United States of America
- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
The United States has the largest economy in the world—with a gross domestic product (GDP) of over US$ 18 trillion and a per capita income of nearly US$ 56,116 (). The country comprises 50 states and several politically designated territories and commonwealths, of which Puerto Rico, the U.S. Virgin Islands, Guam, and American Samoa are just a few. It is one of the original members of the Organisation for Economic Cooperation and Development (OECD) and the Group of 7, and is part of a broad range of international organizations and treaties.
The U.S. population rose 4.1% between 2010 and 2015, from 303,956,272 to 316,515,021 (), making it the country with the third-highest population in the world. Its population is growing older, with the median age increasing from 36.9 years in 2010 to 37.6 years in 2015 (). Further, while the population over 18 years rose 5.6% to 242,831,196 or 76.6% of the total population, the population over 65 years rose 15.1% to 44,615,477 or 14.1% of the total population; the age group 65 to 74 increased nearly 23% to 25,135,167 (). Females comprise over 56% of the population over 65 years (). The population under 18 years fell in those years, dropping 1.1%, to 23.3% of the total population (). Figure 1 shows the population structure in the United States in 1990 and in 2015.
Figure 1. Population structure, by age and sex, United States of America, 1990 and 2015
The United States population increased 27.3% between 1990 and 2015. In 1990, the population structure reflected factors such as the aging of the baby-boom generation and migration trends (wider groups in middle age groups). By 2015, the pyramidal structure shifted to age groups older than 50 years, becoming stationary under that age, reflecting decreases in birth rate and mortality in the last decades.
Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Division of Population, New York, 2015. Updated 2015.
The population of the United States became more racially and ethnically diverse in 2015. Since 2010, the Hispanic population rose 13.6%, to 54.2 million persons, representing 17.1% of the total population (). Hispanics of Mexican descent make up 34.6 million or nearly 65% of all Hispanics. While the non-Hispanic white population grew 2.4% to 197.3 million, it fell from 64.7% to 62.3% of the total population (). The non-Hispanic black population rose 4.5% since 2010, but remained 12% of the total population (). The Asian population increased 14.5%, to 16.1 million, during that period (). Persons reporting two or more races grew nearly 31%, from 5.3 to 7 million, comprising 2.2% of the total population ().
The native-born population in 2015 comprised 86.8% of the U.S. population; however, from 2010 to 2015, the foreign-born population increased to represent 13.2% of the total population (). In 2015, the foreign-born population accounted for 19.6%, 16.0%, 11.4%, and 6.9% of the West, Northeast, South, and Midwest regions of the United States (). A greater proportion of the U.S. population is aging and becoming more racially and ethnically diverse, which will create different demands and strains from social and health support systems, especially at a time of already tight state and federal budgets.
Social Determinants of Health
Of the 116.9 million households in the United States, 77.3 million are family households with a mean income of US$ 88,153; non-family households comprise 39.7 million households, with a mean income of US$ 47,846 (). Of family households, over 12.1 million families make less than US$ 25,000 per year and 22.9 million families make over US$ 100,000 per year (). From 2010 to 2016, the number of families earning over US$ 100,000 rose 13.9%; those earning $25,000 to $99,999 fell by 1.6%; those making under US$ 25,000 barely changed (0.1%) (). In 2014 the mean household income for those in the top quintile (20%) was US$ 193,457, compared to US$ 11,952 for those in the bottom quintile (); the top 5% had a median income of US$ 344,707 ().
In 2015, the percentage of families living in poverty was 11.3% (); 18% of families with related children under 18 years lived in poverty (). Just over 8% of married couples with related children under 18 were living in poverty, compared to 40.5% of families with children under 18 years in families headed by a female householder with no husband (). Nearly 22% of the total US population under 18 years was in poverty (). Over 9% of persons over 65 years of age were in poverty ().
Income inequality also has worsened in the United States. In 2014, the Gini index reached its highest in the United States since 1967 (). In 2010-2014, of the 3,142 counties in the United States, 1,301 (41%) were considered to be high-inequality, high-poverty, compared to only 29% in 1989; 379 (12%) were considered to be high-poverty, low-inequality (). Of counties with small and mid-sized cities, 46% were experiencing high levels of inequality and poverty—a 24% increase since 1989 (). Inequality and poverty increased more slowly in rural counties than in metropolitan areas (). Previously, income inequality and poverty were seen mainly in rural counties of Appalachia, the Deep South, and the Southwest, but now this has spread to new areas, especially in the South (). Most of the low-inequality, low-poverty counties are located in the upper Midwest, Mountain, Middle Atlantic, South Atlantic, and New England states ().
Along with high income-inequality and poverty rates, food and housing insecurity are key social determinants that have an impact on health disparities. Of persons surveyed in 15 states in 2013, the estimated prevalence of perceived food security ranged from 68.5% (Arkansas) to 82.4% (Minnesota); overall, non-Hispanic whites reported being less worried or stressed about having enough money to buy food (81.8%), compared to non-Hispanic blacks (68.5%) and Hispanics (64.6%) (). Food security was highest in persons with four years or more of college education (89.0%); lower in persons with a high-school degree or less than four years of college (75.7%); and lowest in those without any high-school education (59.9%) (). The prevalence rates on housing security were lowest in Arkansas (59.9%) and highest in Minnesota (72.7%) and Iowa (72.8%); with higher insecurity seen among minorities and persons with lower educational levels ().
The Health System
The country’s health system is vast and complex. In terms of hospital facilities, in 2013, there were 5,686 hospitals in the United States down from 5,754 in 2010 (). Most of these hospitals are non-federal hospitals (96.3%), of which 4,974 are community hospitals (). Among those community hospitals, much of the care was provided by the 2,904 not-for-profit hospitals (58.4%); 1,010 community hospitals (21.3%) were state- or local-run community hospitals (). Over 21% () were for-profit community hospitals (). For all hospitals, there were 914,513 beds devoted to patient care in 2014—down from 941,995 beds in 2010 (); of those 875,766 beds, were at nonfederal community hospitals, with 68.4% (543,929 beds) located in not-for-profit community hospitals; 14.1% (117,031 beds) in state or local community hospitals; and 16.9% (134,643 beds) in for-profit hospitals (). Community hospital occupancy rates fell from 64.5% to 62.9% from 2010 to 2013—a decline of 2.5%. For-profit hospitals had the lowest occupancy rates (56.2%) compared with 62.9% for state-local hospitals and 64.5% for not-for-profit hospitals (). The decline in occupancy rates has been occurring for many years, as health care shifts from more expensive inpatient care to provision of services in outpatient settings.
Nursing homes also declined during the period, both in number of installations and beds and in occupancy rates. The number of nursing homes declined 7.5%, from 16,886 facilities in 2000 to 15,643 in 2014, and the number beds dropped 5.7%, from 1.8 million beds in 2000 to under 1.7 million in 2014 (). Nursing home residents decreased 7.5%, from 1,480,076 in 2000 to 1,368,667 in 2014 (). Nursing home occupancy rates fell from 82.4% in 2000 to 80.8% in 2014 (). With the population aging more rapidly over the last few years and in the next decade, along with rising health care costs, the push has been to shift the provision of long-term care systems from institutional-based care to home- and community-based services.
Leading Health Challenges
Critical Health Problems
The recent emergence of Zika and chikungunya in the Americas has heightened awareness in the United States of the need for greater vigilance in monitoring infectious diseases that pose a threat to public health. Zika is only one of several viral infections and/or neglected diseases to have affected the country in recent memory. Back in the 1980s, for example, the United States, and the world, experienced the emergence of a “new” disease (HIV) and the resurgence of a long-neglected illness (tuberculosis). Then, in the 1990s, cyclospora became a major concern for health officials, as it affected the safety of the food supply. The threat of anthrax and smallpox in the early 2000s reminded Americans of the potential for intentional releases of infectious diseases to threaten the security and health of the nation and, more critically, how such outbreaks could overload the public health response system and weaken public confidence in its ability to manage it. Zoonotic diseases, such as mosquito- and tick-borne illnesses, pose a rising danger to many U.S. populations, as people continue to settle into the more humid, subtropical, and dry-arid areas of the country. Tick-borne illnesses such as Lyme disease and Rocky Mountain spotted fever continue to affect large segments of the population living in forested and sub-rural or rural regions. Recent droughts in the Southwest have increased the incidence of Coccidioidomycosis, a fungal infection seen in soils prevalent in the Southwest. Climate change and the altering of the physical environment to accommodate population and industrial activity have only heightened these challenges.
