HEALTH, UNITED STATES, 2011 WITH SPECIAL FEATURE ON SOCIOECONOMIC STATUS AND HEALTH pptx

Prevalence of cigarette smoking Table 63, selected disability and health status measures Tables 57 and 58, and selected access to medical care measures Table 80 by urbanization level, ba

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U.S Government Printing Office

Washington, DC 20402

U.S Department of Health and Human Services

Health, United States, 2011 is the 35th report on the

health status of the Nation and is submitted by the

Secretary of the Department of Health and Human

Services to the President and the Congress of the

United States in compliance with Section 308 of the

Public Health Service Act This report was compiled

by the Centers for Disease Control and Prevention’s

(CDC) National Center for Health Statistics (NCHS)

The National Committee on Vital and Health Statistics

served in a review capacity

The Health, United States series presents an annual

look at national trends in health statistics The report

contains a Chartbook that assesses the Nation’s

health by presenting trends and current information

on selected measures of morbidity, mortality, health

care utilization, health risk factors, prevention, health

insurance, and personal health care expenditures

This year’s Chartbook includes a Special Feature on

Socioeconomic Status and Health The report also

contains 151 Trend Tables organized around four

major subject areas: health status and determinants,

health care utilization, health care resources, and

health care expenditures A companion product to

Health, United States—Health, United States: In

Brief—features information extracted from the full

report The complete report, In Brief, and related data

products are available on the Health, United States

website at: http://www.cdc.gov/nchs/hus.htm

The 2011 Edition

Health, United States, 2011 includes a summary

‘‘At a Glance’’ table that displays selected indicators of

health and their determinants, cross-referenced to

charts and tables in the report It also contains a

Highlights section, a Chartbook, detailed Trend

Tables, extensive Appendixes, and an Index Major

sections of the 2011 report are described below

Chartbook

The 2011 Chartbook contains 41 charts, including 20

(Figures 22–41) on this year’s Special Feature on

Socioeconomic Status and Health (SES) This feature

includes charts on the relationship between SES and

health by using a four-category education variable

and a four-category relative family income variable as

SES measures Charts on trends in poverty and

differences in relative family income by race and

Hispanic origin for children and adults are presented

to provide context for the other charts This feature explores the SES gradient in health measures for both children and adults and how that gradient differs across racial and ethnic groups When possible, trend data are presented to examine changes in SES disparities over time Charts present information on associations between SES and morbidity and mortality, prevention and risk factors, and access to care and health insurance

Trend Tables The Chartbook is followed by 151 Trend Tables organized around four major subject areas: health status and determinants, health care utilization, health care resources, and health care expenditures The tables present data for selected years, to highlight major trends in health statistics Additional years of data may be available in Excel spreadsheet

files on the Health, United States website Trend Tables

for which additional data years are available are listed

in Appendix III Comparability across years in Health,

United States is fostered by including similar Trend

Tables in each volume, and timeliness is maintained

by improving the content of ongoing tables and adding new tables each year to reflect emerging topics in public health A key criterion used in selecting these tables is the availability of comparable national data over a period of several years

Health, United States, 2011 includes eight new Trend

Tables on the following subjects:

Drug poisoning death rates (Table 36), based on data from the National Vital Statistics System

Prevalence of health-related behaviors for children 6–11 years of age (Table 66), based on data from the National Survey of Children’s Health Prevalence of cigarette smoking (Table 63), selected disability and health status measures (Tables 57 and 58), and selected access to medical care measures (Table 80) by urbanization level, based

on data from the National Health Interview Survey and the 2006 NCHS Urban–Rural Classification Scheme for Counties

Utilization of colorectal tests and procedures (Table 92), based on data from the National Health Interview Survey

Cost of hospital discharges with common

hospital operating room procedures (Table 132),

based on data from the Healthcare Cost and

Utilization Project

Appendixes

Appendix I Data Sources describes each data

source used in Health, United States, 2011 and

provides references for further information about the

sources Data sources are listed alphabetically within

two broad categories: Government Sources, and

Private and Global Sources

Appendix II Definitions and Methods is an

alphabetical listing of terms used in the report It also

contains information on the methods used in the

report

Appendix III Additional Data Years Available lists

tables for which additional years of trend data are

available in Excel spreadsheet files on the Health,

United States website

Index

The Index to the Trend Tables and figures is a useful

tool for locating data by topic Tables and figures are

cross-referenced by such topics as child and

adolescent health; older population 65 years of age

and over; women’s health; men’s health; state data;

American Indian and Alaska Native, Asian, black or

African American, and Hispanic-origin populations;

education; injury; disability; and metropolitan and

nonmetropolitan data Many of the Index topics are

also available as conveniently grouped data

packages on the Health, United States website

Data Considerations

Racial and Ethnic Data

Many tables in Health, United States present data

according to race and Hispanic origin, consistent

with a Department-wide emphasis on expanding

racial and ethnic detail when presenting health data

Trend data on race and ethnicity are presented in the

greatest detail possible after taking into account the

quality of the data, the amount of missing data, and

the number of observations These issues

significantly affect the availability of reportable data

and ethnicity are described in an appendix (See Appendix II, Race.)

Education and Income Data

Many tables in Health, United States present data

according to SES, using education and family income

as proxy measures Education and income data are generally obtained directly from survey respondents and are not usually available from records-based data collection systems Categories shown for income

data were expanded in Health, United States, 2010

State vital statistics systems currently report mother’s education on the birth certificate and (based on an informant) decedent’s education on the death certificate (See Appendix II, Education; Family income; Poverty.)

Disability Data Disability can include the presence of physical or mental impairments that limit a person’s ability to perform an important activity and affect the use of or need for supports, accommodations, or interventions

to improve functioning Information on disability in the U.S population is critical to health planning and policy Several initiatives are currently under way to coordinate and standardize the measurement of

disability across federal data systems Health, United States, 2009 introduced the first detailed Trend Table

using data from the National Health Interview Survey

to create disability measures consistent with two of the conceptual components that have been identified in disability models and legislation: basic actions difficulty and complex activity limitation Basic actions difficulty captures limitations or difficulties in movement and sensory, emotional, or mental functioning that are associated with a health problem Complex activity limitation describes limitations or restrictions in a person’s ability to participate fully in social role activities such as

working or maintaining a household Health, United States, 2010 expanded the use of these measures to

many of the tables from the National Health Interview Survey and this year’s report added two tables on disability measure by urbanization level (Tables 57 and 58) Health, United States also includes

the following disability-related information for the civilian noninstitutionalized population: vision and hearing limitations for adults (Table 55) and disability-related information for Medicare enrollees (Table 145), Medicaid recipients (Table 146), and

Hyattsville, MD: NCHS 2008 Available from:

http://www.cdc.gov/nchs/data/misc/disability2001­

2005.pdf

Statistical Significance

All differences between estimates noted in the

Highlights section of Health, United States were

determined to be statistically significant at the 0.05

level using two-sided significance tests (z tests) In

the Chartbook, weighted least squares regression

was performed to test for the presence of a

statistically significant increase or decrease in the

estimates during the time period (see Technical

Notes accompanying the Chartbook) Terms such as

‘‘similar,’’‘‘stable,’’ and ‘‘no difference’’ indicate that the

statistics being compared were not significantly

different Lack of comment regarding the difference

between statistics does not necessarily suggest that

the difference was tested and found to be not

significant Because statistically significant

differences or trends are partly a function of sample

size (the larger the sample size, the smaller the

change that can be detected), statistically significant

differences or trends do not necessarily have public

health significance (1)

Overall estimates generally have relatively small

standard errors, but estimates for certain population

subgroups may be based on small numbers and have

relatively large standard errors Although numbers of

births and deaths from the Vital Statistics System

represent complete counts (except for births in those

states where data are based on a 50% sample for

selected years) and are not subject to sampling error,

the counts are subject to random variation, which

means that the number of events that actually occur

in a given year may be considered as one of a large

series of possible results that could have arisen under

the same circumstances When the number of events

is small and the probability of such an event is small,

considerable caution must be observed in

interpreting the conditions described by the figures

Estimates that are unreliable because of large

standard errors or small numbers of events have

been noted with an asterisk The criteria used to

designate or suppress unreliable estimates are

indicated in the table footnotes

For NCHS surveys, point estimates and their

corresponding variances were calculated using the

SUDAAN software packag e (2), which takes into

consideration the comple x surv ey design Standard

errors for other surveys or data sets were computed

using the methodology recommended by the

programs providing the data or were provided

directly by those programs Standard errors are

available for selected tables in the Excel spreadsheet

version on the Health, United States website at:

http://www.cdc.gov/nchs/hus.htm

Access to Health, United States Health, United States can be accessed in its entirety at:

http://www.cdc.gov/nchs/hus.htm The website is a

user-friendly resource for Health, United States and

related products In addition to the full report, it

contains the In Brief companion report and data

conveniently grouped by topic The Chartbook figures are provided as PowerPoint slides, and the Trend Tables and Chartbook data tables as Excel spreadsheet files and individual PDFs Many Excel spreadsheet files include additional years of data not shown in the printed report, along with standard errors where available Spreadsheet files for selected tables will be updated on the website as available

Visitors to the website can join the Health, United States electronic mailing list to receive announce­

ments about release dates and notices of updates to

tables Previous editions of Health, United States, and

their Chartbooks, can also be accessed from the website

Printed copies of Health, United States can be

purchased from the Government Printing Office at: http://bookstore.gpo.gov

Questions?

