented in this report may be explained by several factors including socioeconomic status, health practices, psychosocial stress and limited resources, environmental exposures, discrimination, and access to health care, the focus of this year's Special Feature (2,3).

In 2004, the number of noncitizen foreign-born persons reached 21.1 million, representing 7.3% of the U.S. civilian noninstitutionalized population (Figure 2). Noncitizen foreign-born persons may be either legal or illegal U.S. residents. They are disproportionately low-income and uninsured (4,5). They are also more likely 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 (5).

Health Care Resources

Health care technologies, facilities, equipment, and provider specialties have changed over recent decades. Sophisticated imaging equipment is more available in the United States, compared with almost all other countries (Table 119). Until the mid-20th century, hospitals and primary care physicians were the major providers of health care, with few specialized facilities. There are now more physician subspecialties and specialized health care facilities including imaging centers, outpatient surgical centers, and dialysis centers (Tables 107, 118). More procedures are being furnished on an outpatient basis and the length of inpatient hospital stays has shortened (Tables 99, 103). The supply of assisted living facilities is increasing rapidly, whereas the number of nursing home beds has declined (Table 117) (6). The number of physicians per capita has been increasing, but they are not distributed equally across the Nation (Figures 22, 23, and Table 106). The supply of allied health professionals is shifting. The numbers of dental hygienists and dental assistants, pharmacy technicians, diagnostic medical sonographers, massage therapists, medical assistants, and medical equipment preparers have increased by 5% or more per year since 1999, whereas the numbers of respiratory therapy technicians and occupational therapist aides have declined by 5% or more per year (Table 109). Projections indicate that there may be an increasing shortage of nurses and pharmacists as well as other health professionals needed to care for our aging population (7,8).

Expenditures and Payors

The United States spends more on health per capita than any other country, and health spending continues to increase (Table 120). In 2005, national health care expenditures in the United States totaled $2 trillion, a 7% increase from 2004 (Table 121). Hospital spending, which accounts for 31% of national health expenditures (Table 124), increased by 8% in 2005 (Table 125). Spending for prescription drugs accounted for 10% of national health expenditures in 2005. This spending increased 6% in 2005, down from an average annual growth of 12% from 2000 to 2004 (Table 124).

Overall, private health insurance paid 36% of total personal health care expenditures in 2005, the federal government 34%, state and local governments 11%, and out-of-pocket payments 15% (Figure 6). Expenditures on mental health services and substance abuse treatment constituted 7.5% of national health expenditures in 2003 and have grown at a slower rate than that of overall health expenditures since 1993 despite an increase in the number of people treated (Figures 7, 8 and Tables 126, 127) (9). The distribution of funding sources for mental health services differs from that for substance abuse treatment, with Medicaid and private health insurance paying the largest shares of mental health expenditures, whereas other state and local government funds account for the largest share of substance abuse expenditures.

Access to Health Care and Utilization of Health Services

The health care delivery system is evolving, and with its evolution, the types of services that are available are changing. New technological advances can prevent, treat, or ameliorate conditions and diseases that were once thought untreatable. Yet, some Americans have difficulty accessing these services because they may be unavailable, difficult to obtain, or too expensive to purchase. In its 1993 report, Access to Health Care in America, the Institute of Medicine defined access as "the timely use of personal health services to achieve the best possible health outcomes" (3). Tracking which Americans do not receive the increasing number of potentially beneficial services or who do not receive them in a timely manner, and the reasons underlying suboptimal use of services, is essential to identifying solutions that can improve access to health care and improve the health of our population.

In 2005, more than 40 million adults (about 19%) did not receive "needed services" because they could not afford them (Figure 21). Nearly 15 million adults did not obtain eyeglasses, 25 million did not get dental care, 19 million did not get needed prescribed medicine, and 15 million did not get needed medical care due to cost. In 2004–2005, reported access problems varied among the 25 most populous states: 3%–9% of people in these states did not get needed medical care, 5%–11% delayed medical care, and 4%–14% did not get prescription drugs because they could not afford them (Table 80).

Health care resources are not distributed equally throughout the country (Figures 22, 23). Many rural areas experience a shortage of physicians and other providers (10). People living in rural areas, or areas without specific services, may have to travel long distances to obtain some health care services. They may experience long waiting times for appointments or be unable to obtain timely urgent or emergency care. Supply shortages of some health care services may affect all population groups, regardless of geography. For example, the supply of donated kidneys falls far short of the demand from people with end-stage renal disease (Figures 24, 25).