A recent review was conducted of the accuracy of the measurement of maternal mortality in the United States (). As part of the review, methodological changes were made to more accurately measure maternal mortality. While maternal mortality is a rare event in the United States, the number of maternal deaths rose from 396 deaths in 2000 to 856 deaths in 2014 (). In addition, the maternal mortality rate increased by 26.6% in 48 states and in Washington D.C., rising from 18.8 per 100,000 live births in 2000 to 23.8 in 2014 (); these rates are higher than previously reported and put the United States far behind other industrialized nations (). While most of the country experienced a rise in maternal mortality rates, California reported declines (), a drop that may be due to a statewide initiative to develop and promote evidence-based tool kits to address two of the most common, preventable contributors to maternal death (obstetric hemorrhage and preeclampsia) (). Texas had slight increases in maternal mortality from 2000 to 2010, which then doubled within a two-year period (). While evidence to explain this spike is not conclusive, the reduction of and access to women’s health centers during this period may be to blame (). Other indications, such as the number of cesarean deliveries, unintended births, unmarried status, being non-Hispanic black, and having had four or fewer prenatal visits have been associated with higher maternal mortality ().
Poisoning Deaths Due to Opioids
Since 1990, the country has experienced a spike in the number of deaths due to drug poisoning (drug overdoses); since 2000, nearly half a million persons have died from such drug overdoses (). Overall, drug-poisoning mortality skyrocketed by 137.1%, from 6.2 deaths per 100,000 population in 2000 to 14.7 in 2014 (). In 2014, 47,055 drug overdose deaths occurred in the United States (). The rate of drug overdose deaths rose faster in females (177%) compared to males (120%) from 2000 to 2014 (). Rates increased significantly among persons aged 25-44 years and 55 years and older among non-Hispanic whites and non-Hispanic blacks; and in the country’s Midwest, Northeast, and South (). The main driver behind this increase has been drug poisoning involving opioid analgesics (prescription opioids), heroin, and synthetic opioids other than methadone (e.g., fentanyl) (). While most age groups between 24 and 65 years old experienced increasing death rates since 2010, it was the 55-64 age group that experienced the greatest increase—383% (). Over this period, mortality rates due to drug poisoning involving opioid analgesics rose 293%; more alarming was the 386% rise in death rates involving heroin (). According to some reports, illicit fentanyl combined with heroin is then sold as heroin, possibly contributing to the increase in drug deaths involving heroin ().
The nature of the epidemic also has changed since 2000. The heroin-overdose-related deaths seen among non-Hispanic blacks aged 45-64 (highest among all groups) in 2000 were eclipsed by the substantial rates seen among non-Hispanic whites aged 18-44 in 2013 (). While the age-adjusted rates for heroin overdose increased in all regions of the country, they were highest in the Midwest (an 11-fold increase from 2000) and the Northeast (a 4-fold increase from 2000) (). Since 2000, drug-poisoning deaths due to opioid analgesics rose most among non-Hispanic white males (304%) and females (400%), compared to the rise in rates among non-Hispanic black males and females (225% and 333%) and among Hispanic males and females (59% and 220%) (). Non-Hispanic white males and females had the highest age-adjusted mortality rates involving opioid analgesics in 2014, followed by American Indian and Alaskan Native males and females ().
Accidents and Violence
The Centers for Disease Control and Prevention reported 36,132 deaths related to firearms in 2015, with an age-adjusted rate of 11.1 per 100,000 population (). The higher rates over 11.4 to 23.4 per 100,000 population were generally located in the South, Central, and Rocky Mountain regions (). Alaska, Louisiana, and Wyoming and Alabama (the last two were tied) reported the highest rates of 23.4, 20.4, and 19.6 deaths per 100,000, respectively, and New York, Hawaii, and Massachusetts, the lowest, at 4.2, 3.6 and 3.0 per 100,000 population, respectively ().
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) has recently become a major health concern in the country, driven by exposure to gun violence/violent personal assaults, natural- or human-caused disasters, accidents, military combat, and other traumatic events. The lifetime prevalence of PTSD in the U.S. population is 6.8% (); the average yearly prevalence is 3.5% of the adult population, with 36.6% of cases classified as severe, representing 1.3% of the adult population (). The average age of onset is 23 years, with 6.3% prevalence in those aged 18-29; 8.2% in ages 30-44; 9.2% in ages 45-59; and 2.5% in those older than 60 (). In the past 12 months as of this writing, 49.9% of those with PTSD were receiving treatment, with 42.0% of those receiving the minimally adequate treatment, or 21% of all those with the disorder ().
Some 117 million adults (about half of all adults in the United States) had one or more chronic health conditions in 2012, with one in four having two or more chronic health conditions ().
As the U.S. population has aged, and life spans in the country have increased, so have the number and type of comorbidities. The circumstances surrounding multiple chronic conditions vary in terms of age and other socio-demographic factors. In 2014, persons over 18 years old were more likely to have had one or no chronic diseases (76.9%), compared to those with two to three chronic conditions (19.1%) or those with four or more (3.9%) (). Although the percentage of those experiencing one or no chronic conditions declined by nearly 2% between 2002 and 2014, it rose by 6.7% for those with two-to-three chronic conditions and by 8.3% for those with four or more (). More importantly, those older than 65 years were more likely to report two-to-three and even four or more chronic conditions than did younger age groups (). In 2002-2014, the number of persons 75 years old and older who suffered one or no chronic conditions fell more than 10%, from 44.6% to 39.9%, but increased 6.2% among those 65 years and older who reported having two-to-three conditions, from 43.4% to 46.0% (a 6.2% rise), and 17.5% for those reporting four or more conditions, 12.0% to 14.1% (). The percentage of those reporting having one or no chronic condition declined between those 12 years, and held regardless of gender, race and ethnic group, or poverty status (). Furthermore, those same groups reported an increase in prevalence of having two-to-three and four-or-more conditions, except for those below 100% and above 400% of poverty, who reported a slight decrease (). In 2014, those living in urban areas were more likely to report having one or no chronic conditions (77.8%) compared to those in rural areas (72.0%); those living in rural areas were more likely to report having two-to-three conditions (23.2%) and four or more conditions (4.8%) than did those in urban areas 18.4% and 3.8%, respectively ().
Changes in the risk factors associated with chronic disease varied during the reporting period. For example, the prevalence of hypercholesterolemia (very high cholesterol)—a major risk factor for health disease—increased in adults age 20 and older, from 25.5% in 1999-2001 to 27.4% in 2013–2014 (). On the other hand, the prevalence of high cholesterol declined from 18.3% in 1999-2001 to 11.1% in 2013–2014 (). The prevalence of overweight, which includes obesity—a major risk factor for many chronic diseases, from heart disease and cancer to diabetes—rose from 64.5% to 70.4%, with those who are obese rising from 30.5% to 37.8% during this period (). The prevalence of hypertension rose slightly, from 30.0% in 1999-2001 to 30.8% in 2013–2014 (). The prevalence rate of persons older than age 20 whose hypertension was uncontrolled declined from 71.9% to 51.3% during this period (). The prevalence of smoking—by far the most important risk factor for chronic lower respiratory disease (CLRD)—declined in the U.S. population overall, but remained higher among adults living in urban areas (). States with a higher percentage of rural population often have a higher prevalence of smoking, earlier age at onset of smoking, and higher use of cigarettes (). The prevalence of persons who were overweight or obese increased from 40.5% in 1960 to 66.1% in 2010. The prevalence among adults age 18 years and older who met federal physical activity guidelines was lower in rural areas and the gap between rural and urban areas widened between 1998 and 2014 ().
The health care sector in the U.S. employs over 12.5 million people, about 9.0% of the total work force. This workforce encompasses jobs from janitorial, to clinical care, to executive/administrative and support services.
From 2010 to 2013, the number of physicians rose 7.5%, (to 1,045,910), of which nearly 82% () were actively engaged in the profession (); 636,707 (74%) are graduates of U.S. medical schools and 217,991 are graduates of international medical schools (). Of the physicians who are actively practicing, almost 95% are involved in patient care—an increase of 7.6% from 2010 (); of those, 74.2 % are in office-based care compared to 25.8% in hospital-based care (). Of the 854,698 active physicians, 37.4% are in general primary care and 10.5% are primary care subspecialists (). In 2013, there were 27.6 physicians per 10,000 population involved in patient care, ranging from 18.6 per 10,000 in Idaho to 66.1 in the District of Columbia (). There were 191,347 dentists in the United States in 2013, an increase of nearly 3% since 2012 (). In 2013, there were 60.5 per 100,000 population dentists who were professionally active, ranging from a low in Arkansas at 40.9 to a high in the District of Columbia at 89.2 ().