If you have questions about Health, United States or

related data products, please contact:

Office of Information Services Information Dissemination Staff National Center for Health Statistics Centers for Disease Control and Prevention

3311 Toledo Road, Fifth Floor Hyattsville, MD 20782 Phone: 1–800–232–4636 E-mail: nchsquery@cdc.gov Internet: http://www.cdc.gov/nchs/

References

1 CDC Youth Risk Behavior Survey (YRBS): Interpretation of YRBS trend data 2010 Available from: http://www.cdc.gov/ HealthyYouth/yrbs/pdf/YRBS_trend_interpretation.pdf

2 SUDAAN, release 10.0.1 [computer software] Research Triangle Park, NC: RTI International 2009

Overall responsibility for planning and coordinating

the content of this volume rested with the National

Center for Health Statistics’ (NCHS) Office of Analysis

and Epidemiology, under the direction of Amy B

Bernstein, Diane M Makuc, and Linda T Bilheimer

Production of Health, United States, 2011, including

highlights, trend tables, and appendixes, was

managed by Amy B Bernstein, Sheila J Franco, and

Virginia M Freid Trend tables were prepared by Mary

Ann Bush, Jeanetta E Churchill, La-Tonya D Curl,

Anne K Driscoll, Catherine R Duran, Sheila J Franco,

Virginia M Freid, Tamyra C Garcia, Nancy Han, Ji-Eun

Kim, Rebecca A Placek, and Henry Xia, with

assistance from Anita L Powell and Ilene B Rosen

Appendix II tables and the index were assembled by

Anita L Powell Production planning and

coordination of trend tables were managed by

Rebecca A Placek Review and clearance books were

assembled by Ilene B Rosen Administrative and

word processing assistance was provided by Lillie C

Featherstone and Danielle Wood

Production of the Chartbook was managed by

Virginia M Freid and Sheila J Franco Data and

analysis for specific charts were provided by Amy B

Bernstein, Anne K Driscoll, Sheila J Franco,

Virginia M Freid, Tamyra C Garcia, Ji-Eun Kim,

Kimberly Lochner, and Elsie Pamuk Charts were

drafted by La-Tonya D Curl, and data tables were

prepared by Rebecca A Placek Technical assistance

and programming were provided by Mary Ann Bush,

La-Tonya D Curl, Catherine R Duran, Nancy Han,

Xiang Liu, and Henry Xia

Publication production was performed by

CDC/OSELS/NCHS/OD/Office of Information

Services, Information Design and Publishing Staff

Project management and editorial review were

provided by Barbara J Wassell The designer was

Sarah M Hinkle The cover was designed by Megan

Griner Layout and production were done by Zung T

Le and Jacqueline M Davis Design and production

for Health, United States, 2011: In Brief were provided

by Kyung M Park Oversight review for publications

and electronic products was provided by Christine J

Brown, Tommy C Seibert, Jr., and Tammy

Stewart-Prather Printing was managed by Patricia L Wilson,

CDC/OCOO/MASO

Anita L Powell, Sharon L Ramirez, Ilene B Rosen, and Barbara J Wassell

Data and technical assistance were provided by

staff of the following NCHS organizations: Division of Health Care Statistics: Vladislav Beresovsky, Frederic H

Decker, Carol J DeFrances, Lisa L Dwyer, Marni J Hall, Lauren Harris-Kojetin, Maria F Owings, and Susan M

Schappert; Division of Health and Nutrition Examination Surveys: Debra J Brody, Margaret D

Carroll, Bruce A Dye, Mark Eberhardt, Jaime J Gahche, Quiping Gu, Xianfen Li, Cynthia L Ogden, Ryne Paulose, Sung Sug (Sarah) Yoon, and Chia-Yih

Wang; Division of Health Interview Statistics: Patricia F

Adams, Veronica E Benson, Barbara Bloom, Robin A Cohen, Susan S Jack, Whitney Kirzinger, Jacqueline Lucas, Michael Martinez, Kathleen S O’Connor, Jennifer Peregoy, Jeannine Schiller, Charlotte A

Schoenborn, and Brian W Ward; Division of Vital Statistics: Joyce C Abma, Robert N Anderson,

Elizabeth Arias, Anjani Chandra, Brady Hamilton, Donna L Hoyert, Kenneth D Kochanek, Marian MacDorman, Joyce A Martin, T J Mathews, Ari Minin˜o, Sherry L Murphy, Michelle Osterman, and

Stephanie J Ventura; Office of Analysis and Epidemiology: Lara Akinbami, Li-Hui Chen,

Deborah D Ingram, Susan Lukacs, Patricia Pastor, Laura A Pratt, Kenneth Schoendorf, Cynthia A Reuben, Cheryl V Rose, Rashmi Tandon, Margaret

Warner, and Julie Dawson Weeks; Office of the Center Director: Juan Albertorio and Francis C Notzon; and Office of Research and Methodology: Meena Khare

Additional data and technical assistance were provided by the following organizations of the Centers for Disease Control and Prevention (CDC):

Epidemiology Program Office: Samuel L Groseclose and Michael Wodajo; National Center for Chronic Disease Prevention and Health Promotion: Sonya Gamble, Steve Kinchen, and Karen Pazol; National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention: Stacy Cohen, Irene Hall, Alexis Kaigler, Rachel S Wynn, and Jill Wasserman; National Center for Immunization and Respiratory Diseases: Christina Dorell and James A Singleton; National Institute for Occupational Safety and Health: John Myers, Kara

Perritt, Roger Rosa, and John Sestito; by the following organizations within the Department of Health and

Human Services: Agency for Healthcare Research

Micah Hartman, Stephanie L Hunt, Christopher

Kessler, Deborah W Kidd, Barbara S Klees, John

Klemm, Kimberly Lochner, Maggie S Murgolo,

Jason G Petroski, Joseph F Regan, Thomas W Reilly,

Loan Swisher, John A Wandishin, Benjamin E

Washington, Lekha Whittle, and Lirong Zhao;

National Institutes of Health: Nancy Breen, Kathy

Cronin, Brenda Edwards, Paul W Eggars, and

Marsha Lopez; Substance Abuse and Mental Health

Services Administration: Jeffrey Buck, James Colliver,

Joe Gfroerer, Beth Han, Laura Milazzo-Sayre, and

Rita Vandivort-Warren; and by the following

governmental and nongovernmental organizations:

U.S Census Bureau: Bernadette D Proctor; Bureau of

Labor Statistics: Daniel Ginsburg, Jeffrey Schildkraut,

Stephen Pegula, Elizabeth Rogers, and Audrey

Watson; Department of Veterans Affairs: Pheakdey Lim

and Dat Tran; American Association of Colleges of Pharmacy: Jennifer M Patton, Danielle Taylor, and Maureen Thielemans; American Association of Colleges of Osteopathic Medicine: Wendy Fernando and Tom Levitan; American Association of Colleges of Podiatric Medicine: Moraith G North; American Osteopathic Association: Margaret Harrison; American Dental Education Association: Jon D Ruesch;

Association of American Medical Colleges: Franc Slapar and Amber Sterling; Association of Schools and Colleges of Optometry: Paige Pence and Joanne Zuckerman; Association of Schools of Public Health: Kristin Dolinski; Cowles Research Group: C McKeen Cowles; NOVA Research Company: Shilpa Bengeri; and Thomson Reuters: Rosanna Coffey and

All those associated with Health, United States would like to give special thanks to Dr Diane Makuc

and Ms Rebecca Placek, who recently retired from the National Center for Health Statistics

Dr Makuc contributed to Health, United States for more than 30 years, providing direction and

insightful guidance for the report Her strong grasp of public health issues, knowledge of NCHS

data systems, and expertise in statistical methodology were key to ensuring the high quality and

continued relevance of this annual report to Congress on the health of the Nation

For 32 years, Ms Placek was the anchor of the Health, United States production team—keeping this

large and complex project well organized and of the highest quality She managed the entire trend table production process with a wonderful combination of meticulousness and good spirits, and

was instrumental in designing systems to track the overall production status of the report

The Health, United States team is truly grateful to both Diane and Becky for their vital and tireless

contributions to the report over their many years of association We miss them dearly and wish

them the very best in their retirement!

