UNITED STATES OF AMERICA

The Healthy People initiative has received bi-partisan support, at the Federal level. The U.S. Congress has enacted Healthy People objectives into law: the Maternal Child Health Block Grant, Preventive Health and Health Services Block and Indian Health Care Improvement Act. The results of the mid-term analysis of progress was presented in the reports Healthy People 2000 Midcourse and 1995 Revisions.

Although, numerous Health Care Reform bills were introduced and discussed in both houses of the Congress, final consensus was not achieved.

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996, commonly referred to as welfare reform, requires work in exchange for time limited assistance. The law contains strong work requirements, a performance bonus to reward states for moving welfare recipients into jobs, comprehensive child support enforcement, and supports for families moving from welfare to work -- including increased funding for child care and guaranteed medical coverage.

Under the new law, unmarried minor parents will be required to live with a responsible adult or in an adult-supervised setting and Maternal and Child Health (MCH) Block Grants for abstinence education were authorized.

The law includes provisions that would deny most forms of public assistance to most legal immigrants for five years or until they attain citizenship.

While legislation was being discussed forty-three States have moved forward with 78 welfare reform experiments.

The Medicaid Program is a medical assistance program jointly financed by State and

Federal governments for eligible low-income individuals. Medicaid covers health care expenses for all recipients of Aid to Families with Dependent Children, and most States also cover the needy elderly, blind, and disabled who receive cash assistance under the Supplemental Security Income Program. Between January 1993 and July 1997, DHSS has approved 15 comprehensive Medicaid demonstration projects.

The Government Performance and Results Act (GPRA) requires federal agencies to develop strategic plans and submit performance measures with their annual budgets. It is anticipated that many of the performance measures in the U.S. Department of Health and Human Services budget will utilize Healthy People 2000 indicators.

Since the Surgeon General=s report on tobacco in 1964, the U.S. has pursued a multifaceted strategy of research on the human and environmental effects of Tobacco use and exposure; Healthy People 2000 covers the majority of the six core components of tobacco control: preventing tobacco use, treating nicotine addiction, protecting nonsmokers from ETS exposure, limiting the effect of tobacco advertising and promotion on young people, increasing the price of tobacco products, and regulating tobacco products.

Access to clinical preventive services is a goal of Healthy People 2000; the U.S. is forced with the problem of 40 million uninsured people of whom many are children.

On 1997, a new Children=s Health Initiative was announced that will extend health care coverage to up to five million children. The new children's health initiative has three parts: Children at Risk Because Their Parents Change Jobs , State Partnership Grants and Children Eligible For Medicaid But Not Enrolled.

The objectives on Substance Abuse: Alcohol and Other Drugs address prevention, treatment, research and public education about substance abuse -- with a particular focus on preventing substance abuse by young Americans.

Family Planning of Healthy People 2000 focuses its first five objectives on adolescent pregnancies. The DHHS in collaboration with the National Campaign to Prevent Teen Pregnancy have established and implemented a comprehensive new plan to (1) prevent out of wedlock teen births, to support and encourage adolescents to remain abstinent and (2) assure that at least 25 % of communities have teen pregnancy prevention programs.

While all Healthy People 2000 objectives address Women=s Health, many of the objectives are specifically targeting women. A new senior level health position was created, Deputy Assistant Secretary for Women=s Health, to address inequities in the health treatment of American women. A Healthy Women 2000 Initiative was launched.

The National Action Plan on Breast Cancer established in December of 1993 by DHHS, provides an unprecedented opportunity to promote public-private linkages and to improve research on one of the most serious threats to the health of women.

Three objectives in Healthy People 2000 that focus on the importance of breast examination, mammogram and pap smears.

The NIH Women=s Health Initiative has begun to examine the major causes of death, disability and frailty in post-menopausal women. The NIH Office of Research on Women=s Health was authorized by law in 1993.

Six National Centers of Excellence in Women's Health were established on October 1, 1993 by DHHS. The centers serve as national models for improving the health care of American women.

In March of 1997, an Advisory Commission on Consumer Protection and Quality in the Health Care Industry was appointed.

Among the challenges the U.S. faces in 2010 is reigning its expenditures on health care, especially in today=s atmosphere of fiscal austerity. Whereas in 1995, 14.2% of the Gross Domestic Product (GDP) went toward health care, by 2000 health expenditures will represent nearly 16 percent of the American economy. Other constraints that the U.S. faces in its efforts to develop health and social policies that support Healthy People, are people=s distrust in the government; also tax payers= unwillingness to pay for services; the growing socioeconomic inequalities that affect individual health; the ever growing number of people without insurance.