In 2014, more than 10 million people were employed as health care practitioners and technical and support personnel in the United States, an increase of 2.7% since 2010 (); over 64%, or 6.4 million persons, were employed as health care practitioners and technical service personnel, of which nearly 2.7 million (41.8%) were registered nurses (); the number of registered nurses increased 1.2% from 2,655,020 in 2010 to 2,687,310 in 2014. Although, nurse practitioners made up only 1.9% of this labor force, their numbers increased by 15.4%, from 105,780 in 2012 to 122,050 in 2014 (). In addition, the number of pharmacists increased by 8.5% to almost 291,000, or 4.5% of this occupational group in 2014 (); pharmacy technicians comprised 5.7% of this category (). Over 3.6 million people are employed in health care support occupations, nearly 36% of the health care practitioner and technical and support workforce (). While nursing assistants comprise nearly 40%, or 1.43 million, of the health care support professions, their numbers declined by 1.6% since 2010 (). Medical assistants and those involved in therapy support saw substantial increases in employment opportunities since 2010 ().
Health Knowledge, Technology, and Information
The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act provided hospitals and eligible providers with monetary incentives for phasing in the use of electronic health record (EHR) systems and meeting federal standards of “meaningful use” of such systems ().
By 2015, nearly 78% of office-based physicians had a certified EHR system, up from 74.1% in 2014 (). Moreover, roughly one-third of all office-based physicians had electronically sent (38.2%), received (38.3%), integrated (31.1%), or searched for patient health information from other providers (34.0%) (). That said, the percentage of physicians who met all those criteria varied considerably by state. For example, the percentage of physicians who had electronically sent patient information to other providers ranged from 19.4% in Idaho to 56.3% in Arizona, while the physicians who had electronically received patient information from other providers ranged from 23.6% in Louisiana and Mississippi to 65.5% in Wisconsin (). Physicians who had electronically integrated patient information from other providers varied from 18.4% in Alaska to 49.3% in Delaware, whereas physicians who had electronically searched for such information from outside providers varied widely, from 15.1% in the District of Columbia to 61.2% in Oregon (). Since 2006, the percentage of physicians who reported having an EHR system that met the criteria for a basic system increased 336%, from 11% in 2006 to 48% in 2013 (), although the rate of adoption of basic systems ranged from 21% in New Jersey to 83% in North Dakota ().
The adoption and use of EHRs by hospital emergency departments also varied widely. In 2011, 83.7% of emergency departments had adopted an EHR, up from 46.2% in 2006; and 73.3% of hospital outpatient departments had adopted an EHR, up from 29.4% in 2006 (). From 2007 through 2011, the percentage of hospital-based emergency rooms that had an EHR system that met the criteria for a basic system increased from 18.5% to 53.6%; the rates for outpatient departments ranged from 8.9% to 57.4% ().
The Environment and Human Security
Between 2005 and 2015, the country experienced extreme or exceptional droughts. The National Center for Environmental Health at the Centers for Disease Control and Prevention reported that every state, except those in the Northeast, and Alaska, experienced such phenomena during that period (). To put this in perspective, between 1980 and 2014, the United States experienced 22 droughts that cost over US$ 1 billion each (). In 2012, the country experienced the most extensive drought since the 1930s, affecting over half of the nation and costing US$ 31 billion (). In California alone, the current drought has cost nearly US$ 5 billion (). Droughts increase the risk of fires and dust storms, which, in turn, release particles harmful to respiratory health and contribute to or worsen infections such as bronchitis and pneumonia. Plus, dry and dusty soils can increase the risk of Valley fever and other fungal or viral diseases injurious to respiratory health. Droughts obviously directly affect access to and quality of water. While the short-term impact of droughts can be measured, the long-term effects of prolonged drought are not easily ascertained.
The importance of having accessible and safe drinking water for a population’s overall health and well-being has been well documented. The Flint, Michigan, water contamination crisis highlights not only the concern about water safety but the costs of not addressing deteriorating infrastructure. The economic decline of many manufacturing areas of the nation has resulted in delayed maintenance and expansion of water procurement and treatment, not only of potable water but the treatment of sewage and toxic waste from the populace and factories, both functioning and derelict. Flint is just one of many cities facing this crisis. The nuclear waste that could potentially leak from the Hanford Nuclear facility in Washington State could have serious environmental and health repercussions from ground water contamination, to contamination of riparian and other ecosystems, potentially and irrevocably altering these environments. Mining and drilling operations often pose serious localized threats to contamination of underground and aboveground water supplies as has been witnessed in many areas of rural Appalachia.
In regards to air quality, the long-term heat exposure from droughts throughout the western and southern areas of the United States may be associated with episodes of respiratory illness and deaths and with the potential spread of dust- and soilborne infections. In the 1980s, airborne pollutants from coal-burning, electricity-generating plants and factories in the Midwest contributed to an increase in sulfur dioxide, CO2, and other particulates, which may have been associated with respiratory illness and deaths.
Since 1990, the life expectancy at birth in the United States has risen 4.5%, from 75.4 to 78.8 years in 2014, while life expectancy at 65 years rose 12.2%, from 17.2 to 19.3 years (). Life expectancy at birth has increased for males and females, with females’ rising by 3.0% to 81.2 years and males’ by 6.4% to 76.4 years (). Between 2010 and 2014, life expectancy for non-Hispanic whites remained unchanged at 78.8 years, but increased for non-Hispanic blacks and Hispanics to 75.2 years and 81.8 years, respectively (). Life expectancy at birth has remained higher among Hispanics than among non-Hispanic whites and non-Hispanic blacks, and over the past few years that gap has widened. The difference in life expectancy between non-Hispanic whites and non-Hispanic blacks has narrowed from a difference of 4.1 years to 3.6 years between 2010 and 2014 (). The flattening out of life expectancy in non-Hispanic whites in recent years has raised concerns. A recent review on changes in U.S. mortality rates points to a substantial rise in mortality rates for non-Hispanic whites aged 45-54 due to drug and alcohol poisoning, suicide, and chronic liver disease and cirrhosis ().
Because Americans are living longer and there is slower growth in younger age groups, the proportion of deaths in persons over 65 has increased compared to those in younger age groups since 1980. In 2014, more than 73% of total deaths in the United States were in persons 65 years and older, compared to 67.4% in 1980 (). Although the proportion of deaths from diseases of the heart in persons 65 years and older fell from 44.4% in 1980 to 25.5% of all deaths in 2014, this cause remained the leading cause of death in persons 65 years and older (). The proportion of deaths due to cancer, the second leading cause of death, rose from 19.3% in 1980 to 20.8% in 2014 (). Stroke fell from the third to the fourth leading cause of death between 1980 and 2014 (). The causes of death remained the same for persons over 65 years, as for all ages, except for suicide, which was replaced by septicemia as the 10th leading cause of death for persons over 65 years in 2014 ().
Monitoring the Health System’s Organization, Provision of Care, and Performance
The U.S. health care system is one of the largest and most complicated health care delivery structures in the world. It is financed through such publicly funded programs as Medicare, Medicaid, the Indian Health Service, and the military, and through private individual and employer-based insurance coverage. Private employer-based insurance coverage has the largest share of health insurance coverage in the health care system in the United States.
The federal government, under the auspices of the Department of Health and Human Services (DHHS) and various agencies such as the Centers for Medicare & Medicaid Services (CMS), the Food and Drug Administration (FDA), the Health Resources and Services Administration (HRSA), and the Indian Health Service (IHS), provide guidance or oversee aspects of various parts of the health care system. The Centers for Disease Control and Prevention conducts and supports health promotion, prevention, and preparedness activities in the United States, with the goal of improving overall public health in coordination with the 50 states and territories. In turn, states and localities oversee health insurance coverage and the provision and delivery of care through legislative statutes and regulations, often enacted in agreement with national standards. In addition, as part of its public health function to protect the population from disease, the federal government monitors the emergence of diseases and illnesses through a network of sentinel sites and state departments of health, in every state and territory, that identify at-risk groups, monitor trends, and control the spread of these diseases.
The United States does not have an all-encompassing health insurance plan. Prior to the Patient Protection and Affordable Care Act (PPACA), persons who did not qualify for Medicaid or Medicare through age, disability, or income, or who were not covered under the Indian Health Service or military health service, chose coverage either through an employer-based insurance or through the individual market, mostly through a managed care organization. Those who could not afford health insurance or did not qualify for programs like Medicaid or Medicare ultimately dropped into the ranks of the uninsured.
The United States is one of two member nations of the Organization for Economic Co-operation and Development (OECD) that has not achieved universal health coverage (). Medicare is a federal health insurance program for individuals 65 or older, certain younger people with disabilities, and other specific groups such as those with end-stage renal disease; it is funded in part through payroll taxes. Medicaid is a means-tested federal and state government health insurance program largely paid through state and federal taxes. The states determine coverage within federal guidelines and negotiate eligibility with private and public health care providers.