In addition to geographic distribution and supply of health care services, there are other obstacles to receiving needed health care. Lack of health insurance coverage has been well documented as a major barrier to receiving health care and has often been used as a proxy for overall access to health care (3). The percentage of the population under 65 years of age with no health insurance coverage fluctuated around 16%–17% between 1999 and 2005 (Figure 28 and Table 139). Uninsured people are substantially less likely to receive health care than their insured counterparts (Figures 33, 35, and Tables 81, 82, 87, 88, 98). Hispanic and American Indian or Alaska Native persons under 65 years are more likely to be uninsured than those in other racial and ethnic groups, and lower insurance rates in these populations is reflected in large part by lower utilization of most health care services (Tables 81, 82, 139). More than 60% of the uninsured population is age 18–44 years and almost one-half are non-Hispanic white persons. More than 40% of the uninsured population had a family income of at least 200% of the poverty level (Figure 30).

Poverty can also be a barrier to receiving health care, particularly for people without health insurance or for certain types of services where insurance coverage is less generous or less common, such as dental and mental health care. In 2005, about one-half of adults with any natural teeth in families with income below 200% of the poverty level did not have a recent dental visit, compared with less than one-quarter of adults with family income more than 400% of poverty (Figure 34).

The burden of out-of-pocket medical-related expenses is greatest for poor and uninsured people. In 2004, more than one-quarter of persons under 65 years of age living below the poverty level reported spending more than 10% of their disposable income on out-of-pocket medical care costs and health insurance premiums (Figure 31). For families with income between 100%–400% of poverty, the out-of-pocket cost of health insurance premiums may impose a substantial burden relative to their income, even with employer subsidies for their workers' health insurance. Higher-income families with health insurance who have catastrophic illnesses also may devote a substantial portion of their income to medical care, health insurance premiums, or both (11). Those lacking insurance through the workplace face individual insurance policy premiums that can cost substantially more than employer-sponsored plans—particularly for people with pre-existing conditions (12).

For both uninsured and insured populations, there may be nonfinancial barriers to health care. These barriers include, but are not limited to, transportation problems, lack of knowledge of where to obtain care or when to seek care, communication difficulties with the provider due to language or cultural barriers, and covert or overt discrimination. In 2004–2005, about 6% of adults living in poverty reported delaying needed medical care because they did not have transportation (Figure 27). Data from 2004–2005 also show that about 11% 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, and about 5%–6% of adults 45–64 years of age with hypertension, serious heart disease, or diabetes did not report a usual source of care (Figure 26 and Table 78).

The relationship between insurance coverage, low-income, and other barriers to access is complex because people who cannot pay for uncovered services may try to limit their health care utilization (13). It is possible that because access to needed health care is in part a function of the perception of need, people with less contact with physicians and other health care providers may not be aware of their undiagnosed conditions or recommended screening and preventive services. However, uninsured people are not significantly less likely than insured people to have undiagnosed elevated blood pressure and high cholesterol (Figure 32).

Differences in utilization among socioeconomic groups also may indicate access issues. Educational or cultural barriers to care may prevent people from knowing when to seek care, or prevent them from seeking or receiving care. If one racial, ethnic, or other population has a lower use rate even among insured members of the group, it could be that other barriers to access including availability, overt or covert discrimination, care-seeking behaviors, or barriers that are difficult to measure, may be obstacles to care. For example, colorectal screening is recommended for all adults age 50 and over, yet rates of scope procedures remain lower for insured black and Hispanic adults than for insured non-Hispanic white adults (Figure 35). Recent use of mammography remains lower for Asian women than for non-Hispanic black or white women, although differences in recent use of these tests between non-Hispanic black and white women have disappeared over time (Table 87). These screening differences may be explained by the propensity to seek care or comply with treatment recommendations. They also may be due in part to barriers in accessing these services, such as the inability to communicate with the provider due to language or cultural barriers or the lack of effective education of these populations about the importance of the procedures. Although differences in use of mammography and colorectal scope procedures may not necessarily indicate a barrier to health care access, highlighting these differences may spur more in-depth investigations that determine the source of these differences. If barriers to receiving these services are uncovered, programs or solutions to eliminate these barriers may be developed.

To improve the health of all Americans and enable policymakers to chart future trends, target resources most effectively, and set program priorities, it is critical that the Nation keep collecting and disseminating reliable and accurate information about all components of health, including current health status, the determinants of health, resources, and outcomes. Equally important is documenting trends in access to and utilization of health care services that improve the health of our population. The trends may identify barriers in access to needed or recommended services. The following highlights from Health, United States, 2007 With Chartbook on Trends in the Health of Americans 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.

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