Preface

Acknowledgments

At a Glance Table and Highlights At a Glance Table

Highlights

Health

Life Expectancy and Mortality

Fertility and Natality

Health Risk Factors

Measures of Health and Disease Prevalence

Health Care Utilization

and Access to Care

Drugs, and Dental Care Due to Cost

Health Care Resources

Health Care Expenditures and Payers

Health Insurance Coverage

Chartbook With Special Feature on Socioeconomic Status and Health Mortality

Life Expectancy at Birth

Infant Mortality

Selected Causes of Death

Motor Vehicle-related Death Rates

Natality

Teenage Birth Rates

Morbidity

Heart Disease Prevalence

Disability Measures

Limitation

Health Risk Factors

Current Cigarette Smoking

Uncontrolled High Blood Pressure

Obesity Among Children

Overweight and Obesity Among Adults

Prevention

Influenza and Pneumococcal Vaccination

Mammography Use

Health Insurance

Coverage Among Children

of Age

Utilization and Access

Prescription Drug Use

Emergency Department Visits

or Prescription Drugs due to Cost

Health Care Resources

Patient Care Physicians per Population

Personal Health Care Expenditures

Source of Funds

Type of Expenditure

Health

Introduction

Children Background

Child Poverty

Morbidity

Current Asthma Among Children

Among Children

Health Risk Factors

Child Obesity

Children’s Screen Time

Prevention

More

Adolescent Vaccinations

Health Insurance

Uninsured Children

Utilization and Access

Dental Visits Among Children

Adults

Background

Adult Poverty

Mortality

Life Expectancy at Age 25

Morbidity

Depression

Edentulism (Lack of Natural Teeth)

Conditions

Disability Measures

Activity Limitation

Health Risk Factors

Adult Obesity

Current Cigarette Smoking

Prevention

Colorectal Tests or Procedures

Health Insurance

Uninsured Adults

Access to Care

the Past 12 Months Due to Cost

Technical Notes

Data Tables for Special Feature: Figures 22–41

Trend Tables Health Status and Determinants

Population

Fertility and Natality

Mortality

Determinants and Measures of Health

Utilization of Health Resources

Ambulatory Care

Inpatient Care

Health Care Resources

Personnel

Facilities

Health Care Expenditures and Payers

National Health Expenditures

Programs

Appendixes Appendix Contents

Appendix I Data Sources

Appendix II Definitions and Methods

Appendix III Additional Data Years Available

Index Index

List of Chartbook Figures

Mortality

Figure 1 Life expectancy at birth, by race and sex

and Hispanic origin: United States, 1980–2008 10

Figure 2 Infant, neonatal, and postneonatal

mortality rates: United States, 1998–2008 10

Figure 3 Death rates for selected causes of death

for all ages, by sex: United States, 1998–2008 11

Figure 4 Motor vehicle-related death rates

among persons 15–24 years of age, by sex and age:

United States, 1998–2008 11

Natality

Figure 5 Teenage childbearing, by maternal

age and race and Hispanic origin: United States,

1998–2008 12

Morbidity

Figure 6 Respondent-reported lifetime heart

disease prevalence among adults 18 years of age

and over, by sex and age: United States, 1999–2000

through 2009–2010 12

Disability Measures

Figure 7 Basic actions difficulty or complex activity

limitation among adults 18 years of age and over,

by sex and age: United States, 2000–2010 13

Health Risk Factors

Figure 12 Influenza and pneumococcal

vaccination among adults, by type of vaccination

and age: United States, 2000–2010 15

Figure 13 Mammography use in the past 2 years

among women 40 years of age and over, by age:

United States, 2000–2010 16

Health Insurance Figure 14 Health insurance coverage among

children under 18 years of age, by type of coverage: United States, 2000–2010 16

Figure 15 Health insurance coverage among

adults 18–64 years of age, by age and type of coverage: United States, 2000–2010 17

Utilization and Access Figure 16 Use of three or more prescription drugs

in the past 30 days, by sex and age: United States, 1988–1994, 1999–2002, and 2005–2008 17

Figure 17 Any emergency department visit

within the past 12 months, by age and type of coverage: United States, 2000–2010 18

Figure 18 Delay or nonreceipt of needed medical care or prescription drugs in the past 12 months

due to cost among adults 18–64 years of age, by type of coverage: United States, 2000–2010 18

Health Care Resources Figure 19 Patient care physicians per 10,000

population, by state: United States, 2009 Personal Health Care Expenditures 19

Personal Health Care Expenditures Figure 20 Personal health care expenditures, by

source of funds: United States, 1999–2009 19

Figure 21 Personal health care expenditures, by

type of expenditure: United States, 1999–2009 20

Special Feature on Socioeconomic Status and Health

Children

Figure 22 Children under 18 years of age, by

percent of poverty level and race and Hispanic

origin: United States, 1990–2010 27

Figure 23 Current asthma among children under

18 years of age, by race and Hispanic origin and percent of poverty level: United States,

Figure 25 Obesity among children 2–19 years of

age, by sex of child and education level of head

of household: United States, 1988–1994 and 2007–2010 30

Figure 26 Children 6–11 years of age who engaged

in more than 2 hours of screen time daily, by sex

and percent of poverty level: United States, average annual, 2003 and 2007 31

Figure 27 Babies breastfed 3 months or more

among mothers 22–44 years of age, by mother’s

education level: United States, 1992–1994 through

2002–2004 32

Figure 28 Vaccinations among adolescents

13–17 years of age, by type of vaccine and percent

of poverty level: United States, 2009 33

Figure 29 No health insurance coverage among

children under 18 years of age, by percent of poverty

level and race and Hispanic origin: United States,

2000–2010 34

Figure 30 Dental visits in the past year among

children 2–17 years of age, by percent of poverty

level and race and Hispanic origin: United States,

2000–2010 35

Adults

Figure 31 Adults 18 years of age and over, by

percent of poverty level and race and Hispanic

origin: United States, 1990–2010 36

Figure 32 Life expectancy at age 25, by sex

and education level: United States, 1996 and

2006 37

Figure 33 Depression among adults 20 years of

age and over, by age and percent of poverty level:

United States, 2005–2010 38

Figure 34 Edentulism (lack of natural teeth)

among adults 45 years of age and over, by age

and percent of poverty level: United States,

2000–2010 39

Figure 35 Two or more selected chronic health

conditions among adults 45–64 years of age, by

percent of poverty level: United States, 1999–2000

and 2009–2010 40

Figure 36 Basic actions difficulty or complex

activity limitation among adults 18 years of age

and over, by age and percent of poverty level:

United States, 2000–2010 41

Figure 37 Obesity among adults 25 years of age

and over, by sex and education level: United States,

1988–1994 and 2007–2010 42

Figure 38 Current cigarette smoking among

adults 25 years of age and over, by age and

education level: United States, 2000–2010 43

Figure 39 Colorectal tests or procedures among

adults 50–75 years of age, by education level:

United States, 2000–2010 44

Figure 40 No health insurance coverage among

adults 18–64 years of age, by percent of poverty

level and race and Hispanic origin: United States,

2000–2010 45

Figure 41 Delay or nonreceipt of needed medical

Summary List of Trend Tables by Topic

High blood pressure

Overweight and obesity

and more

Ambulatory Care (Tables 77–101)

Visits: health care, dentists, emergency departments

and more

Prevention: mammograms, pap smears, vaccinations

Inpatient Care (Tables 102–108)

Hospital stays and procedures

Nursing homes

and more

Personnel (Tables 109–115)

Physicians Dentists Nurses Health professions school enrollment

and more

Facilities (Tables 116–123)

Hospitals Nursing homes

List of Trend Tables

Health Status and Determinants

Population

Table 1 Resident population, by age, sex, race,

and Hispanic origin: United States, selected

years 1950–2009 71

Table 2 Persons below poverty level, by

selected characteristics, race, and Hispanic origin:

United States, selected years 1973–2009 74

Fertility and Natality

Table 3 Crude birth rates, fertility rates, and birth

rates, by age, race, and Hispanic origin of mother:

United States, selected years 1950–2008 76

Table 4 Live births, by plurality and detailed

race and Hispanic origin of mother: United States,

selected years 1970–2008 79

Table 5 Prenatal care for live births, by detailed

race and Hispanic origin of mother: United States,

selected reporting areas 2007 and 2008 80

Table 6 Teenage childbearing, by age and

detailed race and Hispanic origin of mother:

United States, selected years 1970–2008 81

Table 7 Nonmarital childbearing, by detailed

race and Hispanic origin of mother, and maternal

age: United States, selected years 1970–2008 83

Table 8 Mothers who smoked cigarettes during

pregnancy, by selected characteristics: United States,

selected reporting areas 2007 and 2008 84

Table 9 Low birthweight live births, by detailed

race, Hispanic origin, and smoking status of mother:

United States, selected years 1970–2008 85

Table 10 Low birthweight live births among

mothers 20 years of age and over, by detailed

race, Hispanic origin, and education of mother:

United States, selected reporting areas 2007

and 2008 86

Table 11 Low birthweight live births, by race and

Hispanic origin of mother, and state: United States,

2000–2002, 2003–2005, and 2006–2008 88

Table 12 Legal abortions and legal abortion

ratios, by selected patient characteristics:

United States, selected years 1973–2007 90

Table 13 Contraceptive use in the past month

among women 15–44 years of age, by age, race

and Hispanic origin, and method of contraception:

United States, selected years 1982–2008 92

Table 14 Breastfeeding among mothers 15–44

Table 16 Infant mortality rates, by birthweight:

United States, selected years 1983–2007 99

Table 17 Infant mortality rates, fetal mortality

rates, and perinatal mortality rates, by race:

United States, selected years 1950–2008 100

Table 18 Infant mortality rates, by race and

Hispanic origin of mother, and state: United States, average annual 1989–1991, 2002–2004, and

2005–2007 101

Table 19 Neonatal mortality rates, by race and

Hispanic origin of mother, and state: United States, average annual 1989–1991, 2002–2004, and

2005–2007 103

Table 20 Infant mortality rates and international

rankings: Organisation for Economic Co-operation and Development (OECD) countries, selected

years 1960–2008 105

Table 21 Life expectancy at birth and at 65 years

of age, by sex: Organisation for Economic Co­

operation and Development (OECD) countries,

selected years 1980–2009 106

Table 22 Life expectancy at birth, at 65 years

of age, and at 75 years of age, by sex, race, and Hispanic origin: United States, selected years

1900–2009 108

Table 23 Age-adjusted death rates, by race,

Hispanic origin, and state: United States, average annual 1979–1981, 1989–1991, and