Reforms and the Financing of U.S. Health Care
Over the past few decades the increasing number of persons without health insurance, along with rising health care costs, led to calls for reform. Often, these reforms addressed specific inadequacies or inequities, but did little to overhaul the system. For example, in some states, Medicaid—a government-run program for the poor—was expanded to cover children in those families who did not qualify for Medicaid based on income but were determined to be in need (by the State Children’s Health Insurance Program (CHIP)). Medicare, too, was expanded to cover rising out-of-pocket expenditures for prescriptions.
The PPACA not only sought to contain rising cost structures and expand insurance coverage to the uninsured through Affordable Insurance Exchanges and expanded Medicaid eligibility, it also guaranteed that people could not be denied coverage due to a preexisting condition, ended lifetime and annual limits on coverage for most benefits, required minimum standards for health insurance policies or plans, and required everyone to have insurance, have an exemption, or pay a penalty (the “individual mandate”). As of 2016, 32 states and the District of Columbia had expanded Medicaid, with 19 states choosing not to expand it.
With the implementation of PPACA coverage in 2014, the number of uninsured individuals dropped to 10.5% in 2015, compared with 18.2% in 2010 (). Non-Hispanic blacks, Hispanics, and Asians experienced larger gains in coverage than did non-Hispanic whites (), as did the “poor” and “near poor” (). Coverage increased at a faster rate in states that expanded Medicaid (). As of this writing, 8-12 million Americans who have off-exchange health insurance are now protected against discrimination based on preexisting conditions or from terminating policies once persons become ill ().
In 2015, the U.S. spent over US$ 3.2 trillion dollars on health care, an increase from US$ 2.6 trillion in 2010 (). To put this in perspective, the country’s health care expenditure is greater than the GDP of most nations in the world (). Spending on health care as a share of GDP reached 17.8%, and nearly US$ 10,000 per person (). Medicare spending increased 4.5% to US$ 646.2 billion or 20% of total health expenditures, and Medicaid grew by 9.7%, to US$ 545.1 billion or 17% of health care expenditures (). Private health insurance grew 7.2% to US$ 1,072.1 billion, or 33% of total health expenditures (). Out-of-pocket spending rose 2.6%, to US$ 338.1 billion or 11% of total health expenditure ().
In 2015, hospital care accounted for a 32% share of health care spending, having increased by 5.6% to US$ 1,036.1 trillion compared to the 2014 figure of 4.6% (). Hospital services reported a faster growth in Medicaid and private health insurance spending and slower growth in Medicare spending (). Spending on physicians and clinical services increased 6.3% to US$ 634.9 billion, or 20% of health care expenditures (). Growth in prescription drug spending, while slowing in 2015, outpaced all other service categories that year, accounting for 10% percent of health care expenditures (). Residential and personal-care services spending grew 7.8% to US$ 163.3 billion, or 5% of health care spending. Medicaid spending accounted for 57% of all spending for residential and personal-care services ().
The rapid surge in prescription drug costs since 2014 has seriously affected the ability to afford medications for many individuals, and will prove to be a major health care priority for the nation (). Prescription drug spending has continued to climb since the late 1990s, spiking from US$ 192.8 billion to US$ 297.7 billion in 2014 (). This spending category has grown 4.4% annually on average from 2004 to 2014; it increased 12.2% from 2013 to 2014, and 9.0%, to $324.6 billion, in 2015. Medicare was the second largest funding source for prescription drug spending in 2014 ().
Health Care Utilization
Visits to both emergency rooms or hospitals declined in the U.S. between 2000 and 2014 (). From 2000 to 2014, emergency department visits declined for those under 18 years old, 18-44-year-olds, 45-64-year-olds, and those older than 65 years by 17.7%, 10.2%, 0.6%, and 10.5%, respectively (). From 2000 to 2014, hospitalizations (one or more hospital stays) declined for 18-44-year-olds, 45-64-year olds, and those older than 65 years by 28.6%, 11.9%, and 15.9%, respectively (). The number of health care visits (including visits to doctor offices, emergency departments, and home visits) varied by age group (). The percentage of persons who had no health care visits in the past year remained relatively unchanged, from 15.6% in 2010 to 15.3% in 2014 (). Those with one to three health care visits in the past year rose 11.0% from 2010 to 2014, yet declined more than 12% for those with four or more visits in the year prior to the survey (). In 2014, nearly 63% of persons under 18 years old were likely to have a greater percentage of one-to-three visits in the past year, compared to 48.7% of those aged 18–44 years, 46.8 % of those aged 45–64 years, and 36.9% for those 65 years and older (). However, 57% of persons older than 65 years were more likely to have had four or more health care visits in the past year than did those 18-44-year-olds (28.1%) and 44-64-year-olds (38.2%) ().
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
The number of live births in the U.S. has steadily declined since 2007, and the racial and ethnic composition of births has changed. From 2013 to 2014, the number of live births increased 1% to 922,836; decreased 1% for American Indians or Alaskan Natives and non-Hispanic whites to 44,328 and 2,129,657 live births, respectively; and remained relatively unchanged for non-Hispanic blacks and Asians or Pacific Islanders at 589,605 and 281,306, respectively. Women are postponing births to a later age: from 2010 to 2014, the mean age of the mother at first birth rose from 25.9 years to 26.3 years. The mean age for Asian Pacific Islander and non-Hispanic white women was to 29.5 years and 27.0 years, respectively; compared to 24.2 years for non-Hispanic blacks, 24.3 years for Hispanic, and 23.1 years for American Indian or Alaskan Native women (). From 2013 to 2014, birth rates declined in women under age 30 and rose in women older than 30 years().
While the percent of births to unmarried women declined slightly from 40.6% in 2013 to 40.3% in 2014, there was a compositional shift towards live births in mothers of older age groups (). The percent of live births to unmarried women under the age of 20 fell 30.8% and dropped 1.9% for women aged 20-24; on the other hand, it rose by 16% in women over 25 years. The percentage of low birth weight births to mothers fell slightly, from 8.2% to 8.0%, between 2010 and 2014; it ranged from a 13.2% drop for non-Hispanic blacks to a small drop of 1.1% in Hispanics .
Over the past 25 years, the total fertility rate (TFR) for the United States has fallen (except for 2006 and 2007), to below 2,100 births per 1,000 women, a level below replacement (). In 2014, the total fertility rate for all races and ethnicities was 1,862.5 births per 1,000 women, with fertility rates for non-Hispanic white women at 1,762.5, for non-Hispanic black women at 1,873.5, for Hispanic women at 2,130.5, for American Indian and Alaskan Native women at 1,288.5, and for Asian Pacific Islander women at 1,288.5 (). With the exception of Hispanic women, the total fertility rate since 1980 has remained below replacement for non-Hispanic white women and Asian Pacific Islander women; TFR for non-Hispanic blacks has been below replacement since 2008 and for American Indian and Alaskan Natives since 1992 ().
From 2011 to 2013, there were a total of 5,259 pregnancy-related deaths in the United States (). Pregnancy-related mortality rates for those years were 17.8, 15.9, and 17.3 deaths per 100,000 live births, respectively (). The overall increase in mortality is attributed to an increase in maternal mortality among non-Hispanic black women (40.4 deaths per 100,000 black women compared to 16.4 deaths per 100,000 live births for women of other races (). The top causes of pregnancy-related deaths in 2011 were 15.1%, cardiovascular disease; 14.1%, non-cardiovascular disease; 14.0%, infection or sepsis; and 11.3%, hemorrhage (). According to the Save the Children’s 16th annual State of the World’s Mothers Report, women in the U.S. face a 1-in-1,800 risk for maternal death, the worst among the developed nations ().
Infant Health (0 to 11 Months Old)
Factors affecting the survival and health outcomes around birth and the first year of a child have improved considerably for many decades in the United States, thanks to perinatal health and medical interventions.
Infant mortality rates have declined for all races and ethnicities, although levels remain higher in non-Hispanic blacks and American Indian and Alaskan Natives compared to non-Hispanic whites, Hispanics, and Asian Pacific Islanders (). From 2005 to 2013, both infant and neonatal mortality rates declined by 13%, from 6.9 to 6.0 deaths per 1,000 live births in the first year and 4.6 to 4.0 deaths per 1,000 live births for the first 28 days (). During this period, infant mortality rates among non-Hispanic blacks fell 18.4%, from 13.6 deaths to 11.1 deaths per 1,000 live births, with infant mortality rates among non-Hispanic whites and Hispanics declining 10.5% and 10.7%, to 5.1 deaths and 5.0 deaths per 1,000 live births, respectively (). Infant mortality rates among American Indians and Alaskan Natives fell the least during this period, dropping from 8.1 deaths per 1,000 live births to 7.6 (). Infant mortality among Asian Pacific Islanders declined by 16.3%, to 4.1 infant deaths per 1,000 live births in 2013, the lowest infant mortality rate among all groups (). Neonatal mortality rates among non-Hispanic blacks fell 18.4%, from 9.2 to 7.5 deaths per 1,000 live births, followed by a drop in rates among non-Hispanic whites, which fell 13.2% from 3.8 to 3.3 infant deaths per 1,000 live births (). Neonatal mortality rates declined 6.8% among American Indians and Alaskan Natives and 11.8% among Asian Pacific Islanders, to 4.1 deaths and 3.0 deaths per 1,000 live births, respectively (). Neonatal mortality rates fell least among Hispanics, from 3.9 to 3.6 infant deaths per 1,000 live births ().