The guide will contain extensive directories of the Federal Healthy People Steering Committee and work group coordinators as well as information on the more than 600 members of the Healthy People Consortium.

SECTION 2. TRENDS IN SOCIOECONOMIC DEVELOPMENT

The U.S. Gross Domestic Product was US$6,931.3 billions in 1994, compared to US$5,743.8 for 1990, while the annual percentage change of the GDP between 1993-94 was 5.8, compared to 3.0 for period 1990-91 .

During 1994, the country’s national health expenditure represented 13.7% of the GDP, compared to 12.1 for 1990.

In 1995, the number of people below the official government poverty level was 36.4 million, representing 13.8 percent of the U.S.=s population-both significantly lower than the

corresponding 1994 figures of 38.1 million poor and a poverty rate of 14.5 percent. In 1996, 66.9 percent of all persons (age 16 years and older) had a job during the year compared with high of 70.3 percent in 1989.

The "work experience" unemployment rate continued to be much higher for blacks and Hispanics in 1995--19.0 and 17.9 percent, respectively--than for whites (11.9 percent).

For the first time in 6 years, households in the United States experienced an overall increase in

real median income. From 1994 to 1995, real median household income increased by 2.7

percent, from $33,178 to $34,076. Even though income remains below its 1989 prerecessionary

peak of $35,421 (in 1995 dollars), the gap is narrowing.

2. Demographic Trends

On January 1, 1995, there were 261,638,000 people in the United States, with the urban population representing 75.2%. The increase over the January 1, 1994, estimate was 1.0 %. The United States experienced a net gain from migration of 816,000 (736,000 international migrants and 80,000 returning federally affiliated U.S. citizens).

Population growth is concentrated among adults in their thirties and forties, and the elderly.

With a total fertility rate of 65.6 for 1995, and the crude birth rate 14.8 for the same year,

the number of births fell below the 4 million mark for the first time since 1988.

As for the family composition, only 7 of 10 children live with 2 parents.

level.

The percentage of newborns weighing at least 2500g at birth has been 7.3% for 1994 and 1995.

SECTION 3. HEALTH AND ENVIRONMENT

As the percentage of population with safe drinking-water in the home or with reasonable access reached 73% in 1995, Americans are increasingly concerned about the quality of their drinking water. As improvements in analytical methods allow the U.S. to detect impurities at very low concentrations in water, water supplies once considered pure are found to have contaminants.

The 1996 Safe Drinking Water Act (SDWA) Amendments emphasize sound science and risk-based standard setting, small water supply system flexibility and technical assistance, community-empowered source water protection, consumer awareness/right-to-know, and water system infrastructure assistance through a multi-billion-dollar Drinking Water State Revolving Fund.

SECTION 4. HEALTH RESOURCES

The number of active health personnel per 10,000 population, for 1994, was: 24.3 physicians, 78.5 nurses, 6.8 pharmacists, and 6.0 dentists.

The nation=s total spending for health care increased 5.5 percent in 1995 to nearly one trillion dollars, an estimated average of $3,621 per person. Spending grew faster for Medicare than the private sector, primarily because the private sector has garnered greater savings from managed care.

Growth in the nation's health care spending decelerated steadily from annual double-digit and near double-digit increases in the late 1980s and early 1990s to 6.9 percent in 1993.

The total federal, state and local government health expenditures as a percentage of gross domestic product rouse from 28.8% in 1990 to 33.2% in 1994.

Growth in private sector spending decelerated, falling steadily from 11.7 % in 1990 to 2.9% in 1995. However, the magnitude of the deceleration of public sector spending was much less, from 12.7 percent in 1990 to 8.7 percent in 1995.

Medicare and Medicaid financed 36.1% of all personal health care expenditures in 1995.

Medicare funded $184 billion in benefits for the 37.5 million aged and disabled people enrolled in the program. The two largest categories of Medicare expenditures were 61% for hospital care and 22% for physician services.

Federal and state spending by the Medicaid program funded $133 billion for personal health care in 1995, 39% for hospital care and another 27% for nursing home care. In fiscal year

1995, 36.3 million people were poor enough to receive care financed by the Medicaid program.

The United States does not receive international aid for health. It does however provide technical assistance in health primarily to countries through the U.S. Agency for International Development. In FY 1996, the Center for Population, Health and Nutrition obligated a total of approximately $916 million.

The following are ongoing international collaborations under the supervision of the Office of International and Refugee Health, DHHS: the coordinating of the Health Committee of the Gore-Chernomyrdin Binational Commission; the promotion of enhanced cooperation with Mexico, with special emphasis on the border; the U.S. Mexico Binational Commission; the development of a new program with USAID in Egypt, focusing on health policy and decision-making; support for the Gore-Mbeki Commission, a bilateral agreement with South Africa; cooperation with Israel, the Netherlands, Japan, and China on health policy and related issues; provisions of departmental support for global programs with WHO, UNAIDS, UNICEF, and PAHO; and ongoing cooperation with the Office of Refugee Resettlement and USAID and on refugee health issues and emergency response capacity.