2006–2008 110

Table 24 Age-adjusted death rates for selected

causes of death, by sex, race, and Hispanic origin:

United States, selected years 1950–2008 112

Table 25 Years of potential life lost before age

75 for selected causes of death, by sex, race, and Hispanic origin: United States, selected years

1980–2008 116

Table 26 Leading causes of death and numbers

of deaths, by sex, race, and Hispanic origin:

United States, 1980 and 2008 120

Table 27 Leading causes of death and numbers

of deaths, by age: United States, 1980 and

2008 124

Table 28 Age-adjusted death rates, by race,

sex, region, and urbanization level: United States, average annual, selected years 1996–1998

through 2006–2008 126

Table 29 Death rates for all causes, by sex, race,

Table 30 Death rates for diseases of heart, by sex,

race, Hispanic origin, and age: United States,

selected years 1950–2008 133

Table 31 Death rates for cerebrovascular diseases,

by sex, race, Hispanic origin, and age: United States,

selected years 1950–2008 136

Table 32 Death rates for malignant neoplasms, by

sex, race, Hispanic origin, and age: United States,

selected years 1950–2008 139

Table 33 Death rates for malignant neoplasms

of trachea, bronchus, and lung, by sex, race,

Hispanic origin, and age: United States, selected

years 1950–2008 143

Table 34 Death rates for malignant neoplasm of

breast among females, by race, Hispanic origin,

and age: United States, selected years

1950–2008 146

Table 35 Death rates for human immunodeficiency

virus (HIV) disease, by sex, race, Hispanic origin, and

age: United States, selected years 1987–2008 148

Table 36 Death rates for drug poisoning and

drug poisoning involving opioid analgesics, by

sex, age, race, and Hispanic origin: United States,

selected years 1999–2008 150

Table 37 Death rates for motor vehicle-related

injuries, by sex, race, Hispanic origin, and age:

United States, selected years 1950–2008 153

Table 38 Death rates for homicide, by sex, race,

Hispanic origin, and age: United States, selected

years 1950–2008 157

Table 39 Death rates for suicide, by sex, race,

Hispanic origin, and age: United States, selected

years 1950–2008 161

Table 40 Death rates for firearm-related injuries,

by sex, race, Hispanic origin, and age: United States,

selected years 1970–2008 164

Table 41 Deaths from selected occupational

diseases among persons 15 years of age and over:

United States, selected years 1980–2008 167

Table 42 Occupational fatal injuries and rates,

by industry, sex, age, race, and Hispanic origin:

United States, selected years 1995–2009 168

Determinants and Measures of Health

Table 43 Nonfatal occupational injuries and

illnesses with days away from work, job transfer,

or restriction, by industry: United States, selected

years 2003–2009 170

Table 44 Selected notifiable disease rates and

number of new cases: United States, selected

years 1950–2009 171

Table 45 Acquired immunodeficiency syndrome

(AIDS) diagnoses, by year of diagnosis and selected

characteristics: United States, 2006–2009 173

Table 59 Serious psychological distress in the

past 30 days among adults 18 years of age and

over, by selected characteristics: United States,

average annual, selected years 1997–1998

through 2009–2010 217

Table 60 Current cigarette smoking among adults

18 years of age and over, by sex, race, and age:

United States, selected years 1965–2010 219

Table 61 Age-adjusted prevalence of current

cigarette smoking among adults 25 years of age

and over, by sex, race, and education level:

United States, selected years 1974–2010 221

Table 62 Current cigarette smoking among adults,

by sex, race, Hispanic origin, age, and education

level: United States, average annual, selected years

1990–1992 through 2008–2010 222

Table 63 Current cigarette smoking among adults

18–64 years of age, by urbanization level and

selected characteristics: United States, average

annual, 2002–2004 through 2008–2010 225

Table 64 Use of selected substances in the past

month among persons 12 years of age and over, by

age, sex, race, and Hispanic origin: United States,

selected years 2002–2009 230

Table 65 Use of selected substances among

high school seniors, 10th graders, and 8th graders,

by sex and race: United States, selected years

1980–2010 232

Table 66 Health-related behaviors of children

6–11 years of age, by selected characteristics:

United States, 2003 and 2007 235

Table 67 Health risk behaviors among students

in grades 9–12, by sex, grade level, race, and

Hispanic origin: United States, selected years

1991–2009 237

Table 68 Heavier drinking and drinking five or

more drinks in a day among adults 18 years of age

and over, by selected characteristics: United States,

selected years 1997–2010 239

Table 69 Selected health conditions and risk

factors: United States, selected years 1988–1994

through 2009–2010 242

Table 70 Hypertension among persons 20 years

of age and over, by selected characteristics:

United States, selected years 1988–1994

through 2007–2010 244

Table 71 Cholesterol among persons 20 years

of age and over, by selected characteristics:

United States, selected years 1988–1994 through

2007–2010 246

Table 72 Mean energy and macronutrient intake

among persons 20 years of age and over, by sex and

age: United States, selected years 1971–1974

Table 73 Participation in leisure-time aerobic and muscle-strengthening activities that meet the

2008 federal Physical Activity Guidelines for adults

18 years of age and over, by selected characteristics:

United States, selected years 1998–2010 252

Table 74 Healthy weight, overweight, and obesity among persons 20 years of age and over,

by selected characteristics: United States, selected

Table 76 Untreated dental caries, by selected

characteristics: United States, selected years

1971–1974 through 2005–2008 266

Utilization of Health Resources Ambulatory Care

Table 77 No usual source of health care

among children under 18 years of age, by selected characteristics: United States, average annual, selected years 1993–1994 through

2009–2010 268

Table 78 No usual source of health care among

adults 18–64 years of age, by selected characteristics: United States, average annual, selected years

1993–1994 through 2009–2010 270

Table 79 Reduced access to medical care, dental care, and prescription drugs during the past

12 months due to cost, by selected characteristics:

United States, selected years 1997–2010 272

Table 80 Selected measures of access to medical

care among adults 18–64 years of age, by urbanization level and selected characteristics:

United States, average annual, 2002–2004

through 2008–2010 275

Table 81 Reduced access to medical care during

the past 12 months due to cost, by state: 25 largest states and United States, average annual, selected

years 1997–1998 through 2009–2010 278

Table 82 No health care visits to an office or

clinic within the past 12 months among children under 18 years of age, by selected characteristics: United States, average annual, selected years

1997–1998 through 2009–2010 279

Table 83 Health care visits to doctor offices,

emergency departments, and home visits within the past 12 months, by selected characteristics:

United States, selected years 1997–2010 281

Table 84 Influenza vaccination among adults

Table 110 Doctors of medicine, by place of medical

education and activity: United States and outlying Table 111

Table 112

Table 113

Table 114 First-year enrollment and graduates

of health professions schools, and number of

schools, by selected profession: United States,

selected academic years 1980–1981 through

2008–2009 354

Table 115 Total enrollment in schools for selected

health occupations, by race and Hispanic origin:

United States, selected academic years 1980–1981

through 2008–2009 355

Facilities

Table 116 Hospitals, beds, and occupancy rates, by

type of ownership and size of hospital: United States,

selected years 1975–2009 357

Table 117 Mental health organizations and beds

for 24-hour hospital and residential treatment, by

type of organization: United States, selected years

1986–2008 358

Table 118 Community hospital beds and average

annual percent change, by state: United States,

selected years 1960–2009 359

Table 119 Occupancy rates in community hospitals

and average annual percent change, by state:

United States, selected years 1960–2009 360

Table 120 Nursing homes, beds, residents, and

occupancy rates, by state: United States, selected

years 1995–2010 361

Table 121 Certified intermediate care facilities

and specialty hospitals, number of facilities and

beds, by state: United States, selected years

1995–2010 363

Table 122 Medicare-certified providers and

suppliers: United States, selected years

1975–2009 365

Table 123 Number of magnetic resonance imaging

(MRI) units and computed tomography (CT)

scanners: Selected countries, selected years

1990–2009 366

Health Care Expenditures and Payers

National Health Expenditures

Table 124 Total health expenditures as a

percentage of gross domestic product and per

capita health expenditures in dollars, by selected

countries: Selected years 1960–2009 368

Table 125 Gross domestic product, national

health expenditures, per capita amounts, percent

distribution, and average annual percent change:

United States, selected years 1960–2009 370

Table 126 Consumer Price Index and average

annual percent change for all items, selected items,

Table 127 Growth in personal health care expenditures and percent distribution of factors

affecting growth: United States, 1960–2009 373

Table 128 National health expenditures, average

annual percent change, and percent distribution,

by type of expenditure: United States, selected

years 1960–2009 374

Table 129 Personal health care expenditures,

by source of funds and type of expenditure:

United States, selected years 1960–2009 376

Table 130 National health expenditures for mental health services, average annual percent

change and percent distribution, by type of expenditure: United States, selected years

1986–2005 379

Table 131 National health expenditures for substance abuse treatment, average annual

percent change and percent distribution, by type

of expenditure: United States, selected years

1986–2005 380

Table 132 Cost of hospital discharges with

common hospital operating room procedures

in nonfederal community hospitals, by age and selected principal procedure: United States,

Table 134 Sources of payment for health care, by

selected population characteristics: United States,

selected years 1987–2008 387

Table 135 Out-of-pocket health care expenses

among persons with medical expenses, by age:

United States, selected years 1987–2008 390

Table 136 Expenditures for health services and

supplies and percent distribution, by sponsor:

United States, selected years 1987–2009 391

Table 137 Employers’ costs per employee-hour

worked for total compensation, wages and salaries,

and health insurance, by selected characteristics: United States, selected years 1991–2011 393

Health Care Coverage and Major Federal Programs

Table 138 Private health insurance coverage

among persons under 65 years of age, by selected characteristics: United States, selected years

1984–2010 395

Table 139 Private health insurance coverage

obtained through the workplace among persons under 65 years of age, by selected characteristics:

Table 149 Medicare enrollees, enrollees in

managed care, payment per enrollee, and

short-stay hospital utilization, by state: United States,

selected years 1994–2009 419

Table 150 Medicaid beneficiaries, beneficiaries

in managed care, payments per beneficiary,

and beneficiaries per 100 persons below the

poverty level, by state: United States, selected

fiscal years 1999–2009 421

Table 151 Persons without health insurance

coverage, by state: United States, average

annual, selected years 1995–1997 through

2007–2009 422

Health, United States, 2011: At a Glance

Health, United States, 2011

Value (year) Figure/Table no Life Expectancy and Mortality

Morbidity and Risk Factors

All ages 8.9 (2000) 9.9 (2009) 10.1 (2010)

65 years and over 26.9 (2000) 24.0 (2009) 24.4 (2010)

18 years and over 10.9 (1999–2000) 11.6 (2007–2008) 11.8 (2009–2010)

65 years and over 29.6 (1999–2000) 31.8 (2007–2008) 30.4 (2009–2010)

18 years and over 4.9 (1999–2000) 5.8 (2007–2008) 6.3 (2009–2010)

65 years and over 15.2 (1999–2000) 17.0 (2007–2008) 18.1 (2009–2010)

20 years and over 28.9 (1999–2000) 32.6 (2007–2008) 31.9 (2009–2010)

20 years and over 17.7 (1999–2000) 14.6 (2007–2008) 13.6 (2009–2010)

Obese,3 20 years and over 30.3 (1999–2000) 33.9 (2007–2008) 35.9 (2009–2010)

Obese (BMI at or above sex- and

age-specific 95th percentile):

2–5 years 10.3 (1999–2000) 10.1 (2007–2008) 12.1 (2009–2010)

6–11 years 15.1 (1999–2000) 19.6 (2007–2008) 18.0 (2009–2010)

12–19 years 14.8 (1999–2000) 18.1 (2007–2008) 18.4 (2009–2010)

18 years and over 23.2 (2000) 20.6 (2009) 19.3 (2010)

Aerobic activity and muscle strengthening,4 percent Table 73

18 years and over 15.1 (2000) 18.8 (2009) 20.4 (2010)

Health Care Utilization

No health care visit in past 12 months, percent Table 83

Under 18 years 12.3 (2000) 9.1 (2009) 8.1 (2010)

18–44 years 23.4 (2000) 22.6 (2009) 24.2 (2010)

45–64 years 14.9 (2000) 15.3 (2009) 14.8 (2010)

Health, United States, 2011: At a Glance

Health, United States, 2011

Value (year) Figure/Table no

Emergency room visit in past 12 months, percent Tables 93 and 94

Under 18 years 20.3 (2000) 20.8 (2009) 22.1 (2010)

18–44 years 20.5 (2000) 22.0 (2009) 22.0 (2010)

45–64 years 17.6 (2000) 18.4 (2009) 19.2 (2010)

65 years and over 23.7 (2000) 24.9 (2009) 23.7 (2010)

2–17 years 74.1 (2000) 78.4 (2009) 78.9 (2010)

18–64 years 65.1 (2000) 62.0 (2009) 61.1 (2010)

65 years and over 56.6 (2000) 59.6 (2009) 57.7 (2010)

Under 18 years 23.9 (2001–2004) - 25.3 (2005–2008)

18–44 years 37.7 (2001–2004) - 37.8 (2005–2008)

45–64 years 66.2 (2001–2004) - 64.8 (2005–2008)

65 years and over 87.3 (2001–2004) - 90.1 (2005–2008)

18–44 years 7.0 (2000) 6.7 (2009) 6.3 (2010)

45–64 years 8.4 (2000) 8.5 (2009) 8.3 (2010)

65 years and over 18.2 (2000) 17.1 (2009) 16.1 (2010)

Health Insurance and Access to Care

65 years and over 4.5 (2000) 5.1 (2009) 5.0 (2010)

Health Care Resources

Patient care physicians per 10,000 population Figure 19/Table 109 United States 22.7 (2000) 25.7 (2008)

Highest state 34.4 (MA) (2000) 39.7 (MA) (2008)

Special Feature on Socioeconomic

Status and Health

Children

In 2007–2010, obesity among boys and girls 2–19

years of age decreased with increasing education of

the head of household In households where the

head had less than a high school education, 24% of

boys and 22% of girls were obese, compared with

households where the head had a Bachelor’s degree

or higher education in which 11% of boys and 7% of

girls were obese (Figure 25)

On average in 2003 and 2007, children 6–11 years of

age living below 400% of the poverty level were

more likely to have more than 2 hours of screen time

on an average weekday (watching TV or videos,

playing video games, or using a computer

recreationally) (38%–43%) than children living at

400% or more of the poverty level (31%) (Figure 26)

In 2002–2004, babies of mothers who had less than

a Bachelor’s degree were less likely to be breastfed

for at least 3 months (43%–46%) than babies of

mothers who had a Bachelor’s degree or higher

education (75%) (Figure 27)

Between 2000 and 2010, the percentage of children

with a family income below 200% of the poverty

level who were uninsured decreased from 22% to

11%–13%, while the percentage with a family

income at 200%–399% of poverty who were

uninsured decreased from 9% to 7%, and children

with a family income at 400% or more of the poverty

level who were uninsured decreased from 3% to 2%

(Figure 29)

In 2009–2010, children 5–17 years of age living below

200% of the poverty level were more likely to have

been told by a doctor or other health professional

that they had attention deficit hyperactivity

disorder (11%–13%) than children living at 200% or

more of the poverty level (8%) (Figure 24)

In 2010, the percentage of children 2–17 years of age

who had a dental visit within the past year rose with

relative family income, from 73% of those living

below 200% of the poverty level to 88% of those at

400% or more of the poverty level (Figure 30)

Adults

Between 1996 and 2006, the gap in life expectancy

at age 25 between those with less than a high school education and those with a Bachelor’s degree or

higher education increased by 1.9 years for men and 2.8 years for women On average in 2006, 25-year-old men without a high school diploma had a life expectancy 9.3 years less than those with a Bachelor’s degree or higher; women without a high school diploma had a life expectancy 8.6 years less than those with a Bachelor’s degree or higher (Figure 32)

In 2005–2010, the prevalence of depression among

adults 45–64 years of age was 5 times as high for those below poverty (24%), 3 times as high for those with family income between 100%–199% of poverty (15%), and more than 1.5 times as high for those with family income between 200%–399% (7%), compared

with those at 400% or more of the poverty level

(5%) (Figure 33)

In 2010, the percentage of noninstitutionalized

adults 18–64 years of age with a disability (defined

as a basic actions difficulty or complex activity limitation) was inversely associated with relative family income and was twice as high among those

living below the poverty level (40%) compared with

those with family income at 400% or more of poverty (20%) (Figure 36)

In 2010, edentulism (lack of natural teeth) was five

times as high for adults 45–64 years of age with a

family income below 200% of the poverty level

(15%) and nearly three times as high for those with family income between 200%–399% of poverty (8%), compared with those at 400% or more of the poverty level (3%) (Figure 34)

In 2007–2010, women 25 years of age and over with less than a Bachelor’s degree were more likely to be

obese (39%–43%) than those with a Bachelor’s

degree or higher education (25%); obesity among

men did not vary consistently by educational attainment (Figure 37)

In 2010, 31% of adults 25–64 years of age with a high

school diploma or less education were current

smokers, compared with 24% of adults with some

college and 9% of adults with a Bachelor’s degree or higher (Figure 38)

In 2010, the percentage of adults 50–75 years of age

reporting a colorectal test or procedure increased

with increasing education level from 45% among

those with no high school diploma to 67% among

those with a Bachelor’s degree or higher (Figure 39)

In 2010, adults 18–64 years of age with a family

income below 200% of the poverty level were more

than six times as likely to be uninsured (42%–43%),

and adults with a family income at 200%–399% of

the poverty level were three times as likely to be

uninsured (21%), as adults with a family income at

400% or more of the poverty level (7%) (Figure 40)

In 2010, about one-quarter of adults 18–64 years of

age with a family income below 200% of the poverty

level did not get or delayed seeking needed

medical care due to cost, compared with 15% of

those with a family income at 200%–399% of the

poverty level, and 7% of those with a family income

at 400% or more of the poverty level (Figure 41)

Life Expectancy and Mortality

Between 2000 and 2009, life expectancy at birth

increased 1.9 years for males and 1.6 years for

females The gap in life expectancy between males

and females narrowed from 5.2 years in 2000 to 4.9

years in 2009 (Table 22)

Between 2000 and 2009, life expectancy at birth

increased more for the black than for the white

population, thereby narrowing the gap in life

expectancy between these two racial groups In

2000, life expectancy at birth for the white

population was 5.5 years longer than for the black

population By 2009, the difference had narrowed to

4.3 years (Table 22)