Child Health (1-4 Years Old)
In 2014, there were 3,830 deaths in children aged 1-4 years and 5,250 in 5-14-year-olds, less than 1% of total deaths reported for that year (). Among children between 1 and 14 years old, unintentional injuries comprise 29.7% of the 9,080 deaths for the group in 2014, followed by cancers (12.9%), congenital malformation/deformations/etc. (8.2%), homicide (7.1%), and suicide (4.7%) (). From 2001/02 to 2013/14, the prevalence of obesity in children ages 2 to 5 years fell from 10.6 to 9.4 percent, although it rose 16.3% to 17.4% in children 6-11 years old (). This trend increased even more in those aged 12 to 19, where obesity levels rose from 16.7 to 20.6% (). The number of children who currently have asthma is estimated at 6.3 million or 8.6%, with non-Hispanic black children having a greater burden of the disease than other races and ethnicities (). In addition, an estimated 5,000 new cases of type 2 diabetes were diagnosed among youth younger than 20 years, with a higher case rate diagnosed among 10-19-year-olds than among younger children ().
From 2001/02 to 2013/14, dental health improved with children ages 5-19 years old, with untreated caries falling from 21.2% to 17.5% ().
Health of Adolescents and Young Adults (15-24 Years Old)
There were 28,791 deaths reported in adolescents and young adults 15-24 years old in 2014, accounting for 11% of all deaths reported that year (). Unintentional injuries accounted for 41.1% of deaths, followed by suicide (17.6%), homicide (14.4%), cancers (5.4%), and diseases of the heart (3.3%) (). The adolescent birth rate (in women 15-19 years old) fell 9% from 2014 to 2015, continuing the decline that has occurred over many years in all races and ethnicities (45, ).
Since 2001, some risk behaviors among high-school students showed encouraging signs, while others worsened. In 2013, 24.7% of high school students reported having engaged in a physical fight in the year prior to the survey, down from 33.2% in 2001; on the other hand, 17.9% reported carrying a weapon, compared to 17.4% from 2001 (). From 2001 to 2013, risk behaviors associated with motor vehicles, such as not wearing a seatbelt, driving with someone who had been drinking, and driving while drinking, declined from 14.1% to 7.6%, 30.7% to 21.9%, and 13.3% to 10.0%, respectively (). Regarding sexual risk behaviors, nearly half of all respondents (46.8%) reported ever having sexual intercourse, up from 45.6% in 2001, with over 40% reporting not using a condom in 2013 (). While many reported watching less TV from 2001 to 2013 (a drop from 38.3% to 32.5%), nearly three out of four were not physically active at least 60 minutes per day ().
The 2015 SAMHSA Behavioral Health Barometer, reported that about 1.2 million adolescents, ages 12 through 17 years (4.9% of adolescents) in 2014 used cigarettes in the previous month, a decrease from 8.4% in 2010 (), with significant decreases seen in all races and ethnic groups since 2010 (). In 2014, smoking was higher among adolescents in rural (7.9%) than urban (4.3%) areas and also was higher among those in poverty (6.3%) than those above poverty (4.4%) (). The percentage of adolescents in the United States who used marijuana decreased from the early 2000s to the mid- to late-2000s, gradually increasing more recently (). From 2002 to 2014, an estimated 2.3 million adolescents (9.4%) used illicit drugs in the month prior to the survey (); marijuana use and nonmedical use of psychotherapeutics were the most common types of illicit drug use (). In 2014, over 6%, or 1.5 million adolescents, reported binge drinking in the past month, below the “Healthy People 2020” target of 8.6% since 2010 (). The SAMHSA survey reported a lower prevalence of adolescents who initiated alcohol use, cigarette use, and/or the nonmedical use of psychotherapeutics since 2010, though a majority of adolescents in 2014 perceived no great risk from weekly/monthly marijuana use or from having five or more drinks twice a week (). One in three adolescents perceived no risk from smoking one or more packs a cigarettes a day or having four or five drinks per day ().
From 2000 to 2014, the years of potential life lost (YPLL) declined in the disease categories of heart disease, stroke, all cancers (including prostate, breast, colon, and lung), HIV, nephritis, homicide, and motor vehicle-related injuries (). YPLL also declined in that period for all races and ethnicities, declining least among non-Hispanic whites (17.0%), compared to non-Hispanic blacks (42.8%), Hispanics (41.3%), American Indians and Native Alaskans (26.8%), and Asian Pacific Islanders (37.2%) (). While all races/ethnicities experienced rises for nephritis and poisoning, non-Hispanic whites and American Indian and Native Alaskans saw extremely large increases in YPLL related to poisoning (). Non-Hispanic whites saw the greatest rise in YPLL for poisoning (262%) between 2000 and 2014, with blacks (47.4%), Hispanics (60.5%), American Indian and Alaskan Natives (199%), and Asian Pacific Islanders (161%) also experiencing important increases in this regard ().
From 1990 to 2014, overall age-adjusted mortality rates in the United States declined by nearly 23%, with rates declining 29% for males and 18% for females (). From 1990 to 2014, age-adjusted mortality rates declined among non-Hispanic whites by 18.8%, to 742.8 deaths per 100,000; 32.1% among blacks, to 849.3 deaths; 24.4% among Hispanics, to 523.3 deaths; 17.1% among American Indians and Alaskan Natives, to 594.1 deaths; and 33.3% among Asian Pacific Islanders, to 388 deaths (). In 2014, Mississippi (946.6), West Virginia (930.7), Alabama (920.0), Kentucky (907.4), and Oklahoma (900.0) reported the highest age-adjusted mortality rates; with Michigan (649.1), Connecticut (647.0), New York (645.9), California (621.8), and Hawaii (588.6) reporting the lowest (). From 1990 to 2014, age-adjusted mortality rates declined by 48.1% for diseases of the heart, 44.1% for stroke, 25.4% for cancers, 6% for influenza and pneumonia, 6.3% for chronic liver disease and cirrhosis, and nearly 48% for homicide (). Age-adjusted deaths for human immunodeficiency virus (HIV) disease fell by 80.4% in 1990-2014 (). Age-adjusted death rates for unintentional injuries rose over 11% during this period, although motor vehicle-related death rates fell by 41.6%; mortality rates due to accidental poisoning increased by 466.6% (). Age-adjusted deaths due to diabetes remained essentially unchanged ().
Many of the 10 leading causes of death in the U.S. remained unchanged in 2014 compared to those in 1980, except for nephritis and Alzheimer’s disease (). Table 1 shows the age-adjusted death rates and YPLL for the 10 leading causes of death in the country. The proportional distribution of these deaths shifted during this period, however (): of the fifteen leading causes of deaths reported in 2014, three were cardiovascular-related diseases (diseases of the heart, stroke, and hypertension), three were associated with respiratory related illness; and two (Alzheimer’s and Parkinson’s diseases) were diseases of the nervous system ().
Table 1. Age-adjusted death rates and Years of Potential Life Lost (YPLL) for the 10 leading causes of death, United States of America, 1990-2014
|Age-adjusted death rates||Years of Potential Life Lost (YPLL)|
|Deaths (per 100,000 population)||Percent change||Years lost before age 75 (per 100,000 population under age 75)||Percent change|
|Deaths, 2014||Percent of Total Deaths||1990||2014||1990 to 2014||1990||2014||1990 to 2014|
|Diseases of the heart||614,348||23.4||321.8||167.0||-48.1%||1,617.7||952.0||-41.2%|
|Malignant neoplasms (cancers)||591,699||22.5||216.0||161.2||-25.4%||2,003.8||1,310.4||-34.6%|
|Chronic lower respiratory Disease||147,101||5.6||37.2||40.5||8.9%||187.4||174.1||-7.1%|
|Uninitentional injuries (Accidents)||136,053||5.2||36.3||40.5||11.6%||1,162.1||1,081.6||-6.9%|
|Cerebrovascular diseases (stroke)||133,103||5.1||65.3||36.5||-44.1%||259.6||160.1||-38.3%|
|Influenza and pneumonia||55,227||2.1||36.8||15.1||-59.0%||141.5||93.3||-34.1%|
|Nephritis, nephrotic syndrome, nephrosis||48,146||1.8||9.3||13.2||41.9%||50.4||66.7||32.3%|
|Remaining causes of death||687,939||26.2|
a Not reported for the 10 leading causes of death in 1990.