Healthy People has been a bridge for partnerships with other Federal agencies. Healthy People shares the same measure and use the data sets of the Department of Education in their

Education America GOALS 2000 program, such as 90 percent high school completion rates;

early childhood development to ensure that every child enters school ready to learn; and that

school breakfast and lunch programs are nutritious following the Dietary Guidelines for

Americans. Healthy People has worked with the Environmental Protection Agency on their

Environmental Milestones for 2005 to synchronize measures on safe water, smoke free indoor

air, and to minimize risks to children of lead based paints. Healthy People has collaborated

with the National Highway Transportation Safety Administration (e.g. alcohol-related fatalities and graduated drivers licenses requirements).

DHHS launched Healthfinder, a new government gateway site (<http://www.healthfinder.gov>) to lead people to information that addresses not only the leading causes of death, like heart disease and cancer, but also the problems behind them -- like smoking, unhealthy diets, physical inactivity and substance abuse.

National Association of County and City Health Officials= survey in 1992 found 70 percent of local health departments using Healthy People objectives, and using APEX/PH (Assessment Protocol for Excellence in Public Health) or PATCH (Planned Approach To Community Health).

Nevertheless, a large number of States indicated that they lack the resources and infrastructure to collect the data necessary for tracking progress toward State objectives. In addition, States identified the following as challenges in implementing Healthy People activities: lack of funding, limited coordination between the health department and other State agencies, issues of ownership and shared responsibilities for implementation among public, private, and voluntary organization partners.

Through the National Institutes of Health, the U.S. supports nearly 40% of all biomedical research and development in the country. The highest funding priority is for basic research.

SECTION 6. HEALTH SERVICES

In 1995, based on Census Bureau population estimates, there are 59.4 million women aged 15-44 in the United States. Over 30.5 million are at risk of unintended pregnancy.

Data from the 1991 National Vital Statistics System indicate that no State had achieved the

Healthy People 2000 target of 90% of pregnant women receiving first trimester prenatal

care. However, 18 States had first trimester prenatal care rates exceeding 80%. In 1991, American Indians/Alaska Natives had the lowest rate of first trimester prenatal care C59.9%, compared with 61.9% for blacks, 61.0% for Hispanics, and 79.5% for whites.

The Healthy Start Initiative, a demonstration effort in 22 communities with high infant mortality rates administered by HRSA, has developed promising models for collaborative community-based interventions to reduce infant mortality that can be replicated.

Medicaid has expanded eligibility and services for pregnant women and their infants. In addition, high-quality treatment programs for pregnant and postpartum women were funded through the Center for Substance Abuse Treatment (CSAT) in the Substance Abuse and Mental Health Services Administration. Of the women treated in CSAT-funded programs, 95% reported uncomplicated, drug-free births and 75% who successfully completed treatment remained drug free for at least one to three months.

According to preliminary estimates, infant mortality dropped to 7.5 deaths per 1,000 live births in 1995, down 6% since 1994 and 18% since 1990.

Between 1994 and 1995, the white infant mortality rate declined 5%, to 6.3 deaths per 1,000 live births, while the black infant mortality rate declined 6%, to 14.9 deaths per 1,000 live births.

In 1995, the leading causes of infant mortality in the U.S. were: congenital anomalies, disorders related to immaturity (short gestation and unspecified low birth weight), Sudden Infant Death Syndrome and respiratory distress syndrome.

The incidence of low birth weight was unchanged in 1995, at 7.3%. Cigarette smoking

during pregnancy declined for the fifth consecutive year in 1994, to 14.6% of mothers. Over 12% of births to smokers were low birth weight (less than 2,500 grams or 5 pounds 8 ounces) compared with almost 7% of births to non-smokers.

In 1994, the percentages of the 19-35 months old children population vaccinated against Diphtheria-Tetanus-Pertussis, Polio and Measles were 94%, 86% and 89%, respectively.

The infant immunization rate is now at an historic high of 76 percent, and most vaccine preventable childhood diseases are at all-time lows. However, more than one million American preschoolers are still not adequately immunized against vaccine-preventable disease. National Infant Immunization Week (April 20-26) is a critical part of the effort to ensure that all children get the shots they need, when they need them.

SECTION 7. TRENDS IN HEALTH STATUS

1. Life Expectancy

From 1990 to 1995 the life expectancy at birth has changed from 71.8 to 72.6 for males and from 78.8 to 78.9 for women.