Between 2000 and 2009, the infant mortality rate

decreased 7.5%, from 6.91 to 6.39 deaths per 1,000

live births Infant mortality rates have declined for

most racial and ethnic groups, but large disparities

among the groups remain (Table 15 and Figure 2)

Between 2000 and 2008, the age-adjusted heart

disease death rate decreased 28%, from 257.6 to

186.5 deaths per 100,000 population In 2008,

one-quarter of all deaths were from heart disease

(Table 26 and Table 30)

Between 2000 and 2008, the age-adjusted cancer

death rate decreased 12%, from 199.6 to 175.3

deaths per 100,000 population In 2008, 23% of all

deaths were from cancer (Table 26 and Table 32)

2008, 40% of drug poisoning deaths involved opioid

analgesic drugs ( Table 36, a new table in the 2011 edition)

Fertility and Natality

Between 2009 and 2010 (preliminary data), the birth

rate among teenagers 15–19 years of age fell 9%,

from 37.9 to 34.3 live births per 1,000 females—a record low for the United States (Table 3 and Figure 5)

Low birthweight is associated with elevated risk of

death and disability in infants The percentage of low birthweight births [infants weighing less than 2,500 grams (5.5 pounds) at birth] was 8.15% in 2010 (preliminary data) and has declined slowly since 2006 (8.26%) (Table 9)

Health Risk Factors Between 2003 and 2007, the percentage of children

6–11 years of age who did not get daily vigorous

physical activity decreased from 69% to 62%; the

percentage of children who had more than 2 hours

of screen time on an average weekday (watched TV

or videos, played video games, or used a computer recreationally) increased from 36% to 40%; and the

percentage of children who did not get enough

sleep nightly increased from 25% to 28% ( Table 66, a new table in the 2011 edition)

Between 1988–1994 and 2009–2010, the prevalence

of obesity among preschool-age children 2–5

years of age increased from 7% to 12% (Table 69 and Figure 10)

The prevalence of obesity among school-age

children and adolescents increased from 11% to

18% between 1988–1994 and 2009–2010 (Table 69 and Figure 10)

In 2010, 50% of adults 18 years of age and over met

neither the aerobic activity nor the strengthening physical activity federal guidelines

muscle-This percentage increased with age, rising from 39%

of adults 18–24 years of age to 70% of adults 75 years and over (Table 73)

From 1988–1994 through 2007–2010, the percentage

of adults 20 years of age and over with grade 1

obesity [a body mass index (BMI) of 30.0–34.9]

increased from 14% to 20% Those with grade 2

obesity (BMI of 35.0–39.9) nearly doubled, from 5%

In 2010, 19% of U.S adults were current cigarette

smokers, a decline from 21% in 2009 Men were

more likely than women to be current cigarette

smokers (Table 60 and Figure 8)

Measures of Health and Disease

Prevalence

In 2008–2010, 6% of children under 18 years of age

had an asthma attack in the past year, 12% had a

skin allergy, and 6% had three or more ear

infections in the past year Among school-age

children 5–17 years of age, 9% had attention deficit

hyperactivity disorder and 6% had serious

emotional or behavioral difficulties ( Table 46)

In 2010, the percentage of noninstitutionalized

adults who reported their health as fair or poor

ranged from 6% of those 18–44 years of age to 28%

of those 75 years and over (Table 56)

In 2010, 27% of noninstitutionalized adults 18–64

years of age reported a disability (defined as any

basic actions difficulty or complex activity limitation),

compared with 62% of those 65 years of age and

over (Table 54)

In 2009–2010, 45% of men and 31% of women 75

years of age and over had ever been told by a

physician or other health professional that they had

heart disease Among those 75 years of age and

over, heart disease prevalence rose between

1999–2000 and 2009–2010 among men but not

among women (Table 49)

In 2009–2010, 25% of men and 18% of women 75

years of age and over had ever been told by a

physician or other health professional that they had

cancer (excluding squamous and basal cell skin

cancers) (Table 49)

Between 1988–1994 and 2007–2010, the prevalence

of uncontrolled high blood pressure among adults

20 years of age and over with hypertension

decreased from 74% to 49% (Table 70)

Between 1988–1994 and 2007–2010, the percentage

of adults 20 years of age and over with a high serum

total cholesterol level (defined as greater than or

equal to 240 mg/dL) declined from 20% to 14%

(Table 71)

Health Care Utilization Use of Health Care Services

In 2009, there were 1.3 billion visits to physician

offices, hospital outpatient departments, and hospital emergency departments Of these, 1.0

billion were visits to physician offices, 96 million were visits to hospital outpatient departments, and 136 million were visits to hospital emergency

departments (Table 96)

In 2010, 21% of adults 18 years of age and over had

one or more emergency department visits in the

past year, and 8% had two or more visits (Table 94)

In 2010, 79% of children 2–17 years of age, 61% of adults 18–64 years, and 58% of adults 65 years of age

and over had seen a dentist in the past year

(Table 98)

Between 2000 and 2008–2009, the nonfederal

short-stay hospital discharge rate was stable at

1,100–1,200 discharges per 10,000 population, and the average length of stay was 5 days (Table 103) The percentage of the population taking at least one

prescription drug during the past 30 days increased

from 38% in 1988–1994 to 48% in 2005–2008 During the same period, the percentage taking three or more prescription drugs nearly doubled, from 11% to 21%, and the percentage taking five or more drugs increased from 4% to 11% (Table 99)

Use of Preventive Medical Care Services

In 2010, one-half of noninstitutionalized adults 50

years of age and over had received influenza

vaccination in the past year, ranging from 42% of

those 50–64 years of age to 68% of those 75 years of age and over (Table 88 and Figure 12)

Between 2000 and 2010, the percentage of noninstitutionalized adults 65 years of age and over

who ever received a pneumococcal vaccination

increased from 53% to 60% In 2010, 55% of those 65–74 years of age and 66% of those 75 years of age and over ever had a pneumococcal vaccination (Table 89 and Figure 12)

The percentage of women 40 years of age and over

who had a mammogram in the past 2 years ranged

from 67% to 70% between 2000 and 2010 (Table 90)

The percentage of adults 50–75 years of age with any

colorectal test or procedure increased from 34% in

2000 to 59% in 2010 The percentage of adults 50–75

years of age reporting a colonoscopy procedure

nearly tripled from 2000 to 2010, increasing from

19% to 55% (Table 92, a new table in the 2011

edition; and Figure 39)

Urbanization Level: Health

Status, Risk Factors, and Access

to Care

In 2008–2010, the percentage of adults 18–64 years

of age with disability (defined as any basic actions

difficulty or complex activity limitation) was lower in

large central metropolitan counties compared with

the most rural nonmetropolitan counties The

percentage of adults 18–64 years of age with a

disability ranged from 23%–25% in the most urban

(large central and large fringe) metropolitan counties

to 36% in the most rural (nonmicropolitan) counties

(Table 57, a new table in the 2011 edition)

In 2008–2010, the percentage of adults 18–64 years

of age who were current cigarette smokers was

generally lower in more urban (large central and

large fringe) metropolitan counties (19%–21%)

compared with nonmetropolitan counties (28%–

30%) (Table 63, a new table in the 2011 edition)

In 2008–2010, the percentage of adults 18–64 years

of age who reported not receiving or delaying

seeking needed medical care due to cost in the

past year was lowest in large fringe metropolitan

counties (12%), compared with large central

metropolitan counties (14%), medium and small

metropolitan counties (15%), and nonmetropolitan

counties (17%) ( Table 80, a new table in the 2011

edition)

In 2008–2010, the percentage of adults 18–64 years

of age living in large fringe metropolitan counties

who were uninsured (17%) was lower than in

counties of other urbanization levels (21%–25%),

although the pattern differed among the four regions

of the country For example, in the West region, the

percentage of adults who were uninsured was 19% in

the large fringe metropolitan counties compared

with 24% in other metropolitan counties and

27%–33% in nonmetropolitan counties (Table 80, a

new table in the 2011 edition)

Unmet Need for Medical Care, Prescription Drugs, and Dental Care Due to Cost

Between 1997 and 2010, among adults 18–64 years

of age, the percentage who reported not receiving

or delaying seeking needed medical care due to cost in the past 12 months increased from 11% to

15%; the percentage not receiving needed

prescription drugs due to cost nearly doubled,

rising from 6% to 11%; and the percentage not

receiving needed dental care due to cost grew from

11% to 17% (Table 79)

In 2010, 35% of adults 18–64 years of age who were

uninsured did not get or delayed seeking needed

medical care due to cost in the past 12 months,

compared with 8% of adults with private coverage

and 13% of adults with Medicaid (Table 79 and Figure 18)

In 2010, 26% of adults 18–64 years of age who were

uninsured did not get needed prescription drugs

due to cost in the past 12 months, compared with

6% of those with private coverage and 14% of those

with Medicaid (Table 79 and Figure 18)

Health Care Resources

Between 2000 and 2009, the number of physicians

in patient care increased 12%, from 23 to 25 per

10,000 population In 2009, the number of patient care physicians per 10,000 population ranged from

17 in Idaho and Mississippi to 40 in Massachusetts (Table 109 and Figure 19)

Between 2000 and 2009, there were about 5,000

community hospitals and 800,000 community hospital beds ( Table 116)

In 2010, there were about 1.7 million nursing home

beds in 16,000 certified nursing homes Between

2000 and 2010, nursing home bed occupancy for the United States was stable at 82% (Table 120)