Source: Health, United States 2015; Table 17, 18, & 19. National Center for Health Statistics, Centers for Disease Control and Prevention.
Diseases of the heart remained the leading cause of death in 2014, but its percentage of the total deaths decreased from 38.2% to 23.4% from 1980 to 2014 (). Cancer’s percentage increased slightly from 20.9% to 22.5% from 1980 to 2014, and remained the second leading cause of death (). Stroke fell from the third to fifth leading cause of death between 1980 and 2014, while chronic lower respiratory disease moved from fifth to third leading cause of death between 1980 and 2014 (). Accidental injuries remained the fourth leading cause of death in 2014 and 1980 (); of accidental injuries, unintentional poisoning was the leading cause of mortality from injuries in 2014 (). Alzheimer’s disease was the sixth leading cause of death in 2014, replacing influenza and pneumonia, which moved to eighth place (). Diabetes remained the seventh leading cause of death and nephritis the ninth in 2014 (). Suicide remained the 10th leading cause of death in 1980 and 2014 (). Septicemia and chronic liver disease and cirrhosis, essential hypertension and hypertensive renal disease (hypertension), Parkinson’s disease, and pneumonitis rounded out those diseases that comprised the 11th through 15th leading causes of death, respectively ().
Box 1. Rural vs Urban Health in the United States
Excess Deaths from Five Leading Causes of Death in the Rural United States
In 2014, the overall age-adjusted mortality rate in the US was 724.6 deaths per 100,000 population, a historic low, but deaths in rural areas have declined at a slower pace than in urban areas, with a gap that has widened from 830.5 deaths compared to 704.3 deaths per 100,000 population. Rural areas had higher rates than urban areas for all five leading causes of death heart disease; cancer; unintentional injury; chronic, lower respiratory diseases; and stroke. From 1999 through 2014, age-adjusted death rates for heart disease, cancer, and stroke declined in both rural and urban areas, but the rate of decrease was lower for heart disease and cancer in rural areas, which has led to a widening gap in such rates. Mortality due to stroke continued to decline at similar rates for rural and urban areas during this period, but the gap remained between rates in rural areas and urban ones. While deaths due to chronic, lower respiratory diseases fell from 1999 to 2014 in urban areas, it continued to rise in rural areas, further widening the gap between the two areas by 2014. The gap between rural and urban areas for unintentional injuries was the greatest of five leading causes of death. The age-adjusted rates for unintentional injuries were 50% higher in rural than urban areas. The higher prevalence of lifestyle behaviors (smoking, obesity, drinking, and other substance use); lack of seatbelt use and other driving behaviors; and lack of access to prompt health care and substance abuse services are some of the immediate drivers of this phenomenon.
Since the arrival of Zika in the United States in 2015 to March 22, 2017, there have been 5,158 symptomatic cases of the virus in the mainland and 38,212 cases in U.S. territories (). Of the mainland cases, 4,861 (94%) were in travelers who returned from affected areas; 222 cases (4%) were acquired through presumed local mosquito-borne transmission; 45 cases were acquired through sexual transmission; 25 cases via congenital infection; 1 via laboratory transmission; and 1 via person-to-person through an unknown route (). Of the 38,212 cases reported in U.S. territories up to March 2017, 97% occurred in Puerto Rico, with only 147 cases occurring in travelers returning from affected areas (). Nearly all cases (99.6%) were acquired through presumed local mosquito-borne transmission ().
Chikungunya, dengue and West Nile viruses have remained relatively low due to widespread use of screening and air-conditioning, as well as seasonal surveillance (). In 2016, there were 164 confirmed cases of chikungunya, an 82% decrease from the 896 cases in 2015 (). Reported dengue cases rose 11%, from 690 cases in 2010 to 764 cases in 2016 (). Both chikungunya and dengue cases in the US are due to travel-related exposure; however the mosquitos know to transmit these two virus are found throughout many of the regions of the US. In 2016, cases of West Nile disease rose by 89.8% from 1,021 cases in 2010 to 1,938 cases in 2016; however, the number of cases rose to some 2,200 cases for 2014 and 2015 (). Malaria was eliminated many decades ago in the U.S., and most reported cases occur from travel-related exposure ().
Among tick-borne illnesses, reported cases of Lyme disease have fluctuated annually from 2010 to 2016, reaching a high of 38,069 cases in 2015, up 7.6% since 2010 (). Rocky Mountain spotted fever cases rose over 88%, from 1,985 cases in 2010 to 3,739 in 2016 ().
After being a major public health concern during the 1990s, tuberculosis has steadily and dramatically declined after the implementation of a costly but effective public health intervention effort. From 2010 to 2015, tuberculosis cases declined from 11,182 to 9,557, a 14.5% decline (). Hepatitis C cases rose considerably—nearly 160%—from 850 to 2,207 cases ().
Sexually transmitted Diseases
Sexually transmitted diseases remain a major public health problem that has increased for most of the past few years. Based on provisional 2016 data, reported cases of chlamydia increased over 11%, from 1,307,893 cases in 2010 to 1,456,168 cases in 2016 (). During 2010–2016, gonorrhea cases rose by over 36%, to 421,338 cases in 2016, and primary and secondary syphilis cases increased by 75.2%, to 24,135 cases (). The number of persons diagnosed with HIV decreased 8.5% from 43,978 cases in 2010 to 40,234 in 2014 (). Although the number of HIV-related deaths have fallen, diagnoses increased 10.6%, from 35,741 in 2010 to 39,513 in 2015 (). Hepatitis B cases fell nearly 19%, from 3,350 cases to 2,716 from 2010 to 2016 ().
The percent of children 19–35 months old being immunized for many vaccine preventable disease remains high (over 90%) for illnesses such as polio, measles, mumps, rubella, hepatitis B, and chickenpox; it remains low, however, for vaccines against such illnesses as pneumococcal disease, or PCV (83%), Haemophilus influenza (Hib) (82%), and diphtheria, tetanus, pertussis (84.2%) (). Rates for the combined 7-vaccine series were also low (71.6%) (). Low vaccination rates for diphtheria, tetanus, and pertussis are cause for concern, given that the annual number of pertussis cases remains high compared to other childhood illnesses.
The rise in skepticism about vaccination in the U.S. is a matter of concern for those public health officials charged with combatting and controlling diseases. While vaccine-preventable illnesses remain low, the recent outbreaks of measles in the past few years is troubling. In 2014, the United States experienced a record number of measles cases, with 667 cases from 27 states reported to CDC’s National Center for Immunization and Respiratory Diseases (NCIRD); the largest number of cases since measles was eliminated in the U.S. in 2000. Between 2010 and 2016, the incidence of Hib rose over 38%; influenza-associated pediatric mortality rose an astronomical 1,479%; and mumps rose over 103% (). The number of reported cases of invasive pneumococcal disease remained high, but fluctuated from 2010 to 2016 with reported cases declining 12.4% from 16,569 to 14,516 cases (). Chickenpox cases fell almost 53%, from 15,427 cases in 2010 to 7,319 in 2016 (). Pertussis incidence fell nearly 43%, from 27,550 cases in 2010 to 15,737 in 2016, although such levels are considered very high for this and other vaccine-preventable diseases ().
Most cases of pneumonia, a leading cause of death in the elderly, can be prevented by administering a pneumococcal vaccination (). In 2014, there were 50,662 deaths due to pneumonia, while only 61.3% of adults over 65 were vaccinated (). Only 20% of the population over age 18 that should be vaccinated is vaccinated (). Those living in poverty and all racial and ethnic groups, except for non-Hispanic whites, are less likely to be vaccinated (); 83% of children receive the pneumococcal vaccine ().
Chronic, Noncommunicable Diseases
The prevalence of heart disease in the U.S. in adults aged 18 and older who reported having ever been told that they had heart disease has declined slightly, from 11.1% in 1999–2000 to 10.7% in 2013–2014 (). A similar decline was seen among those over 65 years, from 29.6% to 29.4% (). The greatest reduction in the period was among American Indians and Alaskan Natives, from 14.7% to 10.8% (). Heart disease prevalence was higher for those under 100% and between 100% and 199% of poverty, 13.7% and 11.9%, respectively, compared to those over 400% of poverty (9.3%), and higher in rural (12.4%) than in urban areas (10.3%) ().