Some 11.4 years of life (or 15 percent of life years) are estimated to be unhealthy, with limitations of major life activities such as: recreation, school, and work, as well as such activities of daily living, such as self-care (bathing, grooming, and cooking). The number of years of healthy life for Hispanics (64.8 years) was slightly less than that of whites in 1990. Blacks, however, had substantially fewer years of healthy life (56.0 years).

2. Mortality

In 1995, an estimated 2,312,180 deaths were registered en the U.S., the death rate was 880.0 deaths per 100.000 population, 0.5% above the rate for 1994 and same as the rate in 1993.The age-adjusted rate decreased for both white and black populations between 1994 and 1995.

During the 1990’s there were major declines in the death rates for three of the leading causes of deaths among the U.S. population: heart disease, stroke, and unintentional injuries.

Between 1990 and 1995, the age-adjusted death rate for heart disease, the leading cause of death for men and women, declined 9.1%. This dramatic reduction reflects increased high blood pressure screening and control, a decline in cigarette smoking, and an increased awareness of the role of dietary fat in production of cholesterol.

Deaths due to lung cancer among white women showed a 5.8% increase between 1990 and 1995. In 1993, the age-adjusted death rates for all cancers for American Indians, Asians and Hispanic males 45 years and over were similar (around 95 deaths per 100,000); these rates were considerably lower than the rates for whites and blacks (156.4 and 238.9 deaths per 100,000).

The number of deaths due to motor vehicle accidents, in 1994, were 1.7 per 100 million vehicle/miles/traveled; for the age groups under 14 years, 15-24 years and 70 years and over the rates were: 5.0, 29.1 and 23.3 respectively.

In 1994, the number of deaths due to work related injuries per 100,000 full-time workers in mines, construction, transportation and farms were: 27, 15, 13, and 27, respectively.

Real progress has occurred in reducing heart disease and stroke death rates for adults. Slowing the rise in cancer deaths and in HIV infection remains a real obstacle to the achievement of the

year 2000 target for adults.

Deaths among children under 5 years of age from diarrhoeal and acute respiratory diseases were 218 and 124, respectively.

Thirty three thousand babies still die each year before their first birthday in the United States.

The 15 percent mortality reduction set as the target for children aged 1B14 for the year 2000 was nearly reached in 1992 as the child death rate reached 28.8 per 100,000.

For adolescents and youths aged 15 B 24, the goal of reduction in mortality is proving elusive, for 1992, there was 95.6 deaths per 100,000 population.

7.3 Disability

In the United States over 49 million people have physical and mental disabilities.

In FY 1997, DHHS devoted over $62 billion to programs for people with disabilities. The National Center for Health Statistics in 1994-95 conducted the first-ever comprehensive national disability survey. The survey found that the prevalence of disabilities is disproportionately higher among minorities, elderly, poor and rural populations.. In 1997, the estimate of economic loss due to disability, including the increased cost of health care and reduced productivity, was over $350 billion.

Medicare provides health insurance to about 5 million in individuals in 1997 who are considered disabled based on federal criteria, $21 billion were spent during FY 1997. .

Medicaid will provide health insurance to approximately 7 million individuals in 1997 who are

considered disabled based on federal criteria and is expected to spend $33 billion.

SECTION 8. OUTLOOK FOR THE FUTURE

This mid-decade review of Healthy People 2000 shows that the United States is moving in the right direction on more than two-thirds of the national objectives for which we have data. The report demonstrates that partnerships among all levels of government and the private sector continue to make positive differences in people=s health. Life expectancy continues to in-crease. Heart disease and stroke deaths continue to decline. Americans are changing their diets to consume less fat and more fruits and vegetables. More women are seeking prenatal care in their first trimesters and are giving their newborns healthy starts by breast feeding.

However, we still face significant challenges: Americans who have disabilities, come from lower

income families, or are members of minority groups continue to experience disproportionately

worse health outcomes than other Americans. To reach our vision of Healthy People in Healthy

Communities, we must close these gaps.

Full achievement of the goals and objectives of Healthy People 2000 is dependent on a health

system reaching all Americans and integrating personal health care and population-based public

health.

The U.S. is beginning to lay the foundation for the year 2010 national health promotion and disease prevention objectives. The proposed vision for Healthy People 2010 is Healthy People in Healthy Communities: Health for All.

The framework for Healthy People 2010 proposes two overarching goals: increase years of healthy life and eliminate health disparities. Four enabling goals provide strategies to achieve the overarching goals: promote healthy behaviors, protect health, achieve access to quality health care, and strengthen community prevention.

In August 1997, ODPHP will publish the Developing Objectives for the Healthy People 2010 guide.