Health Care Expenditures and

Payers

Health Care Expenditures

In 2009, national health care expenditures in the

United States totaled $2.5 trillion, a 4% increase from

2008 The average per capita expenditure on

health was $8,000 in 2009 (Table 125 and Table 128)

Expenditures for hospital care accounted for 31%

of all national health expenditures in 2009 Physician

and clinical services accounted for 20% of the total,

prescription drugs for 10%, and nursing care facilities

and continuing care retirement communities for 6%

(Table 128)

Prescription drug expenditures increased 5.3%

between 2008 and 2009, compared with a 3.1%

increase between 2007 and 2008 (Table 128)

In 2009, the average cost for the entire

hospitalization involving a heart valve procedure

was $49,000, a coronary artery bypass graft

procedure was $36,000, cardiac pacemaker

insertion or replacement was $33,000, and spinal

fusion was $26,000 ( Table 132, a new table in the

2011 edition)

Health Care Payers

In 2009, 34% of personal health care expenditures

were paid by private health insurance; consumers

paid 14% out of pocket; 23% was paid by Medicare

and 17% by Medicaid; and the remainder was paid by

other insurance, payers, and programs (Table 129

and Figure 20)

In 2010, the Medicare program had 48 million

enrollees and expenditures of $523 billion, up from

$509 billion the previous year Expenditures for the

Medicare drug program (Part D) were $62 billion in

2010 (Table 143)

Of the 35 million Medicare enrollees in the

fee-for-service program in 2009, 18% were under

65 years of age, compared with 15% in 2000

(Table 144)

In 2009, children under 21 years of age accounted for

48% of Medicaid recipients but only 20% of

expenditures Aged, blind, and persons with

disabilities accounted for 21% of recipients and 63%

of expenditures (Table 146)

In 2009, the Children’s Health Insurance Program

(CHIP) accounted for $9.5 billion (less than 1%) of

personal health care expenditures (Table 129)

Health Insurance Coverage Between 2000 and 2010, the percentage of the

population under 65 years of age with private

health insurance obtained through the workplace

declined from 67% to 57% (Table 139)

In 2010, 8% of children under 18 years of age and

22% of adults 18–64 years of age had no health

insurance coverage (public or private) at the time

of interview ( Table 141)

Between 2000 and 2010, among children in families

with income just above the poverty level (100%–

199% of poverty), the percentage of uninsured

children under 18 years of age dropped from 22% to

13%, while the percentage with coverage through

Medicaid or the Children’s Health Insurance Program (CHIP) increased from 28% to 54%

(Table 140 and Table 141)

Mortality

Life Expectancy at Birth

Figure 1 Life expectancy at birth, by race and sex and Hispanic origin:

Lif ga Fr

in

to

81 ex an 19 ha Hi anSODat

e gap in life expectancy at birth between ite persons and black persons persists but

d females in 2008 but had narrowed since

90 In 2008, Hispanic males and females

d longer life expectancy at birth than spanic white or non-Hispanic black males

non-d females

URCE: CDC/NCHS, Health, United States, 2011, Table 22

a from the National Vital Statistics System (NVSS)

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2011.htm#fig01

Mortality

Infant Mortality

Infant and neonatal mortality rates declined

between 1998 and 2008

The infant mortality rate is the risk of death

during the first year of life The 2008 infant

mortality rate of 6.61 per 1,000 live births

was 8% lower than in 1998 During the same

period, the neonatal mortality rate (death

rate among infants under 28 days) decreased

11%, to 4.29 per 1,000 live births, and the

postneonatal mortality rate (death rate

among infants 28 days through 11 months)

remained stable

SOURCE: CDC/NCHS, Health, United States, 2011, Table 17 and

reference 1 Data from the National Vital Statistics System

Postneonatal

0

Year

Mortality

Selected Causes of Death

Figure 3 Death rates for selected causes of death for all ages, by sex:

Unintentional injuries

Diabetes Alzheimer’s disease Alzheimer’s disease

During this 10-year period, age-adjusted death rates among males for stroke declined 33%, heart disease declined 32%, cancer declined 15%, and unintentional injuries increased 10% Among females, age-adjusted death rates for heart disease declined 32%, stroke declined 31%, cancer declined 11%, and unintentional injuries increased 15% In

2008, age-adjusted death rates were higher for males than females for heart disease, cancer, chronic lower respiratory diseases, diabetes, and unintentional injuries, were similar for stroke, and were higher among females than males for Alzheimer’s disease NOTE: Starting with 1999 data, cause of death is coded

according to the International Classification of Diseases, 10th SOURCE: CDC/NCHS, Health, United States, 2011,

Data from the National Vital Statistics System (NVSS)

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2011.htm#fig03

Mortality

Motor Vehicle-related Death Rates

Between 1998 and 2008, motor vehicle-related

death rates declined among males and females

15–19 years of age while fluctuating among

males and females 20–24 years of age

Motor vehicle-related deaths are a significant

cause of preventable death, accounting for

about 40,000 deaths in the United States in

2008 across all ages ( 2 ) Motor vehicle-related

death rates are higher for males and females

15–24 years of age than for most other age

groups ( Table 37) For males 15–19 years

of age, motor vehicle-related death rates

declined 30% from 1998 to 2008, and for

females 15–19 years of age, motor-vehicle

death rates declined 33% during this period

Motor vehicle-related death rates for males

and females 20–24 years of age fluctuated

during this time

Figure 4 Motor vehicle-related death rates among persons 15–24 years of age, by sex and age: United States, 1998–2008

50

Male

Female

20–24 years 15–19 years

Natality

Teenage Birth Rates

150

origin: United States, 1998–2008

Age of mother: 15–17 years Age of mother: 18–19 years

White, not Hispanic

American Indian or Alaska Native American Indian or Alaska Native

Black, not Hispanic

Hispanic

50

White, not Hispanic Asian or Pacific Islander Asian or Pacific Islander

Black, not Hispanic

F a

I 1 1 a t t 1 H 3 y f H oSfr

rom 1998 to 2008, teenage birth rates declined mong most racial and ethnic groups

n 2008, 3% of births were to teenagers under

8 years of age and 7% were to mothers 8–19 years of age ( Table 6) Between 1998

nd 2008, birth rates declined 27% for eenagers 15–17 years of age and 13% for hose 18–19 years of age ( Table 3) Since

998, birth rates have decreased 21% for ispanic teenagers 15–17 years of age and 9% for non-Hispanic black teenagers 15–17 ears of age During this period, birth rates

or 18–19 year olds decreased 18% for ispanic black teenagers and were stable for lder Hispanic teenagers.

non-OURCE: CDC/NCHS, Health, United States, 2011, Table 3 Data

om the National Vital Statistics System (NVSS)

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2011.htm#fig05

Morbidity

Heart Disease Prevalence

From 1999–2000 to 2009–2010, heart disease

prevalence remained stable among women in

all age groups and among men 45–74 years of

age

Heart disease is the leading cause of death

in the United States, accounting for about

617,000 deaths in 2008 ( Table 26) Between

1999–2000 and 2009–2010, the prevalence of

lifetime respondent-reported heart disease

among adults 18–54 years of age was similar

for men and women Among adults 55 years

of age and over, heart disease prevalence

was higher for men than for women

Among adult women in all age groups, and

among men 45–74 years of age, prevalence

remained steady from 1999–2000 to

2009–2010 Among men 75 years of age and

over, prevalence rose from 39% in 1999–2000

to 45% in 2009–2010

SOURCE: CDC/NCHS, Health, United States, 2011, Table 49

Data from the National Health Interview Survey (NHIS)

adults 18 years of age and over, by sex and age: United States, 1999–2000 through 2009–2010

50

40

0 18–44 years 45–54 years

65–74 years 55–64 years

75 years and over

100

Figure 7 Basic actions difficulty or complex activity limitation among

adults 18 years of age and over, by sex and age: United States, 2000–2010

Any complex activity

65 years and over

18 years of age and over, by sex and age: United States, 2000–2010

50

40

30

20

65 years and over

High school seniors

65 years and over

High school seniors 45–64 years

Basic Actions Difficulty or Complex Activity Limitation

The percentages of the noninstitutionalized population with each of two measures of disability—basic actions difficulty or complex activity limitation—were stable from 2000 to

2010

Two constructs for defining and measuring disability status are basic actions difficulty and complex activity limitation ( 3 ) Basic actions difficulty captures limitations in movement, emotional, sensory, or cognitive functioning associated with a health problem Complex activity limitation is the inability to function successfully in certain social roles, such as working, maintaining

a household, living independently, or participating in community activities Between 2000 and 2010, the prevalence

of each measure was generally higher for women than men in the same age group, and higher for adults 65 years of age and over than for those 18–64 years of age.