The prevalence of stroke increased slightly in adults, from 2.2% in 1999–2000 to 2.5% in 2013–2014, and in persons over 65 years, from 8.1% to 7.9% (). Hispanics saw the greatest increase in the prevalence of stroke over this period, rising from 1.9% to 2.5%, higher than among non-Hispanic whites (2.3%) but lower than non-Hispanic blacks (3.8%) (). The prevalence of stroke was higher for those below 100% and between 100% and 199% of poverty, compared to those over 400% of poverty; it also was higher for those living in rural areas (3.1%) than those living in urban areas (2.3%) ().
Cancer prevalence in U.S. adults rose slightly from 5.1% in 1999–2000 to 5.9% in 2013–14, but rose significantly in the elderly, from 15.2% in 1999–2000 to 18.2% in 2013–2014 (). All races and ethnic groups saw increases in the prevalence of the disease over the period (). Non-Hispanic whites had the highest prevalence of cancer, at 6.5% compared to 4.6% in non-Hispanic blacks and 4.0% among Hispanics (). The prevalence of cancer was lower for those with incomes below 100% and between 100% and 199% of the federal poverty level, compared to those with incomes over 400% of the federal poverty level, and higher for those living in rural (6.4%) than those living in urban areas (5.8%) ().
From 1980 to 2012, the number of adults with diagnosed diabetes in the United States nearly quadrupled, from 5.5 million to 21.3 million (), a rise that is attributable to the increase in cumulative prevalence due to improvement in self-management and health care interventions (). It is estimated that more than a third of adults in the United States have prediabetes, which can increase the risk of type 2 diabetes, heart disease, and stroke (). By 2050, as many as one in three adults could have diabetes (). In 2010–2012, the percentage of adults with diabetes was highest among American Indians and Alaskan Natives (15.9%), non-Hispanic blacks (13.2%), and Hispanics (12.8%), compared to non-Hispanic whites (7.6%) and Asians (7.6%) (). While the percentage of adults with diabetes has risen across the United States, the South and Appalachia region, the central Midwest, and the Southwest had higher rates (9.2%-15.2%) ().
Chronic bronchitis and emphysema are two major diseases that make up chronic, lower respiratory disease (CLRD). Asthma, while not a major contributor to mortality (there were only 3,651 asthma deaths in 2014) is a major factor for morbidity. In 2014, the estimated number of adults who currently have asthma is 17.7 million or 7.4% of the adult population and 8.6% of the children (6.3 million) have asthma (). In 2014, 8.7 million adults (3.6%) were diagnosed with chronic bronchitis and 3.4 million (1.4%) adults were diagnosed with emphysema (). CLRD is the third leading cause of death in the United States, and the age-adjusted death rates for this disease have risen over 43%, from 28.3 deaths to 40.5 deaths per 100,000 population (). Smoking is the major contributing factor to CLRD, but exposure to environmental particulates is also a contributing factor in many groups.
In 2014, an estimated 9.8 million adults (4.1%) in the United States had a serious mental illness (SMI), a figure similar to that in 2010 (). SMI was higher among females (5.0%) than males (3.1%) and higher for non-Hispanic whites (4.4%) than non-Hispanic blacks (3.1%), Asians (2.4%), or Hispanics (3.5%) () SMI prevalence was lower for adults aged 65 or older (1.5%) than for those aged 18-25 (4.8%), 26-44 (5.1%), and 45-64 (4.2%); higher for those without health insurance (5.2%); those in poverty (7.0%); and rural residents (4.8%) (). About 6.7 million adults with SMI (68.5%) received mental health treatment/counseling in the year prior to the study, a figure that was not much different from that of 2010 (). Males (37.9%) were less likely than females (27.9%) to seek treatment, while those in older ages groups were more likely to do so than younger ones (). In addition, those without health insurance (52.7%) were significantly less likely to receive mental health treatment/counseling than were those with insurance (27.5%) ().
An estimated 2.8 million adolescents (11.4%) had at least one major depressive episode (MDE) in the year prior to being surveyed (). The prevalence of MDE was threefold for females (17.3%) than males (5.7%) and higher for non-Hispanic-white and Hispanic adolescents than for non-Hispanic-black adolescents (). An estimated 1.1 million adolescents (41.2%) with MDE received treatment, a higher figure than in 2012 (37.0%) (). More white adolescents (46.1%) received treatment for their depression than did Hispanic adolescents (33.1%) (). There was no significant difference between male and female adolescents with MDE in terms of who received of treatment ().
Recent important health reforms—such as the expansion of Medicaid coverage and the protection of those with preexisting conditions—have clearly helped to improve many key aspects of health care. That said, unsolved issues such as the rising cost of insurance premiums and the attrition of insurance providers from local markets in many states threaten adequate insurance coverage for the population. Further, while efforts to lessen the demand for and utilization of health care services as a way to control costs have been effective, the rise in drug costs and other health care expenditures are likely to remain in the nation’s agenda. As of this writing, the final disposition of the Patient Protection and Affordable Care Act is uncertain after two Congressional attempts to revamp the legislation. Clearly, the nation’s citizens and government will continue to work towards a final solution that will benefit all.
The poor state of the nation’s physical infrastructure, such as transport, water supply, and treatment, and the cleanup of hazardous and toxic waste sites will be costly to repair and maintain. The drought in California, hurricanes Katrina and Sandy, and the Flint water crisis highlight the potential effects that natural disasters/phenomena and man-made crises can have on the health and well-being of a nation when the physical and infrastructure is not repaired. The decline in Americans’ attitudes toward the benefits of vaccines and the increased skepticism toward science, benefits of public expenditures on health, and medicine will have deleterious effects on promoting health and social supports for vulnerable and aging populations.
The rise in opioid-related deaths and maternal mortality; the constant threat of emerging diseases such as Zika and chikungunya, and the growth in excess deaths, the higher mortality rates of middle-aged whites, and deteriorating gap in well-being and health outcomes between rural and urban residents require the political and social will to strengthen the health care delivery system; to expand and increase the integration of primary, specialty, and substance abuse services; and to develop innovative, and locally based initiatives and services that address those issues that affect rural and urban areas, and specific regions.
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14. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 27: Death rates for drug poisoning and drug poisoning involving opioid analgesics and heroin, by sex, age, race, and Hispanic origin, selected years 1999–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
15. National Center for Health Statistics (United States). Firearm mortality by state: 2015. Hyattsville, MD: NCHS; 2017. Available from: https://www.cdc.gov/nchs/pressroom/sosmap/firearm_mortality/firearm.html.
16. National Institute of Mental Health (United States). Post-traumatic stress disorder among adults [Internet]. Bethesda, MD: NIMH; 2016. Available from: https://www.nimh.nih.gov/health/statistics/prevalence/post-traumatic-stress-disorder-among-adults.shtml.
17. Centers for Disease Control and Prevention (United States). Chronic disease prevention and health promotion: chronic diseases—the leading causes of death and disability in the United States [Internet]. Atlanta: CDC; 2017. Available from: https://www.cdc.gov/chronicdisease/overview/.
18. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 39: Number of respondent-reported chronic conditions from 10 selected conditions among adults aged 18 and over, by selected characteristics, selected years 2002–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
19. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 53: Selected health conditions and risk factors, by age, selected years 1988–1994 through 2013–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
20. Shan M, Jump Z, Lancet E. Urban and rural disparities in tobacco use [conference presentation]. National Conference on Health Statistics, 8 August 2012. Hyattsville, MD: National Center for Health Statistics; 2012. Available from: https://www.cdc.gov/nchs/ppt/nchs2012/ss-33_lancet.pdf.
21. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 57: Participation in leisure-time aerobic and muscle-strengthening activities that meet the federal 2008 Physical Activity Guidelines for Americans among adults aged 18 and over, by selected characteristics, selected years 1998–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
22. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 84: Doctors of medicine, by place of medical education and activity: United States and outlying U.S. areas, selected years 1975–2013. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
23. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 85: Doctors of medicine, by place of medical education and activity: United States and outlying U.S. areas, selected years 1975–2013. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
24. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 83: Active physicians and physicians in patient care, by state, selected years 1975–2013. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
25. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 86: Active dentists, by state: selected years 2001–2013. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
26. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 87: Healthcare employment and wages, by selected occupations: selected years 2000–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
27. Jamoom EW, Yang N. State variation in electronic sharing of information in physician offices: United States, 2015. NCHS Data Brief 2016;(261):1–8. Available from: https://www.cdc.gov/nchs/products/databriefs/db261.htm.
28. Jamoom EW, Hing E. Progress with electronic health record adoption among emergency and outpatient departments: United States, 2006–2011. NCHS Data Brief 2015;(187):1–8. Available from: https://www.cdc.gov/nchs/data/databriefs/db187.htm.
29. Hsiao CJ, Hing E. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001–2013. NCHS Data Brief 2014;(143):1–8. Available from: https://www.cdc.gov/nchs/data/databriefs/db143.htm.
30. Centers for Disease Control and Prevention, National Center for Environmental Health (United States). CDC features: drought and your health [with infographic “Drought and Public Health in the U.S.”] [Internet]. Atlanta: CDC/NCEH; 2017. Available from: https://www.cdc.gov/features/drought/index.html.
31. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 15: Life expectancy at birth, at age 65, and at age 75, by sex, race, and Hispanic origin, selected years 1900–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
32. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proceedings for the National Academy of Sciences 2015;112(49):15078–15083. doi: 10.1073/pnas.1518393112.
33. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 20: Leading causes of death and numbers of deaths, by age: 1980 and 2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
34. Organisation for Economic Co-operation and Development. Coverage for health care. In: Society at a glance 2014: OECD social indicators. Paris: OECD; 2014. Available from: http://dx.doi.org/10.1787/soc_glance-2014-26-en.
35. Henry J. Kaiser Family Foundation. Key facts about the uninsured population [Internet]. Menlo Park, CA: KFF; 2016. Available from: http://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/.
36. Martinez M, Zammitti EP, Cohen RA. Health insurance coverage: early release of estimates from the National Health Interview Survey, January–September 2016. Hyattsville, MD: National Center for Health Statistics; 2017. Available from: https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201702.pdf.
37. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 94: National health expenditures, average annual percent change, and percent distribution, by type of expenditure, selected years 1960–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
38. Martin AB, Hartman M, Washington B, Catlin A; National Health Expenditure Accounts Team. National health spending: faster growth in 2015 as coverage expands and utilization increases. Health Affairs 2017;36(1):166–176. doi: 10.1377/hlthaff.2016.1330.
39. Centers for Medicare & Medicaid Services (United States). National health expenditure data: NHE fact sheet 2015 (historical NHE, 2015) [Internet]. Baltimore, MD: CMS; 2017. Available from: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html.
40. National Center for Health Statistics (United States). “Health, United States” Spotlight: health care expenditures & payers. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus_spotlight_sept16.pdf.
41. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 73: Emergency department visits within the past 12 months among children under age 18, by selected characteristics, selected years 1997–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
42. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 74: Emergency department visits within the past 12 months among adults aged 18 and over, by selected characteristics, selected years 1997–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
43. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 81: Persons with hospital stays in the past year, by selected characteristics, selected years 1997–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
44. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 65: Health care visits to doctor offices, emergency departments, and home visits within the past 12 months, by selected characteristics, selected years 1997–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
45. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Mathews TJ. Births: final data for 2015. National Vital Statistics Reports 2017;66(1):1. Available from: https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_01.pdf.
46. Hamilton BE, Martin JA, Osterman MJK, Curtin SC. Births: preliminary data for 2014. National Vital Statistics Reports 2015;64(6):1–19. Available from: https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_06.pdf.
47. Hamilton BE, Kirmeyer SE. Trends and variations in reproduction and intrinsic rates: United States, 1990–2014. National Vital Statistics Reports 2017;66(2):1–14. Available from: https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_02.pdf.
48. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion (United States). Pregnancy Mortality Surveillance System: trends in pregnancy-related deaths [Internet]. Atlanta: CDC/NCCDPH; 2017. Available from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html.
49. Save the Children. State of the World’s Mothers Report 2015: the urban disadvantage. Fairfield, CT: SCF; 2015. Available from: https://selectra.co.uk/sites/default/files/pdf/SOWM_EXECUTIVE%20SUMMARY.PDF.
50. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 10: Infant, neonatal, postneonatal, fetal, and perinatal mortality rates, by detailed race and Hispanic origin of mother, selected years 1983–2013. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
51. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 11: Infant mortality rates, by race: selected years 1950–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
52. Bloom B, Jones LI, Freeman G. Summary health statistics tables for U.S. children: National Health Interview Survey, 2012. Vital and Health Statistics 10 2013;(258):1–81. Available from: https://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf.
53. Centers for Disease Control and Prevention (United States). Diabetes Report Card 2014. Atlanta: CDC; 2015. Available from: https://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014.pdf.
54. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 52: Health risk behaviors among students in
grades 9–12, by sex, grade level, race, and Hispanic origin, selected years 1991–2013. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
55. Substance Abuse and Mental Health Services Administration (United States). Behavioral Health Barometer: United States, 2015. Rockville, MD: SAMHSA; 2015. (HHS publication no. SMA-16-Baro-2015). Available from: https://www.samhsa.gov/data/sites/default/files/2015_National_Barometer.pdf.
56. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 18: Years of potential life lost before age 75 for selected causes of death, by sex, race, and Hispanic origin, selected years 1980–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
57. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 17: Age-adjusted death rates for selected causes of death, by sex, race, and Hispanic origin: United States, selected years 1950–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
58. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 19: Leading causes of death and numbers of deaths, by sex, race, and Hispanic origin, 1980 and 2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
59. Kochanek KD, Murphy SL, Xu J, Tejada-Vera B. Deaths: final data for 2014. National Vital Statistics Reports 2016;65(4):1–122. Available from: https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf.
60. Zika erratum: Vol. 65, No. 52. MMWR Morbidity Mortality Weekly Report 2017;66(02):64. doi: http://dx.doi.org/10.15585/mmwr.mm6602a10.
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62. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 69: Pneumococcal vaccination among adults aged 18 and over, by selected characteristics: United States, selected years 1989–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
63. National Center for Health Statistics (United States). Health, United States, 2015, with special feature on racial and ethnic health disparities. Table 38, Respondent-reported prevalence of heart disease, cancer, and stroke among adults aged 18 and over, by selected characteristics: United States, average annual, selected years 1997–1998 through 2013–2014. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/data/hus/hus15.pdf.
64. National Center for Health Statistics (United States). FastStats. Diseases and conditions—respiratory and allergies, asthma [Internet]. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/fastats/asthma.htm.
65. National Center for Health Statistics (United States). FastStats. Diseases and conditions—chronic obstructive pulmonary disease (COPD) [Internet]. Hyattsville, MD: NCHS; 2016. Available from: https://www.cdc.gov/nchs/fastats/copd.htm.
66. Claxton G, Cox C, Damico A, Levitt L, Pollitz K. Issue Brief: pre-existing conditions and medical underwriting in the individual insurance market prior to the ACA [Internet]. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2016. Available from: http://www.kff.org/health-reform/issue-brief/pre-existing-conditions-and-medical-underwriting-in-the-individual-insurance-market-prior-to-the-aca/.
1. Chronic conditions include one or more of the following: hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, chronic obstructive pulmonary disease, and asthma.
2. “Below 100% of poverty” means under the federal poverty level (FPL) defined by the U.S. government. In 2015, the FPL was $11,770 for an individual and $24,250 for a family of 4. A person or family “below 100% of poverty” is extremely poor by U.S. standards.
3. In 2015, being “above 400% of poverty” means a salary of $47,080 for an individual (400% above the FPL of $11,770) and a salary of $97,000 for a family of four (400% above the FPL of $24,250).
4. According to the Centers for Disease Control and Prevention, overweight is defined as a body mass index (BMI) of 25.0 to 29.9 and obese is defined as having a BMI of 30 or higher.
5. A basic EHR system consists of electronic clinical information (such as patient demographics, problem lists, medication lists, and discharge summaries), computerized provider order entry for medications, and a results management capability to review lab, radiology, and diagnostic test results.
6. Replacement is the level at which a population exactly replaces itself from one generation to the next; 2,100 births per 1,000 women is considered replacement level ().
7. A pregnancy-related death is defined as the death of a woman while pregnant or within one year of pregnancy termination—regardless of the duration or site of the pregnancy—from any cause related to the pregnancy or its management (does not include accidental/incidental causes such as injury) (). Maternal mortality is defined just for maternal deaths within 42 days of pregnancy termination.
8. Accidental poisoning includes drug overdoses/poisoning.
9. Below 100% of poverty is a guide to a family’s income that falls under the threshold of poverty. In 2015, the poverty level for 1 person is $11,770 and for a family of 4 it is $24,250. A person or family below 100% of poverty of $11,770 and $24,250, respectively are extremely poor by US standards. In 2015, a person 100-199% of poverty has an income between $11,770 and $23,540 and a family of four between $24,250 and $48,500.
10. Serious mental illness is defined as having a diagnosable mental health, behavioral, or emotional disorder, other than a substance use disorder, that meets DSM-IV criteria and resulted in serious functional impairment.
11. Serious mental illness is defined as having a diagnosable mental health, behavioral, or emotional disorder, other than a substance use disorder, that meets DSM-IV criteria and resulted in serious functional impairment.