SOURCE: CDC/NCHS, Health, United States, 2011, Table 54 Data from the National Health Interview Survey (NHIS)

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2011.htm#fig07

Health Risk Factors

Current Cigarette Smoking

In 2010, 19% of high school seniors, 22%

of men, and 17% of women were current

cigarette smokers

Smoking is associated with an increased risk

of heart disease, stroke, lung and other types

of cancers, and chronic lung diseases ( 4 )

Between 2000 and 2010, cigarette smoking

among students in grade 12 decreased from

33% to 22% for male students and from

30% to 16% for female students During

this period, the percentage of adults who

smoked cigarettes declined for men and

women 18–44 and 45–64 years of age, while

remaining stable for adults 65 years of age

and over

SOURCE: CDC/NCHS, Health, United States, 2011, Tables 60

and 65 Data from the National Health Interview Survey

(NHIS) and the Monitoring the Future (MTF) Study

Health Risk Factors

Uncontrolled High Blood Pressure

100

and over for persons with hypertension, by sex and age: United States,

Hypertension increases the risk for cardiovascular disease, heart attack, and stroke ( 5 ) Between 1988–1994 and 2007–2010, the prevalence of uncontrolled high blood pressure (defined as an average systolic blood pressure of 140 mm Hg or higher, or an average diastolic pressure of

90 mm Hg or higher, among those with hypertension) declined for all age groups of men and women However, in 2007–2010, nearly one-half of adults with hypertension continued to have uncontrolled high blood pressure

SOURCE: CDC/NCHS, Health, United States, 2011, Table 70 Data from the National Health and Nutrition Examination Survey (NHANES)

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2011.htm#fig09

Health Risk Factors

Obesity Among Children

In 2009–2010, almost one in five children

older than 5 years of age was obese

Excess body weight in children is associated

with excess morbidity in childhood and

adulthood ( 6 ) The percentage of children

2–5 years of age who were obese rose from

7% in 1988–1994 to 10% in 1999–2000 and

has held steady since that time ( 7 ) The

prevalence of obesity among 6–11 year

olds increased from 11% in 1988–1994 to

15% in 1999–2000 and has not increased

significantly since then Among adolescents

12–19 years of age, the prevalence of

obesity rose from 11% in 1988–1994 to

15% in 1999–2000 and has not increased

significantly since then

SOURCE: CDC/NCHS, Health, United States, 2011, Table 69

Data from the National Health and Nutrition Examination

2000 2001– 2002 2003– 2004 2005– 2006 2007– 2008 2009– 2010

Health Risk Factors

Overweight and Obesity Among Adults

by sex: United States, 1988–1994, 1999–2002, and 2007–2010

Overweight, but not obese

In 2007–2010, 20% of adults had Grade 1 obesity, 9% had Grade 2 obesity, and 6% had Grade 3 obesity

Excess body weight is correlated with excess morbidity and mortality ( 8 , 9 ) In particular, Grade 2 or higher obesity [a body mass index (BMI) of 35 or higher] significantly increases the risk of death ( 10 ) Between 1988–1994 and 2007–2010, the percentage of men and

with Grade 1 obesity (BMI greater than or equal to 30 but less than 35) increased more for men than for women The percentage with Grade 2 obesity (BMI greater than or equal to 35 but less than 40) and Grade 3 obesity (BMI of 40 or higher) also increased among men and women during this period

SOURCE: CDC/NCHS, Health, United States, 2011, Table 74 Data from the National Health and Nutrition Examination Survey (NHANES)

women who were overweight but not obese was stable while the percentage with obesity increased During this period, the percentage

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2011.htm#fig11

Prevention

Influenza and Pneumococcal Vaccination

Between 2000 and 2010, influenza vaccination

increased among adults under 65 years of age

and pneumococcal vaccination increased

among those 65 years of age and over

Vaccination of persons at risk for

complications from influenza and invasive

pneumococcal disease is an important

public health strategy ( 11 ) Between 2000

and 2010, influenza vaccination in the past

12 months for noninstitutionalized adults

increased among those 18–49 and 50–64

years of age but was stable among those 65

years of age and over Decreases in influenza

vaccination coverage in 2005 were related to

a vaccine shortage ( 12 ) Between 2000 and

2010, the percentage of noninstitutionalized

adults who had ever received pneumococcal

vaccination increased among those 65–74

and 75 years of age and over

of vaccination and age: United States, 2000–2010

100 Influenza vaccination in the Pneumococcal vaccination ever

18–49 years

18–64 years, high-risk category

Prevention

Mammography Use

of age and over, by age: United States, 2000–2010

2010, mammography use within the past

2 years was stable among all age groups of women 40 years of age and over

SOURCE: CDC/NCHS, Health, United States, 2011, Table 90 Data from the National Health Interview Survey (NHIS)

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2011.htm#fig13

Health Insurance

Coverage Among Children

Between 2000 and 2010, the percentage

of children with private health insurance

coverage declined while the percentage with

Medicaid coverage increased at a faster rate,

resulting in a decline in the percentage of

children who were uninsured

Health insurance is a major determinant

of access to care ( 16 ) Between 2000 and

2010, the percentage of children under 18

years of age with private health insurance

declined from 67% to 54% During the same

period, Medicaid coverage [a category that

includes the Children’s Health Insurance

Program (CHIP) ( 17 )] increased from 20% to

36% This led to a decline in the percentage

of children who were uninsured, from 13%

in 2000 to 8% in 2010

SOURCE: CDC/NCHS, Health, United States, 2011, Tables 138

140, and 141 Data from the National Health Interview

by type of coverage: United States, 2000–2010

100

80 Private

Health Insurance

Coverage Among Adults 18–64 Years of Age

age and type of coverage: United States, 2000–2010

Health insurance is a major determinant of access to health care Among adults 18–44 years of age, the percentage with private coverage declined from 71% in 2000 to 60%

in 2010 while Medicaid coverage increased from 6% to 11% The percentage of persons 18–44 years of age who were uninsured increased from 22% to 27% during the same period Similarly between 2000 and 2010, the percentage of adults 45–64 years of age with private coverage declined from 79% to 71%; the percentage with Medicaid coverage increased from 5% to 7%; and the percentage uninsured increased from 13% to 16%

SOURCE: CDC/NCHS, Health, United States, 2011, Tables 138,

140, and 141 Data from the National Health Interview Survey (NHIS)

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2011.htm#fig15

Utilization and Access

Prescription Drug Use

Between 1988–1994 and 2005–2008, the

percentage of children and adults who had

used three or more prescription drugs in the

past 30 days increased

In the United States, spending for

prescription drugs was $250 billion in 2009,

accounting for 12% of personal health

care expenditures ( Table 128) Between

1988–1994 and 2005–2008, the use of three

or more prescription drugs in the past 30

days increased for all age groups of males

and females Some of the most commonly

used prescription medications were asthma

medicines and central nervous system

stimulants for children and adolescents,

antidepressants for middle-aged adults,

and cholesterol-lowering and high blood

pressure control drugs for older Americans

Utilization and Access

Emergency Department Visits

age and type of coverage: United States, 2000–2010

Nationwide, there has been concern about appropriate use of emergency services and crowding of emergency departments ( 18 ) Between 2000 and 2010, children and adults under 65 years of age with Medicaid coverage were more likely than those with private coverage or the uninsured to have used the emergency department in the past

12 months In 2010, adults 18–64 years of age with Medicaid coverage were twice as likely to have had at least one emergency department visit in the past 12 months as those with private coverage or the uninsured.

SOURCE: CDC/NCHS, Health, United States, 2011, Tables 93 and

94 Data from the National Health Interview Survey (NHIS)

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Utilization and Access

Delay or Nonreceipt of Needed Medical Care or Prescription Drugs Due to Cost

Between 2000 and 2010, the percentage of

adults 18–64 years of age who delayed or did

not receive needed medical care or prescription

drugs due to cost increased for the uninsured

and those with private coverage

Delaying or not receiving needed medical

care or prescription drugs may result in more

serious illness, increased complications, and

longer hospital stays ( 19 , 20 ) Between 2000

and 2010, delay or nonreceipt of needed

medical care in the past 12 months due to

cost for those 18–64 years of age increased

among those with private coverage and the

uninsured while remaining stable among

those with Medicaid During this period, the

percentage of adults 18–64 years of age who

did not receive needed prescription drugs

in the past 12 months due to cost increased

among those with private coverage,

Medicaid, and the uninsured

SOURCE: CDC/NCHS, Health, United States, 2011, Table 79

Data from the National Health Interview Survey (NHIS)

needed medical care due to cost prescription drugs due to cost

Private Medicaid Uninsured

Health Care Resources

Patient Care Physicians per Population

Figure 19 Patient care physicians per 10,000 population, by state:

United States, 2009

Patient care physicians per 10,000 population 17–21 22–24 25–26

On average, there were 25 patient care physicians per 10,000 population in the United States in 2009 The New England states, Mid-Atlantic states, District of Columbia, Maryland, Hawaii, and Minnesota were in the highest quartile (27 or more patient care physicians per 10,000 population) States in the lowest quartile (17–21 patient care physicians per 10,000 population) included parts of the South and some of the Mountain states, along with Iowa and Indiana

SOURCE: CDC/NCHS, Health, United States, 2011, Table 109 Data from the American Medical Association (AMA) and the American Osteopathic Association (AOA)

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2011.htm#fig19

Personal Health Care Expenditures

Source of Funds

the average annual growth in Medicare

expenditures was 9%, for Medicaid and

private insurance 7%, and for out-of­

pocket spending 5% In 2009, 34% of

personal health care expenditures were

paid by private health insurance, 23% by

Medicare, 17% by Medicaid, 14% out of

pocket, and less than 1% by the Children’s

Health Insurance Program (CHIP)

SOURCE: CDC/NCHS, Health, United States, 2011,

Data from the Centers for Medicare & Medicaid Services,

Out-of-pocket spending for personal health

care expenditures grew less rapidly than

Medicare, Medicaid, and private insurance

spending from 1999 to 2009

Between 1999 and 2009, total personal

health care expenditures grew from $1.1

trillion to $2.1 trillion During this period,

Medicaid (state) Medicaid (federal)